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HIPPOCRATES VOR, Ut
THE LOEB CLASSICAL LIBRARY
FOUNDED BY JAMES LOEB, LL.D,
EDITED BY 7 T. E. PAGE, C.H., LITT.D. + E. CAPPS, PH.D., LL.D. + W. H. D. ROUSE, tirt.p. L. A. POST, t.u.p. E. H. WARMINGTON, M.4.; F.R.HIST.SOC.
HIPPOCRATES VOL. Ill
REDUCTION OF THE SHOULDER JOINT.
EUBOAH pov 6 Sa TOD KATwLLSOVTOS
HIPPOCRATES
WITH AN ENGLISH TRANSLATION BY Dr. E. T. WITHINGTON
VOL Il
LONDON
WILLIAM HEINEMANN LTD
CAMBRIDGE, MASSACHUSE'TTS
HARVARD UNIVERSITY PRESS
First Printep . 1928 REPRINTED - 1944 REPRINTED . 1948 REPRINTED . 1959
Printed in Great Britain by The University Press, Aberdeen
CONTENTS
3 PAGE TRANSUATORS) PREPAOGE: 5) 6 e's) 6, sie ie) ¢ oc 8% Vv EREFAGEM aT LOE, Ct rip tree ome 40. Fuki y ei manaescVLll TUR ODEGTEON wittensict ic Sckryed: ay isl vasiwure ose mands sear GNEWOUNDSLIN CHE HAD) lores on, 00 is. eae is ye 1 TNCDHEL SURGERY? a es Meteo We CSOs eettale Mree OOS FRACTURES, JOINTS, MOCHLICON . . . +... . 88
ONGENAOLURES Gut ths Gin weiner sue are ee OO ONMUOIND Sieg.) tid Sormsletearsetheteyerys ogi fone ebekm wots ReO INSTRUMENTS OF REDUCTION. .... .. . 399
APPENDIX: SUPPLEMENTARY NOTES . . =: © © » « 451
ILLUSTRATIONS REDUOTION OF THE SHOULDER JOINT . . . Frontispiece THE HIPPOOCRATIC BENCH OR SCAMNUM . facing page 454
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TRANSLATOR’S PREFACE
Anutius Foésius on coming (1594) to the surgical section of his Hippocrates says that some will find fault with him for editing treatises so fully discussed by many eminent writers: they will call his work futile and superfluous. Some will also cry out upon his notes as fragmentary, superficial and useless. Such fears are more natural in one who looks back not only on Foés himself and his contemporaries, but on the translation of Adams, the great edition of Petrequin, and the labours of Littré and Ermerins, nowhere more complete than when dealing with these treatises; while behind them all loom the thousand pages of Galenic Commentaries and the dim light of the illustrations of Apollonius. | He is overwhelmed by his material, and cannot hope to do more that attempt a fairly accurate translation with fragmentary notes condensing the more important discussions of preceding editors.
The recent revolution in surgery due to anaes- thetics, asepsis, radiography and other practical and scientific progress tends to put a modern surgeon rather out of touch with the great ancients. It makes him, perhaps, less able to appreciate their achievements, and more conscious of their un- avoidable errors. On the other side, recent criti-
a* vil
TRANSLATOR’S PREFACE
cism of the Corpus Hippocraticum relieves him from the necessity of assuming that Hippocrates wrote Mochlicon, and therefore of approaching it hat in hand. Its author assumes rather the appearance of a slave surgeon or student to whom his master gave a rather dilapidated copy of Fractures-Joints with instructions to summarise everything to do with dislocations, and be quick about it. That the result should have been held in honour for more than twenty centuries is high tribute to the excellence of the original.
The translation was made independently of that by Adams, though some of his expressions were afterwards adopted. The notes and meanings of words are taken more frequently than usual from the Commentaries of Galen, who is surely our highest authority on the subject. The text is mainly that of Petrequin, a conservative scholar who often successfully defends the manuscript readings against rash alterations by Littré and Erme- rins. The recent edition by Kiihlewein (Teubner, 1902) is doubtless an improvement even upon Petrequin, but was not directly available. Some of his emendations are adopted with due acknowledg- ment, and many of his variants are given in the notes, including all not otherwise attributed. The excessive “lonicism”’ of all previous editions has been reduced in accordance with Kiihlewein’s principles, as in the other volumes.
In treatises so fully discussed by “so many most noble writers in that part of medicine,’ as Foés has observed, any novel suggestions are likely to be wrong, and the editor is duly conscious of presump- tion in submitting views of that character as to the
viii
TRANSLATOR’S PREFACE
Hippocratic Bench, the astragalus and the origin of Chapters LXXIX-LXXXI on joints.
The frontispiece is a reproduction of the Apol- lonius illustration for éuBod% dpov, 6 &a Tod Karw- piovtos [tpomos], “the shouldering method of reducing the shoulder joint,’ taken from the thousand years old MS. “BB.” It is doubtless a fairly accurate copy of the thousand years older original by Apollonius himself, or the artist he employed. I owe this and other assistance to the courtesy of Dr. Charles Singer, and am still more indebted to our chief authority on “ Hippocrates,” Dr. W. H. S. Jones.
PREFACE
Tue whole of this volume has been entrusted to Dr. E. T, Withington, of Balliol College. Only a trained surgeon can explain the surgical treatises of the Hippocratic Collection.
The fourth (and last) volume will contain Aphorisms, Humours, Nature of Man, Regimen in Health I-III, and Dreams. The text of all these works has to be worked out from the manuscripts themselves, as Littre’s text is here very imperfect.
W..HwS: 55
GENERAL INTRODUCTION
Wuen Marcus Aurelius Severinus gave the title De efficaci Medicina to his work on surgery he probably expected to annoy the professors of what was then considered a much higher branch of the healing art, but when he goes on to say that surgery is obviously a strenuous, potent and vital method of treatment, few who have been actively or passively concerned with broken bones, dislocated joints or bleeding wounds will venture to disagree with him, He was doubtless also thinking of Celsus, who had long before declared that the part of medicine which cures by hand has a more directly obvious effect than any other.1 He adds that this is also the oldest part of medicine and, indeed, it must have been recognised from the dawn of reason that, in such common emergencies as those just mentioned, something has to be done, primarily with the hand, and that anyone who can do it quickly, effectively and without causing extreme pain is, for a time at least, “ worth many other men.”’
So says Homer? of the army surgeon, and both he and his hearers were well qualified to judge. As a great authority puts it, ““ Homer was not content to recite in general terms the wounds of the warriors as mere casual slashing; he records each stab with
2 VIL. 8 Jj, XI. 514. xi
GENERAL INTRODUCTION
anatomical precision, describing the path of the weapon and its effects.” Condensing slightly Sir Clifford Allbutt’s examples—* A spear driven through the buttock pierces the urinary bladder and comes out under the symphysis pubis (5. 65). The rock hurled by Ajax strikes Hector on the breast, he turns faint, pants for health and spits blood (14. 437). An epigastric wound exposes the _ pericardium (16. 481). Homer explains that, after the spear of Achilles had transfixed Hector’s neck, he could still speak because the weapon had missed the trachea (22. 328). Yet more remarkable is the record (8. 83) of the rotatory movement of one of the horses ot Nestor, which followed the stab of a spear at the base of the skull (ka/puov, a deadly spot)—the weapon had pierced the cerebellum. We may wonder not only at the poet’s surgery, but also that his hearers were prepared to comprehend such particulars.”’ }
It will perhaps increase the wonder and interest if we contrast the //zad with our mediaeval Romances of chivalry, where there is no end of wounds and violence but an almost complete absence of definite- ness or surgical interest. Take the famous fight between Balin and Balan in the Morte d’ Arthur: the champions first unhorse and. stun one another, but spring up and fight desperately for a prolonged period, “ wounding each other grievously” all the time. At length, when “all the place was red with their blood,” when “ they had smitten either other seven other great wounds so that the least of them might have been the death of the mightiest giant in the world,” they have to take a good rest, but go
1 Classical Review, 37. 1380, Xi
GENERAL INTRODUCTION
at it again with undiminished vigour for an indefinite time till at last Balin faints. To a Greek, the pathos of the incident would be obscured by its absurdity, while, of course, there is nothing surgical about it. Perhaps the only interesting wound from this point of view is that received by Sir Launcelot when shot by the lady huntress, “ so that the broad arrow smote him in the thick of the buttock over the barbs,” and even the ministrations of a hermit could not enable him to sit on his horse for weeks. So too in the Tale of Troy translated by Caxton, there is as much slaughter as in the Iliad. Did not the good knight Hector slay a thousand Greek knights in one day? “He gave Patroclus a stroke upon his head and cleft it in two pieces, and Patroclus fell down dead.” He cleft Archylogus in twain “notwithstanding his harness,” and repeated this immediately on another Greek; in fact he must evidently have kept it up for hours. But the only surgically interesting case is that where Ulysses “struck King Philumenus in his throat and cut asunder his original vein, and smote him as halt dead,” especially if “original”? means “jugular,” for Philumenus is as vigorous as ever soon after- wards. No one would dream of making a table of mortality from these romances, distinguishing the wounds by localities and weapons, as has been done for the 147 wounds described in the Jliad, with results fairly corresponding with surgical probability.!
The object of this comparison is to show that the Greeks, during what has been called their “middle ages,’ were a people who, in interest in their bodies,
1 Frolich, Die Militdrmedizin Homer’s, 1879. xiii
GENERAL INTRODUCTION
knowledge of the nature and results of injuries, and respect for those skilled in the methods of healing afterwards called Surgery, surpassed all those whom we know at a corresponding stage of civilisation.
When we add to this the frequent sacrifices (which may help to explain their greater anatomical knowledge compared with that of our mediaeval ancestors), the vigorous funeral games, and the probably already widespread custom of gymnastic training, there seems no need to suppose borrowings from older civilisation to explain the rise of surgery in a few centuries to the height at which we find it in the Hippocratic writings. As regards the palaestra, if we may judge from the famous group of “the Wrestlers,’ and its great frequency, dis- location of the shoulder joint was often deliberately produced, and Hippocrates will tell us that it was part of a good education to know all the ways of putting it in again.
The fact that medical schools first arose on the rim of the Greek world, especially in that part of the Asiatic coast where Ionian joined Dorian and both came in contact with remains of older cultures from Crete and Caria, as well as with strangers from Egypt and the East, may be partly accounted for by such contacts. Materials and methods of bandaging perhaps came from Egypt, and we may possibly find in a Cretan drain-pipe or Egyptian tomb a sample of that most interesting of Hippocratic instruments, the crown trephine ;! but the special
1A large bronze crown trephine has been found at Nineveh, and was evidently worked with a cord like the Hippocratic instrument. Meyer-Steineg Sudhoff, Geschichte d. Medizin, 1921, p. 25.
X1V
GENERAL INTRODUCTION
treatment of Fractures and Dislocations which forms the main and most remarkable part of Hippocratic surgery was, we may be fairly — developed by the Greeks themselves.
It is, however, only right to cast an admiring glance in passing on what little is visible of the Edwin Smith Papyrus. This dates from the seventeenth century B.c. at latest, and contained a “ Book of Surgery and External Medicine,” the remaining part of which comprises forty-eight typical cases extending from the top of the head to the thorax and breasts. The description of each case is divided into Examination, Diagnosis, Verdict, Treatment. No less than fourteen cases are declared incurable, and in nine of them no treatment is suggested. In only one case is the use of a charm mentioned. The following is Case 18, a wound of the temple, conden ed from Prof. Breasted’s version.! *“You should probe, and if you find the bone whole without a psn, a thm or a fracture you should say, Treat it with fresh meat the first day and afterwards with ointment and honey.”
This remarkable Papyrus indicates that the Egyptians possessed a semi-scientific surgery not much inferior to that of Hippocrates more than a thousand years before his birth. Whether he was indebted to them is another question, but they evidently knew at least two forms of bone injury besides fracture, and it is not impossible that when we are told what “ psn” and “ thm” mean, we may get some light on the origin of the Hippocratic term hedra.
1 In Recueil d’ Etudes Egyptologiques, Paris, 1922. XV
GENERAL INTRODUCTION
The earliest historical Greek practitioner is represented as being most effective as a surgeon. Democedes, coming from Croton, a city famous for its gymnasts, though without instruments, so excelled his colleagues that he became medical officer with large and increasing salaries in Aegina, Athens and Samos successively. Brought as a slave to Susa, and probably again without instruments, he cured King Darius of an injury thus vividly described by a layman—his foot was twisted, and twisted rather violently, for he got his astragalus dislocated from its joints.” The Greek surgeon restored it effectively with little pain, saved the Egyptians, who had failed to do so, from impalement, ted at the king’s table, and, if we may trust Herodotus, became a prominent figure in history. But he can hardly have lived to see the birth of Hippocrates, in whose time the most important of the treatises here translated were composed. According to all surviving evidence from antiquity, they were mostly written by him, and though there is now a tendency to believe that Hippocrates, like other great teachers, may have written nothing, we shall, while indicating the different amount of evidence for the genuineness of the various treatises, use “the writer” and “« Hippocrates ” as synonymous terms.
To show how these works were valued we may quote a paragraph from a high authority on Greek matters, which also introduces us to the remarkable MS. which contains most of them. “The MS. was written in Constantinople about the year a.p. 950, and it begins with a paean of joy over the discovery of the works of this ancient surgeon, Apollonius, with his accurate drawings to show how the various
xvi
GENERAL INTRODUCTION
dislocations should be set. The text was written out. The illustrations were carefully copied. Where the old drawings were blurred and damaged, the copies were left incomplete lest some mistake should be made. Why? Because this ancient surgeon, living about 150 s.c. [75 is more probable], knew how to set dislocated limbs a great deal better than people who lived a thousand years afterhim. It was a piece of good fortune to them to rediscover his work, And his writing again takes the form of a commentary on the fifth-century Hippocrates. Hippocrates’ own writing does not look back, It is consciously progressive and original.” 1
The writer, indeed, though he teaches with authority and confidence, confesses failures and welcomes improvements. His work, especially that on the surgery of the bones, formed the basis for future progress and did not prevent it. There was, in fact, steady progress for five centuries, and ancient surgery reached its culmination about a.p. 100. It began, says Celsus, to have its professors at Alexandria, but the first eminent practitioner whom we know as “the Surgeon” was Meges of Sidon, who practised at Rome shortly before Celsus, and is the source whence he drew much of his surgical knowledge. At the end of the century, Archigenes and Leonidas performed amputation almost in the modern style, while Heliodorus and his follower Antyllus showed themselves capable of doing all a surgeon could do, without the aid of modern dis- coveries. The former was especially famous for his work on the skull and lower part of the body
* Gilbert Murray, Rise of the Greek Epic, 1911, p. 24. XVii
GENERAL INTRODUCTION
(hernia, fistula, stricture), the latter for the ligature of aneurisms and resection of bones, but he follows Heliodorus so closely that we do not know which was the greater or more original. The surgical writings of the earlier Celsus and the much later Paulus are interesting and very similar, but the first was a layman, the second may or may not have performed the operations he portrays; for both are compilers. But when we pass to the Heliodorus- Antyllus fragments we feel a different atmosphere. There is a definiteness and determination in their language which leaves no doubt that they did what they describe. ‘‘ The ancients refused to undertake a ease of this kind, but we shall” etc., is a phrase which recurs. One is convinced that they did what they say and hopes the unfortunate patient had a large dose of mandragora.'!_ This state of excellence, however, does not appear to have lasted. Galen tells us that when he came to Rome he found that serious operations were usually handed over to “those called surgeons.’* Unless Antyllus was among them, none of their names have come down to us, and when, two centuries later, Oribasius made his great “ Collections,’ he had to go back to him and Heliodorus for the best surgery; while for ordinary fractures and dislocations he could find nothing better than Galen’s commentaries on the treatises in this volume.
Heliodorus, however, is introduced here not as part of an inadequate outline of Greek surgery, but
1 They removed the whole arm-bone (humerus) and part of the shoulder-blade, and call resection of ‘‘ the lower part of the jaw” aneasy operation. Oribasius XLIV. 23.
2 X, 455.
XVill
GENERAL INTRODUCTION
because he will help us to explain some of the Hippocratic apparatus. The reader of this volume will hear a great deal about bandaging, but very little about definite forms of bandaging. In the surgery, says the writer, the kinds of bandages are the simple (circular) sceparnus, simus, the eye, the rhomb and the hemitome or hemirhomb. This contrasts vividly with the 50 bandages of Heliodorus, the 60 of Soranus, and the 90 odd given in the De Fascits ascribed to Galen,
We should gather from Galen’s commentary ! that three were simple and three complex, the first being a true circle (<vkvxAos) where each turn covers the former, so that there was no “ distribution”’ up or down. The sceparnus, or “adze,’ was slightly oblique, and the simus, or “snub,” very oblique, both being simple spirals. But Heliodorus,? an older and perhaps better authority on this point, says the simple bandage was a simple figure-of-eight used to fix a limb tosome support, while the circular, which was called “the evxvxAos of Hippocrates,’’ was slightly spiral and could be distributed upwards or downwards, being used to close sinuses. The sceparnus was a complex bandage, and commenced as an open figure-of-eight ; which agrees with a still older commentator, Asclepiades,4 who says the Hippocratic sceparnus was a slightly oblique crossed bandage (yueZopevos). The simus is more puzzling : De Fasciis says it is not a bandage at all, but refers to the shape of parts to which a sceparnus bandage should be applied.® Galen says Hippocrates trans-
1 XVIII(2). 732. 2 Orib. XLVIII. 61. 3 Tbid, 64 4 In Erotian, s.v. ® XVIII(1). 772. xix
GENERAL INTRODUCTION
ferred the term from its use for a snub nose, or the sloping curve at the bottom of a hill, to denote a very sloping bandage, whence Petrequin concludes that it may be our favourite “ spiral with reverses.” But if this form had been known, it is hardly credible that we should not have had some clear account of it, and it seems more likely that it was sloping figure-of-eight.
The complex bandages are described in detail by Heliodorus as “the Hippocratic eye’’ (éd6adpds), very similar to the existing bandage for one eye, “the Hippocratic rhomb” which covered the top of the head, and the hemirhomb intended for the side of the face or unilateral dislocation of the jaw.
Hippocrates was also fond of a bandage rolled up to the middle from either end and put on obliquely from two heads, and was evidently acquainted with many complex and ornamental forms though he does not approve of them. He had a peculiar method ! of bandaging fractures with an under and upper layer separated by splints and compresses, the under- bandaging being done according to a rule clearly laid down, but this, says Galen, went out of use, leaving only the technical terms trddeors and brrobec ples.
Ointments.—The under-bandages and the folded pieces of linen called odjves (pads or compresses) were usually soaked in some application, the most important being two forms of “ cerate,”’ (1) white or liquid, which consisted of wax liquefied in olive oil or oil of roses,” supposed to prevent inflammation, while (2) (which was the same with the addition of
1 Surgery, XIL. 2 XVIII(2). 365. XX
GENERAL INTRODUCTION
some pitch!) was used for inflamed or open wounds, and was supposed to have anodyne properties and to favour the production of healthy pus; wine and vil were also used.”
Splints. —Oft the ordinary splints (vépOyKxes) we know curiously little. The name (like the Latin ferulae) implies that they were stalks of an umbelliferous plant.? They were put on separately ; Celsus ¢ tells us they were split ( /issae) and Paulus ® that they were wrapped in wool or flax. The nature of the large hollow splint (cwAjv), the canals of Celsus,® is not altogether certain, in spite of much description, It is usually taken to be gutter-shaped, but Galen tells us? that it went right round the limb, more so than did the box splint (yAwoodxopov), from which it also differed in being circular outside ; it was therefore tubular and cylindrical, But the limb could be put upon it, so it must have been opened, and, indeed, we hear of an opened (dvotxtos) solen in the Galenic writings.8 Perhaps this was a gutter splint, and the only form used in later times, for Paulus, who says the solen was made of earthenware as well as wood, uses cwAnvoedys in a sense which must mean “like a gutter.” So also in Soranus (1. 85) a baby’s pillow is to be hollowed, cwAnvoedas, so as not to go right round its head: but Rufus uses the word of the spinal canal, and Dioscorides of a funnel pipe, so it will be prudent to keep to the ambiguous ‘ hollow
4 XVITI(2). 538.
- In the case of club foot the ointment was stiffened with resin.
3 The giant fennel, light and strong, used by the Bacchants.,
4 VIII. 10. 1. 5 VI. 99 6 VIII. 10. 5.
7 XVIII(2). 504. & XIV. 795.
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GENERAL INTRODUCTION
splint.” The writer’s account of more complicated “machines” can only be made clearer by illus- trations.
In conclusion we must mention a theory which brings together, and throws light upon, most of these treatises. Wounds in the Head has a place by itself, to be considered shortly, the other four have peculiar titles. In Fractures the Greek adypos (for kataypa) is strange, as observed by Galen. Joznts clearly means Reduction of dislocated joints, and is so given in our oldest MS., but the correction seems too obvious to be correct. Both these treatises have abrupt beginnings, are probably mutilated and certainly in disorder, yet they rank in the first class of “ genuine” works of Hippocrates. /n (or About) a Surgery, often ambiguously shortened to Surgery, but more instruc- tively expanded to Concerning things done in the Surgery, is a collection of notes, chiefly on bandaging, and is obviously derived in part from Fractures, yet it contains at least one passage requisite to explain a statement in Fractures. Lastly the Mochlicon (Leverage), usually rendered /nstruments of Reduction, begins with a chapter on the Nature of Bones, while the rest is almost entirely an abridgment from Joints.
The Hippocratic Corpus contains a treatise on the Nature of Bones which, after a very few remarks on that subject, is occupied by a variety of confused accounts of blood vessels. It is a wreck which has gathered debris from various sources; yet it contains several peculiar words which are quoted in the
1 See Appendix: Supplementary Note.
2 Still, the wep) &p@pwv of Apollonius and Galen may be an abbreviation; following which example we shall call it “¢ Joints.”
Xxil
GENERAL INTRODUCTION
Hippocratic Lexicons of Erotian and Galen as being closely connected with Mochlcon. ‘The author of Joints says he intends to write a treatise on the veins and arteries and other anatomical matters.
This condensed summary may suffice to lead up to the following inferences :—
The Hippocratic part of the Nature of Bones originally came after the first chapter of Mochilicon, which is really its first chapter. ‘his treatise, thus enlarged, had as Preface our Surgery, the whole being an abridgment from an earlier work by the great Hippocrates “for use in the Surgery,’ which was perhaps its original title (see p. 56). Such a work would be well adapted either for teaching or for refreshing a surgeon’s memory.
Of the larger and older work our Fractures and Joints are important fragments, but there was probably an Introduction (now lost) containing the passage now extant in Surgery necessary to explain the later statement in Fractures. ‘This earlier work may also have comprised an original treatise by Hippocrates on bones and blood vessels, of which part of our Nature of Bones is an abridgment. Both these surgical works got broken up, and assumed something like their present form before reaching the haven of the Alexandrian Library.
Littré has hints of the above theory, but it is more fully worked out by O. Regenbogen,! who carries it a step further. The seven books of Epidemics were, even before Galen’s time, divided into three sections: I and III were universally held to be the oldest and most genuine; II, IV, VI,
1 Op, cit., infra, XXiii
GENERAL INTRODUCTION
which, as Galen says,} are not composed works (cvyypéppara) but memoranda (iropvyjpata), were generally supposed to have been compiled by Thessalus, son of Hippocrates, from his father’s note-books; V and VII, as Galen remarks,? are beyond the range of the Hippocratic spirit (yvopn), and, we may add, within that of the Macedonian artillery, which indicates a date later than 340 B.c.3 Galen has his doubts about the single authorship of the middle section, and these are shared by modern critics; but there is no doubt that Epidemics I1. 1V and VI are closely connected with the three works, Surgery, Bones, Mochlicon, which we have ventured to call an abridgment, but which, if we had not got a good deal of the original, might aptly be termed memoranda. Not only do whole passages in either set correspond verbally, or almost verbally, but there are peculiar philological similarities ; in particular the verb dpav, which, before the rise of drama, was typically Doric, occurs in all six treatises, and a few others belonging to what may be called the middle Hippocratic period, but neither in the earlier nor the later ones. It is not found, for instance, in Fractures or Joints, nor in Epidemics V and VII. Perhaps it is not too fanciful to suggest that after the triumph of Sparta (404 B.c.) these strangers from Cos, who had their surgeries along the northern edge of the Greek world from Perinthus to Crannon, may have remembered that they too might claim to
1 VII. 890. Cf. also VII. 825, 854. 2 XVII. 579.
3 Littré tries, not very successfully, to get them all into the fifth century. V.16ff. The date of Epidemics V, VII, is fixed by the siege of Daton where a patient (94) was wounded by ‘“‘an arrow from a catapult.”
XXiV
GENERAL INTRODUCTION
be Dorians and might have expressed the claim by occasional use of a strong Doric word.t Anyhow, there seems all the evidence we can expect that Surgery and Mochlicon formed part of an “ abridg- ment” used in the first half of the fourth century by the practitioners who compiled Ep‘demics II, IV, VI, while Fractures, Joints and Wounds in the Head belong to the previous generation.”
Some little evidence as to the order of these treatises is given by grammarians, They point out that the infinitive used as imperative, characteristic of older Greek, is especially prominent in the Hippocratic Corpus. During the fifth century it was being driven out by the imperative and became demoralised in the process. This “depraved”’ use was shown mainly by the substitution of the accusa- tive for the nominative of the participle to represent the second person imperative.* Now, as regards our treatises, “ depraved infinitives”’ occur only in Surgery and Mochlicon, and are absent from Fractures and Joints, except those parts of the latter which are interpolated from Mochlicon. We thus have further evidence that these chapters are interpolated, and that Surgery and Mochlicon are not by the author of Fractures—Joints.
1 The popularity of the Athenian dramatists, who use the word frequently, is perhaps a simpler explanation.
2 Cf. Schulte, op. cit., infra.
% <*In cases of the second person the subject is in the nominative, but when the infinite is equivalent to the third person of the imperative its subject is in the accusative.” Goodwin, Greek Moods and Tenses, p. 784.
XAV
GENERAL INTRODUCTION
Manuscripts, Epirions AND COMMENTARIES
The Hippocratic manuscripts and editions have already been discussed in these volumes by a more competent authority. The chief MSS. of the surgical works are: (1) B (Laurentianus 74. 7) ninth or tenth century, referred to above, and described in detail by Schone in the preface to his Apollonius, (Teubner, 1896); (2) M (Marcianus Venetus 269) eleventh century; (3) V (Vaticanus Graecus 276), twelfth century. M and V, with their progeny, form the basis of all editions up to the last by Kiihle- wein (Teubner, 1902), in which B is for the first time fully utilised. Unfortunately the whole of Mochlicon and the last five chapters of Wounds in the Head have been cut out of this oldest MS.
The chief editors have paid marked attention to these treatises,and Petrequin’s Chirurgie d’ Hippocrate* —text and translation with very copious notes and appendices, the fruit of thirty years’ labour by a practising surgeon—probably represents the most thorough treatment of any ancient medical docu- ments. It is to this work that the present edition is mainly indebted.
Francis Adams translated the treatises in his Genuine Works of Hippocrates.2 He could spare less time and had fewer advantages than Petrequin. The translation, based upon Littré’s text, is straight- forward and readable, and the notes have special value owing to the author’s practical experience in almost Hippocratic circumstances, though they are
1 Paris, 1877-1878. 2 Sydenham Society, 1849.
XXVi
GENERAL INTRODUCTION
sometimes flatly opposed to the views of the equally experienced Petrequin.
Since the appearance of Schéne’s beautiful edition of Apollonius of Kilium (Mustrated Commentary on the Hippocratic Treatise on Joints), German scholars have paid much attention to the subject. Schéne himself attempted to show that Fractures—Joints at any rate was a genuine work of the great Hippocrates, but was opposed by the eminent scholar Hermann Diels.1 More recently, three interesting Theses on the connections,? grammar ® and style 4 respectively of the surgical treatises have appeared. Their con- tents are very briefly outlined in the introductions, and will repay study by those interested in the subject.§
' Diels, Sitzwngsberichte der k.p. Akademie, 1910, p. 1140f.
* Regenbogen, O., Symbola Hippocratea, 1914.
* Schulte, E., Observationes Hippocrateae Grammaticae, 1914
* Kroémer, J., Questionwm Hippocraticarum capita duo, 1914
* See also Kiihlewein, H., Die chirwrgischen Schriften des Hippocrates, Nordhausen, 1898.
A BBREVIATIONS IN Nores
B. M. V. = the three chief MSS. noted above.
Erm. Pg. Kw. =the three more recent editors: Ermerins 1856, Petrequin and Kiihlewein as above.
XXVii
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HIPPOCRATES
ON WOUNDS IN THE HEAD
VOL. IL. B
INTRODUCTION
No Hippocratic work has attracted more attention than this short treatise. All the prominent Alex- andrian medical commentators discussed it, and it is in Erotian’s list of genuine works. Galen, of course, wrote a commentary, though only a fragment survives.! All ancient writers on the subject from Celsus to Paulus had it before them. At the Renaissance it attracted the attention both of anatomists and surgeons, and continued to do so almost to our own times. Its genuineness has hardly been questioned except by those who doubt whether Hippocrates wrote anything.
This celebrity is perhaps equally due to its excellence and its peculiarities. The former may be seen in its clear descriptions and magisterial language; the writer teaches with authority. The latter are two: its account of the sutures, and its doctrine as to trephining. With regard to the former, we may say that, as modified by Galen to the effect that the H form is the only normal one, it is fairly correct so far as it goes, and that it is much better than the later account of Aristotle —that men have three sutures radiating from a centre and women one, which goes in a circle.? The ancients (and Vesalius) accepted this view of
1 In Oribasius, XLVI. 21. 2 Hist. Anim. 1. 7.
INTRODUCTION
the sutures, but all surgeons, from the post-Hippo- cratic age onwards, have been troubled by his rule as to trephining, which may be condensed as follows :—
If the skull is contused or fissured, you should trephine at once, but an open depressed fracture does not usually “‘come to trephining,” and is less dangerous; in short, an injured skull should have a hole made in it if there is not one already.
The Alexandrians, as we gather from Celsus, rejected this: “the ancients,” he says (piously leaving Hippocrates unnamed), advised immediate operation, but it is better to use ointments—and wait for symptoms. The vast majority of surgeons have done so, but many have regretfully wondered, after the patient’s death, whether the Hippocratic trephining might not have saved a life. ‘ Hippo- crates”’ (as the supposed author of Epidemics V. 27) is praised by Celsus, and many others, for confessing that he thought a fissure was a suture and so left a patient untrephined. Symptoms appeared later; he trephined on the fifteenth day, but the patient died on the sixteenth; yet this is just what any later surgeon would have done, even had he recognised the fissure. The reader will find in Littré and Petrequin extensive quotations from French surgeons, and from our own Percival Pott, on the probability of lives being saved by preventive trephining used as an operation of choice before it is obviously necessary, but the Hippocratic rule is no more likely to be reintroduced than is the use of vigorous venesection, which would also doubtless sometimes save life.
The use of the common word zpiwy as a semi-
3
INTRODUCTION
technical term for a complicated surgical instrument brings us to another noticeable point in the treatise : there seems to be an attempt to establish a medical vocabulary. Eminent theologians have recently settled the controversy on St. Luke’s alleged medical language by declaring that the Greeks had none, “the whole assumption of medical language in any ancient writer is a mare’s nest,” ! but if the writer of Acts had told us that St. Paul at Lystra got a hedra in the region of the bregma which penetrated to the diploe, they would have been fairly confident that he was a physician who made a rather pedantic use of his medical vocabulary. Here are three simple Greek words which are given such peculiar meanings that they have to be defined and not translated.
The last term had some difficulty in keeping, or recovering, the somewhat unnatural sense ? here given to it, and probably did so only through the prestige of this little work. Hedra could not be saved even by the authority of Hippocrates and his care in defining it. It is that form of skull injury which is left as its mark (or seat) by the weapon, and varies in size and shape accordingly from a prick to a gash, but without depression, “for then it becomes a depressed fracture.”’ It included mainly what are now called “scratch fractures”’ and, as Galen says, would also comprise an oblique slice—dzooxerap- viopos. It was too vague to last, and was partly replaced by éyxory—incision. Its vagueness has made some confusion in the treatise, for though
1 Jackson and Lake, Prolegomena to Acts, I1. 355. 2 i.e. the porous bone tissue between the two hard layers of the skull bones,
4
INTRODUCTION
there is little doubt that Hippocrates intended to describe five forms of skull injury—as is twice asserted by Galen!—later scribes by splitting up the hedra have tried to make seven, though, strange to say, no MS. mentions a sixth.
Several cases in Epidemics V. seem intended as illustrations to this treatise. A patient with con- tusion of the skull is trephined largely down to the diploe, he gets inflammatory swelling of the face (erysipelas) and is purged: the Hippocratic rules being thus followed, he recovers (V. 16). The patient with fissure (V. 27) is left untrephined till it is too late A girl dies because the trephining was insufficient. She has spasm on the side opposite the injury (V. 28).
These cases are more remarkable because skull injuries have nothing to do with epidemics, and there is no such notice of bodily fractures or dis- locations. Epidemics V., as we have seen, probably belongs to the third Hippocratic generation, when the rules of the Master, as to the treatment of wounds in the head, may have begun to be called in question.
With regard to the style of the treatise, every reader will be struck by the frequent repetition of the same words and phrases, often unnecessarily. This occurs in another manner and to a less extent in Fractures and Joints, where we shall discuss it further in considering the probability of a common authorship.
1 XVIIT(2). 672. Orid, as above.
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ITEP] TON EN KE®@AAHI TPOMATON
I. Tav avOparav ai Kxedaral ovdév opotws cpio. avtais, ovde ai pahat Ths Keharjs TavTov KaTa TaUTa TepvKaci. arr GoTIs pev ever €x TOU Eum poo ev THS Kepanris mpoBornv—n sé m poBorn core avtov Tov} datéov efeXov oT pory- ryUXov mapa TO OMe re etolv ai papal mepuKviar ev TH Keparh as? ypaupa TO tab, ily ypaperat, THY [Lev yap Bpaxutépny YPaneny EVEL ™po THS ™poBoas emexapo inv mepucviay: TH be éTepny papper exer oud péons Tis Keparts KaTa pKosS mepuKviay és TOV Tpaxy ov altel. darts é dma Dev THS KEeparis THY m™poBodny EXEL, a pagal TOUT@ mepvukace TavavTia ) TO TpoTepo 7) [eV yep. Bpaxurépn ypappun po Tijs 7 poBorijs mepuKey émuKapoin 7 6€ paKpotépn bua péons TAS. Kepants mepiuce KATA phKos és TO péTWTOV aiet. Oats b€ Kal? audhotépwOev Ths Kedhadis mpoBorny exer, Ex Te TOD EumpocOev Kal ex TOD dma bev, TOUT ai papat eiow opoiws Tepuxviat OS ypap pa TO Ta, H, ypaerar mepuKaoe bé TOV ypappewy at pev paxpal ™ po Ths mpoBorHs ExaTtépys eTLKapolaL mepuviae’ » 6€ Bpaxein dua péons THS Keparhs Kata pwhKos mpos éExaTépyv TEAEUT@CA THY pmaKpHy ypaupnv.s Garis b€ woe 6
ON WOUNDS IN THE HEAP
I. Men’s heads are not alike nor are the sutures of the head disposed the same way in all. When a man has a prominence in the front of his head—the prominence is a rounded outstanding projection of the bone itself—his sutures are disposed in the head as the letter fau, T, is written; for he has the shorter line disposed transversely at the base of the prominence ; while he has the other line longitudinally disposed through the middle of the head right to the neck. But when a man has the prominence at the back of his head, the sutures in his case have a disposition the reverse of the former, for while the short line is disposed transversely at the prominence, the longer is disposed through the middle of the head longitudinally right to the forehead. He who has a prominence at each end of his head, both front and back, has the sutures disposed in the way the letter eta, H, is written, for the long lines have a_ transverse disposition at either prominence and the short goes through the middle of the head longitudinally, ending each way at the long lines. He who has no
re * So B. Kw. for 72 rod Pq. The older MSS. BV omit the letters TH X. 2 Sa7ep. > Omit kat. * riot waKphior ypauuiow,
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TIEPI TON EN KE®AAHI TPQOMATON
érépade pndeplny mpoBorav EXEL, ovToS EXEL Tas papas THIS. KEPAATS WS ype pupa TO xe, X, ypa- perau mMéepuKact dé at yeappat bev érépy emexapotn, T pos TOV Kporagov apnkcovga: 1 O€ ETEpN KaTAa pNKOS Sia péons THs Kepars. Aitroov & éoti TO oatéov Kata péony THY Kepahny oKANPOTATOV ao kal TUKVOTQTOV avroo mepuKey TO TE dveratov a” ” omox poin Tov daTéou " bro TH capt Kal TO KAT@OTATOV TO Tpos TH penveyye 9) ” 0mox poin TOU doréou a) KATO" aTroy@wpéov é amo TOU aVWTATOU OGTEOU Kal TOD KAT@TATOV, ATO TOV CKANPOTAT@V Kal TUKVO- TaTov éml TO padOaxeTepov Kal ocov mTuKVOV Kal émixotroTepov és tiv SuTrAONV aiel. 1) € duTAON KOLNOTATOV Kal HaNOaKwTAaTOV Kal LadLoTa onpayyadés €oti: éote b€ Kal Tay TO baTéoV THS Keharhs, TANV KapTa Odiyou TOU TE AVWTATOV Kal TOU KATwWTATOV OTOYYo Opmotov: Kal exer TO doTtéov ev EwUT@O Opmola capKia Toa Kai vypa, Kal el Tis avta dtaTpiBou Totat SaxTUAOLOL aipa av Siayivoito €& avtav: éveots 8 ev TO OoTéw Kal préBia AeTTOTEpA Kal KoLhOTEpa aipaTos Téa. Il. SrAnpotyntos pév ody Kal parOaxornTos Kal KotAOTNTOS* woe Exe. TayvTnTe 8é Kal AeTTOTHTL, oVT@S'® GuuTdons THs Kehadhs TO da Téov NemTOTATOV €oTe Kal do Pevéatartov TO Kara Bpeypa, Kal odpKa OduyiaTny Kal New TOT a- THY Exel ed EWUT@ TauTy Ths Kepanas TO daTéoV, Kal 0 eyKeparos KaTa TOUTO THS Kepariis mAclaTos imeotiv. xal 6) Ste ovTw@ TadTa éxEL, THY TE
1 Kw. omits. * So BV. Kw. Pq. has dative throughout. 2? Kw. omits.
ON WOUNDS IN THE HEAD, 1-11.
prominence at either end has the sutures of his head as the letter chi, X, is written: the lines are disposed one transversely coming down to the temple, the other longitudinally through the middle of the head.
The skull is double along the middle of the head, and the hardest and most dense part of it is disposed both uppermost where the smooth surface of the skull comes under the scalp, and lowest where the smooth surface below is towards the membrane.! Passing from the uppermost and lowest layers, the hardest and most dense parts, the bone is softer, less dense and more cavernous right into the diploe. The diploe is very cavernous and soft and particularly porous. In fact, the whole bone of the head except a very little of the uppermost and lowest is like sponge, and the bone contains numerous moist fleshy particles like one another and one can get blood out of them by rubbing them with the fingers. There are also rather thin hollow vessels full of blood contained within the bone.
II. Such then is the state of hardness, softness and porosity, but in thickness and thinness of the skull generally, the bone is thinnest and weakest at the bregma,! and has the least and thinnest covering of flesh in this part of the head, and there is most under- lying brain at this part of the head. It follows from such a state of things that when a man is wounded
1 Dura mater.
2 The bregma comprises the front part of the top of the head, where the skull remains longest open.
9
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EPI TQN EN KE®AAHI TPOMATON
Tpwolwy Kal TOV Beréwv icwy Te eovTwY KaTa péyeVos Kal éXacaover, Kal opoiws Te TpwOels Kai ooov, TO OoTéoY TAa’TH THS Keparhs PrAaTAaL Te “adrov Kal pHyyvuTat Kal ~ow eoprATat, Kal Pavacipwrepa €oTt Kai yareTwTepa intpeves Pai Te Kal exguyydvew tov Oavatov TavTn } TOV GAOL THS Kepartys: éEicwy Te eovTeov TOV Tp@MaToOV Kal opoiws Te Tpadels Kab jooov, atroOvnaKet oO dvOpwros, 6 OT OTAaV «al aAXws HEN ar obaveia bar ex TOD _TPOLATOS, év eAdooovt XpOve Oo TAUTH EXoY TO TpOpa THs Keparhs a) mou arrAo08t. 0 0 yap éyxéparos TaxyioTa TE Kal padtora. Kara 70 Bpéypa aicOaverar TOV KaK@Y TOY yivopevev év Te TH capKl Kal T OaTéw: UTo NeTTOTATO yap ooTe@ éaTl TAUTH O eyéharos Kal Oduyiorn oapKl, Kal 0 TelaTos éyKéparos bTd TO Bpéypate KelTal. T@V 5€ AAAwWY TO KATA TOUS KpoTapouUsS acQevéatatov éotw: asupBoryn Te yap THs KaTw yvalou pos TO Kpaviov, Kal Kivnots évertiv év TO KpoTabw avw Kal KaTw WoTrep apOpou: Kal 1) ako) ™Anotov yiverat auTov, Kal prey dla TOU Kpotaou TéTAaTaL KOLAN TE Kal io Xupy). ioxv- potepov © éote THs Keparijs TO oa TEov amav TO dmislev THS KOpudyAs Kal TOV ovaTwY 4 ata TO mpocbev, Kal cdpka Tréova Kal Babvutépnv ep EWUT@ EXEL TOUTO TO OoTéop. kal 67) TOUT@Y ” , ‘ A i oUTws éxyovTwY, ITO TE TOV Tpwciwy Kal TOV Beréwv icwr éovtwr,! Kal opoiwy cal petovwr Kal Omolws TLITPwWoKOMEVOS Kal paAXOV, TaUTH THS cepaniys TO Oatéov Hooov pyyvuTat Kal prarau €or, KV pedry vO pwTos amoOunaKety Kal AXXWS €x TOD TpwpuaTos, €v TH Omiabev Tis KEeparis 10
ON WOUNDS IN THE HEAD, 1.
equally or less, the wounding and weapons being equal or smaller, the bone in this part of the head is more contused or fractured, and fractured and contused with depression, the lesions are more mortal, medical treatment and escape from death more difficult here than in any part of the head. When wounded equally or less, the wounds being alike, the patient, if he is going to die in any case from the wound, dies sooner when he has it in this part of the head than anywhere else; for it is at the bregma that the brain is most quickly and especially sensitive to evils that arise in sealp or skull, since the brain is covered here by thinnest bone and least flesh, and the greatest part of the brain lies under the bregma. Of the other parts, that at the temples is weakest, for the junction of the lower jaw with the cranium is at the temple, and there is an up-and-down movement there as ina joint. Near it is the organ of hearing, and a large and thick blood vessel extends through the temporal region. The whole skull behind the vertex and the ears is stronger than any part in front, and this bone has a fuller and thicker covering of flesh. It follows from such a state of things that when a man is stricken equally or more severely by woundings or weapons which are equal and similar or larger in this part of the head, the bone is less fractured, or contused with depression ; and if the man is going to die in any case from the wound, he takes
1 ardytwy Pq. It
50 51
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TEPI TON EN KE®AAHI TPOMATON
éyov TO Tp@ua ev trElove ypovw amoOaveitat: év Telove yap Xpovw TO daTéov éutvicKeTat TE kat dvatvicKeTar KaTw él Tov éyKéparov bia THY TaXUTHTAa TOU oaTéoV, Kal éAXdoowY TavTH Ths Keharis o eyxépanros Urects, Kal TEoveES eK guyyavover Tov Oavatov Tov dmLiabev TLTPwWOKO- pévoyv THs Keparhns ws éml TO TOAD 7 TOV éumpooBev. Kai év yeim@ve mrElova xXpovoyv fH avOpwros 1 év Oéper, datis Kal adrws pérres 4 amoOaveicPa, €x Tod Tpwpmatos Sirov av THs Keparis éyov? TO Tpama.
Il. Ai dé &épar trav Bedréov tav d&éwy Ka- KovpoTtépwv, avtal él chav avtéwy yiwopevae év TO OoTéw dvev pwyuns te Kal prdovos kal éow éoprdovos—atrar dé yivovrau opoias év Te TO Eu poo Bev THS Kcepariys Kal €v TO oma bev— €K TovTeV 0 Oavatos ov yiverat Kata ye OiKnD, ovd iv yévnta. padn dé év Exes haveica, datéou Wirwhévtos, TavtTayov THs Kehadis TOD EAweos EVO MEVOD, aa bevéoraror yiverar 7H TPOTEL Kal TO BérEL avTéveu, EL TUX OL TO Beédos és avry THY padyy orn pix ev: — mavT wv dé pddora, my to Bédos® év TO Bpéypate yevopevov Kata TO aa bevéctatov TNS ceparis—Kal al papat el TUX OLED éodoar _Tepl 70 ékos Kal TO BéXos QuTéewV TUXOL TOV papav.
IV. Titp@oxerac dé oatéov TO ev TH xebary tocovade tpoTous: TaV dé TpoOTwY éExdaTOU a AELOVES iSéae yivovTas TOD KaTHYyMaTOS Ev TH TPOCEL. eT EOD pyyvuTas TUT PW KOMCYOY Kal TH poymn* év TO TEpLeXovTL doTe@ TH poymny, avaykn prdaow ‘mpoayevécOar, ivrep payh Tov 12
ON WOUNDS IN THE HEAD, u.-w.
longer time dying when he has it in the back of the head. For suppuration of the bone takes longer to come on and penetrate down to the brain because of the thickness of the skull; also there is less brain in this part of the head, and, as a rule, more of those wounded in the hinder part of the head escape death than of those wounded in front. In winter, too, a man lives longer than in summer, if he is going to die from the wound in any case, in whatever part of the head he may have the wound.
III. Hedrae? of sharp and light weapons, occurring by themselves in the skull without fissure, contusion or contused depression (these happen alike in front and at the back of the head) do not, at any rate by rights, cause death even if it occurs. If a suture appears in the wound when the bone is denuded, wherever the wound may be, the bone makes very weak resistance to lesion or weapon [if the weapon happens to get stuck in the suture itself] *—most of all if the weapon gets in the bregma, the weakest part of the head—and if, when the sutures happen to be in the region of the wound, the weapon also happens to strike the sutures themselves.
IV. The bone of the head is injured in the following number of modes, and for each mode several forms of fracture occur in the lesion. The bone is fractured when wounded, and the fracture is necessarily complicated by contusion of the bone about it, if it was really fractured. For the very
1 See Introduction. 2 This seems a superfluous gloss,
1 Gotis by HAAwS MEAAD.
2 xn Kw.’s conjecture.
8 éAnos Pq. Erm. BéAos Kw. codd, 4 ris pwyuis Pq. ; V omits.
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TIEPI TON EN KE®AAHI TPQMATON
yap Berewr 6 Tt TEp paryvuce TO ooréov, TO auto ToUTO Kal pre TO oaTéov i) paddov Y Hooov, auto TE €v OTEP Kal pyyvuoe THY poyuny Kal Ta TEpLeXovTa oorea TH porymny: els ovTOS TpoTros. idéar 6€ poyHeav TavTolat yivovrac: Kal yap AemTOTEpal Te Kal NETTAL Tavu, @oTE OV KaTA- pavees yivovTat, got al TOV porypeewv,” OUTE avtixa pera THY Tpactr, ouT’ ev THOW Lepyoww éy now av Kab TOvOOV dpedos yevorTo TOD Gavatou TO avO parm. ee TIN av TaxuTEpal TE Kal evpuTEpar paryverTas TOV POyHEan, Evia 6€ Kab T™ avu evped. éote O€ QUTE@Y Kal al pev ért jua.kpoTEpov pyyvuvrat, ai o€ € emt Bpaxvtepov: Kal al pev iOvrepat, al d€ (Jelat mavu, at 6€ Kap V- Aw@rTEpat TE wal Ka pT vat" Kal Badvrepat Te €¢ TO KAT@ Kal bua TAT OS Tov oatéou [Kal oor Baetat cal ov d1a Taytos TOU oatéov].3
Ve Pracbety & ay TO ooTéov pévov ev TH éwvu- Tov pucet, Kal poyen Th drdaoe ovK av 7 poo- YyévolTo éy TO OaTéw ovdepia: SevTEpos oUTOS TpOTrOS. iSéar 8 THS pragtos TAELOUS yivovrac: Kal yap jaddov TE Kab ooov prarar Kal és Baburepov Te Kal ua TAVTOS TOU oaTEéou, kal Hooov 6s Badd Kai ov dia TAVTOS Too da TEOU, Kal él TEOV TE Kal EXagoov papkeos Te Kal TAATUTITOS. avArka ov! tovtTwy TeV dear ovdeplay éoTly iSovra Toto Ww oplanrpois yavar omroin Tis eoTLW Ty (deny Kab omoon TiS TO peyeOos: ovde yap él méphag tat covT@V TE Tepac Levon Kal TOU KaKOU yeyevnwevou yiverau roicw op0armotcw Katapaves ideiv avTixa peTa
1 fo. 8 altiov pwypéewy Pq., Ve
14
ON WOUNDS IN THE HEAD, w.-v.
same part of the weapon which breaks the bone also contuses it more or less; and this happens just at the place where it makes the fracture, and in the bones containing the fracture. This is one mode.! As to forms of fracture, all kinds occur, for some are rather small and very small, so as to be not noticeable either immediately after the lesion or in the days during which the patient might be helped in his sufferings and saved from death. Again, some of the fractures are larger and wider, and some very broad. Some are longer, some shorter, rather straight or quite straight, rather curved or bent, going rather deep and right through the bone [and not so deep and not through the bone].? V. The bone may be contused and keep in its place, and the contusion may not be complicated by any fracture of the bone, This is a second mode. There are many forms of contusion; for the bone is more contused or less, to a greater depth, going right through, or less deeply, not going through the bone, and to a greater or smaller extent in length and breadth. Now none of these forms can be distinguished by the eye as to its precise shape and size, for it is not even clear to the eye immediately after the injury whether contusion has taken place, even if the parts are contused and the damage done;
1 «Fissure fracture.” 2 Tiittré’s insertion. 3 ** Contusion.”’
—_ eee"
® Obscure passage: ‘‘help for sufferings may be also help against death.” Littré suggests «al rod @avdrou.
3 Added by Littré.
* ob Kw. ; Pq. omits,
I5
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TEP] TON EN KE®AAHT TPOMATON
THY TpaoW, domep ovee TOV por peov éviat éxas } éovcai Te Kal eppwryoros Tod daTéov.
VI. "Eo pharac TO OoTéov eK THS puaros THIS éwuToU éow ov poypiow: ANS yap OUK av eopracdein TO yap éodrA@pevor, damoppnyyu- pevov Te Kal KATAayVUpEVOY, eapratar éow amo Tov adov daTéov pevovTos év pice TH EWUTOD" Kal 57 oUT@ pop) dv mpocein TH eaprdcet’ TpiTos ovTOS TpoTros. eoprarac Sé 76 baréov Todas idéas* cal yap él mr€ov Tob datéov Kal em Edacaon, Kal padQov Te kal és Badvrepov
10 KaT@, Kal HoooV Kal emuToNaLorepor.
10
VII. Kai edpns syevopevns év TO OTTEW BeXeos pass lntael dv peyun TH pn, TH Sé Poyen pracw mpooryeréabat dvaryxatoy éoTe a
nad Nov i iooov, Trp Kal poypn T pooyevntat évOamrep Kal edpn eyévero Kal 1) porypn, €v TO date TEPLEXOVTL THY TE eopny Kab Ty poypay: TETAPTOS ovTOS TpOTOs. Kal eopn pev av yevorTo praow éxouoa Tov oaTéov TeEpt aur ny, poyen 6é ovK av T poaryevoLrTo TH edn Kal TH draoes VTO TOU Bede0s° [méumrros ovTos Tporos] [cal &dpn dé Tod Beh€os yiverau ev TO oaTew espn b€ Kanel- Tal, OTaV pévoV TO daréov ev TH E€wWUTOU pucet TO BéXos ornpitay € és TO da TEov dfjAov TOUon O7rov éor7) pesev 2] év dé TO Tpome EKAOTO TeLovEes idéae yivovTat Kal arepl bev pddords Te Kal poyuiss ay appeo Taira T poorer Tat TH edpn, Kal iy prdots povvyn yévnTat, OH méppactat OTL TOhAAL
1 2adcoovs Kw.’s suggestion in Hermes XX., but he does not print it. 2 Kw. puts this passage first, as is done in the translation.
16
ON WOUNDS IN THE HEAD, v.-vu.
just as some fractures are not visible, being far from the wound,! though the bone be broken.
VI. The bone is contused and depressed inwards from its natural position with fractures, for otherwise it would not be depressed. For the depressed bone, broken off and fractured, is crushed inwards away from the rest of the bone, which keeps its place; and of course there will thus be a fracture as well as a contused depression. This is a third mode. Contused depressed fracture has many forms, for it extends over more or less of the skull, is more depressed and deeper, or less so and more superficial.
VII. Again, a weapon hedra occurs in the skull. It is called “hedra” when, the bone keeping its natural position, the weapon sticks into it and makes a mark where it stuck.2_ When a weapon hedra occurs in the skull, there may be a fracture as well as the hedra ; and the fracture must necessarily be accompanied by more or less contusion (if a fracture also occurs) where the hedra and fracture happened, in the bone containing the hedra and fracture. This is a fourth mode. And a hedra may occur with contusion of the bone about it, without being accompanied by a fracture in addition to contu- sion by the weapon. [This is a fifth mode.3] Of each mode there are many forms; and as regards contusion and fracture (whether both of them accompany the hedra, or contusion only), it has already been declared that there are many forms,
1 Or, ‘‘rather small,” Kw.
2 Vestigium teli, ‘‘scratch fracture.” This passage is obviously out of place in the Greek text,
3 Py. omits.
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10
EPI TQN EN KE®AAHT TPOMATON
> y / \ iol / \ lel € fol idéat yivovtat Kal THs PAdaLos Kal THs pwypis. 4 ’ n 7 O€ €dpn avTnH ep EwUTHS yiveTar waxpoTtépyn Kal Bpaxutépyn éodoa, Kal Kautrudwtépn, cal (Outépn, \ / \ \ ” 2»O7 la) Kal KuKXoTEpHsS. Kal TodkAal AAXraL idéat TOU € Tad \ a fal ToLoUTOV TpoTou, om-otov av TL Kal TO oxXhua : Tob Bénreos 7° ai 5é avai Kat Baburepat TO KaT@ Kal paddov Kal Hooov, Kal oTevoTEpal Te Kal jooov oTeval Kal evpvtepat, Kal mavu evpéat, 7 SLa- Uj ig a / Kexopatar' dtaxomn S€ oTOanTLCGODY yLVOMEVH "3 ¢ fal byKkeos TE Kal EVPUTHTOS ev TO OoTEw, Edpy EaTiv, WV Ta dANa OoTéaA TA TEpLeyovTA THY SLtaKoTHY pévyn ev TH hVoEL TH EWUTA@V, Kal 4n TUVETPAATAL Th StaxoTyn Eaw Ex THS PVaLos THS EwUT@V" OVTW NTE x ” \ > yv 7 dé €opraats av ein Kal ovK Ett Edpn. VIII. “Ooréov titpeoKetat AdAXy Tis KEparts 9 TO EdXxos Eyer BVOpwm0s Kal TO oaTéoV , n f e ‘ eYidwOn THs capKkos: TéuTToSs? ovTOS TpOTOS. Kal TavTnY THY cUuupopHY, OTOTAY YyévnTaL, OVK XN BA ’ lol > / > \ / > / av éxous mpernoat ovdév: ovde yap, et Tétrovie N a ¢ \ \ TO KaKOV TOTO, OvK éoTLY OTwS YPH avTOV > / > / , la \ \ cal éferéyEavta eldévat, et Térov0e TO KaAKOV TOUTO @vOpwros, ove Orn ® THs KEhadis. IX. Tovtwv Tov TpoTwy THs KaTHELOS és TpioL > 2 eo 4 € > \ ? a \ a adiKet n TE pracus 1 apavns: iSety KOs NY THMS TUXY pavepy ryevowenn Kal um porn Hy adavns idety Kal my. pavepy 7. Kal mY &dpns yevopevns TOU Bedeos € év TO oaTew, T™ poaryevy Tat poyen Kal prdous ™ pn Kat av praas Howry Tpooyevn- TAL avev poywns TH edpy), Kal aiTn és mpiow adie. TO dé ow éapapevov OaTéOV €K THS gva.os THS EwuToD oALya TOV TONY Tpiavos Tpocoeitary Kal Ta pddiota éeopracbévta Kai 18
ON WOUNDS IN THE HEAD, vwu.-ix.
both of the contusion and of the fracture. The hedra taken by itself is long or short, rather bent, or straighter, or rounded; and there are many other forms of this mode, according to the shape of the weapon. These same fhedrae vary in depth and narrowness, and may be rather broad or very broad where there is a cleft; for a cleft in the bone of any size whatsoever as to length and breadth is a hedra if the rest of the bone round the cleft keeps its natural place and is not crushed in by the cleft ; for this would be a contused depressed fracture, and no longer a hedra.
VIII. The skull is wounded in a part of the head other than that in which the patient has the lesion and the bone is denuded of flesh. This is a fifth mode.t_ When this accident occurs, you can do nothing to help; for if the man has suffered this injury, there is no possible way of examining him to make sure that he has suffered it, or where- abouts in the head it is.
IX. Of these modes of “tracture,’2 contusion, whether invisible or somehow becoming manifest, is a case for trephining, also fissure-fracture, whether invisible or manifest ; and if, when there is a weapon hedra in the bone, the hedra is accompanied by fracture and contusion, or if contusion alone accom- panies the hedra without fracture, this also is a case for trephining. But as for contused depressed fractures, only a small proportion of them require trephining ; and the more the bones are contused,
? Seventh Kw., our ‘‘contrecoup.” * Evidently taken as = injury.
1 ordua. 2 €Bdopos. 3 ém0v Erm.
19
15
10
20
IIEPI TON EN KE®AAHI TPQMATON
parara KaTapparyevTa, Tatra Tptovos ikora KEXpNTAL ouvoe edpn aut) ep E@UTAS yevomevn aTeEp porns Kal praregs, ove auTn mptovos Seirat:+ odd’ 4 Saxon 7) py * weyarn Kal eupela 7; ovd avtn: diaKoTr) yap Kal €dpn T@UTOV €oTLV. X. Uparov | b€ xp” TOV Tpavpatiny oxorreiabau, Onn exet TO Tpapa THS Kepanrts, elt ev ToLoW iaxu- potépotaty elt’ é€v Totow doer /eTEPOLT L, Kal TAS Tpixas carapan Adve TAS mepl TO ENKOS, él Pie: Kopatas ure TOU Bedeos, Kal eb ow hicav® és 70 TpOpya, Kal Vv, TOUTO 1; pdvar xuvduvevew TO daréov wporov eivat THS gepros Kal exer Te oivos TO oaTéOV UO TOU Bédeos.4 Tabra pev ovv xpn) arom poabev oKerpapevov NEEal, fu) ATTOMEVOY TOD avOpwrov: ATT OMEVOY | & mn meipaobar eldévat cada el eoTt airov TO datéov THS TapKos ay ov: Kat ay pe KkaTapaves an Totat opOarpoicr TO daTéov, prrov: el O€ Ha}, Th pry oxeTTea Oa. ral ny pev etpns wporor éov TO daTéov THS gapKos Kal pH bytes aro TOU TPWLATOS, xp” TOU €v TO date eovT oS Thy Srayvoow mpara moveiobau, opavra om og ov Té earl TO KaKOv Kal Tivos deirat épryou. xpi dé Kal époray TOV TETP@MEVOV Omes emrabe kal Tiva TPOTOV. au dé BY Karapaves 7 TO daréor, él EXEL Tb KaKov ° ) pb EXEL, TOANG ETL xpn parhov THY epornow Toveto Gat, porod Te €OvTOS Tou daTéou, 70 Tpapa. Omas eryévero Kal évTwa TpoTrov" Tas yap prdovas Kal Tas poypas TAS ov pawvouevas ev TO doTE@, éveovcas Oé, €x tis bToKpictos® Tov TeTPwpEevou TPaTOV Stayiwo-
1 Se?rai—eipera Kw. B. ? odd’ Hv dtaxomg. * elnoar. 20
ON WOUNDS IN THE HEAD, 1x.-x.
depressed and comminuted, the less they require trephining. Nor does a hedra, occurring by itself without fracture or contusion, require trephining, and even if the cleft is large and wide, not even then; for cleft and hedra are the same.
X. The first thing to look for in the wounded man is whereabouts in the head the wound is, whether in the stronger or weaker part, and to examine the hair about the lesion, whether it has been cut through by the weapon and gone into the wound, If this is so, declare that it is likely that the bone is denuded of flesh and injured in some way by the weapon. One should say this at first inspection, without touching the patient. It is while handling the patient that you should try to make sure whether the bone is denuded of flesh or not. If the bone is visible to the eye, it is bare; if not, examine with the probe. Should you find the bone bare of flesh and injured by the wound, you should first distinguish the nature of the osseous lesion, its extent, and the operation required. And you should also ask the wounded man how he suffered the injury, and of what kind it was. If the bone is not visible so as to show whether it is or is not affected,! it is far more necessary than when the bone is bare to make the interrogation as to the origin and nature of the wound. For, in the case of contusions and fractures which do not appear in the bone, though they are there, you should first try to
1 Reading véonua.
4 I give Kw.’s order of these sentences, © yoonua B, Kw, § aroxplovos.
21
TIEPI TON EN KE®AAHT TPOQMATON
oKew Treipacbat, el Te TéTOVOE TOUTWY TO GaTéoV Ul h ov métovOev. érerta O€ Kal Aoym Kal épyo 9 / \ ek / \ > eEeheyyelv, mAnv bynAwWOLOS. pnro@os yap ovK eeey el, él mem ove TL TOUT@D TOY KAK@V TO 30 OaTEéoV, KaL €l TL EXEL év EWUTO, » ov meémovGev" arn edpnv te Tov Bédeos éLenéyyeu pnrAwals, Kal A a NE AAD: ‘ nan a fal na Hy éuhracbyn To oatéov Ex THs Hvatos THs EwuToOd, vey > A A , 9 A Kal Iv taXUp@s payn TO daTéov, dtrep Kal ToloL b) a € lal 34 odOarpotor katapavéa éeotiy opwvta ywooKkey+ ¢ / \ \ ’ / , y / XI. ‘Pyyvutar dé To oatéov Tas Te afpavéas € 5! \ \ / \ nr \ > / poyras Kal Tas pavepas, cal prarat Tas apaveas prdovas, Kal eoprarar éow €k THS puavos THS EwuTod, pdadtoTa oToTav EtEpos UP’ érépou TUTp@- oKOfLEVOS emitnoes Tp@aat * BovdAopmevos 7 7) OT OTaY déxov—Kal om oTay €& ixpnrorepou yeunra a) Born F % TANY > omroTépn av ue padov * oTroTav e& icomédov Tov xYwpiov, Kal ay TEpLK parh TH xerpl TO BeXos, nv te BAAN Hv Te TUT TD, eal 10 ia XupoTeEpos E@V ag Jevertepov TITPOOKY. om oc oe 6é Tim TOvTEs TUTp@oKovTat pos TE TO dar éov Kal avTo TO daTéov, 0 amo UWndoTaTOU TiTTwY Kal Ud / , / éml cKANPOTATOV Kal A4UBAUTATOV, TOUT KiVSUVOS ’ a / a TO OaTéov paynval Te Kal dracOhvat Kai Eow > an > fol / fol e lal wn N, 3 éahracbjvar €x THs Hvavos THs EwuTod: TO O€ €& id a \ icomrésou MadXOV Ywpiov TimTorTL Kal ETL pwadOa- / lal \ ? / K@TEPOV, ooov TavTa TaoXel TO OoTEOY OvK av twa@ot. om0ca € € éomimrovTa és THY cepaday Berea TUTp@o Kel Tpos TO daTéov Kal avTo TO 20 daotéov, TO ATO UWNAOTATOU euTETOY Kal TKLOTA b] ’ / \ / / av \ > ’ €& icomrédov, Kal oKANPOTATOV TE dua Kal auPv- Tatov kal Baputatov, Kal hKiota Kovdov Kal 1 Lobeck considers the last two words superfluous, but they are in all MSS. aie,
ON WOUNDS IN THE HEAD, x.-x1.
distinguish by the patient’s report whether the skull has or has not suffered in these ways. Then test the matter by reasoning and examination, avoid- ing the probe; for probing does not prove whether the bone has or has not suffered one of these evils, and what is the result. What probing proves is the existence of a hedra or weapon mark, or whether the skull has a contused fracture with depression, or is badly broken, things which are also clearly obvious to ocular inspection.
XI. The skull suffers invisible and visible fractures, invisible and visible contusions, and contused tracture with depression from its natural place, especially when one person is deliberately and wilfully wounded by an- other, rather than when the wound is unintentional ; when the missile or the blow, whichever it be, comes from above rather than from level ground ; when the weapon, whether used to throw or strike, is in full control,! and when a stronger man wounds a weaker. As to those who are wounded about the skull or in the skull itself by falling, he who falls from a very great height upon something very hard and blunt is likely to get his skull broken or contused, or to have a contused fracture with depression; while if a man falls from more level ground on to something rather soft, his skull suffers less in this way, or notatall. As to missile weapons which wound the parts about the skull or the skull itself, a thing will fracture or contuse the bone in proportion as it falls from a great height rather than the level, and is very hard as well as blunt, and
1 Adams’ ‘‘if the instrument be of a powerful nature” seems hardly correct.
* &rpwoev; Pq. text obscure.
23
40
50
TIEPI TON EN KE®AAHI TPQMATON
HKtoTa O€v Kal parOakor, TodTO av prykee TO ootéov Kal prdcelev.
Kal padtota ye tatdta maoxew 1d dorTéov Klvouvos, OToTay Tav’Ta Te ylvyntas Kal és iO tTpw0h Kal Kat avTtov yevnrae TO OCTEOV ee Bedeos, ay TE my ex XELpos ay te BrANOR 7 Té TL euTéon avT@ Kal av avr os KATATET@Y tpwOn Kat oTwaody Tpwlels KaT avTiov yeEvo- févou Tod daTéov T@ Bede. TA O es WAaYLOV Tob oat €éou mapacvpavra Berea jooov Kal piyyuce TO oa TEov Kal pra Kal €ow éopnra, KV PrOOh TO daTéov Ths capkos: gna yap TOV TPWMATOV TOV OVTM TPwWOEYTMYV OVSE Yridod- Tae TO Ootéov THs TapKos. Tov o€ Pédewr payruce Kamora TO OoTéov tds TE pavepas poypas Kal Tas adpaveas Kal pre Te Kal eoprg éow €k THS pvatos THS EwuTod TO oa Téov Ta oTpOy Ura TE Kal mepupepea Kal dprictopa, apBréa Te éovta kal Bapéa Kal oxANpa’ Kat THY ocdpKka TAaUTA PAG TE KAL TETELPAY TrOLEl Kal KOTTTEL Kai Ta €\KEea yivetat UTO TOY TOLOUTWY BEréwr, és Te TAG YLOY Kat Ev KUKAW UTOKOLAA, Kal diaTTUa TE paXXov yiveTat Kal uypa ear Kal emt m)éova Xpovov cabaipet ac avayen yap TAS capKas TAS prac beicas Kal KoTretaas mov ‘yevo- pévas éxtaxhvar. ta bé BérXea TA TpOUHKEA éml moAU AeTTA €ovta Kal o&éa Kal Kova, THY TE capKka SlaTapver parrov 7) PAA Kal TO daTéov @ocavTws? Kal ES pip wey éurovet auro Kat OLa- Koway * —SvaKory) yap Kal epn TWUT OV eT TL—PAG d€ ov para TO dotéov Ta TovauTa BéXea ovdé pyyvvaw ovd éx THs pvavos cw eoprd.
24
ON WOUNDS IN THE HEAD, xi.
heavy—in other words, the least light, sharp, and soft.
And the skull is especially likely to suffer this when the wound happens in those circumstances, and is perpendicular, the skull being directly op- posed to the weapon, whether the agent be a blow or missile or something falling on the patient, or the patient falling himself, or being wounded in any way whatsoever, so long as the bone is at right angles to the weapon. When weapons graze the skull obliquely, they are less apt to cause fracture, or contusion, or contused fracture with depression, even if the bone is denuded; for in some wounds of this kind the bone is not even denuded of flesh. Those weapons which especially cause visible and invisible fractures, and contuse and crush in the bone out of its natural place, are rounded, smooth-surfaced, blunt, heavy and hard. These contuse the scalp, and pound it to a pulp. The wounds caused by such weapons become undermined both at the side and all round, and more likely to suppurate ; they are moist and take long to cleanse, for the crushed and pounded tissue must necessarily become pus and slough away. Elongated weapons being usually slender, sharp and light, cut through the flesh rather than bruise it, and likewise the skull; they make a hedra in it and a cleaving! (for cleft is the same as hedra), but such weapons do not readily contuse the bone or break it, or crush it inwards out of its place.
1 Or, ‘‘It leaves a hedra while cleaving.”
1 In these words aitd refers to doréov, diaxdpav to Bédrea (BéAos), Erm,
25
60
i0
20
TIEPI TON EN KE®AAHI TPOQMATON
"AANA xpr T pos. ™ oper TH EwuTod, OTe dv oot paivntae év TO date, kal epoTnaw Tovtcbat TaVTWY TOVTWV. TOU yap MaNXOV TE Kal Hacov TpwlévTos tabra €oTl onmela, Kal ip O Tpavets KapoO) Kal oKOTOS TeEpLXVOH Kal iv divos € EX Kal Téon.
XII. ‘Omotav 8€ rvxn Wirobev 70 datéov Tis aapkos UTO TOD BédEos, Kal TUXN KAT aUTas Tas papas yevouevoyv To Edkos, YaXeTrOV yiveTat Kal THY edpnv Tov BéXEos ppdcacbar Thy €v T@
addep ore pavepry yevoperny, eit’ ever Tuy ev TO OT TED elite pn eveorTly, Kal Iv TUX yevoperit, n pn ev adthar Tho papjow. auyKrérrter! yap avTn 7) padyn TenyuTepyn €ovca Tov adXovU oaTéov, Kal ov OLaddnrov 6 TL TE AVTOD pady éaTe Kal 6 TE Tov BéXeos Edpn, hv fn) KAPTA pEeyadn yévynrat 1) epn. mpoayiverat d€ Kal pH&ts TH ete Os em TO TOND Th ey THal papHnae ywvomévy,” Kat yiveras Kal avTn a pnges Xarerw@répn ppacacba, éppo- yoros TOU da Tou, bua TOUTO ore KaT aurny THY padny ) PIgLs yiverat, oy pyyvutat, os én TO TOU: éTo.uov yap TavTn pyyvucbat To oatéov Kal ouaxaray bua THY do evetny THS puovos Tob OaTéov TAUTY Kal bua THY apaoTnta, Kal 69 & ate Ths padys éroiuns eovons pryyvuc0a Kai dia- Narav. Ta, dé dda oaTea Ta TepleXovTa TP pany pevet apparyéa, ore lo xuporepa eoTL Tis papas. 1 b€ pHéis Kata thy padnv yivomévyn Kal dtaydraals éote THs padhs, Kai ppdcacbat ovK evuapys, ovTe eb? amo &dpyns tod PBédEos ryevouevns ev TH pahh, emesday payn Kat dsaya- Adon, UTE Iv PradUEvTOS TOU daTEOU KATA TAS 26
ON WOUNDS IN THE HEAD, x1-xn.
Now, besides your own inspection of what you may see in the bone, inquiry should be made into all these things, for they are indications of the greater or less gravity of the wound, also as to whether the patient was stupefied and plunged in darkness, or had vertigo and fell down.
XII. Whenever the skull happens to be laid bare of flesh by the weapon, and the wound happens to occur just at the sutures, it becomes difficult to make an assertion as to the presence or absence of a weapon fedra in the bone which would be obvious in another part, especially if the hedra happens to come in the sutures themselves. For the suture itself being more uneven than the rest of the skull is deceptive, and it is not very clear which part is suture and which hedra, unless the hedra is very large. As a rule, too, fracture accompanies the hedra when it occurs in the sutures, and the fracture itself is harder to make out—though the bone is broken—for this reason, viz. that when there is a break it comes, as a rule, just in the suture. For the skull here is readily fractured or comes apart owing to the natural weakness of the bone in this place, and because of its porosity. Besides, the suture as such is ready to rupture and come apart, but the bones containing it remain unbroken because they are stronger than the suture. Fracture occur- ring in a suture includes a giving way of the suture, and: it is not easy to make out whether the breaking and coming apart follows a weapon hedra occurring in the suture, or whether it is after contusion of the
1 Scaliger’s emendation for oupuBAémet, confirmed by B. (ouvKAeTTN). 2 aitjow .. « yryvoueviot Pq. 3 iy,
27
30
TEPI TQN EN KE®AAHT TPOMATON
cadpkas, payh Kal Siaxdracn: arn éorte Xarera- TEPOV ppdcacbar THY amo (THs praoros poypny. ouyKheTTovat yap THD qvepny Kal TI dpev TOU intpod avral at papat porypoerdées parvopevar Kal TPNXUTEPAL covoau TOU adXov GaTéOU, STL pi) iaxupas Ouexomrn Kal due dhacev: Svakom dé Kal edpn T@UTOV €oTLD. ara XP's el Kara TAS padas TO TpOLa YEVOLTO Kal Tpos ye TO ooTEov Kal és 70 da Téov armpitere TO BéXos, 7 poaéXovTa TOV voov dveupio Kew OTL ay met ovOn TO daTéov. aro yap icwy Te Bedéwv Td peyeBos Kal opotwy Kal TOAA® !
Te éXacaovar, Kal onoiws TE Tpweis Kat TONG ®
Horo, TORO péCov éextnoato 76 KaKOV ev T@
40 doTéw 0 €s TAS padas SeEapwevos TO Bédos 7 0 py
44
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, 8 a b) ’ b \ Spe \ € \ mpter Gat et arr ov Xp avTas Tas padas mplewy, arn’ amoxwpyravra ev TO TWANGiov ootéw THY TpLow Toveia bar, 9 nv mpins.
XIII. Tepi b€ inoLos Tpa@d tov TOV EV TH ceparh Kal OTS xpr) ebereyxewv Tas maQas tas év TO Oo Téw yevopevas Tas pI) pavepas, GSE por Soxel. Eros é ev TH KEPAAT OV Y py Téeyyetv OvV5EVL, OVOE OlVH, addrXws Hxrota’® ove KaTaTAdaCELY, OVSE [LoT@ THhv inow TovetaOat, ovd éemidety yp EXKos ev TH Kepary, WY Lp ev TO meTOT@ 7 TO EXKOS, 1) EV TO Wik TOV TPLX@V, 1) Tepl THY OppiY Kal TOV ’ / bd lal , \ vA opOarpov. évtad0a 5é yivopeva Ta EXKEA KaTA- TArAdoLos Kal émLdéaos paAXOV KEXPNTAL 7 TOU
1 ToAAdy.
2 rodv.
3 GAN’ &s hxiora Pq., but with less support from MSS. or the context.
28
ON WOUNDS IN THE HEAD, xu.-xm.
skull and flesh that it breaks and comes apart. Still, the fracture that follows contusion is harder to make out. For the sutures themselves, having a fracture-like appearance, and being more uneven than the rest of the skull, deceive the mind and eye of the physician, when not violently cleft or gaping —cleft and hedra are thesame.! Now, if the wound is at the sutures, and the weapon penetrated the parts about the bone, and to the bone, you should devote your attention to finding out what injury the bone has suffered. Fora person wounded by weapons of equal, similar or much less size to a similar or much less extent suffers far greater mischief in his skull if he receives the weapon at the sutures than when it is not so received, and the majority of these cases require trephining. You should not, however, trephine the sutures themselves, but, leaving an interval, operate on the adjacent part of the bone, if you do trephine.
XIII. The following is my view of the treatment of wounds in the head, and the way to discover affections of the skull which are not manifest. A lesion 2 in the head should not be moistened with anything, not even wine, much less anything else,? nor should the treatment include plasters or plugging, nor ought one to bandage a lesion in the head, unless it is on the forehead or in the part devoid of hair, or about the eyebrow or eye. Wounds occurring here are more suited to plasters and bandaging than those
1 Surely an insertion.
? €Axos is defined by Galen as ‘a lesion of continuity in the parts.” The ‘‘wound,” therefore, concerns the scalp only.
Or, reading GAA’ as fixiota ‘‘ except the least possible,” but the ‘‘ correction” seems needless,
#9
20
30
THEPI TQN EN KE®AAHI TPOMATON
aro THS Keparns TIS aAANS* _Teplexel yap 1) cepary n adhn TO petr@mov may €x O€ TOD TE plex OvT oY Ta édKea, Kal év OT@ av an Ta Edxea, preypaiver Kal emavoldiaKeTat bu Qi martos eT Up- pony. xpr dé ovdée Ta ev TO HeTOT dua TavTos TOU Xpovou KaTamAdooew Kab emoeiy, ann émeloay Tavontar preyuatvovta, Kal TO oldnwa KaTaoTh mavaacbat KataT hao oovTa Kal é7e- déovra* év O€ TH adAH xepanrs éX.KOS ovTe HoTouy XPM» oUTE KaTaTTAdoCELY OUT emLOElV, Eb un Kal Tomns S€OLTO.
Tapvery be xen TOV EAKE@D TOY év xepah yevowevov, Kal ep TO HETOT, omou av TO pen daTéov porov: 7 THS TapKos, Kab Sox Tt oivos Exew vUmro Tov Bédeos, TA O€ EAKEa py (Kava TO méyePos Tov pujKeos Kal THS evp’THTOS és THD oKéiy TOD OoTéoU, El TL TETTOVOEV UTD TOD BédEOS KQKOV Ka) OTrOLOV Tt merrove, Kal omdcov bev 7 oape mepracrat wal TO oaréov exee Te givos, Kal é are el aowés Té eoTe TO ooTéoy uo TOU BeXeos Kal pnoev Tétrovle KaKov, Kal és THY naw, OToLNs Tivos OeiTat TO TE EXxos TE TapE Kal 7 TAdOn Tov oatéov' Ta O€ To.adTa TOV EXKEWV Toms detran. kal Otay} fev To da Téov prod THs TAPKOS, vToKolha dé 7 és maryLov éml modu ETAVATAMVELY TO rothov, Omou Ty) EDV EPES T@ papmak@ apixéa bar, omoi@ av TwWt xp?" Kal Ta KUKNOTE PED TOV EAKEwY Kal UToKoUNa, éml moXv Kal Ta TOLAVTA ETaVaTadyVaV TOV KUKAOV Bix} KaTa pnKxos, ws mépucey w@vOpwos, paxpov MoLety TO EXKOS.
Tauvovtt dé Kehadynv, Ta pev adra THs 30
ON WOUNDS IN THE HEAD, xm.
elsewhere in the head, for the rest of the head surrounds the whole forehead, and it is from the surrounding parts that lesions, wherever they may be, get inflamed and swollen by afflux of blood. Not even on the forehead should you use plasters and bandaging all the time, but when inflammation ceases and the swelling subsides, stop plasters and bandaging. On the rest of the head you should not plug, plaster, or bandage a wound unless incision is also required.
One should incise wounds occurring in the head and forehead where the bone is laid bare and seems to be in some way injured by the weapon, while the wounds are not long and broad enough for inspection of the bone, to see whether it has suffered any harm from the weapon, the nature of the injury and extent of the contusion of the flesh and any lesion of the bone, or, on the other hand, whether the bone is uninjured by the weapon, and has suffered no harm; also, as regards treatment to see what the wound requires, both as regards the flesh and the bone lesion. These are the kinds of wounds that require incision. When the skull is laid bare and there is considerable undermining on one side, open out by incision the hollow part where it is not easy for the suitable remedy to penetrate. In the case of circular wounds which are undermined to a considerable extent, open these out also by a double incision up and down as regards the patient ! so as to make the wound a long one.
Incisions may be safely made by the surgeon in
1 j,e. at opposite sides of the wound above and below.
1 ty perv P. 3!
50
10
20
TEPI TON EN KE®AAHI TPOMATON
eedaris aopanreinv exer Tapvopeva o 6é KpoTa- gos, Kat avwlev ett Tod Kpotagou, KaTa THY preBa THY dua TOD KpoTaddou pepoperny, TOUTO d€ TO xeoptov 1) Taye, oT aT Mos yap Emap Baver tov THNBEvTO Kal av pe én’ apiorepa TunOn Kpotadou,: Ta emt deEla 0 oTAT MOS ETLAap- Baver, hv Sé emt ta dela TyunOH Kpotadov, Ta em aploTepa 0 oTacmos émiAap Paver.
XIV. “Orav otv tapvyns Edxos év Kepary éatéov eivexa THS capKos epidopévov, OéXwv eidevau el TL éxel TO Oa TEéOV KaKOV vmo TOU Béreos 7 Kal ouK EXEL, TAPMLVELV xen TO péyebos TID @reuhyy,” oToan av Soh am ox phar. Tamvorra, dé xpr davacreihat TIy odpKka ao Tov oaTéov 7 Tpos TH pyviyyt Kal pos TO OaTéw Tédpuxer, ererta Sraporacas TO EAKOS may por®, dates av eupUTaTtov TO EhKos mapeger és THY borepatny avy éMaylor@ T OVO poTmoavTa be KaTaTAdo are xpHaGas émdaov dy mep YVpovov Kat oO foTO, Het éx det Tov anrpitor, ev Ofer € paccel, eye 6 € Kal ydaxpny TOLELY @S padtora. TH O€ voTe- pain 7 7HEpD €rrecOav efeAns TOV poTon, KaTioo@v TO daTéov 6 TL memrovOev, éav pa} cou Katapavns 7 1) Tpwcts, o7rotn Tis ear ev TO OOTED, pn de Sraywadaonys el TE TL eXet TO OGTéOV KaKoV éV EwuTO, v7) Ka ovK EXEL, To 6€ BéXos SoKA aine- aOat és TO dareov Kat civacbat, emt vely Xp) TO Evorhipe KaTa Babos Kal KaTa pipKcos Tob ivOpo- TOU WS mé PuKe, Kal av0us émuKdpovov TO da Teor Tov pytiov eivexa ToV adpavewy ideiy Kal TIS
léy 7G... Kxpotdpw also below ev rq em) dehid tTundh Kpotapy, Kw.
32
ON WOUNDS IN THE HEAD, xu1-—xiv.
any other part of the head, but he should not incise the temple, or the part above it in the region traversed by the temporal blood-vessel, for spasm seizes the patient. And if incision of the temple is made on the left, spasm seizes the parts on the right, while if the incision is on the right, spasm seizes the parts on the left.
XIV. When, therefore, you incise a head wound because the bone is denuded, and you want to know whether it has, or has not, suffered any injury from the weapon, the size of the open wound should be such as seems fully sufficient. When operating you should detach the scalp from the skull where it is adherent to the membrane ! and to the bone. Then plug the whole wound with lint, so that next day it will present the widest possible lesion of continuity with least pain. When plugging use a plaster of dough from fine barley meal to be kept on as long as the lint. Knead it up with vinegar and boil, making it as glutinous as possible. Next day, when you take out the lint, if, on looking to see what the bone has suffered, the nature of the lesion is not clear, and you cannot even see whether the skull has anything wrong with it, yet the weapon seems to have reached and damaged the bone, you should scrape down into it with a raspatory, both up and down as regards the patient, and again transversely so as to get a view of latent fractures and contusion which
1 Vidius suggests that this refers to the connections between pericranium and dura mater at the sutures Celsus seems to translate ‘‘membranula quae sub cute, calvariam eingit.” VIII. 4.
* rounv, Kw’s conjecture,
33
VOL, II, 0
30
50
TIEPI TON EN KE®AAHI TPQMATON
prdov0s elvexa THS apaveos THS OUK ea prwperys €ow kK THS pvovos THS Keparns TOU adXov 6 doTEou. eeheyXev yap 1 Evers pda TO KaKov, ve pay Kal ddhos KaTapavecs € wou avTat au i mab at ai €ovcat év TO doTEw ) [tod Béreos].1 wal iy edpny ions é ev TO daTe@ TOU Bereos, émeEvew xr aur ay TE THD ESpnv Kal Ta TeplexovTa auTny eared, i) TON aus TH eopy T pooyevntat pecs Kal paAdots, 1 povn gdddots, Emerta avOavyn ov Katadavéa éovTa.
*"Erresdav € Evons TO datéov TH Evothpr, iv pev doKx7} és mpiouy aprixer ” TPOTUS TOU OGTEOU, mpiew Xp, Kab Tas Tpels nmepas Ty) brepBdrrew am piorov, arr’ év Tavryot mpi, GXXWS TE Kal TAS Geppis @ @pNs, ayy é& apis, Nau Bavys TO nea.
“Hy 6¢€ UmomTEevns fev TO OOTEOV epperyevar a) meprdobau, n dpporepa TAaUTa, TEK MALL PO [MeEVOS ote loxupas TéeTpoTaL € ek TOV Aoyov TOU Tpopariou, Kal OTL vmo ia XupoTépov Tou TPwTAVTOS, nv ETEpos ip’ ETEpou TpoOh, Kal TO BeXos oT eTpon, OTL TOV KaKOUpY@DV Beréov 7, emrerTa, Tov avO pwrrov ore divos TE eae Kal TKOTOS, Kal exapwn Kal KATETED EV" TOUT@D dé ovr ryevope vov, iv pn SiaywoaKnys él Eppare TO Oa ‘ov TEprUT TAL, » Kab duorepa Tava, pajre ahhos opewy dvvn, Set dn Ewt TO OaTEOV TO THKTOV TO peravtatov devaas,? TO pedave papwaxe TO THKOMEV® oTElNaL* TO EXKos, UToTelvas 0 6vi0v édaiw téyEas:® eita KataTAaaas TH malty eredh- oa. TH OE VaTEpaln aTroAvaas, ExKabypas TO EXKOS eriEdoat. Kal Hv pn 7 UyLes, GAN eppwyn Kal
1 Omit B. Kw. ® dAws Pq. 3 SevoayTa.
ps
34
ON WOUNDS IN THE HEAD, x.
is latent because the rest of the bone is not crushed in out of its natural position, For rasping shows up the mischief well, even if these lesions though existing in the bone are not otherwise manifest. And if you see a weapon fhedra in the bone, you should scrape the hedra itself and the bone containing it, in case, as often happens, fissure with contusion or contusion alone accompanies the hedra, and not being well marked, is overlooked.
When you scrape the bone with the raspatory, if the skull lesion seems to be a case for trephining, you should operate and not leave the patient untrephined till after the three days, but trephine in this period, especially in the hot season, if you take on the treatment from the first.
Should you stispect the skull to be fractured or contused or both, judging from the patient's account that the blow was severe and inflicted by a stronger person—if he was struck by someone else—and that the instrument with which he was wounded was of a dangerous kind; further, that the man suffered vertigo and loss of sight, was stunned and fell down: in such circumstances if you cannot otherwise dis- tinguish by inspection whether the skull is fractured or contused or even both, then you must drop on the bone the very black solution, anoint the wound with the dissolved black drug, putting linen on it and moisten with oil, and then apply the barley- meal plaster and bandage. Next day, having opened and cleansed the wound, scrape further, and, if it is not sound but fractured and contused,
4 Difficult text. oreiAat = supertegere, inungere. 5 réyiat
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TEPI TQN EN KE®AAHI TPQMATON
mephag wevov > TO pev ado éorar daTéov AevKOY émeEvopevov" n 6€ pwypn Kal 1) prdous, KaTaTa~ KEVTOS TOU dappaxov, deEapevn TO pdppaxov és EwUTHY péday € eov, €or ae pédawwa € ev AevK@ TO doTe@ TO ANAM. GAA xpn avis THv poyeny TavT yD gaveioav péXatvay émuEvew Kata Babos: Kal hv pev ércEver [THv p poypyany TavT HY paveioay pedar- vav]1 é&éXns cai adavéa troinons, prdots pev yeyevntat TOU oaTéov 7) MAadroV Hocov, TLS mepéppnee Kal THY pOyynvy THY apaviabeicay b7e tov Evotnpos: Hoo ov 6é poBepov kal hocov av T pipy wa am auras yevorTo adavabetons THS poyuns. nv dé kata Bados 7 n Kal 7) €Oédy efcévae emiEvopern, adnner és mpiow n TovavTy ouppopy.
XV. ’AAAA yYpr) TpicavTa TA Noumea int pevewy TO EXxos. purdacesbar dé xPr) oTwsS [7 Tt Kaov aTrohavan TO daréov amo THis gTapKos, iy KAKOS intpevntat. d6oTéwm yap Kal mempio- pero Kal ados arpicre epiropévep 66, Kal 2 Dryvet O€ €ovTL xal exovti TL OLVOS oTO Tov BéXeos, Soxéovte dé Uytel elvat, Kivduves éore waddov brotuov yevécOat, iv Kal ars py MéEAAD, HV Kat » oape 17 mepléxovoa TO oo réov KAKOS Jeparrevntat, Kal preypatyy TE Kal mepia ply- yntae: TupeTOoes yap yiverae Kal mOXOD proyuov mAéov' Kal én, TO OaTéov é€K TeV TEpLeXOVTOY capKav és EwuTo Oépuny TE Kat proypov Kab dpasov eumrouel Kab opuypov, Kab omora Tep 1) oapé éxer Kaka év EwUTH, Kat én TouTwy woe® wiroTvoy yivetat. Kaxov 6€ Kal bypyv te eat THY cdpKa ev TO EdKel Kal
1 Probably a gloss: many codd. and editt. omit. 36
ON WOUNDS IN THE HEAD, xwv.-xv.
the rest of the bone will be white after scraping, but the fracture and contusion will have absorbed the dissolved drug and will be black in the white bone. You should again scrape down into this fracture which shows black, and if on further scraping [this fracture which shows black] you clear it away and make it invisible, there has been more or less contusion of the bone, which also produced the fracture now abolished by the raspatory, but it is less formidable and less danger will result from it now the fracture has disappeared. Should it go deep and refuse to disappear when scraped, such an accident is a case for trephining.
XV. After the operation you should use the other treatment requisite for the wound. You should guard against any mischief spreading from the tissues to the skull owing to improper treatment. For when the bone is trephined or otherwise denuded without trephining—whether really sound, or injured in some way by the weapon though apparently sound —there is greater risk of suppuration, even if it would not otherwise occur, if the flesh about the bone receives improper treatment and gets inflamed and strangulated. For a sort of fever occurs in it, and it becomes full of burning heat, and finally the bone draws into itself heat and inflammation from the tissues about it, also irritation and throbbing, and everything bad which the flesh already con- tains, and so it becomes purulent. It is also bad for the tissues in the wound to be moist and
1 Vidius: ‘cetera facienda sunt quae ulceris curatio postulat.” anplatw 5€, nal B,Kw. ; the rest omit, 3 otras.
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TWEPI TON EN. KE®AAHT TPQOMATON
pvddcav Kal ért TONNOV Xpovov xabaiper Bar: anda xpn dvdr voy pev Too at TO €AKoS os TAXLOTA" ovT@ yep av heiora preypaivor TH TeplexovTa TO Ed«os Kal TAXLOT ay xalapov fe avaykn yap exer TAS wapKas TAS Korreias Ka pracbeicas umd Tov BédrE0S, UmoTvOUS en oe EXTAKHVAL. émreLoav dé KadapO7, Enporepov xpn yiver Ba TO &AKOS* ore yap ay Taxiora vryees yevorTo, Enpis capKos Brac- TOVvoNS Kat fn vVypHs, Kal oUTwS ovUK av Umepe apxijacie TO EXKos. 0 be QUT0S Novos Kal vmep THs pajveryyos TIS mepl TOV eyxepanor: ay yap autixa exTr pio as TO daTéov Kal adehov amo THs pavuyryos praons auTny, cabapny xP?) TOLnoat as TaXLOTa kal Enpynv, @s pn él TONY YXpovoy vp? éodaa mvoH Te Kal éEaipnrar?
/ \ e/ / an 3 \ TOUTWY yap oUTM YyWouevev caThvar avTny KivOvvos.
XVI. ’Ooréov 6€°6 te 8% arootivar Sel ard ToD adXoU daTéou, EXKEOS EV Kepanrh yevomervon, edpns Te é€ovons Tod Bédeos ev TO oaTew, 7) GOS emt ToNU prodevtos TOU oaTéou, adbiorarat ent TonU eFarpov ryevopjievov. avatn- paiverat yap TO aia €x Tov oatéov Uo TE TOU xpovou Kal v0 pappwaxey TOV TrELT TO. Ta- yicta © av arroaTain, el TLS TO Edxos @S TAXLETA cal npas Enpaivor TO oLTrov TO ré EXKOS, Kal. 70 daréon, Kal. TO. méSov. Kal TO. 1000... TO yap Taylor, arroEnpavOev Kal dmoatpaxwbev TOUT@ addicta apictatat ato TOU aNXovV daTEéoV TOD
1 rept.
38
ON WOUNDS IN THE HEAD, xv.-xv1.
macerated, and to take a long time to clean up. You should rather make the wound suppurate as quickly as possible ; for thus the parts about it will be least inflamed and it will be most rapidly cleansed ; for the tissues that are pounded and contused by the weapon must necessarily become purulent and slough away. When the wound is cleansed it should get rather dry, for so it will soonest become nealthy, the growing tissue! being dry and not moist, and thus the wound will have no exuberance of flesh. The same principle applies to the mem- brane covering the brain. For if you trephine at once and by taking away the bone denude this mem- brane, you should make it clean and dry as soon as possible, lest by being moist a long time it should fungate and swell up, for in such circumstances there is risk of its becoming putrid.
XVI. Any bone which is bound to separate from the rest, when a wound has occurred in the head and there is a weapon fedra in the skull, or when the bone is otherwise extensively denuded, usually separates after becoming bloodless, for the blood in the bone is dried up both by time and by most applications. The separation would occur most rapidly if, after cleansing the wound as soon as possible, one should next dry both the wound and the bone whether larger or smaller. For what is soonest dried up and made like a_potsherd, thereby most readily separates from the rest of the bone which is full of blood and life, having
* Our “‘ granulation tissue.” a ee * étepira.
14
10
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TEPI TON EN KE®AAHT TPOMATON
évaipov te Kai Ca@vtos, avTO éEarpov TE yevopevov Kal Enpov [76 eValLe | Kal Cavre pda apiotarat]. =
XVII. “Oca 6€ TaY doTéwr éoprarat é ow éx THS PvaLos TIS EwuTO”, KaTappayevTa y Kab dvaxoTévta Tavu evpéa, AKLVSUVOTEPA TA TOLAUTA yliverat, ery ”) ptveyé bys Us Kal Ta TET poryynaty éoxaTappayevTa Kab evpurepnow ets axwduvorepa Kal evpaperTepa és Ty apatperww yiverat. Kal ov xen mplew TOV TOLOUT@Y OvOED, ode KuvOuvevery TQ area TEL PO MEVOV apatpeiy T piv 7 avromara émavin: €lKOS ™ p@Tov yana- cavros.® emavepXeTal Sé Tis TapKoS Uropuo- pevns® Umopveral be EK TNS Sumrhons TOU daT€ou Kal éx ToD DyLéos, mv um avobev botpn Tou daréov povvn ohakerion. ovtTw 6° av TaXlora fH Te cape umogvorTo Kal Bracravo Kal Ta OoTéa érmaviol, el Tus TO EXKOS @S TayLoTAa SLdTrVOY TOLI}o as xabapov TromonTas.® Kal Hv bua TAVTOS Tov daTéou aud o at polpac éopracbacw éow és Thy pappeyya, TE AVM potpn TOU oaréou Kal a) KATO, intpevovte @TAVT@S TO EdKOS bytes TayloTa otal, Kal TA OoTéa TdyLoTA eTdVELoL Ta éopracberta éow.
XVII. Taév 8 wadiov ta dotéa Kal NerTO- Tepa ear Kab parOakarepa bua TOUTO, OTL éva- poTepa éoTt, kal Kotha kab onpayyosea Kab ovUTEe TUKVa OUTE OTEped. Kal bro THY BEdéwv
1 Following Kw.’s reading and punctuation of this much controverted passage. Scaliger and others omit the last words. -
2 “This passage is corrupt and depraved in all the examples.” Foés.
40
ON WOUNDS IN THE HEAD, xvi.-xvim.
become itself bloodless and dry [it readily comes away from the vascular and living part}.
XVII. Cases of contused fracture of the bones with depression when they are broken up and even comminuted very widely, are less dangerous (than other injuries) if the covering of the brain is unharmed, and where the bones are broken in with many and rather wide fractures they are still less dangerous, and are more readily removed. In such cases you should do no trephining, nor run risk in trying to remove bone fragments before they come up of their own accord: they naturally come up when there is a loosening. Now the frag- ments come up when the flesh grows from below, and it grows up from the diploé of the skull and its healthy part, if there is necrosis of the upper table of the skull only. Such upgrowth from below and burgeoning of the flesh will take place most rapidly if one brings the wound as soon as possible to suppuration and cleanses it. If the whole bone with both its ‘tables,’ 2 both upper and lower, is contused inwards and depressed into the cerebral membrane, it is by the same treatment that the wound will heal soonest and the bone fragments that are crushed inwards come up most quickly.
XVIII. The (skull) bones of young children are thinner and softer because they contain more blood and are hollow and porous and neither dense nor hard. And when wounded by equal or weaker
? “ Subsidence of the swelling,” Adams, reading ofSeos for
eixds as Littré. ? Literally ‘‘ parts.”
8 Tomoeser,
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ITEP] TON EN KE®AAHI TPOMATON
loco TE eovT@Y Kal ao ever tépwr, Kal Tpwbévtwr opotws TE Kal hoo, TO TOU VEWTEPOV mawdtov Kal “adXrov Kal Oaocov b vTomVviaKETaL i) 70 Tou pea BuTEpou, Kab év éXdooove X pore Kal dca av adros HEAD aroBavetabat éx Tov TP@LATOS, 0 VE@TEPOS 700 mpeaButépou daooov am OrUTAL.
"ANNA XpPy, mp Vroh THs TapKoS TO daTéor, T poo éxovTa TOV voov, Tetpnabat Sayivac Key oT pn, éore Tolow opParpoicw idety, Kal
yvavat el Eppwye TO dotéov Kal e& TépAaaTaL,
7 Hovvoy mMépraa Ta, Kal él, epys syevopwevns TOU Béreos, T pogeaTe praais H) porypn. i) dupeo TavTa. Kal iy TL TOUT@Y meéTrovOe 70 oo Téov, apeivar TOU aiaros TpuT@vTa TO Oa TEéOV TLL PD TPUTTaV EO, pudacoopevov em’ odiyou" Aer TOTEpOV yap To oatéov Kal émitodatoTepoy TV véwv 7) TOV pea BuTépwr.
XIX."Ootis be pedree éx Tpaparav ev Kepanrh ar abiiclee Kal pay duvatov avTov byed ryeve- Oar pndé cwb vat, éx TovVde TOV onmElwy YXpN THY Srdyvoow Toveta Oat Tov méXXOVTOS atrodYN- oKELY, Kal T poneryeLv TO [EN OV éveo Bau. maaXet yep Tade* oTOTAaV Tes ooTéov Karenyos v7) Eppwryos y} Tepdac mevor, 7) oT your TpOTD KaTenyos evvorjoas aapty, Kab pnre Evon pajre mpion pate Seomevov, pntet b€ ws Dy Leos OVTOS TOU daTéov, pd TOV Teaoepaxaidera 7 eepéwv TUpeTOS emOujrpera, as emt Tohu €v NEMO, ev O€T@ Bépet peTa Tas ETA nHEpas 0 TUPETOS érihapPaver. Kal €meloav TOUTO yEevnTtat, TO EAKOS AYXpooV yiveTat
1 This fourth pyre puzzles nearly all the translators, They leave it out. I follow Petrequin. je6 5¢ Litt. Erm, 42
ON WOUNDS IN THE HEAD, xvin.-xrx.
weapons to a similar or less extent the skull of the younger child suppurates more readily and rapidly than that of the elder and for a shorter period,' and when they are going to die in any case from the wound, the younger perishes sooner than the elder.
But if the bone is denuded of flesh you should devote your intelligence to trying to distinguish a thing which cannot be known by inspection— whether there is fracture and contusion of the skull or only contusion, and whether, if there -is a weapon hedra, it is accompanied by contusion. or fracture, or both of these. If the bone is injured in any of these ways, let blood. by perforating with a small trepan, keeping a look-out .at short intervals,” for in, young. subjects. the. skull is thinner and more on the surface? than in older persons. ~ XIX. When anyone is going to die from wounds in the head, and it-is impossible to make him well or even save his life, the following are the signs from which one should make the diagnosis of approaching death and foretell what is going to happen. He has the following symptoms— when, after recognising that: the skull is injured, either broken or contused, or injured-in* some way, one makes a mistake. and neither scrapes nor trephines as though it were not required, yet the bone is not sound, fever as a rule will seize the patient within fourteen days in winter, and in summer just after seven days, When this occurs, the lesion
* So Petrequin, avoiding a tautology. * Cf, Saud oxorotuevos, XXII. | 8 7,e. has less depth.
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TEPI TON EN KE®AAHI TPQMATON
Kat €€ adtod ivwp pet o [LK pos” Kal TO elottagee voy sl erie gg ef auTov* kal Bruxy ades * yiverat
paiverar _daorep TaplXos, xX poury TUppov, Sartre kal To ooTéov opaxehivew ee apxerar, Kal yiverat TEPKVOV Aelov Ov,” Tedev- Tavov 6é Em wX pov yevopevov ) €xdevKov. Otay o 70n vmoTvoy 7, él TH yAwWoon prvetaivar ytvovtTat, Kal mapadpovéwy TedEUTG. Kal TTA [105 emthapBaver Tous Tela TOUS Ta eTrh Odrepa TOU TOLATOS" Av pev év T@ én apiorepa THS xepanijs exN TO EdKos, Ta éTrh beEua ToD Teparos 0 oTAT LOS AapBdver ny & ev 7 emt beEia TIS xeparis eXn TO EXKOS; Ta eT apa repa Tob T@paToS O OTA [LOS emrauBaver. elat 8 od Kat amonhnkrot yivovran, Kal oUTws dmodhuvras 7 po émTa TmEpov év Géper 7) 1) Tecoapwv Kal déxa ev Xeepeove opoias O€ Ta onpeta Tava onpaivet, Kal év TpeaBuTépm €ovTL TO TpwmaTe 7 Kal év VEWTEPY.
"AdXAa XPM eL évvoins Tov mupeTov emia Ba- vovTa Kal TOV adNOV TL onpelov TOUT@ Tpooye- VOMevOr, 77) drat piPeww, adda Tpicavra TO oatéov T pos THY amy ye n catatioavra TO Evo thpo— eUm piaTov * be yiverat Kal evEvotov—erevta Ta Noumea oUTws int pevewv drrws av doxh cupdéperr, mpos TO yevopevov opav.
XX. “Orav & ért Tpwpare év Kkeparn avOpo- TOU u) TET pLeomevov U7] arrpL@rov, pirate dé Tod datéov, oldnua ervyevntar epuO pov Kal epuat- méeNaT@deS EV TO Tpoo wre Kal €v Totow opOan potow dpporépouc wv TO ETEp@,, Kal ev Tes aMTTOLTO TOU OdnMaTOS, éduv@rTO0, Kal TrupeTos
44
ON WOUNDS IN THE HEAD, xix.-xx.
gets a bad colour and a little ichor flows from it, the inflammation dies completely out of it, it gets macerated and looks like dried fish of a rather livid reddish colour. Necrosis of the bone then sets in, it gets dark coloured instead of white, finally turning yellowish or dead white. When it has become purulent, blebs appear on the tongue and the patient dies delirious. Most cases have spasm of the parts on one side of the body; if the patient has the lesion on the left side of the head, spasm seizes the right side of the body; if he has the lesion on the right side of the head, spasm seizes the left side of the body. Some also become apoplectic and die in this state within seven days in summer and fourteen in winter. These symptoms have the same value both in an older and a younger patient.
If, then, you recognise that fever is seizing upon a patient and that any of these symptoms accom- panies it, make no delay but, after trephining the bone down to the membrane, or scraping with the raspatory (for the bone becomes easy to saw or scrape), treat the case in future as may seem best in view of the circumstances.
XX. When in case of a wound in the head, whether the patient has been trephined or not, the bone being denuded, there supervenes a red erysipelatous oedema of the face and one or both eyes and the oedema is painful when touched,
1 Reading Aeuvxdy. Aeiov Pq. and codd. ‘‘ without ceasing to be smooth” (?).
1 So Kw. following Erotian and Archigenes. yA:wxpades Pq. codd,
Aevxdy edv Kw. ete, 3 Kamupdv.
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MEPI TON EN KE®AAHI TPOMATON
1 2
éminauBavort Kal piyos, TO 5é€ éAKos avTO TE aro TIS apres Ka@s Exot idéo Bar Kal Tuo TOU OaTEOU, Kal Ta TEPLEXOVTA TO éXKOS EXO Karas, TAY TOU OLONLATOS Tob év T poten Kal aXAnV apapTada prjdepiay EX OU TO oidnwa THS adAns dvaitys, TOUTOU xPn TY KATO Kourny vmroxalhpar pappaKg 6 Te Xodgy ayeu’ Kal ovUTw KkatapbévTos, 6 Te TUPETOS apings kal TO oldnua caioratat Kal uyens yivetat. TO € puppaxov xP”. didovat 7 pos THY OUvamLY TOV avOpwrrou Opar, @S av EVN LaXVOS.
XXI. [epi 6€ wpicwos, 6tav KaTarapy avayKn mpioa av0 pwmor, ade yu@oKew. a €& apxis AaBov TO inpa Tpiyns, ov xp” ex plew TO oa Téov 7 pos THY pajveyya avtixa: ov yap ouppeper wi prypeyya Wirnv eivat tod datéov él TONY ‘ povov caxor abovear, adda TEEUTOTE 7) Kal demvonaev.? éote O€ Kal ErEpos civdvves, iy aurixa ad atpys T™pos THY ppeyya ExT ploas TO da Téon, TpOTaL év TO Pe TO Tplove oe penveyya. adr xp?) mT ptovTa, érerdav ONtyov * mavu én dtatreTpicOat, Kal On KWHTaL TO daTEoV, mavoacbat Tplovra, Kal Edy él. TO avTomaTov doa Tipit TO OOTEOV" éV yap TO Ota- T plot @ oaTE@ Kal EmreheAELppEevey THS T piovos OUK émuyévolTo Kakov ovdév, ETTOV Yap TO AecTromevoyv On yivetar. Ta sé Nova inaGat yp), @s dv doxh cuppépery TH EdKEL.
1 émiAauBavn. 2 +a re Reinhold.
8 cameica diewvdnoey Scaliger ; but this is surgically the
wrong order. Reinhold suggests dieudince wal redrtevtaca éoann.
46
ON WOUNDS IN THE HEAD, xx.-xx1.
and fever also seizes him with a rigor, but the lesion itself has a healthy appearance in the part affecting the scalp and skull, and the parts about the weund look healthy except for the oedema of the face, and the oedema is not further com- plicated by an error in regimen, in this case you should cleanse the bowel with a cholagogue. After such purging the fever departs, the oedema sub- sides and the patient gets well. In giving the drug you should have an eye to the patient’s vigour, what strength he has.
XXI. As to trephining when it is necessary to trephine a patient, keep the following in mind. If you operate after taking on the treatment from the beginning, you should not, in trephining, remove the bone at once down to the membrane, for it is not good for the membrane to be denuded of bone and exposed to morbid influences for a long time, or it may end by becoming macerated.} There is also another danger that, if youimmediately remove the bone by trephining down to the mem- brane, you may, in operating, wound the membrane with the trephine. You should rather stop the operation when there is very little left to be sawn through, and the bone is movable; and allow it to separate of its own accord. For no harm will supervene in the trephined bone, or in the part left unsawn, since what remains is thin enough. For the rest the treatment should be such as may seem beneficial to the lesion.
1 «* Becomes macerated, and finally putrefies.” R.
4 OAl you.
47
20
30
TIEPI TON EN KE®AAHI TPQMATON
IIpiovra 5é xp7 muKva efaupey TOV TMplova THs Oepuacins elvexa Tod datéov, Kal bare Puxp@ évarroBaT Tew. Bepparvopevos yap TO TIS TepLooou O T™ piov Kal TO ooTéov éxDeppaiven Kal avaknpatvoy KaTaKatel, Kal péCov TOLeL agioracdat TO OoTEéOY TO Tepe ov THY Tpiow i) door ENEL apictacban. Kal yp avtixa Boudn ext pioar TO ™ pos THY faveyya, érre:ta aeneiv TO oaréov, MOAUTWS XP) TVKIVA TE eEarpely TOV mpiova Kal éevaTroBamretv T@ VOaTL TO wx XpP@.
“Hy dé pur) €E apyts AapBarys TO inpa, anda Tap Grou Tapacéyyn vorepitor THs injovos, Tptove xP» NapakT@ * expe pep avtixa TO daTéov Tm pos THY pHvLyya, Gapuve dé efarpebvra TOV mptova oxoreia bar Kal cadhos Kal TH pry mépiE KaTa THY OOOV ToD mplovoss Kal yap TONY Oacaov Oram plera TO daréop, WY vTOoTrUOY TE edV 7169 Kal dudrvov Tpins, Kal TOANAKLS Tuyyavel émiTrohatov éov TO oa Téor, adrws ee Kal ov TAavTN THS Kepaniys a TO TpOpa 7 TuyNaver AeTTOTEpoV éoV 70 oar éov i) TAXUTEPOV. ANG gurdocerbar XP2) @S fn aOns T poo Badav Tov mptova, aX ory OoKel maXa TOV elvan TO OaTéor, €s ToUTO aleL evoTnpitey tov mptova, Pama TKOTOUMEVOS, KaL TreLpacOaLt avaKWéwy TO 6a TéOVv avaBarrew, apehov d€ Ta Nowra int pevew os ay doxh ocupupépery TO Edxer [pos TO yuvdpevoy épéav |.
Kal hv, €& apyis XNaBwv 76 inua, adtixa Bovrn éxtpicas TO daTéov aderely amd THS pvuyyos, 1 «Serra acutiori” Vidius. Cf. Galen’s Lexicon.
2 Pq. omits, but see Kw.’s note.
48
ON WOUNDS IN THE HEAD, xx.
While trephining, you should frequently take out the saw and plunge it into cold water to avoid heating the bone, for the saw gets heated by rotation, and by heating and drying the bone cauterises it and makes more of the bone around the trephined part come away than was going to do. If you want to trephine down to the membrane at once, and then remove the bone, the trephine should in like manner be often taken out and plunged in cold water.}
If you do not take on the cure from the be- ginning, but receive it from another, coming late to the treatment, trephine the bone at once down to the membrane with a sharp-toothed trephine, taking it out frequently for inspection, and also examining with a probe around the track of the saw. For the bone is much more quickly sawn through if you operate when it is already suppurating and full of pus; and the skull is often found to have no depth, especially if the wound happens to be in the part of the head where the bone inclines to be thin rather than thick. You must be careful not to be heedless in placing the trephine, but always to fix it where the bone seems thickest. Examine often, and try by to-and-fro movements to lift up the bone; and, after removing it, treat the rest as may seem beneficial to the lesion [having regard to what has happened].
If you take on the case from the beginning, and want to trephine the bone at once completely and remove it from the membrane, you should likewise
1 As we learn from Celsus, VIII. 3, and Heliodorus in Oribasius XLVI. 11, the trephine was rotated by a bow and cord, not by a handle as in modern times.
49
ITEP] TON EN KE®AAHI TPOQMATON
@TaAVTWS xP” TuKia TE oxoretabat TH undyn THY
meptodov TOU Tplovos, Kal és TO TAXUTATOV aiel 50 Tov oatéouv TOV Tplova, evan pivew, Kal aVvaKLWewv
Bovreo ba aeneiv TO OaTEoV. iv Oe TpuT ave
XPD T™pos THV pnviyya 7) adixvets Pat, my é€&
apxis Aap Paver TO inwa TpuT-as, arn’ erect ey
ToD Oatéou AeTTOV, WaTEP Kal ev TH Wploes 55 yeypamTat.
50
ON WOUNDS IN THE HEAD, xx.
often examine the circular track of the saw with the probe, always fixing the trephine in the thickest part of the bone, and aim at getting it away by to-and-fro movements. If you use a perforating trepan, do not go down to the membrane, if you perforate on taking the case from the be- ginning; but leave a thin layer of bone, as was directed in trephining.
SI
IN’ THE SURGERY
INTRODUCTION
Concerning Things in the Surgery—(repi tov Kar’ intpeiov) is, according to Galen, the full title for works of this kind, which were written by Diocles, Philotimus and Mantias as well as by Hippocrates. Our surviving sample has not only a mutilated heading, but contents which, as Galen admits, might be more accurately called for the most part, Notes on Bandaging. He thinks this incompleteness is perhaps due to its being intended for beginners, but recognises its need of a commentary many times longer than itself! — ak
It is a note book in which many things, gram- matical and didactic, are left to be understood and have been understood diversely by various commen- tators, while some remain unintelligible, requiring, as Galen says, a diviner rather than a commentator. The note book style is combined with a tautology which converts the whole into a curious mixture of brevity and repetition, due perhaps to insertion of comments into the text, or to another cause mentioned below.
On account, probably, of its obscurity the work attracted as much attention in antiquity as did Wounds in the Head. All the chief Hippocratic commentators from Bacchius (early in the third century B.c.) to Galen have dealt with it. Besides a long and careful exposition by Galen, a good deal
1 XVIII(2). 629-632. 54
INTRODUCTION
of the treatise is comprised in the preface to the Galenic work On Bandages, while the whole of the later treatise on that subject ascribed to him is taken from it and the commentary. Almost all ancient authorities considered it “ genuine,” though Galen suggests that it was not intended for publica- tion and may have first been given out by Thessalus, who, according to some, was its author.
In modern times, Littré at first considered it spurious, an analysis or abridgment of some lost work, just as Mochlicon is certainly. abridged from Fractures—Joints, but he afterwards changed his mind for the following reasons:—It has a peculiar con- nection with fractures: Thus a _ statement in Fractures IV on the quantity of bandages is un- intelligible unless we know their length, and this is only given in Surgery XI1; on the other hand “7” used to denote “rather than,” Surgery XIV, seems (as Galen had observed) addressed to persons who knew Fractures XXII, where the context shows that it must have this sense. In Surgery XX, dru (and still more é.w7. read by some) strongly suggests a note which the writer intends to enlarge upon. Littré concludes that Surgery is probably a “ canevas’’ or preliminary sketch for a larger work of the kind which has perished, though part of it survives in our Fractures, and since Surgery X1X almost repeats XV, there may have been two such preliminary outlines which have been imperfectly conflated. We shall notice a similar duplication in Mochlicon.
Littré, however, does not entirely reject the view that Surgery is a later abstract or collection of memoranda from an earlier work; and the philo- logical evidence is strongly on this side,
55
INTRODUCTION
The verb épav is common, in fact reaches its highest frequency, in this treatise. “ Depraved” infinitives with accusative participles posing as second person imperatives also occur, e.g. IV (where the two are combined) XII, XXIV. We naturally look for some connection with the dpay (or middle) division of the books on Epidemics, and find that the beginning of Epid. IV. 45 corresponds verbally with part of Surgery 1 and II. We conclude that the work probably belongs to the second Hippocratic genera- tion, may have been written by Thessalus son of Hippocrates, but can hardly have the same author as the great treatise Fractures—Joints.
Galen! and Palladius? tell us that, according to some, ‘In the Surgery ” was the original title of the combined treatises Fractures—Joints, and this tradition may represent a truth. There was, perhaps, a great work on the surgery of the bones (of which we have fragments), and one or more abridgments of it, or possibly both an abridgment and a collection of memoranda in note-book style. Our Surgery would represent the beginning of the latter, our Mochlicon the end of the former, while the dupli- cations may be due to an imperfect mixture of the two.
There are other curious resemblances between Surgery and Fractures, Thus, Surgery XVI seems condensed from Fractures 1V, but while the writer of the latter says he has only seen over-extension in the case of a child, the epitomist has “ over-extension is harmful except in children.”
1 XVIII(2), 323. * In. Hp. Fract. Preface.
56
INTRODUCTION
Surgery XVIII corresponds to Fractures VI, but it is only by reference to the latter that we can discover that splints are to be applied on the seventh day, and not at the seventh dressing, which is the more natural translation. The writer was, perhaps, relying upon memory, but this appears to be further evidence that Surgery is a later epitome, not a preliminary outline.
57
10
KAT “IHTPEION
1 a8 GpoLa 7 _dvopoua, e& apxis aro TOV peyloTov, ato TaV pyiotor, aT Tay mavTy TAVTWS Yivoa Kopevor, & kal idety Kal Cuyew Kal axovoat eorey a Kal Th dvet Kal TH apy) Kai TH akon Kal TH pit Kal 7H yocon Kal TH yvony eoTw alicQéclat' a, ols yiwwoKoper, aTaciw éoTe yvaovat.
Il. Ta de és Netpoupyiny Kar’ intpetov: 0 ac bevéwr, 0 (Spar, ot varnpera, Ta Sst is TO pas, Orrov, éTws' boa, oiow, Omws,! omrores TO TOLa, TA Appeva* 0 Xpovos, O TpoTros, 0 TOTOS.
III. ‘O Spar, y) Kab nwevos éoTéws, Up HETPOS 7 pos EWUTOV, TPOS TO XeLpLfomevov, pos THY avYyHD.
Avyis pev obv dvo eidea, TO ev KoLVoV, TO 5é TEXVNTOV" TO pev ov Kowvov ouK ep’ Hutv, TO be TexyyTov Kal <<) july. @v ExaTepov diooal Xprnoves, 1) Mpos adyny 1) Um avynv. vm’ adynv ev obv ony TE ) Xphos KaTapavns Te 7) HET PLOTS” Ta O€ Tos av ys ex TOY Tapeovoewy, €x TOV TUULhEepovaéwY avyéwY TPOS THY NapmTrpO- TaTNHV Tpémew TO xerpelopevor, TAHV orga rAabeiv Set a opav aixpov, obTe dé TO jev xerpelopevov évavTlov TH avyn, TOV dé xerpilovra evavtiov TO xerpiCouevw, TANY WOTE f1) €TITKO-
1 ois: ds. But Galen read éxws twice (X VIII(2). 669). 2 5u
IN THE SURGERY
I, [Examination: look for] what is like or unlike the normal, beginning with the most marked signs and those easiest to recognise, open to all kinds of investigation, which can be seen, touched and heard, which are open to all our senses, sight, touch, hear- ing, the nose, the tongue and the understanding, which can be known by all our sources of knowledge.
II. Operative requisitesin the surgery; the patient, the operator, assistants, instruments, the light, where and how placed; their number, which he uses how and when; the (patient’s?) person and the apparatus ; time manner and place.
III. The operator whether seated or standing should be placed conveniently to himself, to the part being operated upon and to the light.
Now, there are two kinds of light, the ordinary and the artificial, and while the ordinary is not in our power the artificial is in our power. Each may be used in two ways, as direct light and as oblique light. Oblique light is rarely used, and the suitable amount? is obvious. With direct light, so far as available and beneficial, turn the part operated upon towards the brightest light—except such parts as should be unexposed and are indecent to look at— thus while the part operated upon faces the light, the surgeon faces the part, but not so as to overshadow
‘ « Part affected,” according. to Galen: XVIII(2). 674. 2 This is the usual meaning of perpidrns. See Fractures V.
pe
20
30
40
KAT’ *IHTPEION
Tate: oUTw yap dv o pev Spav open, TO Oé Xeepelopevov oux Op@TO.
Il pos EwvTor dé, Kabnpwevep pev trodes 5 Thy avo iEw Kar idvd yovvact Ouida tao d€ OXLyov oupBesares. youvata 6é avatépo BovBaverv oLLKpoD, Sidoracww 6é, dry KOVOV Bécet," Kab mapabécer fpatiov eVaTaréws, evKpivéws, tows, Omotws ayKn@ow @MLOLoLv.
IIpos dé xeepelouevor, Tob Mev mporw Kal eyes [peor | 2 kal TOD avw Kal TOD KaTw, Kal évOa H év0a 7) wéoov. Tov pev TpdTw Kal eyyvs Opton, ayKa@vas €s wev TO Tpocev yovvata pn apuetPBeLy, és 6€ TO oma Gev mAeupas: TOD O€ aVw pI) dvaTepo palov dxpas xelpas ExeLY" tov oé Kato, 1) KATWTEPO » Os TO oTHOos emt youvaci EXovTa, xetpas dxpas Exelv eyyovious T pos Bpaxtovas. Ta ev KaTa pécov ovT ws: ta o€ év0a » évOa,
pn &&m THs &dpns, Kara Aoyou b¢ THs emia T pois mpocBarropuevoy TO c@pua, Kal TOU GwpaTos TO épyalopevov.
‘Eote@ta 6€, ideity pév cal én’ audotépwv BeBawta €& icov tev Today ads, dpav Sé TO étTépw émiBeBata, wi TO Kata tiv Spacav yetpa’ trios youvatwy® mpos BovBavas ws év épn" Kal Ta GNX Gpla TA ALTA.
“O 8€ Xetprlouevos TO xerpitovre 7 aAXW TOD THp"ATOS péper i ae 0) EoTews v7) Kabijevos Keipevos, OTws4 av _pyiota 0 bei oXipa EXeov duateAn, pvrddoowy vroppvaw, vroctacu, ék-
1 aykaoow, Gece.
2 Omit Pq. Litt. and codd. : except V. 3 tyos: yourata Kw. tos youvaros Littré. 8 os.
60
IN THE SURGERY, m1.
it. For the operator will in this way get a good view and the part treated not be exposed to view.
As regards himself, when seated his feet should be in a vertical line straight up as regards the knees, and be brought together with a slight interval. Knees a little higher than the groins and the interval between them such as may support and leave room for the elbows. Dress well drawn together, without creases, even and corresponding on elbows and shoulders.
As regards the part operated upon, there is limit for far and near, up and down, to either side and middle. The far and near limit is such that the elbows need not pass in front of the knees or behind the ribs, and for up and down, that the hands are not held above the breasts, or lower than that, when the chest is on the knees, the forearms are kept at right angles to the arms. Suchis the rule as regards the median position but deviation to either side is made by throwing forward the body, or its active part, with a suitable twist, without moving the seat.}
If he stands, he should make the examination with both feet fairly level, but operate with the weight on one foot (not that on the side of the hand in use); height of knees? in the same relation to groins as when seated, and the other limits the same.
Let the patient assist the surgeon with the other (free) part of his body standing, sitting or lying so as to maintain most easily the proper posture, on his guard against slipping, collapse, displacement, pen-
1 According to Galen, the anatomical ‘‘ seat ” or pelvis.
2 The other foot is on some elevated support: see /ractwres VIII. Galen XVIII(2). 7
61
46
10
13
KAT’ “IHTPEION
Tperwpe, Kataytiay, @s 0 bef oatntas Kal oxXnpa Kal eidos ToD yerptCouévou ev mrapéEa, ev yeupt- OU, €v TH ETELTA eE eu.
rv. "Ovuyas [TE UmrepeXelv pre éNXELTrELY
SaxTUhoy Kopupas: 1 és yphow acKetv SaKTUhOLOL pev aKxpolgt, Ta TAEicTA ALKA 7 pos pea ddAn O€ KaTampnvel, aphorépyat 6€ evayTiyaly. SaxTUNwy eupvin peya. TO év péo@ T@V Oak- TUAOD, Kal dmevay lov TOV peyav TO ALXaLO. votoos é, de Hv Kat BrXaTTOVTAL, ToloWw éK ryevens 1) €v tpoph elOictar o péyas TO TOY adiwv Saxtirwv KatéyecOar SHrov. Ta Epya TAVTAa acKelv ExaTEépn Op@VTa, Kal aupotépnow adua—Opotat yap eiow apporepat—oroxa- Copevov ayabas, KANOS, TAXEWS, ATOVwS, EvpU- Ouws, evTropas.
V. "Opyava péev cal bte, cal olws, eipynoetat. Omrov Set pn EuTrodw@v TO Epyw pmnde ExTOd@v TH avatpéoel, Tapa Td épyalouevov dé TOD GwHpaTos €oTw" ad2ros 6€ ty 6160, ETOLmos OA’yY@ TpOTEpoV €OTW, TOLELTW O€, éTav KEAEUNS.
Vi= O1n,0c mepl TOV daevéovra, TO pev XEtpe- Copevov TApEXOVTOV, @s av 6005"? TO 6€ GAO cHpma KATEXOVTOV, @$ Oov aTpELH, TlY@VTES, aKOVOVTES TOD epeaTEMTOS.
VII. ’Emidéoros S00 eidea, eipyacpuévov Kai épyalouevov. épyalopevov pev Taxéws, aTrovas, EVTOPwWS, EUPUO UWS. TAaYewWS peV aVvYELY TA Epya*
1 Kopupis. 2 Soxh.
1 The meaning can only be fully understood after reading Fractures.
62
IN THE SURGERY, 1m.-vu.
dency, so that the position and form of the part treated may be properly preserved during presenta- tion, operation, and the attitude afterwards.1
1V. The nails neither to exceed nor come short of the finger tips. Practise using the finger ends especially with the forefinger opposed to the thumb, with the whole hand held palm downwards, and with both hands opposed, Good formation of fingers : one with wide intervals and with the thumb opposed to the forefinger, but there is obviously a harmful disorder in those who, either congenitally or through nurture, habitually hold down the thumb under the fingers. Practise all the operations, performing them with each hand and with both together—for they are both alike—your object being to attain ability, grace, speed, painlessness, elegance and readiness.
V. As to instruments, the time and manner of their use will be discussed. Their proper position is such as neither to be in the way of the operation nor to be out of the way when wanted ; their place is by the operator’s hand,” but if an assistant gives them, let him be ready a little beforehand, and act when you bid him,
VI. Let those who look after the patient present the part for operation as you want it, and hold fast the rest of the body so as to be all steady, keeping silence and obeying their superior.
VII. Of bandaging there are two aspects, com- pleted and in process of application. As regards application, speedily, painlessly, with resource and neatness, Speedily to bring the operation to an end,
* This seems to refer to the surgeon, as above, not to the part operated on (7d xeipiCduevor),
63
10
12
10
14
KAT’ ‘IHTPEION
3 Ud x € «Qs a > iy Ns, ed a atrovas € pnidiws dpav: evtopws} 6é, és wav ETOL LOS" evpvO wars dé opha ae noéwst ad wv d€ TavTa acKknpatov elpnta. elpryao mevov be ayabas, Karas karas bev aT AOS evapivews: i) dpowa Kal ica, tows Kai Opolws: 7 dvica Kal avomowa avicws Kal cVO[0lwsS. Ta fev eldea am ovv [eveveror] = oxeTapvoy, oLLOV, opParpos, Kal popBos Kal Huitopov dppolov TO eldos TO elder Kal TO TAOEL TOU érrLOeomevou.
VII. ‘Ayadas é évo eldea TOU émbeopevour laxvos bev ” meet, i) TAO Et adovier. TO pep ovy aurn a) emideats i ira, TO 6é Totow bo pevoroey UTNPETEL. €S LEY OVY TAUTA VOMOS: ev O€ TOUTOLCL péyvata emudéatos: mieEls ev MOTE TA em inet eva. Ta) apertavar, pence épnpetcOar [xdpra],? GX’ Hppoa ar pe, mpoonvayxacat 6é Ln, Ho cov pev Ta éxxata, Hevora dé Ta péoa. appa Kal pappa vEeLomevov fun) KATO, aX avo, ev tapéEer Kai oxéoe Kal émrLdéoes Kal meee. apxas Barreobas a) éml TO EXKOS, aX’ evOa TO appa. TO O€ a dupa pare év TpiBe pajre év epy@, pune exeiae Orrov évedr, @S pn €s TO éveov KeloeTa.* dupa 5é Kal pappa parOaxov, wn méya.
1 cimopin . . . evpubutn.
2 etkukAoy or &yxuxAoy was inserted as explanation of amd odv by Artemidorus and Dioscorides. Cf. Galen, X VIII(2). in ‘Added by Littré from Galen de Fase.
4 Kw.’s reading of this obscure passage.
1 So Galen.
2 As Galen remarks, there is no ‘‘second” unless we take it to include all other good qualities ; some apply it to the two objects of bandaging.
3 A puzzle to commentators as contrasted with later directions, cf. XII.
64
IN THE SURGERY, vu.—vim.
painlessly to do it with ease, with resource ready for anything, with neatness that it may be pleasant to look at. Exercises for attaining these ends have been mentioned. Completed bandaging should be well and neatly done. Neatly means smoothly, well distributed,1 evenly and alike where the parts are even and similar, unevenly and unlike where they are unlike and uneven. As to kinds, simple (circular), oblique (adze like), very oblique (reversed ri); the eye, the rhomb, the half rhomb, (use) the form suited to the shape and the affection of the part bandaged.
VIII. “ Well” has two aspects when applied to the part bandaged: first? firmness got either by tension or by the number of bandages. Now, the bandaging may either cure by itself or assist the curative agents. There is a rule for this and it includes the most important elements of bandaging. Pressure so that the applications neither fall away nor are very tight, fitting to the part without forcible compression, less at the ends and least in the middle. Knot and thread suture carried upwards and not downwards in presentation, attitude, bandaging and compression.* The ends (for tying) to be put, not over the wound, but where the knot is to be. The knot where there is neither friction nor motion, and not where it will be useless, lest its purpose be not served.® Knot and suture soft and not large.
* tec ‘‘ fixation” is what we should expect, but the whole is obscure.
® A much discussed passage. Perhaps means not close to the edge of the dressing lest it slip off. Heliodorus (Orid. XLVIII. 70) and Galen seem to ignore the last six words, but both say that évedy=xevedy ‘ useless.” Canit be a pun, ‘‘not
where there is a void lest it be void of use”? As Galen says, we should expect ‘‘ not over a hollow ” such as the armpit.
65
VOL, IIL, D
10
20
27
KAT’ IHTPEION
IX. Ed ye pry éots yvovar bre és Ta KaTavTH \ ’ , 4 la) ’ ie e an kal amroén devyer Tas émidecpos, olov Keparis \ \ ” / \ \ / ’ na \ fev TO ava, KYHnuns 5€ TO KaTw. émdety deka a , > \ \ ortho tact , \ a ém aptotepa, apiotepa Oé ert SeEra, TAM THS fol he ’ v \ be € / 1 Kepargys, TauvTnv Kat iki. Ta o€ vTevaytia > \ 6 / > / x Oe ? \ an 94? € / 2 amo dvo apXéwy* iv 6€ ato mins, éb [exatepa] étrep Opotov és TO pLovipmov, olov TO mécov THS fo xX o& 7 a \ \ / Keparns, 7) 6 TL ANNO ToLOUTOV. Ta Sé KLVEvpEVa, olov apOpa, 6mn péey auykKauTTeTal, WS HKLoTA \ ’ / , 2 5) , me Kab EvoTAAETTATA TEPLAaNNELY, OLoV iyvUNY: brn / lal dé mepiTeiveTal, ATA TE Kal TAAaTEA, Olov pUAN: mpootepiBarrew S€ KaTady\Los pev TOY Trept TadTa elvexa, avadrnwios 5€ ToD cUmTaYTOS émt- déopou, €v Toto aTpE“éovel Kal AaTapwTépotct TOU gwp-LaTOS, olov TO avw Kal TO KdTwW TOD € a / by \ youvatos' omoroyet Oé€, wou pev » mepl tHv éTépny pacxarnv treptBory, BouBwvos Sé } Trepi Tov ETEpov KEvewva, Kal KYHUNS nH UTEP yaoTpo- / € / / KUnpmins. oTocoLoe ev ava 7 puyy, KdTwOeEv 7 ’ / pi 4 > , 47 \ \ avtirnis, olat dé KaTw, TovvavTiov: olat Oé jn) a“ rn e got, olov KEeporAn, TOUT@Y EV TO OMawTAT@ \ / a Ge a a Tas KaTadmpias Trovetobat, Kal NKioTa N0E@® TO emridéopo Ypiolat, @s TO movimwTtatoy LataTov e mepiBrHOev TA TAAVwWOETTATA KATEXN. OTTOTOLCL 5€ Tolcw dOoviotct wn evKaTAaAnTTO@S, NOE Ev- avarynTTws exer, Padupact TAS avadsy Las TroL- na an A lol elaOa éx KataBorgNs 7 cuppadis. 1 rd Kad” Exarepoy pépos duolws diaxelueva.—Galen. 2 Most MSS. omit. 66
IN THE SURGERY, ix.
IX. It is well to bear in mind that every bandage slips towards the pendent and conical parts, such as the top of the head and the bottom of the leg. Bandage parts on the right side towards the left, and those on the left to the right, except the head; do this vertically.t_ Parts with opposite sides alike 2 require a two-headed bandage, but if you bandage from one end, extend it each way so that it may have a similar relation to the fixed part, such as the middle of the head or the like. As to mobile parts, such as joints, where there is flexion the turns should be as few and as contracted as possible, as with the back of the knee, but where the part is extended, like the knee cap, spread out and broad. Make additional turns both to hold fast applications in these parts, and to support the dressing in the fixed and flatter parts of the body, such as those above and below the knee. In case of the shoulder, a turn round the opposite armpit is suitable, for the groin, one round the opposite flank, and for the leg, the part above the calf. In cases where the tend- ency is to slip up, the support is from below, when down the reverse. Where this is impossible, as on the head, make the hold-fasts on the smoothest part, and avoid obliquity as far as you can, so that the outermost and firmest turn may hold down the most mobile ones. Where it is not easy to get either good fixation or support with the bandages, make supports with threaded sutures in loops 3 or continuous suture,
' “From vertex to chin.” Galen.
2 Galen’s paraphrase.
* Apparently our interrupted sutures, with long ends to tie. ‘Stitching with ligatures.” Adams,
67
10
KAT ‘IHTPEION
a a
X. ’Emidécpata Kxabapd, xodfda, padOaka, NeTd. EXiccev appotépnow apa, cal éxatépn Ywpls aoKEetv. TH TpeTovon O€ és Ta TAATN Kal Ta TAYN TOV wopimv* TexpaLpomevoy yphaOat. cy / \ roe / > 7 n €ALELos xeparat oKAmpat, OMAaNAL, EVKPLVEES. ‘Ta bé 67) peddovTa arom im rely [xara]? TAXEWS aT OT ET OVTOY” ; Ta dé ws pnte TiéEew pute aro- TimTel TA eLpnueva.
XI. *Ov dé éyetar 7) émidecis 7) brddecrs 7} appotepa UTOdETLS eV aiTin WaTE 1) AbecTeaTa MpoaTetNal, 1 exTEeTTAMEVvAa TUaTEAAL, 7) TUVE- oTadpéva dracteinat, 1) dueatpampeva SiopOacat, 3 , \ n , ) TaVAaVTLA. TAapacKern O€ aovia Kova, hewTa, uanbakd, cabapa, TraTEG, pen éXovTa ouppapas, pn? éfdo reas, cal Uyla WaTE Tdvuow hépey Kal oniry Kperow, pny Enpad, arn eyxvpa xuee o exaorTa curt popa. aperreata pee © WOTe TA peTewmpa us epns waver pév, mréSew Oe pon* dpxecbar® dé eK TOU vytéos, TedeuTav 6é _Tpos TO EAKOS, @OTE TO pev UrEdv efaderynras, Erepov dé puny) EmritvdAdrEyNTaL ETLdeiy TA pev OpOAa és b 4 BN \ \ / b) / > / oplor, Ta O€ roEa AoEws, ev TXMATL aTrove, év © pnte atrooguyéis pte amoctacts éoTat
7h GAD / A > ’ id [rus]? €& ob OTav petadrAUdcon, 1) és avadrynyw nx > Gé \ / ’ > iva Hn €s Oéow.v, pn petadrAadEovcw, arr Opmota
a 8 v4 4 / fal > / e tavta® 飀ovot pves, pr€Bes, vevpa, ootéa [7
1 68oviwv.
2 grdnpat puzzled Galen. Ermerins inserts a negative, uh. The edges of a bandage should not be hard.
3 xariw Kw. codd. xadés Erm. Pq.
4 A much discussed passage. G. says amomecdytav is a
solecism, either as imperative or participle. 5 Add mpooretAa.
68
IN THE SURGERY, x.—x1.
X. Bandages, clean, light, soft, thin. Practise the rolling with both hands at once, and with each separately. Use one of suitable size, estimating by the thickness and breadth of the parts. Edges of the roll firm, not frayed, without creases. When things are really going to fall off, it is well that they do so quickly (7). Modes of bandaging such as neither compress nor fall off are those mentioned.
XI, What bandaging, whether upper or under or both, aims at. The function of an under bandage is to bring together what is separated, reduce everted wounds, separate what is adherent, adjust what is distorted, or the reverse. Apparatus. Linen bandages light, thin, soft, clean, broad, without sutures or projections, sound so as to bear the tension required, and a little stronger; not dry, but soaked in a liquid suited to each case. Close a sinus? so that the upper parts touch the base without pressing on it, begin bandaging from the sound part and end at the open wound, so that while the contents are pressed out no more is accumulated. Bandage vertical ones in a vertical direction and the oblique obliquely, in a position causing no pain, without either compression or laxity, so that when the change is made to a sling or fixation the muscles, vessels, ligaments and bones will retain their normal
1 G. refers this to. bad bandaging.
2 A sinus is a superficial abscess which has opened and continues to discharge.
3G. refers this to the sinus, not to affected parts generally.
® ipxda Galen Kw. 7 Omit Galen Vulg. Kw. 8 6uodrara Kw.
69
20
30
10
KAT’ ‘THTPEION
udduora evOeTa Kal evoxera].! dvarehapbar ® b€ 9) Keto bar év oXNMATL aTrove 7 Kara puvow- ov SS a av [un] amoaTh, TavavTias ay bé exTre- TTau“eva TvaTELAAL, Ta pev adra Ta aura, eK TONNOU 6€ TWos Et THD ouvayoryy, Kal ék Tpoa- ayoyhs THD mleELy, TO 7 p@TOV Kwara, émerta em paXddXor, Gptov TOD padioTa TO oupyavery. av 6é TVET TAN[LEVAL Siac reidan, ouv pev prey- Movi}, TavavTia. davev Oé TAUTNS, TAPATKEUH [Mev TH avTn, émdéoet dé evayTin. Sue Tpaypeva be SiopIdcar, TA pev adra kata tavta: bel dé Ta pev atednruvOoTa éerayew [ta dé émedrndrAvOoTa amayety |,* emrOéoel, TapaKorAyoel, avarner, [Oéoe]:* Ta dé évavtia, évartiws.
XII. [Katijypacr 5€] orAnvav unxea, wraTEAa, maxed, Trea. bAKoS Gon 7 émiéeois: TRATOS, TpLov 7 Weis daxTvAwy? Tdyos, TPLUTTVXOUS o7 TETPATTUXOUS”” Ti00s, KuKevvTas pn UTEp- Barrew, pndé éANetTreLy” oloe 6é és StopIwow, pNKOS KUKEDVTA® TAX 0S Kat TAATOS TH evdely Texpatper Oar, un AOpoa TANpOdDVTA.
Tov é obovier vmrobeo pides eial dvo: T TPOTH €K ToD oiveos és TO advo TehevT@Ty:® T dé deutépyn €x Tod aiveos és TO KATH, ex TOD KATW
DW
1 Read by Galen; not in the codd. 2 avaredaupbat. 3 uh Kw. ; suggested by Galen’s predecessors, - Omit BV. 5 rpimtuxa TeTpawTUXA. 6 7... TeAevtaoa Erm. Reinhold. Pq. suggests reAev- Tao, as Ald.
1 Restored from Galen’s Commentary. 2G. gives three other interpretations, without the negative.
7O
IN THE SURGERY, xi—xi.
positions [in which they are best put up and sup- ported]. Let the part be slung or put up in a natural comfortable position, Where there is no open sinus the reverse.2, Where there is a gaping wound bring the parts together just as in other cases, but start the joining up at a good distance ; and graduate the pressure, first very little, then increasing, the extreme limit being contact of the parts. In separating what is adherent, if there is inflammation the reverse holds good,’ if not use the same apparatus, but bandage in the opposite way. To adjust what is distorted act generally on the same principles ; what is turned out must be brought in [and what is turned in brought out] by bandag- ing, agglutination,* suspension, setting—the reverse reversely.
XII. In fractures, the length, breadth, thickness and number of compresses. Length to correspond with the bandaging, breadth, three or four fingers, thickness, folded thrice or four times. Number, sufficient to go round without overlapping or vacancy: when required to adjust the shape,® long enough to go round, estimating breadth and thickness by the deficiency, but not filling it up with one compress,
Of the linen bandages, the under ones ® are two in number. Start with the first from the lesion and end upwards, but carry the second downwards from
3 7.e. avoid bandaging as far as possible ; Galen.
4 Refers to turned in eyelashes.
5 7.e. in conical or irregular parts: not ‘‘deformity” es Adams,
6 This Hippocratic division of under and upper bandages did not survive. brodeculdes remains a peculiar Hippocratic word for bandages below the pads or compresses, XVIII(2). 785 Galen.
71
20
30 31
KAT’ *IHTPEION
és TO dvw TeXEUTOON TA KATA TO civos Tete fardioTa, KicTa Ta axpa, Ta S€ AAA KaTa Aoyov. 17 O€ émidects TOAD TOD Uytéos Tpoc- AapBavéeto.
*’Emidéo pov 6€ TAHO0s, unKos, WAAaTOS’ TAHOOS ev py nooadcOat tod aiveos, pydé vapOnéwv évéperowv eivat, poe axyOos, pndé Tepippeyrur,
unde exBriRuvow" pijKos be Kal TATOS, TPLOV 7) Tecoupwv 1 TévTE 1) EE THXEwY bev pHKOS, OaK- TUAWY O€ TAATOS. Kal Tapa’pynuaTos TeptBoral TOTAUTAL WaTE a) muelew" parbane 5é, un) max ea" TAUTA TAVTA WS ET pIKEL KAL TAATEL Kal AXEL Tov tadovTos.
NdpOnxes dé evor, omanol, oLpot Kat apa, opLeK pp iis évOev kab evOev THS émidéavos, TAXUTATOL é€ q eEnpetre TO KaTHYypHa. Omroaa &é kupTa Kal doapxa duce, puraccdpevoy TeV UmEepeXOvT@Y, | olov Ta Kata SaxTvAovs 7) odupa, ) 7H Oéce i) 7h Bpaxvtnt. Tapatpypace bé appotewv, Kn mete: TO 7 pat ov KnpoThH parGanh Kal AEin Kat KaOapy éEdocéTO.
XILI. “datos Oeppotns, wAHOGos: Oeppwotns mev KaTa THS EwvTOD Yelpos Katayelv, mANOos Sé Yardoar péev Kal ioxvivat TO TAElaTOV apLaToOD, TapKaaar € Kal amranrdva TO péT plop: pETpov é€ TIS KATAXUGLOS, ETL perewprtomevov det, mplv oUpTiTTE, mavecOa' TO pev yap Tmp@Tov aetpeTar, errerta O€ loxvaiverar.
XIV. Oéous 5é barbaxn, OMAN, dv dpporos toiat é&éyovo. Tod o@aTos, oloy mTépyn Kal
1 Or ‘‘where the fracture occurred.”
72
IN THE SURGERY, xu.—x1v.
the lesion, bringing it up again to end at the top. Make most pressure over the lesion and least at the ends, the rest in proportion. Let the bandaging include a good deal of the sound part.
Amount, length and breadth of the bandages. Amount suflicient to deal with the lesion, without either pressing in the splints, or being burdensome, or slipping round, or causing weakness. As to length and breadth, three, four, five or six cubits for length, fingers for breadth. The supporting bands in such a number of coils as not to compress, soft and not thick. All these suited to the length, breadth and thickness of the part affected.
Splints, smooth, even, tapering at the ends, a little shorter in each direction than the bandaging ; thickest over the prominence at the fracture ;+ avoid- ing either by position or shortening the convexities naturally uncovered by flesh, such as on the fingers and ankles. Fit them on by supporting bands with- out pressure. Let the first dressing be made with bandages rolled in soft, smooth and clean cerate.?
XIII. Of water (one must consider) temperature, quantity. ‘Temperature by pouring it over one’s own hand. Quantity, for relaxation and attenuation the more the better, but for flesh forming and softening observe moderation, and for moderate douching one should stop while the part is still swollen up before it collapses, for first it swells and then becomes attenuated.
XIV. Permanent position: soft, smooth, sloping up for projecting parts as with the heel or hip, so
* So Galen, for cerate see Introduction, Pq. ‘‘ before bandaging anoint the skin with.”
73
10
15
oc
KAT’ ‘THTPEION
ioxio, @S MATE avakdatat [unre amoKxNaras) ° pate extpémntat,2 cwrgjva Tavtl ™@ oKéhet i) nutcer> és TO TaGos bé BAréTELY Kal Ta GAA oxoca Branre dhra.8
XV. Ildpefis yap,4 cai S:atacis, Kal ava- Tracts, Kal TA dAXa KaTa pvow. vats Sé ev pev épyous, Tov épyouv TH mpynker, 6 BovreTat Texuaptéov: és O€ TavTa, x Tov édLYVOVTOS, eK TOU KoLVOU, éx TOD eOEos: ex pev TOV édALYVOYTOS Kal dperpevov TAS i@veptas oxerreo Gat, olov TO Tis YELpos® éx d€ TOU Kowon, ExTALY, ouyKaprpw, otov TO eyyus TOU éyyevtou TayXEos pos Bpa- ylova: €x Tov €Geos, OTL OvUK ara oxnara hépey Suvvatwtepa. olov oKédlea ExTaciv: ato TOUTwWY yap pHicta TrEloTOV YpovOY EXoL AV [1 petadArAdooovta. év 5é TH peTadrrAayn éx Sia- TaoLOS Omototata éxXovow ® és &Ew % Oéow pves, préBes, vedpa, ootéa, 7 pddtoTa evleTa Kai evo YeTa.
XVI. Avaraous, padtota Ta héyvora Kal Ta- XLoTA, kal Omrov app orepa (devTepa, @V TO UTro- TETAYMEVOV, HKLoTA WY TO AV" padXov 6é Tou peTptov BraBn, TAHNY Tadior: exew avavTn Oo [LbK pov: SopAwavos mapaderypa, TO OM@VULOV, TO omotuyov, TO Gpotov, TO vyLEs.
1 Galen omits.
2 extpémerat vulg Galen; éxtp!Bnra Py. The things to be feared are distortion or abrasion which would be é«tpiBnrat ; amokAatrat, which implies fracture, seems hardly possible.
nuloec—Galen says } is negative (avr? amopdcews) as in Iliad 1. 117, but we discover this only by reference to Fractures XXII,
3 §nrAadh. 4 3é.
74
IN THE SURGERY, x1v.-xv1.
as neither to be bent back [bent aside? broken off ?] or distorted. Apply a hollow splint to the whole leg rather than to half. Consider the affection and also the obvious disadvantages (of this splint).
XV. Presentation, extension, setting, and the rest, according to nature. Now nature shows itself in actions, and one must judge what nature wants+ by the performance of action: for the above matters (judge) from the state of rest, from what is normal, from the customary. From rest and relaxation esti- mate proper direction, for example as regards the arm: from what is normal judge extension and flexion, such as the nearly rectangular relation of the fore- arm to the arm; from habit infer the posture more easy to maintain than any other, such as extension in the case of the legs; for one would most easily keep such postures for the longest time without changing, and in the change after | surgical] extension the muscles, vessels, tendons and bones have the most similar relations as to habit and posture, and are thus most conveniently put up or slung.
XVI. Extension, most when the largest and thickest and when both bones [of the arm] are broken. Next in cases where it is the underneath one [ulna], least where it is the upper. Excessive tension does damage except in children.2. Keep the limb a little raised. As model for adjustment take
the homonymous,’ corresponding, similar, sound limb.
1 Littré-Adams ‘‘ what we want.”
* Because their tendons are more elastic, G. ; but it may be a confused reference to the case in Fract. IV.
3 G. says it should be ‘‘ synonymous.”
5 duoidrara €xovow Kw. Spora tavra etovor Pq., as in XI. # 1+»
75
KAT’ "IHTPEION
XVII. ‘Avdrpupes dvvatat ADoat, dfjoae, oap- KOoaL, purvd joa ” oKdnpn dijoau }) parann 3 AVoaL’ 7 TON puvvdijoas: 9 m pet pin stillet XVIII. ’Exidety 5é 70 mparov" 0 emrdedeMevos pddora pata ene yOED Kara TO oivoS' HKLoTAa Ta dK pa: npHoobar” dé, pn mem vex au: TrOer, pen Loyve’ TID dé 7) pépny TavTnY Kal VUKTA, oriryep padXov, THhv be vaTEpny, no oov" Tpit, yahapa. evpeOntw Oé Th jeev Datepatn ev akpotow oldnua parOakov. TH Tpitn Sé TO émideOev AvOE, LOXVOTEPOY, Tapa Tacas Tas émLdéoLas TOdTO. TH O€ VaTEpalyn ETLOEGEL, HY SiKAalwS éTrLdEdEeMEVOV 10 davyn, pabeiv dei évredOev Sé wadXov Kal él TAr€oat TiexyOntw: TH dé Tpityn éml padAdov Kal éml mAéoov. tH O€ EBdopn amo THS Tporns émidéotos AVOgVTA EevpeOnTw laxvd, Xarapa Ta dared. és be vapOnkas dedevra, ay loxva Kal aKvno pa Kal avédnea Db éav eX pes eLKOTLY 1 [e- péwv amo TOU aiveos: Hv O€ TL UTOTTEUNTAL, ADTAL 17 €v TO péow: vapOnxas dia TpiTys épetdeuv. XIX. “H avaryn es, 7 Oéors, 7 éridects, ws év TO AUTO TX pate SiahvrAdooew. Kepadava cyn- patov, EJea, dvotes ExdoToV TOV pedéwv: Ta O€ elOea, Ex TOU TPEXELV, OdOLTOpPEELY, ETTAaVaL, KATA- 5 xetaOat, x Tod Epyou, x Tov apetoOat. XX. "Ore? ypiows xpatovver, apyin O€ THKEL. XXI. ‘A mie&is 7wAnVe, wn? ioxe. 1 jpudo@at. 7d dé, drt; Kw. 3 4.
1 Cf. Fract. VI. 2 i.e. on alternate days, 3 G. considers XIX. a marginal note to XV. 4 Cf. Joints LVIII.
76
IN THE SURGERY, xvu.—xx1.
XVII. Friction can produce relaxation, constric- tion, increase of flesh, attenuation. Hard friction constricts, soft relaxes: if long continued it attenuates, when moderate it increases flesh.
XVIII. As to the first bandaging: the patient should say there is pressure chiefly over the injury, least at the ends: that the dressing fits firmly but without compression: pressure should be got by amount of bandaging not by tension. During this day and night pressure should increase a little, but be less during the next day, and lax on the third. A soft swelling should be found on the second day at the extremities. On the third the part when unbandaged should be less swollen, and so with every dressing. At the second dressing one must find out whether it seems properly done, and then use more bandages and greater pressure; at the third still more with more coils of bandage. On the seventh day! after the first dressing the parts when set free should be found without swelling and the bones mobile. When put up in splints, if the parts are not swollen and are free from itching or wound, leave alone till twenty days after the injury ; but if there is any suspicion remove in the interval, Make the splints firm every third day.
XIX. In suspension, putting up, bandaging, take care that the part keeps the same attitude, the general principle being the habitual natural position of each limb. The kinds of attitude are derived from running, walking, standing, lying, work, relaxation.
XX. (Remember) that use strengthens, disuse debilitates.4
XXI. The pressure by quantity (of bandages) not by force.
77
10
12
10
KAT *IHTPEION
XXII. Oroca bé exXupopara, ) prdopata, 7) omaopata, 2 oldnuata apheypavra, éFapverae aima é éx TOD TP@MaTOS, €s ev TO avw Tob Toa Tos TO mheiotop, Bpaxv 6é Te Kal és TO KATO:
1) KaTaven THY YElpa ExovTa ” TO oKENOS TLOé- fevov THY apxny Kara TO TpOpa Kal pddiora, €pelOovTa, KioTa TA aKkpa, Méows TA Sta péaov.
\ \ v fal TO ETYATOV TPOS TO dVW TOD THLATOS VE“omEvor: >? / , ” \ n , n émoéoel, TLeEEL’ ATap Kal TAUTA TANOEL WaNXAOV ) taxvt. pardota dé TovToLoL odovta, Newra, Kova, parlaxa, cadapa, TAarTéa, vyla, ws av avev vapOnkwr Kal Kataxvoet xphio Gat TAEOVL.
XX eT ayoe EXT TOMATO, a OT pPeLpbaTa, n
x Stactimata, i) aTooTdop“aTa, 1) ATOKNaT MATA, 4) dtaotpéupata, ola Ta KUAAd, TA ETEpoppoTa, d0ev! wey é&éotn, acvuvdidovta, Orn 5é, cuvTeEi- vovTa, WS €> Tavavtia pémn, émideOévta % mpl eTudeO vat, TuLKp@ “aAAov } WaTe €E ioou elvat:
\ { i ? ie ee e a lal / \ Kal Tolow émidéapolcl, Kal TOoloL omANVEGL, Kal TOloLY avaAnMMATL, Kal TOloL OXHMACL, KaTA- Tdoel, avatpier, dtopbwcer, [TavTa Kal]? Kata- yvoet TAEOML.
XXIV. Ta 6€ puvvOjnwata, Toru tTpocdAap- Bavovta Tov wytéos, émideiy ws av €& éridpomns
\ f / XN > \ 3 > Wal > /, an TA CUVTAKEVTA TAEOV 1) AUTA ® EwtvUOEL, AOL TH > 66 / ’ / 4.) \ ” emLoéoet TapadrAakarta, exkrIveL 4 €s THY avVENnoW Kal THY avaTAaClW TOV GapKOY TrolnonTat. Bértiov 6€ Kal Ta advwbev, olov KYnuns Kal Tov bnpor, Kal TO Erepov aKéXOS TO UYLEt® TuvETLOELD,
is
1 2 dev. 2 Omit Galen. Kw. 3 gitduata.
4 excAlyy. 5 rd byes.
1 Includes club foot, knock knee, bandy leg.
78
IN THE SURGERY, xxi1.—xxiv.
XXII. In case of bruisings, crushings, ruptures of muscles or swellings without inflammation, blood is expressed from the injured part [by bandaging] mostly upwards, but some little downwards. This is done (with neither arm nor leg in a pendent position) by beginning the bandage at the wound and making most pressure there, least at the ends and moderate in between; the final turns being brought upwards. By bandaging, by compression— but here, too, pressure must ‘be “got by quantity of bandage rather than by force. In these cases especially, the linen bandages should be thin, light, sott, clean, broad and sound, as one would use without splints ; use also copious douching.
XXIII. [ Bandaging as regards] dislocations, sprains, separations, avulsions, fractures near joints or dis- tortions, such as deformities to either side:! yield- ing on the side from which it deviates, bracing up on the side towards which it deviates, so that when it is put up, or before it is put up, it is not straight but has a slight inclination the opposite way. The treatment includes use of bandages, com- presses. suspension, postures, extension, friction, adjustment; and in addition copious douching,
XXIV. {Bandaging as regards] atrophied parts : Apply the bandage, taking in a good deal of the sound parts in a way that the wasted tissues may gain more by afflux than they lose spontaneously ; by changing to a different mode of bandaging? it may divert (the tissues) towards growth and bring about flesh formation. It is a rather good plan to bandage the upper parts also, such as the top of the leg and the thigh, also the sound leg that it may be
* From that described in XXII. A very obscure passage.
79
10
12
10
17
KAT’ *IHTPEION
@S OpoLoTepov 9 Kal omolas édwin, Kal opoiws THS Tpopijs aToKXEinTaL Kal déxnTar. oOoviwv mAnOEL, 7) mekeu" avievTa (Tm p@Tov TO padara deopevon, Kal avarpiret YVpwmEevov capKovan Kal KaTayvoes’ avev vapOikov.
XXV. Ta dé éppdcpata Kal atootnpiypata, olov o770et, mAEUPH/ ot, xepant, Kal ToloWw addou- ow, boa Toabra: Ta pev opuypav évexer, Os Ty évoeintar Ta dé xal TOV b1agractoy TOD KaTa Tas appovias év Toict [7a] Kata TIV ceparny oaTéwy } epeta maT ov vapw emi Te Bnxev 7) TTAPLOY, i) cds KLVITLOS, oiov® KaTa Gopnea Kal Keparny arroaTnpiyara ylyveran. TOUT@Y amavrav at avrat Tupper plat THS €mt0é- alos: 4 ev yap Ta oN pariora mem vex Pau umoTiOévat ody [elpcov]* parOakov dppolov TO made é7rLoetv 6€ ra) paddov mielevrTa 7) dare Tovs oduypous 1 évociew, poe pad dov 7) @OTE TOV Svea TNKOT OV Ta éoxata TOV appoviey oUp- rave aAnAwD, bende TAS Bnxas Kal Tous TTAPMLOVS WOTE KWAVELY, GAN OOTE ATrOTTIpLYLA elvat ws pte OtavayKalyntat, pte evoeintat.
1 607€o1s Omit Tav. 2 ola Ta.
® Littré and Pq. omit and add 1 after padrdandy.
80
IN THE SURGERY, xxiv.—xxv.
in a like state, and share alike in rest and the de- privation or reception of nutriment. Use plenty of bandages, not compression; relaxing first where it is most needed, using friction of the flesh-forming kind and douching-—-no splints.
XXV. Supports attached or separate,! such as those for chest, ribs, head and other such parts; sometimes used because of pulsations? that the part may not be shaken; at other times, in cases of separation of the commissures in the bones of the head, as supports: also in case of coughings, sneez- ings and other movements they serve as separate supports (cushions?) for the chest and head. The suitable modes of bandaging in all these cases are the same, for where the lesion is there should be the chief pressure. Put something 3 soft underneath suited to the affection. Donot make the bandaging tighter than suffices to prevent the pulsations from shaking the part, or than is necessary to bring the edges of the separated commissures into touch with one another; nor is it intended to prevent coughings and sneezings,4 but to act as a support for the avoidance both of forcible separation and shaking.
* So Galen, who says the words are usually synonymous.
* Includes everything from twitchings to respiratory move- ments. G.
8 Reading waddandy th.
* The text seems corrupt, but it can hardly mean ‘‘so tight as to prevent sneezing”!
81
ayn Hea apap ro-gaidlouo
sa Bedi aliog 2 Kir de
5 ine MSS eet Berra Malicts ‘aba Ria ited 8: Headend Toate : Srmtbue en aepsaige yealie AcoRaTenONT qaldow f t ofS raters! vine -4 dostovodagh Cj ag te | Sielpotmn: smart i Bhs waigakantl ro, of sh whirnada: aeselt.ai oid ald; o% pulesqre bins fine Fasidianwady yy Bainabyend.. atlt sola dos afk ph Fret ty aaniiaalncp, othe nays Gs ot. zopis A iP i i ae mig. GS Kap AIBOR, al ainld a ee ae diy rigve} tek eretree dirtetiO9 “batt fe 42, pet Yo" care
apa ie deovorg of babigdiit $3 if sot S386 oe ‘a ey. i Tot Jaocgysie B Se ze os" rd Bhissare 5 “ahidede bis ott: 38 pitiisrat Ve User erate i
Ss te cc {hi frre. Sony aon ys eiies ein ehirow ald aye ody sole -6VG8T ss shypaar od eg urtes sé G07 Lasik ocabareae u ¥ bane halk Ay mit viet odd. we eyer sad ap «hurt Aouey “ynthg oa" “? Rat wee ited df rc dent 709 srtsoe dzed gat “guuisoaiia ee, ot BB a trgis
7.)
18
FRACTURES, JOINTS, MOCHLICON
INTRODUCTION
Tere is no question as to the relationship of these three treatises. Fractures and Joints probably once formed a single work, and are certainly by the same author,! while Mochlicon is composed of an ab- breviation of those parts of them which treat of dis- locations. In antiquity no one doubted that Fractures and Joimts were by the great Hippocrates, except a few who attributed them to another man of the same name, his grandfather, the son of Gnosidicus,? Galen, in all his lists, classes them first, or nearly first, among the yvyo.wrara ? or “ most genuine” works. Of the two things we know for certain about the teach- ing of Hippocrates, Plato’s statement that he held it impossible to understand the body without studying nature as a whole has proved too vague to be attached to any particular treatise, but the condemnation by his kinsman Ctesias of his reduction of the hip- joint (unless it refers to verbal teaching or to some work which has vanished) must apply, as Galen says,* to Joints, where the subject is treated in detail.
1 This seems sufficiently proved by the fact that references are made from Joints to Fractures in exactly the same terms as to the earlier parts of Joints: e.g. J LX VII, LXXII, as kal mpdaOev elpnra. elpnta [etonka B. Apoll.] kat mpdodev, which refer to F XXXI and XIII respectively. Reference to another treatise is put differently: eg. év Erépw Adyw J XLV.
2 Galen, XV. 456. * XVII(1).577. ‘ XVIII(1). 731.
84
INTRODUCTION
The work was known to, and in part paraphrased by, Diocles,! who was probably adult before Hippo- crates died, and there is no record that he doubted its authorship. We may therefore, perhaps, con- clude that nothing in the Corpus has a better claim to be by Hippocrates himself than Fraclures—Joints, and proceed to discuss them in some detail.
The question asked in antiquity was: Why does Fractures contain a good deal about dislocations (joints) while Joints has some sections on fractures ? To which Galen replies that Hippocrates cared less for words than for things, and fractures and dislocations often come together. This answer is not quite satisfactory, for the weak point of the work is precisely the absence of any clear account of fracture-dislocations: besides, it seems probable to most careful readers that the result is mainly due to a work on fractures and dislocations having been broken up and put together again in disorder.
We may perhaps indicate this most clearly and briefly by taking Mochlicon, in which a natural order is preserved, as our guide, showing at the same time its relationship to the older treatise, or treatises. The order of Mochlicon is face, upper and lower limbs from above downwards, spine and ribs, though, like other Hippocratic works, it ends in a confused mass of rough notes.
M II-III, nose and ear, are derived from J XXXV— XL. M 1V, lower jaw, from J XXX-XXXI. MV epitomizes in one chapter the remarkable account oft shoulder dislocations, J I-XII. M VI is from J XIII, on dislocation of the outer end of the collar- bone considered as avulsion of the acromion.
1 Apollonius, 13; Galen, XVII1(1). 519. Cf. Littré I. 334. 85
INTRODUCTION
We are surprised to find that M VII-XIX are not an epitome but a verbal repetition of J XVII-XXIX. They are derived mainly (VII—XV) from F XXX VIII- XLVII, on the elbow; XVI-XVIII, on the wrist, have no extant original, and XIX, on the fingers, does not appear to be an abridgment of the long account in J LXXX.
There seems no reasonable doubt, from the nature of the case, the style of the writing and peculiarities of language, that the epitome was made by the author of Mocklicon and afterwards transferred to Joints to fill up a vacancy. A reader of the latter observes a sudden change of style, the appearance of new words (éfaipvys for éfarivns) and a whole string of depraved infinitives;1 but the section is in perfect harmony with the rest of Mochlicon.
M XX-XXIV abbreviate the very full account of thigh dislocations in J LI-LX, while the directions for reduction, given at length in J LXX-LXXVIII, are condensed into M XXV.
M XXVI-XXXI on knee, ankle and foot repeat the phenomenon of VII—-XIX. They correspond verbally with J LXXXII-LXXXVII and are epito- mized from Fractures X-X1V—except XXVI, on the knee, which is, in part, from F XXXVII. We shall find that J LXXXII-LXXXVII form part of an appendix to the original treatise.
M XXXII condenses the account of club foot given in J LXII.
M XXXIII-XXXV deal with compound disloca-
1 We may note that, according to our text, M XII has the more normal nominatives which have become accusatives on transference to J XXII.
86
INTRODUCTION
tions, loss or amputation of parts, gangrene and necrosis. They are derived from J LXIII-LXIX.
M XXXVI feebly represents the long account of spinal curvature in J XLI-XLVI, also fracture and contusion of the ribs, J XLIX.
In XXXVII M begins to go to pieces. It is based partly on J XLI, partly on J L, and the rest of the treatise is a mass of confused notes on dislocations and fractures, often hardly intelligible, but obviously all taken from Fractures—Joinis. Imbedded in it is a paragraph (XX XIX) on disease of the palate corre- sponding almost verbally with passages in Epidemics II, 1V, and VI; and interesting as showing that Mochlicon, like Surgery, has some connection with the middle division of this series.
Fractures and Joints may now be summarized briefly. About one-fourth of Fractures deals with dislocations The first seven chapters treat fracture of the forearm in detail as a typical case. Chapter VIII fracture of the upper arm: I1X—XXIII disloca- tions of the foot and ankle, and fractures of the lower limb. We are surprised to be told in chapter IX that dislocation of the wrist has already been mentioned. The remainder is devoted partly (XXIV-XXXVII) to compound fractures, and partly (XXXVIII-XLVIII) to dislocations of the elbow, with a few words on dislocation of the knee (XXXVIII) and fracture of the olecranon.
Joints begins similarly with a sample case, dis- location of the shoulder-joint, described in great detail (I-XII)._ Then comes fracture of the collar- bone and its dislocation (XIII-XVI). Next (XVII- XXIX) is the interpolation from Mochlicon, on elbow, wrist, and finger-joints. Injuries of the jaw, nose
87
INTRODUCTION
and ear (XXX-XL) are given great attention, doubtless owing to the vigorous boxing methods then in use. XL-—L treat of the spine and ribs in detail, and show much anatomical knowledge. LI-LXI include the celebrated account of disloca- tion of the hip and its results, and LXII has the excellent description of club foot. In LXIII-LXIX we are diverted to the consideration of compound dislocations, amputation, necrosis and gangrene, and finally return to the hip-joint and its reduction in LXXI-LXXVIII.
According to Galen, chapter LX XVIII is the last, and his commentary ends here. So does that ot Apollonius, except for some rough notes, most of which occur at the end of our Mochlicon.
This view is confirmed by the nature of chapter LXXIX, which is a brief introduction to the study ot dislocations, and would come more appropriately at the beginning.
Chapter LXXX looks like the original account of finger-joint dislocation; but was unknown to Apollonius, who says (on chapter XXIX) that Hippocrates made only .a few remarks on the subject owing to its simplicity, and proceeds to supplement them by an extract from Diocles, which seems almost certainly based upon LXXX, and to form part of the ‘paraphrase’? mentioned by Galen. We may perhaps conjecture that chapter LXXX was lost and discovered again after its place had been occupied. The rest of the appendix is an epitome of knee, foot and ankle lesions supplied from Mochlicon, the originals having somehow got into Fractures.
The answer to the question of antiquity is, then,
88
INTRODUCTION
that the great work on Fractures and Dislocations got into disorder soon after it was written, and that parts were lost, either temporarily (as J LXXX) or permanently, as with the original account of the wrist. The excellences of, its disjecta membra speak for themselves, and have been recognized by all surgeons ancient and modern. An editor has the less agreeable task of dealing with defects and difficulties.
Many questions which occur to a modern reader are unlikely to receive satisfactory answers. Why does Hippocrates say that the fibula is longer than the tibia and projects above it} (apparently because he saw and exaggerated its analogy with the ulna) and that twenty days are “ very many ” for consolida- tion of a broken collar-bone, whereas we allow three to six weeks?2 Why does he assert with emphasis that inward dislocation of the thigh-bone is much the most frequent,® and all antiquity (together with Ambrose Paré)* agree with him, whereas all modern evidence is to the contrary? Why does he ignore injuries of the knee-cap, and the use of that ancient instrument the safety-pin? These problems and other statements which will surprise the surgeon, such as the cure of hump back by varicose veins and the frequency of dislocation of the knee, must
1 Fractures, XII, XXXVII.
2 Joints, XIV. 3 Joints, LI.
4 So Adams (558). In his chapter on hip dislocation (XVI. 38) Paré says ‘‘ le plus souvent en dehors et en dedans, en devant et en derriére rarement.”” He may have held the modern view (dehors comes first) but have been unwilling to contradict such authorities as Hippocrates, Celsus and Galen. Possibly some grip in ancient wrestling made the internal form then more frequent.
89
INTRODUCTION
remain unsolved. Two subjects, however, require further consideration: the accounts of elbow and ankle dislocations. The former is treated by most editors at some length, and it is generally admitted that the latest and longest discussion (that of Petre- quin) throws light on the subject. He points out that some difficulties are removed by supposing the Hippocratic attitude of the arm to be that with the bend of the elbow turned inwards, not forwards, and since Hippocrates speaks of dislocation of the humerus or upper arm (the convex from the con- cave), whereas we speak of dislocation of the fore- arm, a double correction is necessary, his inwards and outwards becoming our backwards and forwards respectively. Similarly, with lateral dislocation, the Hippocratic forwards and backwards become our inwards and outwards. This seems the best that can be done, though it brings the two surgical editors, Petrequin and Adams, into violent contra- diction on some points.
The second puzzle is why—though Herodotus knows exactly what happened to the astragalus of Darius when he sprained his ankle—does. Hippo- crates never mention the bone, and give us a very obscure account of ankle dislocation? In part, doubtless, it is the layman rushing in where the specialist fears to tread; but the existence of a duplicate epitome of each of these subjects will enable us to discuss them further in the text.
Soranus tells us that the father of rhetoric, Gorgias, was one of the teachers of the father of medicine, and so long as such works as T’he Art and Breaths were considered genuine, they might have been adduced either as showing the result of this teach-
go
INTRODUCTION ing, or as possibly giving origin to such a legend. But the story may very well be correct, for Gorgias and Hippocrates were both in Thessaly about the same time, and the physician may have admired not only the fine constitution of the elder man, which was destined to prolong his life well beyond a century, but also his fine language, and have taken some lessons in composition, But if we look for traces of rhetoric in what are now considered pos- sibly genuine works, we are surprised to find them most prominent in the great surgical treatises. Fractures—Joints abound, if not in purple patches, at least in purple spots, as if the writer was trying to make use of recently acquired knowledge of rhe- torical forms. Attention was called to this by Diels, and it has been more fully worked out by Krémer. Some rhetorical forms show through even the worst translation, and the reader will easily discover at least twelve examples of the rhetorical query. Plays upon words are also frequent and obvious in the Greek, though difficult to repeat in English. Of special interest is the frequent occurrence of chi- asmus and other forms of the evenly balanced sentence. A short sample of either may be found respectively in Fractures, XLVII: zodAGv pev yap av KoAvpa ein, OpeAin 5é dALywv, and Joits, XLVI: adda Kal ovtws av arobaynn, Tapaxpyua € ovK arobdvou.
The latter, with the allied form of anaphora, or needless but ornate repetition of the same word (e.g. of dAdo in Fractures, 11; focov, Joints, X1) may remind readers of the less artistic repetitions common in Wounds in the Head, and suggest that in spite of diversity of style it may be by the same author. We notice also a similarity of doctrine,
gt
INTRODUCTION
especially the statement that contusions of bones are usually more serious than fractures, applied respectively to skull and ribs.
Too much weight may, perhaps, be given to this. Thus Littré (IV. 566) notes a resemblance between Fractures, XX XI, and Diet in Acute Diseases, VII. In both there is a disapproval, expressed in very similar language, of any marked interference, operative or dietetic respectively, during the third, fourth, or fifth days. He considers that the identity in sense and form of criticism, together with “the identity of the epoch,” is enough to prove identity of author- ship. He might have added that there is a number of curious terms common to Diet in Acute Diseases and Fractures—Joints: e.g. dyxuora, in the sense of partora, and WoeAdiopevos, amapti, TO érizav.t But there are differences which raise doubts. Thus the favourite drink of the author of Fractures—J/oints is oxyglyphy (hydromel, prepared by boiling squeezed- out honey-combs),?_ Duel wm Acute Diseases never mentions this, though it has much to say about the closely allied oxymel and melicrate, which are ignored in Fractures —Joints.
The most formidable opponent of the Hippocratic authorship was H. Diels, whose main contention is that ancient writers did not refute one another by name, nor mention those whom they copied. There- fore, probably, neither Ctesias nor Diocles named Hippocrates. That they refer to him is only Galen’s assumption. Reasons to the contrary are adduced by Krémer, and seem equally potent.? The “ para- phrase”’ of Diocles at least shows that the work was
1 See Kiihlewein op. cit. p. 6. * Galen, XVIII(2). 466 Op. Cit peed. g2
INTRODUCTION
well known early in the fourth century, which is sufficient to refute the second argument usually brought against its Hippocratic origin, that the writer knows too much anatomy, and in particular distinguishes clearly between arteries and veins. If we may trust Caelius Aurelianus, their distinction was known to Euryphon,t who was older than Hippocrates, while the writer's ability to give a good account of the shoulder-joint and spine, and promise of further details, is only what we should expect from what Galen says about the anatomical studies of the old Asclepiadae.?
Still, we must agree with Diels that this last attempt to demonstrate at least one genuine work of Hippocrates may be met by the ancient warning, doxds 0 éxl raou rérvuxra, or rather that the whole sentence of Xenophanes may appropriately be applied to the Hippocratic problem, “ Even if one hit upon the truth, he would not be sure he had done s0, for guess-work is spread over all things.”
BST ORY D* 10) 2 Anat. Adm. 2,1
93
10
20
TEPI ATMON
’ a \ a ,
T. "Eyphv tov intpoy trav éxmtwciwov te Kal
KaTaypdtwy ws (OvTaTa Tas KaTAaTaOLas ToLel- cf \ e / / BY /
cOau: atitn yap n Stxatotatn dvaws. Hv b€é TH > if A fal x fal \ / eyeAtvn 7) TH 1 TH, El TO Mpnves péretv éXdoowy yap 7 auaptas %) emi To Urtuov. ob pev > \ , > NY ’ / ody pndev TpoBovrevovtat ovdev €EaumapTtavovaty @s €ml TO TOU? avTOS yap émLdnodpevos) Tiy
n / ¢ \ a , = YEelpa atropéyel OUT@S UTO THS SiKains “Pvaros > / € \ Lu \ / a avayxalopuevos* ot 6€ intpol codilopevor dHOev
” >
got apa ép ois” auaptdvouvct. a7rovdn pev ovv ov ToAdy YElpa KaTenyviay Yepicat, Kal mavTos 5€ inTpod, ws eros eltrety: avayKxafomar dé eym TAciw ypihev Tepl avTOV® GTL olda inTpovs aopovs So€avtas eivar amo aynpmaTwv YeLpos év > / ’ ’ oe ’ / > \ 3 n lal émidéoer, ah wv auabéas avtovs éxphy Soxetv 7 ox 4 \ \ ec 4 fal / etval. AXA” yap TOXAA OVTW TAUTNS THS TEXVNS Kpivetau: TO yap EevoTpeTtés OVTIw GULLEVTES, Eb XpnoTov, adAov E€rratvéovow % TO ayes, Od ” ” 4 / \ \ > , A \ non oldacw OTL ypnaTOV, Kal TO GNNOKOTOV 1 TO oy ( , (2 ig 4 BY »/ lal € eVOnAOV. pyTéov ovV oTrocas av EVéhw TOV apuap- TUdwY TOV inTpar, Tas pev atrodidakEat, Tas dé dudaéai[: apEopar de]® mept tis puavos Tips
2
1 § émideduevos. éotiy od.
3 gurijs.
94
ON FRACTURES
I. In dislocations and fractures, the practitioner should make extensions in as straight a line as possible, for this is most conformable with nature ;1 but if it inclines at all to either side, it should turn towards pronation (palm down) rather than supina- tion (palm up), for the error is less. Indeed, those who have no preconceived idea make no mistake as a rule, for the patient himself holds out the arm for bandaging in the position impressed on it by con- formity with nature. The theorizing practitioners are just the ones who go wrong. In fact the treatment of a fractured arm is not difficult, and is almost any practitioner’s job, but I have to write a good deal about it because I know practitioners who have got credit for wisdom by putting up arms in positions which ought rather to have given them a name for ignorance. And many other parts of this art are judged thus: for they praise what seems outlandish before they know whether it is good, rather than the customary which they already know to be good ; the bizarre rather than the obvious. One must mention then those errors of practitioners as to the nature of the arm on which I want to give positive
1 Galen makes this a general statement; but the writer is
apparently speaking of the forearm, which he had already mentioned in a lost introduction.
4 GAAGd 5 Omit Kw. BMY. 95
24
10
20
TIIEPI ATMQON
XElposs Kal yap a\dwv daTéov TOV KATA TO TOLa didaypa 65¢€ 0 6 ovyos €oTL.
Il. Tyv pev odv xetpa, mept o81 0 Réyos, GdwKé Tis KaTadnoa, Tpnvéa® Toijoas: o bé nvayKkatey olTws Exe WaTEp ol TOEEVOYTES, env TOV Lov euBadrwOL, Kal oUT ms Exougay eT €OEL, vopilwv EWUTO eivau TodTO aur) TO Kara pou Kal papTuplov eM NYETO TA TE GOTEA nus Ta ev TO TI XEl, ore (Oveptny catadhyha eixe,? THY Te OM0ypolny, Ore avr) Kal é@uT iy THD iOvepiny éyer o0Tw Kal €x Tod éEwOev pépeos Kal éx Tod érwbev: ottw 5é€ ébn Kal Tas cdpKxas kal Ta vedpa Tepuxévat, kal THv ToELKHY éTNYyETO LapTU- ptov. TavTa Aeyou Kal TadTa Toléwv coos edoKer eivae TOV dé dd\Xwv TEX VEY emereyGer Kal omroca ioyve epyatovtas Kal oToga TeX pacw, ovK elas OTL AAO év AAAW TO KATA pu TYHpa eoTLD, Kal €v TO auT@ Epye erepa Tis deEuns xELpos oXpaTA kara guow éoTi, Kal Erepa THS aplarephs, my oT TUXD ado pev yap oxhpa év aKxovTicu@ Kata dvaw, Addo é év opevdovncet, ddho dé év ALOoBorinot, adro év TUY iL), ado év TO éduv vey. oTdcas 8 av Tes Téxvas eUpou év now ov TO avo oXTpua TOV xerpav KaTa puow éoriv kal 4 ev exdorn TOV TEXVOY, ara * mwpos TO dppevov 6 Exn ExacTos, Kal pos
1 of because it is an idiom or phrase not referring specially
to 7 xelp. 2 exidfjocat KaTampnvea.
3 Eyer KaTaAANAG. £ GAAG (omitting kal).
1 Commentators, from Galen downwards, point out the absurdity of teaching ‘‘errors.” Ermerins got rid of it in
g6
-ON FRACTURES, 1.-11.
and negative instruction,’ for this discourse is an instruction on other bones of the body also.
II. To come to our subject, a patient presented his arm to be dressed in the attitude of pronation, but the practitioner made him hold it as the archers do when they bring forward the shoulder,? and he put it up in this posture, persuading himself that this was its natural position. He adduced as evidence the parallelism of the forearm bones, and the surface also, how that it has its outer and inner parts in a direct line, declaring this to be the natural disposition of the flesh and tendons, and he brought in the art of the archer as evidence. This gave an appearance of wisdom to his discourse and practice, but he had forgotten the other arts and all those things which are executed by strength or artifice, not knowing that the natural position varies in one and another, and that in doing the same work it may be that the right arm has one natural position and the left another. For there is one natural position in throwing the javelin, another in using the sling, another in casting a stone, another in boxing, another in repose. How many arts might one find in which the natural position of the arms is not the same, but they assume postures in accordance with the apparatus
his usual bold manner by reading ra for rds. Diels considered it a glaring hysteron proteron which can be simply remedied by reversal, and this is practically done in the translation. lt seems a play upon words at which the writer is more successful elsewhere. See chap. XXX end.
* Galen says the archer held his left arm back downwards or nearly so; but this is contrary to ancient representations, What the writer chiefly objects to is putting up a broken forearm with the elbow extended,
97 VOL. Il. =
30
40
IIEPI ATMQN
TO Epyov 0 av emiteneoacdar Gérn, oxXnpativovrar at Xelpes* TOELRTY é doKéovte elKos TOUTO TO oXTa KpatiaTov elval THS erTépns xeLpos* TOU yap Bpaxtovos TO yuyyrvpoeces, €v TH TOU THYEOS Bab wide é€v TOUT® TO TX MATL épetOov iOvwpiny Tolet TOOL OTTEOLALY TOD THYEOS Kal TOV Ppayi- ovos, @s av év elin 70 may: Kal Y avaKraais TOU dpO pov KEKNATTAL 1 éy TOUT TO OX MATL. el os pev obv oUTHS dxapmToTaTov Te Kal TETAVWTATOV elval TO Xeptov, Kal Hy) noodobat, pnoe ouvdiddvat, EAK OMENS. THS veupys urd Tis deEuns xetpos” Kal ovTws éml m)hetorov bev THY veupry EXKUTEL, apnae O€ avd otTepewTdtov Kai aOpowrdTou: aT0 TOV TOLOVTAY yap apecinv TAY ToEEVLATOY, Taxelar Kal ai ioyves Kal TA pKEea yivovTat. emidéaet O€ Kal TOELKH OvdSEéV KOLVOY. TODTO meV yap, et émidyncas Exe THY YElpa oUTwS EuErre,” TOVOUS ay d&dous TOANOVS mpocetiOer petCovas Tob TP@ Mar os” ToUTO &, el oui pra éxcheven, ouTe Ta ooTea ouTe Ta vetpa oUTE ai aapKes ETL év T@® AUTO éyivovTo, anna ary METEKOT MELTO KpatéovTa THY émiSeo ty Kal TL dpeos eort TOELKOU TXMATOS ; 5 Kal TavTa lows ovx ap eEnudptave copi Fopevos, el Ela TOV TETPwLEVOV
49 avTOV THY Velpa mapacxeo Ban.
ETT. “AdXos & av tus tov intpav imriny THY xEtpa dovs, OUT@ KaTaTELVEW éxéheve,® Kal ovTwS eXoucay émré0et, TOUTO vou Sov TO Kara puow elval, TO TE x pot OAL OMEVOS Kal Ta ooréa vopitor Kara prow eival OUTWS, Ore paiverat 1) e&éyov datéov TO Tapa Tov KapTOV 7 O GpLKpOS
1 rérarat Kw. (retac@a B’).
98
ON FRACTURES, 1.-11.
each man uses and the work he wants to accom- plish! As to the practiser of archery, he naturally finds the above posture strongest for one arm: for the hinge-like end of the humerus in this position being pressed into the cavity of the ulna makes a straight line of the bones of the upper arm and forearm, as if the whole were one, and the flexure of the joint is extended (abolished) in this attitude. Naturally then the part is thus most inflexible and tense, so as neither to be overcome or give way when the cord is drawn by the right hand. And thus he will make the longest pull, and shoot with the greatest force and frequency, for shafts launched in this way fly strongly, swiftly and far. But there is nothing in common between putting up fractures and archery. For, first, if the operator, after putting up an arm, kept it in this position, he would inflict much additional pain, greater than that of the injury, and again, if he bade him bend the elbow, neither bones, tendons, nor flesh would keep in the same position, but would rearrange themselves in spite of the dressings. Where, then, is the advantage of the archer position? And perhaps our theorizer would not have committed this error had he let the patient himself present the arm.
Il]. Again, another practitioner handing over the arm back downwards had it extended thus and then put it up in this position, supposing it to be the natural one from surface indications : presuming also that the bones are in their natural position because the prominent bone at the wrist on the little finger
2 exedever. 8 éxéXeuoe.
99
10
20
30
TIEPI ATMON
ddxTuros, KaT (Ovepiny elvat Tob Oo Téov, ag’ oTéou i TOV TAX YY Ot avOpwrot pet péovow tabra Ta _Maprupia em nryeTo éTt KaTa pvow ovTwsS EXEL, Kal édoxer ev every.
"AAG TobTo peV, él umrin 7 xelp KaTaretVvo.to, ioxXupas movoin av: yvoin 8 av THs THY EwuTob xelpa Kkatareivas os ém@wouvov TO ox TMA. émrel Kal avnp joowy Kpéocova drahaBav oUTws ev 2 THOU | EwuTod Nepal, os Kratar 0 ay Kav UmTL0s, aryou ay oan eG eRou- ovre yap el Eos év Tarn TH xetpl EXOL, EXO ay 6 TL Xpycarto TO Eien’ oUT@
(alov TOUTO TO TX Ta éoTw. Todo dé, ef éme- Snoas TUS év TOUTY TO oxXnaTE eo, pelav bev TOvos, el Teptiot, peyas 8e kal el KATAKEOLTO. TovTO éé, él i ovy Kayne Thy velpa, dvaynn maca® tous TE pas Kal Ta bare adrio oyhwa EXEL. ayyvoee bé Kal Tade Ta ev TO TX MATL Yopis THS adds AUENS* TO yap oar éov TO Tapa TOV KapTov e&EXov, TO Kara TOV o puLK pov Oaxtunop, TovTO wey TOU ™XEOS €oTIV: TO O€ ev TH ouyKapryer éov amo Tev* Tor TiyXvy ol avOpomor eT péouat, TOUTO oe Tob Bpaxiovos » 1) Kepann € ear. 0 ) O€ WETO T@UTO Gotéov eivat ToUTO Te Kaxeivo, TodOL é Kal adrou éore O€ exci TO OGTEW TWUTO 6 ay Kav KANOUMEVOS, @ TOTL 5 ornprtopeba. oUTwS ov UTTiNnu EXOvTL THY YElpa, TODTO pev TO oo Téoy bu- EoT papLjuévov paiverar, TOUTO be Ta vedpa Ta amo ToD KapTov TeivovTa ex ToD éow HE peos Kal ato TOV dakTvhor, TavTa vrrinv ExovTe THY xeipa be- eoTpappeva yivetar’ TelveTat ® yap TadTa Ta vEedpa
1 aw Srev. 2 2p, 8 Kw. omits.
100
ON FRACTURES, u1.
side appears to be in line with the bone from which men measure the forearm (cubit). He adduced this as evidence for the naturalness of the position, and seemed to speak well.
But, to begin with, if the arm were kept extended in supination it would be very painful ; anyone who held his arm extended in this position would find how painful it is. In fact, a weaker person grasping a stronger one firmly so as to get his elbow extended in supination might lead him whither he chose, for if he had a sword in this hand he would be unable to use it, so constrained is this attitude. Further, if one put up a patient’s arm in this position and left him so, the pain, though greater when he walked about, would also be great when he was recumbent. Again, if he shall bend the arm, it is absolutely necessary for both the muscles and bones to have another position. Besides the harm done, the practitioner was ignorant of the following facts as to the position. The projecting bone at the wrist on the side of the little finger belongs indeed to the ulna, but that at the bend of the elbow from which men measure the cubit is the head of the humerus, whereas he thought the one and the other belonged to the same bone, and so do many besides. It is the so-called elbow on which we lean that belongs to this bone.t In a patient with the forearm thus supinated, first, the bone is obviously distorted, and secondly, the cords stretching from the wrist on its inner side and from the fingers also undergo distortion in this supine position, for
1 7.¢, the olecranon process is part of the ulna.
* aw brev, 5 éy work, 6 relver, IOI
40
50
TEPI ATMQN
mpos TO TOU Bpaxtovos oatéov, b0ev o THXUS [ET PELTAL. avras TocadTas Kal TOLADTAL at dpaptades Kal aryvoiat THS pva.os THS yerpos. €b 5é, as éy@ KENEVO, xelpa Katenyutav xarareivou TLS, ema Tpewer bev TO oaréov és (00, TO KATA TOV o ju pov ddxtuRov, TO €5 TOV aycava Telvov, (Ovapiny dé &er Ta vebpa Ta aro Tov KapTrov ™pos TOU Bpaxtovos Ta akpa TelvovTa’ avahap- Bavopevn be n Kelp éVv TapaTAnoato TX MATL éotat, &v @ TEP Kal emUOEoHLevN, amrovos bev dSorTropéovTt, amrovos O€ KATAKELMEVD Kal akda- Haros. cadivyve bat oe xpn TOV avOpwomov oUTwS, oT as H] TO €&éyov Tob daTEou ™ pos THY Aapm pord- THY TOV Tapeova ewy avyewy, as Ka AdOn Tov xetpifovra. év Th KaTAT aoe, el (KAVOS eEtOuvrar. TOU ye pay € émmretpou ovo ay THY Xelpa rAaBot € éma- youevny TO efexov aTap Kal adyel pddwoTa KaTa
64 TO e&éyvov pavopevov.
10
IV. they d€ Oo TEWY TOD TNXEOS, ov To) dpuporepa KaTENYE,” pawv n inows, nv TO ave daTéov TETPO- pevov 2 Kat ep TAXUTEPOY eov" apa ev ore TO bryees UTOTETAMEVOY yiverat avtt Bepertou, a dpa dé OTL eVK puTTOTEpOV yiverat, may el 2 TO eyyus Tov KapTov Tmaxeln yap 1 THS TapKos érriduats a emt TO avw. TO O€ KATO daTéov aoapKov Kal OvK eV VYKPUTTTOD, Kal KATATATLOS loXUpOTEpNS | detract. Av o€ a) TOUTO out pipy, GXAa TO Erepor, pavrorepy ° oD) KaTatacts apKel. Hv O€ aupotepa KaTENYN: laxXupotatns KaTaTaotos Setra: matbiov pev yap Sn eldov Katatabévta paddov 7) ws
1 Karényev, » . . €L ee. TETPWTML. 2 i. 3 érapporepn. 19032
ON FRACTURES, u1.-iv.
these cords extend to the bone of the upper arm from which the cubit is measured. Such and so great are these errors and ignorances concerning the nature of the arm. But if one does extension of a fractured arm as I direct, he will both turn the bone stretching from the region of the little finger to the elbow so as to be straight 1 and will have the cords stretching from the wrist to the (lower) end of the humerus in a direct line; further, the arm when slung will keep about the same position as it was in when put up, and it will give the patient no pain when he walks, no pain when he lies down and no sense of weariness. The patient should be so seated that the projecting part of the bone is turned towards the brightest light available, that the operator may not overlook the proper degree of extension and straightening. Of course the hand of an experienced practitioner would not fail to recognise the prominence (at the fracture) by touch; also there is a special tenderness at the prominence when palpated.
IV. When the bones of the forearm are not both fractured the cure is easier if the upper bone (radius) is injured, though it is the thicker, both because the sound bone lying underneath acts as a support and because it is better covered, except at the part near the wrist, for the fleshy growth on the upper bone is thick; but the lower bone (ulna) is fleshless, not well covered, and requires stronger extension. If it is not this bone but the other that is broken, rather slight extension suffices: if both are broken very strong extension is requisite In the case of a child I have seen the bones ex-
* de. the styloid process in line with the olecranon, 103
20
30
40
TTEPI ATMQN
° , a eee, ot 6é Tela TOL Hooov TeivovTat ws Sel. xpn © ery Tetvwot, Ta Oévapa mpoo Baddovta dtopOoby" emerta Xpicarra KNPOTH pn mavu TOANN, @s Th _TepiT en Ta émidéeopara, oUTwS emidetv 6 omas pay KATOTEPO apy THY xelpa eee Tov ayKxOvos, anra opLKPD TLVL AVWTEPW, WS MN TO aiua és aKpov émippén, aAAXG aTroAaMBarntat: ” > lal lol > / \ ? \ / érerta erioeivy TO GOoviw, THY apxnv Baddopmevos
pS \ / 5 , KaTa TOKaTHYypHa: épeldwv pev ovv, un miéSwv Sé , ee \ / \ Siege Nev A , Kapta. émny O€ TEptSadrn KaTa TwUTO Sis % Tpis, éml TO ava vewecOw erridéwy, iva ai érippoal Tod \ aipatos ato\auBdvwrvtat, Kal TedAevTHTATw a \ \ 3 \ a / Kei0t. pr dé un paxpa civar TA TPaTA dOoua. fal \ / bd , \ \ > \ s Tov O€ devTépwv OOoviwy THY wEéev apynV Barre Bat éml TO KaTHYypa TEepLBarwv Te” Arak és TwUTO, \ érretta veweaw és TO KATH Kal eT! Haoaov Tiélwr, \ 2-4 l is , re ADK > 1g ¢ \ Kal érl pélov dtaBiBdoxov, ws av avto® ixavor , a a “f yévntat TO OOovioy avatradivdpounoas KetOe tva , a \ mep TO Etepov éTedevTHGEV. EevTavda pev oY TA wa wa peat ee) VN A eN \ by 4 od ovia em apiatepa 7 emt deka eridedéabw, 7) él omotepa av cupepy pos 76 oxipa Tob KaTeayoros,® Kal ep omorepa av mepippémeww ouudépy. pera dé tabdta, omdijvas xaratelvew xpn KEX Plo MEVOUS KNPOTH oriyy” Kal ap ™poon- ver TEpov Kal ebfer@repoy. émerta ovTws émibely toiaw dOoviotcww ws ® évarrd€, bre pev ert deka, ore dé er’ apuatepa Kal Ta jeev Thelo xatobev dpXopevos és TO dveo aye, éote 8 OTE Kal avwbev és TO KdtTw. Ta dé omoEnpa axetaOat Toice omAnvert KUKAEDVTA’ TO O€ TWAOEL THY Tept-
1 Omit ody. dé. 3 air@.
104
ON FRACTURES, w.
tended more than was necessary, but most patients get less than the proper amount. During extension one should use the palms of the hands to press the parts into position, then after anointing with cerate (in no great quantity lest the dressings should slip), proceed to put it up in such a. way that the patient shall have his hand not lower than the elbow but a little higher; so that the blood may not flow to the extremity but be kept back. Then apply the linen bandage, putting the head of it at the fracture so as to give support, but without much pressure. After two or three turns are made at the same spot, let the bandage be carried upwards that afflux of blood may be kept back, and let it end off there. The first bandages should not be lengthy. Put the head of the second bandage on the fracture, making one turn there ; then let it be carried downwards, with decreasing pressure and at wider intervals, till enough of the bandage is left for it to run back again to the place where the other ended. Let the bandages in this part of the dressing be applied either to left or right, whichever suits the form of the fracture and the direction towards which the limb ought to turn. After this, compresses should be laid along after being anointed with a little cerate ; for the application is more supple and more easily made. Then put on bandages crosswise to right and left alternately, beginning in most cases from below upwards but sometimes from above down- wards. Treat conical parts by surrounding them with compresses, bringing them to a level not all
4 Kathyuatos, 5 Omit ds.
105
47
10
20
MEPI ATMQON
Boréov pn av abpoov cvvdvophobvra, anra Kara pEpos. meptBadhew dé yp) Narapa Kab Tept TOV KapTov THS XELPOS adore Kal adore. TAGs &€ TOV OOoviwy ikavov Td TpATov ai dSvo potpar.
V. Xnueta 5é Tod Karas intpevpévov tadrta, Kal pbs emideopievou, él EPWTWNS avTov et
TeTLEKTAL, Kal et pain pev meme Pau, ovxeos dé, Kal padiara, él Kara TO KATHY BA pain: TolavTa Tolvuy davar Xp} TeTPHyMWEeva Oia TEEOS TOV opbas em deouevov. onueta d€ Tavita TiS HETPLOTNTOS, TV Lev HEPNY, iv av erie, Kal THY VUKTA SoKetTeo auTos EWUTO By éml Hooov memléxOat, arr emi parrov: TH b€ vaTepain oldnmareov erdeiv és xelpa apy parOaxov: HETPLOTNTOS yap onpetov Tis TuéELOS GoU" Tehev- Toons O€ THs TMEPNS, éml Haocoy SoKEiTw TreETTLE- yOat- TH O€ TplTn Xahapa cot OoKELT@ elvat Ta emdéo para. KH Lev Te TOUT@V TOV elpnpevev édreiTN, yiv@oKery xn OTL Xaaporepn éorly a émideais TOD peTptou: iy éé TL TOV el pn Leveov Teovaly, xpi) yivon Key OTL pardov emveyOn TOU pleTplou: Kal TovTOLCL oNMALVOWEVOS TO baTepov em Loon 7} 7) Narav paxdov, i) melew. dmonucavra dé xP TpiTaioy €ovTa KaTaTelvdwevov Kab d10pe- oajmevov" Kab ny peT pos TO ™p@Tov TETUXNHKNS ETLONTAS, TAUTHY THY eTLdETLY YP2 OALy@ Baddov
1 Littré inserts ad@:s ém:djoo:—and renders (as followed by Adams), ‘‘ Having removed the bandages on the third day, you must make extension and adjust the fracture and bind it up again.” As Petrequin remarks, this seems con- trary to common sense, surgery and the express directions
106
ON FRACTURES, 1tv.-v.
at once but gradually by the number of circum- volutions. You should put additional loose turns now and then at the wrist. The two sets of bandages are a sufficient number for the first dressing.
V. These are the indications of good treatment and correct bandaging :-—If you ask the patient whether the part is compressed and he says it is, but moderately and that chiefly at the fracture. A properly bandaged patient should give a similar report of the operation throughout. The following are the indications of a due moderation. During the day of the dressing and the following night the pressure should appear to the patient not to diminish but rather to increase, and on the following day a slight and soft swelling should appear in the hand; you should take this as a sign of the due mean as to pressure. At the end of the day the pressure should seem less, and on the third day you should find the bandages loose. If, then, any of the said conditions are lacking you may conclude that the bandaging was slacker than the mean, but if any of them be excessive you may conclude that the pressure was greater than the mean, and taking this as a guide make the next dressing looser or tighter. You should remove the dressing on the third day after the extension and adjustment, and if your first bandaging hit the
of the author (XX XI). The limb is supposed to be set, any further adjustment being made on the seventh day. Celsus (VIII. 10. 1), Galen (Meth. Med. VI. 5) and Paulus (VI. 99) all follow Hippocrates, but make no mention of a second setting on the third day. Still, in the case of the leg he seems to recommend interference at every dressing; and grammar is on the side of Littré,
107
30
40
47
ITEPI ATMON
C7] exeivny TET AL. BarreoPat dé xpn Tas dpxas Kara TO KATHY, @oTEp Kal TO TpOTEpoV™ AY pev yap TOUTO T poTepov éridéns, efeipvatar * éx ToUTOU ol ix@pes és TAS eoyarteas évOa kai évOa: ay dé Tt AXXO 7 poTepov mieEns, €S TobT0 é€erpvatatt éK Tov mex OevTos” és moAAa 6 edXpyatov TO * ouvlévat. obras ouv dpxecOar peev altel xpr THY émideoiy Kal THY mieEw ex TOUTOU Tob Xeplou, TQ b€ adda Kara oyov, OS Tporwrepo amo TOU KATY LATOS aydyys, eTth ooov Thy mleEL Trovel- o Bat. Xarapa d€ TavtTdtact pndérore Te pl- Barrew, aNXra TpoonemT@Kvia. émerta dé meloo ww aoviorss xpn érrudetv exdorny TOV emer lov. EPOT@[LEVOS dé pare onriryep paddov ol meme Pau, i) TO ™ poTepov, Kal pdduara para Kara TO KATHY [LAL Kal Ta adra O€ Kara oyov" Kal appt TO oldnpare, Kab appl TO TOVEELY, Kab aupi TO pnifew, Kara doyov THS mporEpys TL déovos pvécboo. ery d€ TpLTatos iE Narapwrepa of SoKeiT@ elvat Ta émidéopata: éTelta aTrodv- cavTa XP abs ETON TAL, oALye@ padrov miéetovta, Kai év Tact Toto d0oviorsw oli TEp Tye dev éemidetabar: éTmerTta de TavTa avTov TAUTA catahaPéero, amep Kal év That TeeTHaL TepLosorat THY émrlOeciov.
VI. "Eni dé TpeTatos yevnrat, €Bdopatos b¢ aro THS Tporns ET LOET LOS, 4) yy opA ds emiSen Tal, TO pev oidnua év apn TH xELpl éoTat, ovoe TobTo Aimy péya: TO 8 érriDeo pevov X@plov ev maonot Thow eTidéoeaw eT TO AeTTOTEpoY Kal la-xvore- pov evpeOnoerat, év € TH EBSopn Kal Tavu NET TOV:
1 éteipyara bis. See note, p. 158. 108
ON FRACTURES, v.-v1.
proper mean this one should be a little tighter. The heads of the bandages should be applied over the fracture as before, for if you did this before, the serous effusions were driven thence into the outer parts on both sides, but if you formerly made the pressure anywhere else, they were driven into this place (the fracture) from the part compressed. It is useful for many things to understand this. It shows that one should always begin the bandaging and compression at this point, and, for the rest, in proportion as you get further from the point of fracture make the pressure less. Never makc the turns altogether slack, but closely adherent. Further, one should use more bandages at each dressing, and the patient when asked should say he felt a little more pressure than. before, especially at the point of fracture, and the rest in proportion. And as regards the swelling, feeling of pain and relief, things should be in accord with the previous dressing. When the third day comes, he should find the dressings rather loose. Then after undoing them he should bandage again with a little more pressure and with all the bandages that he is going to use, and afterwards the patient should experience all those symptoms which he had in the first periods of bandaging.
VI. When the third day is reached (the seventh from the first dressing), if he is being properly bandaged, there will be the swelling on the hand, but it will not be very marked. As to the part bandaged, it will be found to be thinner and more shrunken at each dressing, and on the seventh day
2 ToiTo,
109
10
30
TIEPI ATMON
Kal Ta OoTéa Ta KaTEnyoTa él WAAXOV KLVEvLEVA Kal eUTapayoya és catopbwow. Kal iy uP Tada TOLAUTA, catoplwadmevov xp emTLonTaL & os ’S vap- Onkas, OALY@ pa ov mlecavTa 7) TO Tporepor, ay p21) TOVOS TLS T)elov 7] ATO TOD oldnpat os TOD ev apn Th xevpl. eriy & emOoNS Toto Ww dfoviovas, Tous vapOnKas mepibeivar xp? Kal mepirafetv € ev TOLCL Seo potor WS Nahapworaros.y, | omog ov 7)pe- pelv, OarTe pu Sev oupParreo Oat és THY TieELY THS KELpos TH TOV vapOnkov mpoaderw. pera dé TavUTa, O TE TOvOS, ai Te paoravar ai avtal yivécOwoav ai tep Kal év Thor TpwTHOL! TepL- ddotot THY ETideolwV. émnv O€ TpLTalos ewv PF Yahapov eivat, TOT eTEtTa yYpr TOvs vapOnKas épelcac0ar, wadtoTa Mev KaTA TO KATHYMA, ATA Kal TadAAa KaTa AOyov, rep Kal 1 érridects xara dpa.” faXXov 3) emieter. TAXUTATOY be xp?) elvat Tov vapOnKa 7 7 eféorn TO KATHY [La pe) Mapp TOAD. eTLTNSEVELY OE YP?) pddiora pev Kar’ iOuwpinv Tod peydhou SakTvXOv, os fn KELOETAL O vapOn€, ddra TH i) Th, poe Kara THY Tod apex pov (Ovepiny, H) TO da Teov UmEepexer év To KapT®, ad\Aa TH 7) TH Hv O€ Apa Tpos TO KaTHYypa avppépn xeto bau KATA TAUTA TLVAS TOV vapOnkev, Bpaxurépous avTous xP” Tov adrov Tovel, ws BN etevéwr Tar T pos Ta doTéa Ta uTEepéXovTa Tapa TOV KapTov" KivOuvos yap EAK WO LOS Kal vevpwv wWihworos. xpi) 5é dia Tpitns épeidery toto. vapOn& wavy ynovxyn, ovT@® TH yvoun éyovta, ws of vapOnxes hudraxhs elvexa ths
1 mpotépyct.
ON FRACTURES, vi.
it will be quite thin, while the fractured bones will be more mobile and ready for adjustment. If this is so, after seeing to the adjustment you should bandage as for splints, making a little more pressure than before, unless there is any increase of pain from the swelling on the hand. When you dress with the bandages you should apply the splints round the limb and include them in ligatures as loose as possible consistently with firmness, so that the addition of the splints may contribute nothing to the compression of the arm. After this the pain and the relief following it should be the same as in the previous periods of bandaging. When, on the third day, he says it is loose, then indeed you should tighten up the splints, especially at the fracture, and the rest in proportion where the dressing also was loose rather than tight. The splint should be thicker where the fracture projects, but not much so, and you should take special care that it does not lie in the line of the thumb, but on one side or the other, nor in the line of the little finger where the bone projects at the wrist, but on one side or the other. If, indeed, it is for the bene- fit of the fracture that some of the splints should be placed thus, you should make them shorter than the rest, so that they do not reach as far as the bones which project at the wrist, for there is risk of ulceration and denuding of tendons. You should tighten the splints every third day! very slightly, bearing in mind that they are put there to maintain
1 7.e. every other day.
* Pq. éxaddpa codd. ; but this is not Greek. Kw. omits dpa. Itl
38
10
20
TIEPI ATMON
émidéatos mpocKéovtar! arr ov Tihs amékvos elvexev émdédevTau.2
Wilk “Ap pev ovv ev el OS OTL (KaV@S TA ooréa amiOuvrat € év THOL 'TpoTEpnat emLoeoerl, Kal [NTE KUT MOL TLVES uméwoe, pre TLS EAKWOLS pndenia Uromreynrar elvat, éay xP émibedéaPat év TOIL va pOnée, éot ay Umep ELKOO LV Hmépas yevntat. ev TplnKovTa 6é pddora Thee oupT donot Kpa- TUVETAL OOTEéA TH ev T@ TX EL TO émimay" aT pees dé ovdév: dda yap Kal gvots puaeos Kal nrLKin NALKLNS Sua eper. émny Oé AVons, Udwp Gepyov KaTax eat xen Kal MeTETLOHT AL, 2 HOCOV [Lev odiy@ TlecavTa 7 TO m™ poo ben, eddoooot O€ Totow dOoviotcw 1) TO MpoTepov? Kal Erreta Sia TpiTNS nmepyns AVoaVTA eTLOELY, ETL MEV Hacov TieCoVTA, él 6€ €EXdaooct Toicw dGoviotaww. émnv é, OTaV toiat vapOnée Se0H, varomre’ns Ta ootéa pH opOas KélcOat, 7) AAO TL OYAEN TOV TETPwWLEVOD, odcat ev TO Hutoer® Tod ypovov 7 orALyw TpodOeD, Kal avOis peteTLdjoa. Sltaita dé ToVTOLCLY OlaL av pn EdKea é& apxiys yévntat 7 oatéa &&w é€ic Xn, apKel vropavhy. [opxpov TL Kal yap|4 évOeéa TEpov © xPn dvarTav ax pus Tyme peo d€éxa, ate 5) Kal €Awvovtas Kal dYrotow amradoior XphoPar oT0ca TH bueEddep MET PLOTH TA Tapa- TX ITE, oivou b¢ Kal Kpenpayins amTréxeoOau* émeuta HEVTOL x TpoTayoryhs dvaropller Par. OUTOS O AOYOS WomeEp vomos KElTaL Sixatos Trepl KaTnyuaTwV inolos, ws TE YEupitey Xp, Ws TE atoBaivey amo Tis Sucains xerpiEcos: 6 te O av pn ovTwS aTroBaivyn, eidévat xp OTL ev TH
1 rpocxewvta Vulg.: mpooxéara: Kw.
112
ON FRACTURES, vi-vi.
the dressing, but not bound in for the sake of pressure.
VII. If you are convinced that the bones are sufficiently adjusted in the former dressings, and there is no painful irritation nor any suspicion of a sore, you should leave the part put up in splints till over the twentieth day. It takes about thirty days altogether as a rule for the bone of the forearm to unite. But there is nothing exact about it, for both constitutions and ages differ greatly. When you remove the dressing, douche with warm water and replace it, using a little less pressure and fewer bandages than before; and after this, remove and re-apply every other day with less pressure and fewer bandages. If, in any case where splints are used, you suspect that the bones are not properly adjusted, or that something else is troubling the patient, remove the dressing and replace it in the middle of the interval or a little sooner, Light diet suffices in those cases where there is no open wound at the first, or protrusion of the bone, for it should be slightly restricted for the first ten days, seeing that the patients are resting; and soft foods should be taken such as favour a due amount of evacuation. Avoid wine and meat, but afterwards gradually feed him up. This discourse gives a sort of normal rule for the treatment of fractures, how one should handle them surgically, and the results of correct handling. If any of the results are not as described, you may
2 emidewyrat Vulg. : émidedéara: Kw.
3 weonyd.
* So Galen and some MSS. Omit Littré, Erm. Kw. 5 évdeeartepoy 5¢.
1i3
30
40
47
10
TEPI ATMQN
eepifer Tb evdees meTroinTal 1 mer NeovagTat. éte O€ Tabe xen T™ poo a uveevat év TOUT@ TO aT T POT, a@ ov KapTa. em LpehEOvTAL ol int pot, KaiToL Tacav pedéTnV Kal wacav éridecw oid Te Olvapeipe éott, a) opOas Tovevpevas iv yap Ta pev ootéa Audw KaTHYyH, 1) TO KaTw pobvor, o oe CHD EaCHSUCS. év Tawiy TLL THY xEtpa EXn avareappevny,» TuyKxavy 88 9 n Tawin KaTa TO KaTNYy La TeioTn €ovca, evOev bé Ka évOev 7) xXElp atratwpytat, ToUTOV avayKn TO oa TEOv evpeO hvac OverTpay.pevov EXovTa m™pos TO avo pépos: yw dé, KATENYOTOY Tov daréov obTws, depny TE THY xetpa év TH Tawin éyn Kal mapa Tov Hee 0 O€ adXos TAXYS [ui]? HeTéEwpos 7; ovTas ® eUpeOnoeras TO oaTéov és TO KaT@ pépos deat pappevas € EXOV. Vpn) ovV, ev Tawvin TAT OS exovon, pardakh, TO TAELTTOV TOU THXEOS Kal TOV Kapmov THS xELpos OLANOS aiwpeta Pav. VIII. *Hv be 0 Bpaxtov KaTayn, ay peév TUS aToTaviaas TI Xetpa év TOUT® TO TX MATL duateivy, 0 pos Tob Bpaxtovos KATATETAMEVOS érideOncetar eri 8 émidebels ocuyKapyn Tov ayKava, 0 pis ToD Bpaxeovos ado oxi wa TXNCEL. SuKaloTraTn ou Bpaxiovos KaTaTaous 78" EvNov amnxXvatov H OdLy@ Bpaxurepon, orrotou ot orethatot elot TOV TKadiwY, KpE“da at YPN évOev Kal évOev, relph onoavta: xadioavta 6€ TOV avO pom ov emt _UYnrob TiVOS, THY xetpa umep- Keio Gat, QS umo Ti) paaXary yévntat 0 oTELAALOS Exov ocuumeTpas, WaoTE Mods SvvacOat Kaliv-
1 GvarcAaumeves.
114
ON FRACTURES, vu.—vu.
be sure there has been some defect or excess in the surgical treatment. You should acquaint yourself further with the following points in this simple method, points with which practitioners do not trouble themselves very much, though they are such as (if not properly seen to) can bring to naught all your carefulness in bandaging. If both bones are broken, or the lower (ulna) only, and the patient, after bandaging, has his arm slung in a sort of scarf, this scarf being chiefly at the point of fracture, while the arm on either side is unsupported, he will necessarily be found to have the bone distorted towards the upper side; while if, when the bones are thus broken, he has the hand and part near the elbow in the searf, while the rest of the arm is unsupported, this patient will be found to have the bone distorted towards the lower side. It follows that as much as possible of the arm and wrist should be supported evenly in a soft broad scarf.
VIII. When the humerus is fractured, if one extends the whole arm and keeps it in this posture, the muscle of the arm! will be bandaged in a state of extension, but when the bandaged patient bends his arm the muscle will assume another posture. It follows that the most correct mode of extension of the arm is this :—One should hang up a rod, in shape like a spade handle and of a cubit in length or rather shorter, by a cord at each end. Seat the patient on a high stool and pass his arm over the rod so that it comes evenly under the armpit in such a position that the
1 Biceps.
2 Omit; but Galen defends both readings (xviii(2). 415), 3 oiTos . . . dieaTpaupevoy Exwy.
E15
20
30
40
TWEPI APTMON
vucOat Tov avOpwtov, cpixpod SéovTa petéwpov eivat: émerta Oévta tL AdrAO Ededpov, Kal Uiro- devra oKUTIVOY UmoKxepiratoy, nH & i) Treio, OTwS TUMPLET POS TXT Dypeos TOU TN XEOS marytov Tos opO ny yeviny, dpurtov pev OKUTOS TraTY Kat padOakov 7 Talvinv mraTény aude- BadXovta, Tov weydrov Tt oTAaO pion éEapTicat, 6 TL peTpleos efeu KaTarelvely® et Oe Hy TOV dvd pov doTls Eppwpevos, ev TOUT TO TXHMATL TOU TXEOS €0vT0s Tapa TOV ayKava KaTavay- KaleTw &s TO KaT@. 0 O€ int pos opAos peev eo neupelereo, Tov ETEpov moda emt iYynrorépov TLVOS éyov, KatopOwaas Oé Totct Bévapor TO daréov" pnidios b¢ KaTop0woetat: arya yap 7 Kara- oTacts,) Hv Tes KaNOS TapacKevdonTat. émerta ETLOELTW, TAS TE apyas PBanrdopevos él TO KaTnypa, Kal Tara TUYTaA WaOTTEP TPOTEpPoOV mapyvedn, xetpefera Kal EporTi mara. TavTa epoTara Kal onpetowoe xprjo Peo Totow avtotat, El peeTpios exer, 7 ov: Kal dia TpitTyns érrideiTa, Kal émt wadrAov meeléTw. Kal EBdopaiov 7 év- vataiov év vapOné& dnodta: Kal nv bTontevon bt) KaX@S KEelcBaL TO OoTéov peEeonyd ToOUTOV TOD Xpovov, AvoaTw, Kal evOeTLTapEvOS peET- ETLONT ATO.
Kpardveras dé padora Bpaxiovos datéov év TecoapaKovta Hmepnow. emp d€ Tavtas umepBary, Avewv xP» Kal éml Hhooov meétew Totow dOoviocs Kal el EXdoooow émideiv. Siat- tav 6€ axpiBeotépny Tiva %) TO TpoTEpov SvacTay, kal wAelw ypovov: Texpaipecbas b€ mpos Tod oidipatos ToD év akpn TH Nelpl, THY pomnv 116
ON FRACTURES, vut.
man can hardly sit and is almost suspended. Then placing another stool, put one or more leather cushions under the forearm as may suit its elevation when flexed at a right angle. The best plan is to pass some broad soft leather or a broad scarf round the arm and suspend from it heavy weights sufficient for due extension; failing this, let a strong man grasp the arm in this position at the elbow and force it downwards. As to the surgeon, he should operate standing with one foot on some elevated support, adjusting the bone with the palms of his hands. The adjustment will be easy, for there is good extension ! if it is properly managed. Then let him do the bandaging, putting the heads of the bandages on the fracture and performing all the rest of the operation as previously directed. Let him ask the same questions, and use the same indications to judge whether things are right or not. He should bandage every third day and use greater pressure, and on the seventh or ninth day put it up in splints. If he suspects the bone is not in good position, let him loosen the dressings towards the middle of this period,? and after putting it right, re-apply them. The bone of the upper arm usually consolidates in forty days. When these are passed one should undo the dressings and diminish the pressure and the number of bandages. A somewhat stricter diet and more prolonged (is required here) than in the former case. Make your estimate from the swelling in the hand, having an eye to the patient’s strength.
1 Reading kararaois. 2 7.e, the period in splints.
4 xatdtacis Galen Kw.
117
60
10
TEPI ATMQON
opewr. Tpooawvievat bé xp? Kal Tabe, OTL O Bpaxtov KUpPTOS méepuKey és To &&o peposs és TOvTO Tolvuy TO [Epos prrel diaatpepec bar, émrny ery Karas int pevn as aTap Kal Tada mara oaréa és Omrep TephuKE Svea Tpappeva, € és ToUTO Kal intpevopeva pret dvaatpéherOar, € emmy KaTeayi. Ypn ToivuV, eTIVY TOLOUTOV TL vromreunTal, Tawiy TATED TpoceT hap Saver TOV Bpaxiova KUKXO mept TO atHGos Tepidéovta: Kal ery dva- mavecOat perry, meTnyU TOU ayKa@vos Kal TaY TNEUPEWV omN iva Twa TOUT TUX OY mrveavra brotevas, 1) u ado TL O TOUTO EorKev: oUTw yap av i0v1 To KUpT Opa TOU oaréov yevorto: purdo- ceo Gar dé péevtTo. Xp, OTwS 1) 7 ayav és TO éow pépos.
IX. [lovs dé avOpwmou eK TONY Kat Oo LK P@V Oo TEWY ouyKetrar, @oTep Kal xelp apn: Kar ayvuras fev ov mavu Tt Tatra Ta OoTéa, IV pay oy TO Xpeort TUT P@OKOMED(D uTrO og€os TLVOS » Bapéos” TQ bev Ov TUTpwWTKOmEVa, év ELKe@oiwv jeéper elpnoeTar Os xen int pevew. ny O€ TL neh ex THs XOpnS, H TOV SaxTUAMV apO pov 7) GXXO TE TOV orev TOU Tapoov Kahoupévou, dvarynatery jpev xen és THY EwuToU yopny ExaoTop, @oTEp Kal Ta év TH xeupl elpntau’® intpevew O€ KNpwTh Kal omdnvert Kat dOoviotct @ontep Kal TA KATHYpaTA, TAY TOV vapOijKwr, TOV {Lev AUTOV TPOTTOV muetevvTa, dia tpitns 6é émdéovTa* Urroxpiver Bw dé 0 ET OO LEVOS Tapa- TIT, old mep Kal év Toto KATHYLACt, Kal mepl ToD TeTlevOat Kal Tepl TOU YaXapov eivat.4
1 Gdopdéraroy B. Kw. ja) MV Pa. Littré. 118
ON FRACTURES, vin.-1x.
One must also bear in mind that the humerus is naturally convex outwards, and is therefore apt to get distorted in this direction when improperly treated. In fact, all bones when fractured tend to become distorted during the cure towards the side to which they are naturally bent. So, if you suspect anything of this kind, you should pass round it an additional broad band, binding it to the chest, and when the patient goes to bed, put a many-folded compress, or something of the kind, between the elbow and the ribs, thus the curvature of the bone will be rectified. You must take care, however, that it is not bent too much inwards.
IX. The human foot, like the hand, is composed of many small bones. These bones are not often broken, unless the tissues are also wounded by some- thing sharp or heavy. The proper treatment of the wounded parts will be discussed in the section on lesions of soft parts.1 But if any of the bones be displaced, whether a joint of the toes or some bone of what is called the tarsus, you should press each back into its proper place just in the way described as regards the bones of the hand. ‘Treat as in cases of fracture with cerate, compresses and bandages, but without splints, using pressure in the same way and changing the dressings every other day. The patient’s answers both as to pressure and relaxation should be similar to those in cases of fracture. All
1 Rather “‘ compound fractures,” cf. XXIV, XXV. Galen defines €Axos as a lesiun of a soft part.
2 xpdés = 7d capr@es (Galen). * A lost chapter, condensed in Moch. XVI, Joints XXVI. # yahar
119
20
29
10
17
TIEPI ATMON
e / \ lf 3 yy € / i? Uytéa 6€ yiverar ev elxoow nuépnot Tedréws amTavTa, TAY OTOTa KOLV@VEL TOLCL THS KVHLNS dotéotat Kat avTH TH Ee. aupdéper S€ KaTa- Keto0at TovTOY TOV Ypovov. adda yap ov TOAMEOUG LY imrepopavres TO voonma, Ara TEpL- épxovrar mpl vytées yevécOar. dia TovTO Kal Ob WAELTTOL OVK eEvytatvoucr TEAEWS. GAA TOANGKES QUTOUS O 0 ToVvosS DMO LVI T KEL elKOT@S, ddov yap TO ax Gos Too TOMATOS ot m08es Ove- ovol. o7roTav ovy pijtw wyLées éovTes odou- Topéwat, Pavpws cvvahOdcoetar® Ta apOpa ta con bevra: dla TOvUTO addotE Kal addoTe odoc- TOpEovTeEs oduvavrat Ta T pos TH KYB.
X. Ta dé KOLV@VEOV Ta ToloL TAS KVHLLNS daréowat pellw Te TOV érépav €otl, Kal KuvnOevTwY ToUTwY TOAUXpove@rEpn 7 &dOckis. —inaoes bev ow avTn" aPoviorse 6é Tretooe ypnolar Kal omdn- veol, Kal er may evOev Kal &vOev émibetv- meer dé woTep Kal Taha TAVTA, TAVTN paroTa 7 exw On, Kal Tas TpPoTas mepiBoras tov dOovior Kata TavtTa TrovetoGar év 6€ Exdotn TOV aTrOAV- aiwy voaTt TOAD Gepue XeHo Gar év maou 6é TONDOV vowp Kataxel Tote Kar’ apOpa oiveow. ai dé meELes Kal al Narddoves €v ToLow avroioe Xpovoree Ta aUTA onpeta SeckvvovT wv arep emt Toio mpoabev Kal Tas petemdéotas acavTas vpn TovetcOar. wryrées 6€ TEA<WS OTOL yivovTaL é€v TeooepdKovTa Heepnoe Hadiora, Hy ToApEwo Kataxeio@as inv b€ py, TacxXovot TavTa & Kal ™ poTepov, Kal éml madrov.
XI. “Ooo 6€ mndijcavtes ad’ tyynrod Tivos
l kar’ abrhy thy ti.
I20
ON FRACTURES, 1x.-x1.
these bones are completely healed in twenty days, except those which are connected with the leg-bones in a vertical line. It is good to lie up during this period, but patients, despising the injury, do not bring themselves to this, but go about before they are well. This is the reason why most of them do not make a complete recovery, and the pain often returns ; naturally so, for the feet carry the whole weight. It follows that when they walk about before they are well, the displaced joints heal up badly ; on which account they have occasional pains in the parts near the leg.
X.1 The bones which are in connection with those of the leg are larger than the others,’ and when they are displaced healing takes much longer. Treatment, indeed, is the same, but more bandages and pads should be used, also extend the dressings completely in both directions. Use pressure, as in all cases so here especially, at the point of displacement, and make the first turns of the bandage there. At each change of dressing use plenty of warm water; indeed, douche copiously with warm water in all injuries of joints. There should be the same signs as to pressure and slackness in the same periods as in the former cases, and the change of dressings should be made in the same way, ‘These patients recover completely in about forty days, if they bring themselves to lie up; failing this, they suffer the same as the former cases, and to a greater degree.
XI. ‘Those who, in leaping from a height, come
1 Displacement of the astragalus ? 2 “Those of the wrist.” Adams.
3 guvadbeirat. 121
LO
20
TTEPI ATMQN
éatnpi—avto TH TTéEpvn taxupas, TovTas Stic- TavTar pev Ta ootéa, PréBia Se exyumodvtrar appipracbeions ths capKos audit TO dcrtéov, old ju dé _emruyiver at Kal TOvOS TORUS. TO yap daTéov TOUTO OU o [LL pov eoTt, Kal Umepéever peep vmd THY (Ove piny Tis KV}LNS, KoWwevel dé fret kal vevpolae (em iKatpoioe: 0 TEVOY be omlabtos TOUT TpoarpTnTat TO OOTEO. ToUTOUS xen intpevery ev KnpwTH Kal omdinere kal obovt- ovoiv voaTe b€ Oepu@ TAclaTw éml TovTOLGL ypnc0at Kail oboviwy TrELOvwY etl ToOvTOLGL Set Kal dAXwsS @s BerXTicTwY Kal TpoTnVErTaTOD. Kat ny pev TUXN amr andy 70 Sépya puaet Exov TO appl Th TTEpvy, eav ovTa@s: ny Oe Tax Kal oKAnpov, ola peteférepor ioxovowr, KATATAMLVELY Xpr OMaras Kat vareTTUvELW, py StaTLTPwWOKOVTA. émdeiy 5é ayabas ov Tadvtos avdpos éote Ta TolavTa’ Hv yap TLS érLdén, WoTTEp Kal Ta AANA Ta KaTa Ta ohupa éerideitar, Ste wey Tepl Tov Toda meptBardopevos, éte O€ TreEpl TOV TévovTa, ai arroapiy Eves avrat xepivovar THY mWTEeEpynv 7 TO prdopa eyéveTor Kal obTe KivSuvos opa- KeAloaL TO GaTEOY TO THS WTEépyyns' KalTOL HV ahakedion, TOV al@va Tavta ixavov avticyew TO vor nua. Kal yap Tada dca wn ek TOLOUTOU TpOTroU opaxediver, GX’ €v KATAKNLGEL peday- Oeions THs TTEpPUNS vm apeheins Tou TXNMATOS y év Kvn TPOMaTos yevopevou emuKaipou Kat xpoviov Kal Kowod TH mTEpVN, %) év unp@ y} én ado VOT Mare imrTiag woo Npoviou ryevopLevov, omas Kal Totoe TOLOUTOLTL Xpovia, | Kal oxrwsea Kal TOAAdKLS avappnyvipeva, Vv bw) NPNTTH jen 122
ON FRACTURES, x1.
down violently on the heel, get the bones separated, while there is extravasation from the blood-vessels since the flesh is contused about the bone. Swell- ing supervenes and severe pain, for this bone is not small, it extends beyond the line of the leg, and is connected with important vessels and cords. The back tendon! is inserted into this bone. You should treat these patients with cerate, pads and bandages, using an abundance of hot water, and they require plenty of bandages, the best and softest you can get. If the skin about the heel is naturally smooth, leave it alone, but if thick and hard as it is in some persons, you should pare it evenly and thin it down without going through to the flesh. It is not every man’s job to bandage such cases properly, for if one applies the bandage, as is done in other lesions at the ankle, taking one turn round the foot and the next round the back tendon, the bandage compresses the part and excludes the heel where the contusion is, so that there is risk of necrosis of the heel-bone; and if there is necrosis the malady may last the patient’s whole life. In fact, necrosis from other causes, as when the heel blackens while the patient is in bed owing to carelessness as to its position, or when there is a serious and chronic wound in the leg con- nected with the heel, or in the thigh, or another malady involving prolonged rest on his back—all these necroses are equally * chronic and troublesome, and often break out afresh if not treated with most
1 Tendo Achillis, 2 §ua@s, Littré’s emendation for éuws, ‘‘ nevertheless” (Kw. and codd.),
1 qhy mrépyny.
123
40
50
60
TEPI ATMON
perETY OcparrevOh, TORT é hovxin, @S TA Ye opaxehivovra €x TOU ToLOUTOU O€ TpoTrou opaxe- Aifovra Kal KLYOUVOUS peyddous TO TWOMATL TapeXet Tpos TH addy AUN. Kal yap TupeTol Umepokees, TUVEX EES, Tpope@oecs, Avyyosecs, qvopns amr TOMEVOL, Kal ONery I] [EPOL KreivorTés TE yévowTo © av Kal prcBov ai woppowy TEALWOLES vapKracves ” Kat yayypawocces ume THs méEos* yévowto & av Tavra ew TOU aou opaKedic pov. TAUTA ev ob elpntat, ola Ta ioxuporara prado pata yiverau TA LEVTOL TAELTTA nouxatos appt prarar Kal ovdeuin wo) o7rovdn THS HErETNS, ann Opes opOas ye det xeepiber. emmy pévTOL ia xupov S0&y elvan TO épetopa, TA TE elpnpeva Toteiy Ypy, Kal THY émideow TH mrELaTnVY TolEicPar appt Ty mT épynv Tept- BdddXovta, adrNoTe TPOS TA AKpa Tod TrOb0s dytimeptBadrovra, dddoTE Tpos TH pleca, addoTeE T pos, Ta mept THY Kung T poem .Oety d€ Kal Ta Tyo Lov TavTa evOev. Kal ever, Oomep Kal m™ poo Oev elpntar' Kat loxupiny pev py) moveia Oat Thy mlekiv, év modNotot O€ TotoLY OPoviotow. dpewvov de Kat EXAEBopov mimic KEL 2 avOnwepov ) TH VaTepaln’ amoddaar Se Tputatov Kal avdis peremdijo-ar. onpcia dé Ta0e, et madwyKoraiver 7 ou" emny wey Ta exXU MOAT a Tov preBav Kat Ta peddopata Kal Ta eyyvs éxelvov mépvOpa yivntat Kal UrooKhnpa, Kivouvos TANLYKOTHT AL GX” pV pev dm UpeTos Db pappa- KEVELV se Xpy, OoTTEp elpnTat, Kal Goa av 7) ouveyh 3 muperaivnrac® iy be ouvey TupeTat- pntal, ui pappaxevew, améyew S€ olTiwy Kab
124
ON FRACTURES, x1.
skilful attention and long rest. Necroses of this sort, indeed, besides other harm, bring great dangers to the body, for there may be very acute fevers, continuous and attended by tremblings, hiccoughs and affections of the mind, fatal in a few days. There may also be lividity and congestion of the large blood-vessels, loss of sensation and gangrene due to compression, and these may occur without necrosis of the bone. The above remarks apply to very severe contusions, but the parts are often moderately contused and require no very great care, though, all the same, they must be treated properly. When, however, the crushing seems violent the above directions should be observed, the greater part of the bandaging being about the heel, taking turns some- times round the end of the foot, sometimes about the middle part, and sometimes carrying it up the leg. All the neighbouring parts in both directions should be included in the bandage, as explained above ; and do not make strong pressure, but use many bandages. It is also good to give a dose of hellebore on the first and second days. Remove the bandage and re-apply it on the third day. The following are signs of the presence and absence of aggravations. When there are extravasations from the blood-vessels, and blackenings, and the neighbouring parts become reddish and rather hard, there is danger of aggrava- tion. Still, if there is no fever you should give an emetic as was directed; also in cases where the fever is not continuous; but if there is continued fever, do not give an evacuant, but avoid food, solid
1 vavoidores (regurgitations), Galen and most MSS., but hard to accept. 2 rio, ® guvexei. 4 guperalyy bis.
125
70
76
10
10
TEPI ATMON
podnudtav, mote 5é ypjobar bdate Kal pH oive, ada TO oEvydvKes. ay b€ wy WéAAN TANLYKO- Taivewv Ta exXup@pmara Kal Ta Heddo para Kal Ta TEPLEXOVTA, vmoxAwpa yiveTat Kal ov oKAnpa aryab ov TOUTO TO papTupvov év Taoe Tolow éx- Yupwopacl, Tolot py péAdovol TaduyKoTaivey Oca 6€ ovY TKANPUT MATL TeALOUTAL, xlvouvos bev HeravO hvac. Tov 6é T00a émuTnOevew xP? bK@S avOTEpo Tou dddou TOMATO éotat Ta TAEloTAa OALyoV. wyins O dv yévorto év EEjKovTA nmEepnaw, eb aTpeuel.}
XII. “H dé Kkvnun S00 datéa éxes,2 TH pev cvXYVO heTwTOTEpov TO EtEpov Tod Etépov, TH Sé OV TOAA@ AEmTOTEpov: auVéxEeTAaL € GNANXOLOL Ta TWpos TOV TodOs, Kal éeridvaow KoLWHy EXEL, év (Ovwpin S&€ Ths Kvnuns ob avvéyetat: Ta O€ Mpos TOV unpod cuvéxeTat, Kal eTidvow EXEL, Kal n étidvots Orava? paxpotepov dé To [érepov] doTéov culkp® TO? KaTa TOY GpLKPOV SaKTVAOY* Kal wev pots ToLa’TN TOV doTéwY TAY ev TH KUHN.
XII. "OdrcOdver 8 oti Ste Ta pwev pds TOD TO00s, OTE pev GY TH eTIpvoe aupoTepa Ta OoTéa, OTE O€ 1) emridvors exwvyOny, STE Sé TO Erepov ootéov. tavTta oé oxadea bev io cov y) Ta évy TO KapT@ TOV XELPOV, EL TOA @ED aT pepe ot éivOporror. inaus 5€ Taparhyoin, olin Téep exelvov* Tv TE yap eu Bodny xP” moveio Gat é€xk KaTa- TAG LOS, Oomep exelvor, ioxuporéepys 6 detras TIS KaTaTaoos, ba@ Kal ioxuporepov TO coma TavTy. és dé Ta mreloTa pev apxéovow dvdpes
1 arpeucor. 2 early.
126
ON FRACTURES, x1.—x111.
or fluid, and for drink use water and not wine, but hydromel may be taken! If there is not going to be aggravation, the effusions and blackenings and the parts around become yellowish and not hard. This is good evidence in all extravasations that they are not going to get worse, but in those which turn livid and hard there is danger of gangrene. One must see that the foot is, as a rule, a little higher than the rest of the body. The patient will recover in sixty days if he keeps at rest.
XII. The leg has two bones, one much more slender than the other at one end, but not so much at the other end. The parts near the foot are joined together and have a common epiphysis. In the length of the leg they are not united, but the parts near the thigh-bone are united and have an epiphysis, and the epiphysis has a diaphysis.* The bone on the side of the little toe is slightly the longer. This is the disposition of the leg-bones.
XIII. The bones are occasionally dislocated at the foot end, sometimes both bones with the epiphysis, sometimes the epiphysis is displaced, sometimes one of the bones. These dislocations give less trouble than those of the wrist, if the patients can bring themselves to lie up. The treatment is similar tuo that of the latter, for reduction is to be made by extension as in those cases, but stronger extension is requisite since the body is stronger in this part. As a rule two men suffice, one pulling one way and one
1 A decoction of honeycomb in water, cf. Galen xviii(2). 466. * Spinous process or medial projection,
3 Pq. 7@ for te codd.: omitting ¢repoy ef. XVIII, XXXVI,
127
20
30
40
TIEPI ATMON
dvo, 6 pev evev, 0 6€ évbev TELVOVTES. Ay &é ps) iaxvoow, io uporépny pnidvov €oTL TroLely THY KaTaTacwy: Q yap mn pevny KaTtopvéavta xP, }) AXXO TL G TL TOUTM EouKen, panrlaxov TL mept Tov m00a mepiBdnrrew* emretTa, mhatect Boetouo (maou Tepioyoavra Tov 7000. Tas apxas Tov ipavtav } 7 pos Orepov 7) 7 pos Erepov Evhov TpocdnaavtTa, TO over 7 pos THY TAN NY akpov évtiOévta eravakhay,) TOUS b€ a avreretvew dvabev, TOV Te Cov EXOMEVOUS Kal THS byvuns. €ote O€ Kal TO ave TOU TWMATOS aVayKN Tpooha- Beiv tovto péev nv BovrAH, EVAOV oTpoyyvAor, Aelov, Katopv—as Babéws, pépos TL avtod UTEepexov Tov Evhou peonyv TAY aKEréov Tomaacbat Tapa TOV mepivavov, Ss Kohvn aoroudeiv TO oO wa Toto T pos Today Telvou- ow ETELTA TPOS TO TELVOMEVOV GKEAOS Li) PETrEL, Tov 6é Tia TAY LO maparabrwevov atr@betv TOV YrouTov, és [1 Tepredenrar TO capa. TOUTO 6é Kal nv Bovnry, Tept Tas pacxXaras évOev Kat évOev Ta EUAa raparémnyev,” ai bé Yelpes TapateTapévar puddooovrat,® Tpocent- hapBavere 4 o€ TLS Kata TO 7ovu, kal OUTS GVTLTELVOLTO. ToUTO & iv mapa To youu Bovrn- Tau,” aAXous imavras Teployjaas kal Tept Tov penpov, Tajpyny aXdnv vmép Keparns Katopvtas, eEapTynaas Tous imavTas éx TWOS Evdov, TO EUNov oTnpil@y &€s THY TAHLINY TavayTia TOY TpOS moo@y édxev. TodTo 8 hv Bovryy, avtTl Ttav TAnuvéwy oxida UToTteivas vmod THY KALYHY peTpinv, erecta mpos THs Soxidos évOev Kal évOev Thy Keparyy otnpitov Kal avakdov ta Evra, 128
ON FRACTURES, xn.
the other, but if they cannot do it, it is easy to make the extension more powerful. Thus, one should fix a wheel-nave or something similar in the ground, put a soft wrapping round the foot, and then binding broad straps of ox-hide about it attach the ends of the straps to a pestle or some other rod. Put the end of the rod into the wheel-nave and pull back, while assistants hold the patient on the upper side grasping both at the shoulders and hollow of the knee. The upper part of the body can also be fixed by an apparatus. First, then you may fix a smooth, round rod deeply in the ground with its upper part projecting between the legs at the fork, so as to prevent the body from giving way when they make extension at the foot. Also it should not incline towards the leg which is being extended, but an assistant seated at the side should press back the hip so that the body is not drawn sideways. Again, if you like, the pegs may be fixed at either armpit, and the arms kept extended along the sides. Let someone also take hold at the knee, and so counter-extension may be made. Again, if one thinks fit, one may like- wise fasten straps about the knee and thigh, and fixing another wheel-nave in the ground above the head, attach the straps to a rod; use the nave as a fulerum for the rod and make extension counter to that at the feet. Further, if you like, instead of the wheel-naves, stretch a plank of suitable length under the bed, then, using the head of the plank at each end as fulcrum, draw back the rods and make exten-
1 éyOévra avakAar. 2 mrapamennyn- 8 puAdoowrTat. * wapemiAauPavnTas 5 BovAn.
129 VOL. III. F
50
58
10
IWEPI ATMON
KaTaTElvELY TOUS imavtas: Hv b€ Oédns, dvicKoUS KaTaotyoas évlev Kai evOev, em’ éxeivov tHv KaTaTaow TroveiaGar. morrot b€ Kat adAXoL TpoTroe KataTac tov: dptorov dé, bors €v TrodeL peryann int pever, Kextnobat €oKevac pévov Ev)op, év @ maoar at avayKat éoovtat Tavt@v pev KAT NY LaTov, Ta TOV € apOpev éuBorgrns &x KaTAT Ao LOS Kal poxAevatos: dpret dé To Evry, Wy 7 ToLodTov olov ot TeTpdywvoL oTUNOL OLoL Spuivor yivovTat, pijKos Kal TNATOS Kai TAXOS.
"Emnv 6é iKavas Katatavvays, pytosov 6n TO ap6 pov euBareiv: UTEpatwpeltar yap és LOvepiny vmép TAS apxatns eopys. Karopbotabat ouv xP? toiat Oévapor Tov XE(pav, Tolol pev és TO éFeaTnKos épeloovta, Toiar dé él Oatepa KaTwre- pov Tov adupov avTepeioovTa.
XIV. "Ex 8 éeuBarns, vy péev olov te FH, KaTaTeTapmévov émideiy yxpy nv b€ KwAUNTAL vmod TOY iLadvT@V, ékelvous AVCAaVTAa aVTLKaTa- Teivetv, oT av éemidnans. émideiy b€ TOV avTOV TpOTToV Kal TAS apYas wWoa’TwS Baddopuevoy KaTa TO 退eaTnKOS, Kal TAS TepL_Boras Tas TpwTAS TA€LTTAS KATA TOUTO ToLelcbaL, Kal TOLS OTANH- vas WAEeloTOUS KATA TOUTO, Kal THY mie~W uddtoTa KaTa TwWUTO TpoceTLbety b€ Kal évOeED kat évOev éri oUX Vor" paddov oé TL TOUTO 70 ap pov memlexGar xpn ev TH TpPOTn emLoevel 7} a TO €v TH XEUpt. ery O€ émidijons, av@Tépw@ wey Tov aAAov cwpaTos exéTW TO éTLdeDEV, Ti bE Oéow Set mroveicPat ovTws, OTwS KioTAa aTALW-
130
ON FRACTURES, x11.-x1v.
sion on the straps. And if you choose, set up wind- lasses at either end and make the extension by them. There are also many other methods for extensions. The best thing for anyone who practises in a large city is to get a wooden apparatus comprising all the mechanical methods for all fractures and for reduction of all joints by extension and leverage. This wooden apparatus will suffice if it be like the quadrangular supports such as are made of oak? in length, breadth and thickness.
When you make sufficient extension it is then easy to reduce the joint for it is elevated in a direct line above its old position. It should therefore be adjusted with the palms of the hands, pressing upon the projecting part with one palm and with the other making counter pressure below the ankle on the opposite side.?
XIV. After reduction, you should, if possible, apply a bandage, while the limb is kept extended. If the straps get in the way, remove them and keep up counter extension while bandaging. Bandage in the same way (as for fractures) putting the heads of the bandages on the projecting part and making the first and most turns there, also most of the compresses should be there and the pressure should come especially on this part. Also extend the dressing considerably to either side. This joint requires some- what greater pressure at the first bandaging than does the wrist. After dressing let the bandaged part be higher than the rest of the body, and put it up in a position in which the foot is as little as
1 Adams’ ‘‘ threshing boards”—Littré’s tpiSoAo, a rash suggestion which he afterwards withdrew. * The nature of these dislocations is discussed on pp. 425 ff.
13
30
36
IEPI ATMON
pnOnoerar 6 Tovs. Tov Ooé€ io xvac pov TOU T@MATOS oUT@s moveia Oat, omroiny Tiva Sdvapuy éyveu Kal TO Od\toOnwa: Ta per yap T HLLK POV, Ta dé péya oro Odvet. TO érimay be io xvaivew adhov Kal éml rete Xpovov x pty ev TOLoL een TA oKENEA TPOLATL 7) ev TOlTL KATA Tas xelpas:? Kal yap pélw kal TayvTEepa TadTa exelvwr" Kal Hn Kal avayKatoy édwWvEW TO Toma Kal KaTa- KeloOar. peteTionoat O€ TO apOpov ovTE TL KWAVEL TPLTALOVY oUTE KaTeTTELyEL* Kal Ta GAA TdavTa TapaTAnolws YXpr) inTpEevetv, WoTEP Kal Ta Ta poLxopera. Kal Vv pev TOW aT pepa cataxetobar, ixaval TecoapaKovta mee pat, ay podvov és Thy é@uT av Xeopny Ta Ostéa adds Kabibnras iy b€ pn Oéryn aTpemeiv, Xp@TO pmev dv ov padtars * TO oKE)eL, émdetabar b& avay- Kacor ay moby Xpovov. OTOTa MévTOL TOV ooTéwy a) TEAEWS iGeu és TI EWUT@V Xeopny, anna TL emchetmet, TO Npove AemTUVETAL to xtov Kat pnpos Kal Kump’ Kah av pev &ow orion, 70 é&w pépos Lew TUVETAL, ay bé€ é&w, TO ecw? Ta mAElaTa O€ €S TO eo odio Gaver.
XV. "Erny é KUN UNS dared ch OT Epo, KaTayn dvev EAK@TLOS, KATATACLGS laxuporépns delta. Teivetv ® TovToY TOV TPOTOY éviotolt TOV ™ poeepn)- péevov Tic, Nv peyddae at Tapaddadé€tes Ewa. ixaval dé Kal ai aro Tov avopav KaTaTaoles: Ta Trelo ra yap apKéovev av dvo avd pes Eppoie- Vol, o pev évOev, 0 oe evOev duriTeivovTes. TelveLy Sé és TO 100 ypy Kata dtow Kal Kata THY
1 kath Xeipa. 2 Bpadéws, omit ed. 8 watatelvew.
132
ON FRACTURES, xiv.-xv.
possible unsupported. The patient should undergo a reducing process corresponding to his strength and to the displacement, for the displacement may be small or great. As a rule the reducing treatment should be stricter and more prolonged in injuries about the leg region than in those about the arm region, for the former parts are larger and stouter than the latter, And it is especially needful for the body to be at rest and lie up. As to rebandaging the joint on the third day, there is neither hind- rance nor urgency, and one should conduct all the other treatment as in the previous cases. If the patient brings himself to keep at rest and lie up, forty days are sufficient, provided only that the bones are back again in their places. If he will not keep at rest, he will not easily recover the use of the leg and will have to use bandages for a long time. Whenever the bones are not completely replaced but there is something wanting, the hip, thigh and leg gradually become atrophied. If the dislocation is inwards the outer part is atrophied, if outwards, the inner: now most dislocations are inwards.
XV. When both leg-bones are broken without an external wound, stronger extension is required. If there is much overlapping make extension by some of those methods which have been described. But extensions made by man-power are also sufficient, for in most cases two strong men are enough, one pulling at each end. The traction should be in a straight line in accordance with the natural direction
1 Not merely prevented from hanging down, but kept at right angles to the leg (cf. Galen). 2 7.e. of the foot outwards and the leg inwards,
133
10
20
30
40
TIEPI ATMON
(Ovepinv TS KUNLNS Kal Tod pnpod, Kal Ag KvIuNS datéa Katenyvins KaTaTElWys, kal Vv pnpod. Kal emucetv 6€ ovT@s EXTETAMEVOV apuporéepor, OTOTEpov av TovTwY em 1oens” ov yap TavTa gupeper oKédel TE Kal xeELpt TIXEOS ev yap kal Bpaytovos ernv emidelaow 6 ooréa KaTenyora, dvahapPaverat 1 xetp, Kal my exTeTapeva emoeys, Ta TX MATA TOV TapKar erepovodTat ev 7H ouyKdprper TOU ayn @vos: aduvatos yap 0 ayKav exteracOae TONY Xpovov: ov yap ToAdaKls ev TowovT@ elOictat éoynuatioba., adr é€v TO cuyKexdupGar' Kai 6 Kal ate Suvapevot ot avOpwroe tepti€var cuyKxexaudbar KaTa TOV ayx@va Séovtar. aédos dé &v Te THAW odotTropinow Kal év TO éEctavat elOictat STE ev éxtetac0ar, te O€ oputxpod ety éextéTacOat Kal elOtotar Kabetcbar és TO KaTwW KaTa THY ho, Kal 61) Kal TpOos TO OXEELY TO AAXO GOLA’ Oa TOUTO evpopov avt@ éatl TO exteTaaIat, btav avayKny t éyn: Kal 6) Kal éy THaL KOLTHOL TOAAAKIS eV TO oxXnuaTL TOUT éoTly [ev TO ExTETAaOat]*® Ernv dé 67 TewOn, avayxn? Katabdovrodtar THYV yrouny, OTe adivaror petewpiver Oat yivovtat, dare ovoe HempnyTa jwepl Tov cuycaph Ojvar Kal dvacThvat, arr’ at pepéovar® év TOUT@ TO TXNMATL Ketpevol. bua obv TAUTAS Tas mpopa- gLas KELpos Kal TKEAEOS OUTE 1) KaTaTAGIS OUTE n emloerts Tod TX MATOS cuppéper ) avTn. ip pev ovv ixavn) KaTATAGLS 1) amo TOV avd pav 7; ov bet patny movetabar—kat yap _gohoreoTepov wnXavor ovety pn dev déov—ijv dé pn) ikavn 1) kata- Tacls ato TOV avdpar, Kal TOV G\NwY TWA TOV 134
ON FRACTURES, xv.
of the leg and thigh, both when it is being made for fractures of the leg bones and of the thigh. Apply the bandage while both! are extended, whichever of the two you are dressing, for the same treatment does not suit both legand arm. For when fractures of the forearm and upper arm are bandaged, the arm is slung, and if you bandage it when extended the positions of the fleshy parts are altered by bending the elbow. Further, the elbow cannot be kept extended a long time, since it is not used to that posture, but to that of flexion. And besides, since patients are able to go about after injuries of the arm, they want it flexed at the elbow. But the leg both in walking and standing is accustomed to be sometimes extended and sometimes nearly so, and it is naturally directed downwards and, what is more, its function is tosupport the body. Extension therefore is easily borne when necessary and indeed it frequently has this position in bed. If then it is injured, necessity brings the mind into subjection, because patients are unable to rise, so that they do not even think of bending their legs and getting up, but keep lying at rest in this posture. For these reasons, then, the same position either in making extension or bandaging is unsuitable for both arm and leg. If, then, extension by man-power is enough, one sould not take useless trouble, for to have recourse to machines when not required is rather absurd. But if extension by man-power is not enough,
1 7.e. thigh and leg.
1 avd-yrn. 2 Seems an obvious gloss. Most editors omit. 3 kal N avdyKn. * toApGow.
135
10
20
TIEPI ATMON
avaryKéov Tm porpépew, WvTwa ye mwpooywpén.) dtav b€ 61 ¢ iKavars Karatady, pntbiov 76n KaTop- Qwecacbar Ta dotéa Kal és Ti diUow ayayeir, toto. Oévapot TaV yepav amevOtvovta Kal eFevKpwwéovTa.
XVI. ’Esriy 88 KatopOeons, émideiv Totow oGoviotct KaTaTeTapevory, Hv T él SeEva hv T em? apiaTepa Tepipépery cuudépyn avToiot TA TPwTA edorea: Barrco0at dé THY apxynv Tou oBoviou Kata TO KaTHY La, Kat mepiBarrea Oa Kata TovTO Tas “Tpetas mepiBoras* KATELTA vewer Oar éml tHv advo Kevyn emidéwv, dom ep éml Tolow arXoLoe Kary Lace elpyTat. Ta 6€ d0oma mrarurEepa xen elvau Kal pax porepa Kab TED
ToOnU av Ta” KaTa TO oKEXOS THY ev TH xetpt. emay oS emlOyons, carabeivar ep’ omarod TLVOS Kal parOaxod, wate pr) SteotpadOar 7 TH} TH, fenTe Nopdoy pyte Kupov elvary parrata 6é auppéper mpookeparavov, 7 Aiveov 7) épiveor, pi) TKANPOY, AaTTAPOY pécOY KATA pHKOS ToLN- cavTa, 7) dAdo TL O TOUTM éoLKeD.
Ilepi yap TOv coANnVwY TaV UTOTWELEevwr UTO TA oxéhea TA KaTENYOTA, ATOpéw O TL cupSovretow: y Uroriévat xen Ov; opereovar pev yap, ovx daov dé ot vmoreBértes olovTat' ov yap avaynagouar ot Twdives aTpenelv, ws olovrae’ ore yap TO addAO copaTe orpepopmerey » &v0a 7) év0a éravaryedter 0 aowAnv py) éraxonovdeiv TO GKENOS, HY pn eTLpEAHTaL avTOS @VOpwTos: ovTe av TO? oKéXOS AvEeV TOD THmaToS KwWATEL O cwrAnv KwnOhvar 1) TH 4 TH GNA pV aaTep-
1 mpoxwph. 136
ON FRACTURES, xv.—xv1.
bring in some of the mechanical aids, whichever may be useful.1 When once sufficient extension is made, it becomes fairly easy to adjust the bones to their natural position by straightening them and making coaptation with the palms of the hands.
XVI. After adjustment, apply the bandages while the limb is extended, making the. turns with the first bandage, either to right or left as may be suitable. Put the head of the bandage at the frac- ture and make the first turns there, and then carry the bandaging to the upper part of the leg as was directed for the other fractures. The bandages should be broader and longer and much more numerous for the leg parts than those of the arm. On completing the dressing, put up the limb on something smooth and soft so that it does not get distorted to either side or become concave or convex. The most suitable thing to put under is a pillow of linen or wool, not hard, making a median longitudinal depression in it, or something that resembles this.
As for the hollow splints which are put under fractured legs I am at a loss what to advise as regards their use. For the good they do is not so great as those who use them suppose. The hollow splints do not compel immobility as they think, for neither does the hollow splint forcibly prevent the limb from following the body when turned to either side, unless the patient himself sees to it, nor does it hinder the leg itself apart from the body from moving this way or that. Besides, it is, of course,
1 Hvrwa Littré; 4v vulg.: ‘‘if any is of use.”
2 For aira (codd.) ; cf. below, line 25. ra Kw. 3 gird,
137
30
40
50
TEP] ATMQN
yéoTepov EvAov uToreTaa bat, nv fn) omas av tis parOaxov TL €s avTo évteOn* evXpyoToTaron 6¢ éotw év That peluTroatpacect wal év Thaw és aposov mpoxwpnaecw. éaotw ov adv cwrAgnU Kal avev owAnvos, Kal Kad@s Kal aloypas KkatacKevacacbat. _Tubaverepov d€ ToLCL (On. Tho €oTt Kal Tov intpov avapaptnt oTEpov elvat, ny ow@dHV DroKéntau KALTOL aTeXvérTEpov yé €otev. Sel wev yap ep opmarod Kal par@axod Keio Cat TAaVvTn TavTwS és (OU: émei Tol ye avaykn KpatnOjnvar tiv émidesw wre THs dia- aotpopis THs év Th Stabécer, Orrot av pérrn Kal omooa ay pen. Uroxpwéabo dé 0 émidedenevos TavTa, dep Kal T pore pov elpntae Kal yap. THY émideow xpPn TowavTny sivae ral TO oidn ja obras éEactpecOar és Ta aKpea Kal Tas YaXadotas ovTa, Kal Tas peteTredéoras bia Tpitys: Kal evpicKxéa bw ioxyvoTepov TO émidedpuevov, Kal Tas émidéovas ert MadXov Troveta Bat Kal Tr€OTL TOloW oboviovgiy TepihayBavew - Te TOV mo6a Xarapas, my pa) ayav eyyus TOU youvaTos TO TPOua. KaTAaTELVELY be eT pLos Kal emixatopboby ep’ éxdory eTrLOET EL xpr Ta ootéa: iv yap opOas pev intpevntat, KaTa Aoryor d€ TO oldnpua. yoph, TL” pev eT TOTEpoV Kal laXvoTepov TO émredeomevov x@plov état, Te dé av Taparyoryorepa Ta eared, avaxovovTa THIS KaTa- Talos “arArov. env bé€ EVdSomaios 7) evvataios
évdexataios yévntat, Tous vapOnKkas mpoati- Oévat,? @omrep Kal émt ToiaLv adAOLTL KATHYMAGL elpntat. Tav é€ vapOyiKwv tas évédpas yxpn gurdcoeaOat cata Te TOV opvpav Tv LEW Kat KaTa TOV TévovTa TOV ev TH KYHUN TOD Todds.
138
ON FRACTURES, xvi.
rather unpleasant to have wood under the limb unless at the same time one inserts something soft. But it is very useful in changing the bed clothes, and in getting up to go to stool. It is thus possible either with or without the hollow splint to arrange the matter well or clumsily. Still the vulgar have greater faith in it, and the practitioner will be more free from blame if a hollow splint is applied, though it is rather bad practice. Anyhow, the limb should be on something smooth and soft and be absolutely straight, since it necessarily follows that the bandaging is overcome by any deviation in posture, whatever the direction or extent of it may be. The patient should give the same answers as those above mentioned, for the bandaging should be similar, and there should be the like swelling on the extremities, and so with the looseness and the changes of dressing every third day. So, too, the bandaged part should be found more slender and greater pressure be used in the dressings and more bandages. You should also make some slack turns round the foot if the injury is not very near the knee. One should make moderate extension and adjustment of the bones at each dressing; for if the treatment be correct and the oedema subsides regularly, the bandaged part will be more slender and attenuated while the bones on their side will be more mobile and lend themselves more readily to extension. On the seventh, ninth, or eleventh day splints should be applied as was directed in the case of other fractures, and one must be careful as to the position of the splints, both in the line of the ankles, and about the back tendon
1 Guadov Kw. in Hermes XXVIII. adris in text. 2 én) bis. 3 xph mpoorOévat.
139
60
62
10
TIEPI ATMON
datéa O€ KYHUNS KpaTiVeTaL ev TETTAPaKOVTA HmEepnou', Nv opOas intpevntar. Hv dé vromrtevyS Tav dotéwy Te detcOai Tivos dvopOwctos % TLva EXK@ow Oppwdys, EV TO peonyd Kpove Xp?) AUoavTa Kal ever ia dpevov HETET LOT AL.
XVII. “Hv 6€é To Erepov obaTéov KaTENYH ev KUN LN, KATATACLOS wey ao bevertéprs deirat. ov pny erireltrew ypyn, ovdé BXaKkevEely ev TH KaTA- TUGEL, [AALTTA MEY TH WOT ETTLOETEL KaTA- teiverOat boov epixvetTat aiel ToTE TaVTA Ta KaTnypata, eb S€ py, ws TaxyloTa’ 6 TL yap av Ln KaTa TpOTOY nuOeT Lo peveay * TOV ooTEwy A EROEDR TUS men, oduvairepov TO X@ptov yiveTa.
O€ GAAH (NTPELN 7 Quy.
"XVII Tov o€ dctéwy, TO mev Eow TOD avTi- Kynulov Kadeopévov OYAWETTEpOY ev TH inTpEiN €oTl, Kal KaTaTaoLos paddov Seomevov, Kal Hv pn Op0ds Ta daotéa TEOH, advvaTtov Kpirat havepov yap Kal dcoapKov wav éotiys Kat ért- Baivewy éri 76 oxéXos TOAAM Bpadvrepov dvvawT av, Tovtov KATENYOTOS. yy 6€ To &Ew oorTéov Karenyy,” TORU pev evpopwrepov pépoval, TOAV é evKpUTTOTEPOV, Kal iy cy) KAXOS cvvTeb 7 (énicapkov yap €oTLV), ent Tooas TE TAaXéws toTavTal, TO TAeio TOV yap Tod ax Geos oxet 70 écw0ev Tov avteKynpiov da Téov. cpa. jev yap avre TO OKENEL Kal Th iOvwpiy TOU dx eos Tob Kara TO TKEROS, TO metov éyet TOV TOVvOU TO éow oaTtéov: TOU yap pnpov y} Kepant) Umepoxel TO bmepGev Tov THLATOS, avtTn oé eo wOev TepuKe Tov oKédeos Kal OUK &EwOeV, AXXA KATA THY TOD
1 eiGeTITUEV@V. = Katayf. 140
ON FRACTURES, xv1.-xvitt.
from leg to foot. The bones of the leg solidify in forty days if properly treated. If you suspect that one of the bones requires some adjustment, or are afraid of ulceration, you should unbandage the part in the interval and reapply after putting it right. XVII. If one! of the leg-bones be broken, the extension required is weaker: there should, however, be no shortcoming or feebleness about it. Especially at the first dressing sufficient extension should be made in all fractures so as to bring the bones together, or, failing this, as soon as possible, for when one in bandaging uses pressure, if the bones have not been properly set, the part becomes more painful. The rest of the treatment is the same. XVIII. Of the bones, the inner of the so-called shin is the more troublesome to treat, requiring greater extension, and if the fragments are not properly set, it cannot be hid, for it is visible and entirely without flesh. When this bone is broken, patients take longer before they can use the leg, while if the outer bone be fractured they have much less incon- venience to bear, and, even if not well set, it is much more readily concealed ; for it is well covered: and they can soon stand. For the inner shin bone carries the greatest part of the weight, since both by the disposition of the leg itself and by the direct line of the weight upon the leg the inner bone has most of the work. Further, the head of the thigh-bone sustains the body from below and has its natural direction towards the inner side of the leg and not the outer, but is in the line of the shin
1 Littré and others apply this to the fibula, but the limitation seems uncalled for,
I4I
20
28
10
20
TTEPI ATMON
avrTexvnpiov iEcvs dua Oé TO ado Tuo Too Tw "aATOS (yeeToveveT au padov TAUTY TH t&et, Gdn ovxXL TH efwOev apa 6é, ore “TAX UTEpoY TO éow TOU efwlev, Gomep Kal Ev TO TWHYEL TO Kata Ty TOU pK poo SaxTUdov (Ew emTOTEpor Kal }aK porepor. ev pEVTOL TO apO pe TO Kato ovx omoin 0 broracis Tou daTéou Tov HaKpoTtépou: avopotws yap 0 yea Kab 7 iyvun Kap TET AL. Sia ovv TavTas Tas Tpopdaias Tov pev EwOev daTéov KaTENYOTOS,” Tayelar ai émtBacies, TOU dé écwblev Katenyotos, Bpadetar ai émuBacres.
XIX. “Hy d€ 70 Tov pnpod datéov Katayn, THY Katdtaow Xp?) moveta Oat Tepl TAVTOS, Oras 7) evdeeaTépas oXNTEL Teovac0eica jeep yap ovdev av oivo.ro: ovoe yap él duecTEOTa Ta dctéa UTO THS taxvOos THS KaTaTdatos émd€éoL Tis, ovx av duvatTo Kpateiy n émidecis waoTE dveoTavat, adda auvérOou av pos adda Ta daTéa OTL TaXiaTa [av]* adelnoav ol TelvovTes: TAXetae yap Kal ioxupal ai odpKes éovcal, KpaTnaoval THS émldéctos, AAN ov KpaTn- Oncovtat. tTept ov odv oO AOyos, StaTeivey ev para Kal adiaaTpEenT@s XP", pendev émredeiTrovTa: peyary yap n aloxuvn Kal BraBn Bpaxurepov TOV penpov am obetEat. xelp bev yap, Bpaxurtepy yevouevn, Kal auyxpupGein av Kat ov peya TO opahpma’ TKENOS é Bpaxvtepov yevomevov X@dov atrode/Eeve 4 Tov avOpamov: TO yap Uytes ENE KEL mapatiléuevov pakpoTepov éov, Wate AUaLTENEL Tov péAXovTa KaK@s intpeverOat, apoTepa KaTaynvat Ta oKée\Ea padrov % TO. €TEpoY" iaoppoTros your av ein avTos EwuT@. €mnv mévToL 142
ON FRACTURES, xvu.—xix.
bone. So, too, the corresponding half of the body is nearer the line of this bone than that of the outer one, and besides, the inner is thicker than the outer, just as in the forearm the bone on the side of the little finger is longer and more slender; but in this lower articulation the longer bone does not lie underneath in the same way, for flexion at the elbow and knee are dissimilar. For these reasons, when the outer bone is fractured patients soon get about; but when the inner one is broken they do so slowly. XIX. If the thigh-bone is fractured, it is most important that there should be no deficiency in the extension that is made, while any excess will do no harm. In fact, even if one should bandage while the bones were separated by the force of the ex- tension, the dressing would have no power to keep them apart, but they would come together immedi- ately when the assistants relaxed their tension. For the fleshy part being thick and powerful will prevail over the bandaging, and not be overcome by it. To come to our subject, one should extend very strongly and without deviation leaving no deficiency, for the disgrace and harm are great if the result isa shortened thigh. The arm, indeed, when shortened may be concealed and the fault is not great, but the leg when shortened will leave the patient lame, and the sound leg being longer (by comparison) exposes the defect ; so that if a patient is going to have unskilful treatment, it is better that both his legs should be broken than one of them, for then at least he will be in equilibrium. When, therefore, you have made sufhi-
1 rg@ xdtw ipdy ToTy. 2 Kkatayévtos bis.
3 Omit BM V Kw. 4 drobdeiter. 143
30
10
20 21
IIEPI ATMQON
iKavas KaTaTavions, Kat ope amevov xpr Toice Oévapor Tov YELpa@V émridely TOV avrov TpoTror, OoTrEp Kal 7 poo Gev yeypar rar, Kat Tas apxas BarXopuevorv, WaoTrep eipyntat, Kal vewopmevov és TO advo TH émidéce. Kal UToKpivécOw TavTAa WaoTEp kat mpocGev, Kal Toveitw Kata TaiTa Kal pnivérm: Kal peteTideiaOw woavtws, Kal vap- Onkwv mpocbects 1) avTH. KpaTUVETaL O€ O NpOS EV TEVTIKOVTA NLEPNOLW.
XX. Hpocavmévas 5é ypy Kai rode, bte o bnpos yavaos éatuv és TO €Ew pépos wadXov 1) és TO éow, Kal és TO EumpocGev paddov 7) és ToUTria ev: és tadra Towuy Ta pépen Kal bua- orpéepeTar, émny cy) KANOS b intpevnta: Kal én) Kal KaTa TavTa Lg apKOTEpPOS aUTOS EwUTOD eo TLV, BOTE ovdé acuyxpirtev Svvavtat, év TH Staactpody. ny ou tT ToLodTOV UTOTTEUNS, unxavorroveto bas Xp ola TEep ev TO Bpayiove TO OleoTpaypeve@ Tapyvyt as. mpoaepi are 8é XP? odiya TOV oovioy KUKAW aul TO ioxtov Kal Tas iEvas, OTws dv of BovBavés te Kai TO apOpov TO KaTa THY TrUXAba Kaoupevny TpooeTLoenrar* Kal yap d\Xws Tuppéper, Kal Omws jo) TA AKpea TOV vapO nKkov oiwntar Tpos Ta averioera, mpoo Bar- Aopeva. amronet TEL dé XP? amo TOU pen aiel Tovs vapOnkas Kat évOev nal évOev ixavas Kal THY Géow aiel Tov vapO nkov mpounbeia Pat XP» bKos pte KATA TO OaTéoY TOV efeyovTav mapa Ta sd pice: TepvKoTwY jute KATA TO [apOpov]|* vevpov éotat.
XXI. .Ta be oldnwara TA KAT byvinr, 7 Kata Toda, 1) KATA TL AddrO eEaecpevpwevat UT THs 144
ON FRACTURES, x1x.—xx1.
cient extension, you should adjust the parts with the palms of the hands and bandage in the same way as was described before, placing the head of the bandage as directed and carrying it upwards. And he should give the same answers as before, and experience the same trouble and relief. Let the change of dressing be made in the same way, and the same application of splints. The thigh-bone gets firm in forty days,
XX. One should also bear the following in mind, that the thigh-bone is curved outwards rather than inwards, and to the front rather than to the back, so it gets distorted in these directions if not skilfully treated. Futhermore it is less covered with flesh on these parts so that distortions cannot be hidden. If, then, you suspect anything of this kind, you should have recourse to the mechanical methods recommended for distortion of the upper arm. Some additional turns of bandage should be made round the hip and loins so that the groins and the joint at the so-called fork may be included, for besides other benefits, it prevents the ends of the splints from doing damage by contact with the un- covered parts. The splints should always come considerably short of the bare part at either end, and care should always be taken as to their position so that it is neither on the bone where there are natural projections about the joint, nor on the tendon.
XXI. As to the swellings which arise owing to pressure behind the knee or at the foot or elsewhere,
1 Cf. VIII. 2 tardy. 3 &pAoov codd., except B, which omits. Kw. omits. 4 éfaeipoueva.
145
10
16
10
WEPI ATMQN
muéELOS, E€lploloL TOAXOLCL puTapotow, ev KaT- elpyaopévoioty, olv@ Ka’ é\alw pHVAas, KnPwTH UToXplwv, KaTadely, Ka HY TLECwOLY Ol VapOnxKes, yarav Oacaor iaxvaivors & av, ei érravw és1 Tovs vapOnkas aoviowce ioxvototy emud ous Ta 0t8f- para, dpEduevos amo ToD KATOTATO em TO avo VE/LO{LEVOS" ovr yap av Taxiota ioxvov TO olOnua YyéVOLTO, KAL Umepbotn * av UTrep Ta apxaia eT LOEC - para: adr ov xP” TOUT® TO _TpoT vena Par TAs emidéctos, iv ph Kivduvos % ey TO O10 Mate prvKTAWodzos oy peXac mov: yiverau dé ovdev TOLOUTOL, iy 1) ayay TLS mely TO KATNY a, n KOTAK PE [Lc LEvOV EX, 1) eas dee TH Xetpl, ) ado Tl TpooTiTTH epeiarixoy € es ® TOV Xpara.
XXII. LSorjva 6 Hv pév tis UT aurov Tov Enpov vmobein wn wmepBardrovtTa THY iyvuiny, Brarrou av Haddov 7) @penr€ou ove yap av TO coua K@NVOL ovre THY KUT LNY, avev Tod pnpod Kivetabat aonpov yep a ely T™ pos TIV bypuny mpoo Bardopevov: Kat O eora el, Toor ay emrOT PULOL Tmovelv, [ixvora yap dec] 4 Kara TO youu KGUTTELW* TATAV yap av TUpByv mapéexor Thaw emdéaealv, Kal ponpov emidedeuévov Kal KYnpNs, OoTLS KATA TO YOVU KauTTOL. avayKn yap av eln TOUT® TOUS peas adore Kal dd)ote aXXo ox pa ioxeuv" avayKn 8 ap ein Kal Ta ooréa Ta KaTenyora Kipnow éyelv. mepl TavTos ov Tountéov tHv iyviny évtetacOar. Soxéou av [opoiws|>o cwAnv 0 TEepleX@v® pos TOY Toba aro
1 éravels Kw. suggested by Erm., confirmed by B.
2 brepbein codd. wsmepOoln Littré. streAdor. . . bd B Kw. 3 apdos Kw.
146
ON FRACTURES, xx1.-xxu.
dress them with plenty of crude wool, well pulled out, sprinkling it with oil and wine, after anointing with cerate, and if the splints cause pressure relax them at once. You will reduce the swellings by applying slender bandages after removing! the splints, begin- ning from the lowest part and passing upwards, for so the swelling would be most rapidly reduced and flow back above the original dressing. But you should not use this method of bandaging unless there is danger of blisters forming or io rlifcation at the swelling. Now, nothing of this kind happens unless one puts great pressure on the fracture, or the part is kept hanging down or is scratched with the hand, or some other irritant affects the skin.
XXII. As to a hollow splint, if one should pass it under the thigh itself and it does not go below the bend of the knee it would do more harm than good; for it would prevent neither the body nor the leg from moving apart from the thigh, would cause discomfort by pressing against the flexure of the knee, and incite the patient to bend the knee, which is the last thing he should do. For when the thigh and leg are bandaged, he who bends the knee causes all sorts of disturbance to the dressings, since the muscles will necessarily change their relative positions and there will also necessarily be movement of the fractured bones. Special care, then, should be taken to keep the knee extended. I should think that a hollow splint reaching {evenly ?] from hip to
1 Reading éraveis. 4 Kw. omits.
5 duolws seems out of place, wo B Kw. ® jwepéxwv.
20
12
10
15
TWEPI ATMON
TOD iaxiou, apenetv UmotiOéuevos: Kat ddws Kat lyvunv Tawiny Narapas meptPBarrew oUv TO TONVE, Oomep Ta Tada ev THO KolTnot oT apyavovTat eira emp 0 HNpos és TO avo Siaarpeporro © H €@> TO TraYLOV, evKaTaaXe- T@TEPOV ely ay ouv TO cohiut obTws. Hv ouv Stapetrepes in,? tointéos o ohn, y] ou ToLnT Eos.
XXIII. ITrépyns 6é axpns Kapra xP” em pereio Oat os evOeTas &XM: wal €v Tolat Kara xvrjpny Kal év Tote Kara pnpov KAT IY HAGLW. ny pev yap aT aLwpirat 0 Tous THS addas KUN ENS MpHares wevns, avaykn Kara TO avr LK VI LLOV Ta oatéa KUpTa paiverbar iy dé n ae TTEpYN tn rorépy [77] Tob petplov npteapevn,> 7 éé addy KUHL UmoMEeTEWpOS 7}, avayen TO daTéOV TOTO KATA TO AV TLKVI} JLLOV TovTO KOLNOTEPOV pavijvac TOD HeTplou, TpocéeTe Kal Hv » mTEpyn ruyxany éotoa TOU avOpwmov pices pmeyann. drap kal KpaTuverau mavra Ta OoTéa BeaOur Pats Hy v) Kata puow Keiweva [7 Kat Ta pn] * aT pe- péovta &v TH avT@O oXHpaTL Kal al Twpwc~eEs da bevéertepat.
XXIV. Tatra pév $y, doorct Ta pev dotéa KaTenyer, eFEXer dé Ha}, pn de GArws EXKos eyevero. ola 6é kat Ta dotéa KaTényev ATA TO TpoT@ Kal pay ToduaXLOE!, avd nuepa éuBrnbevra a TH voTepatn, Kal KaTa Yopnv iCopevar, wal ee émido£os ) amooracts Tapacxioov daréwy an vevat, Kal olow &XKos pmev éyéveTo, Ta be 0 ootéa Ta KarenyoTa oux e&laxet, oUd Oo TpoTros (THs KatnEtos ToLodTos olos Tapacxioas daTéwy eovaas
1 Siuctpéepnra. 2 Siaumepys cot.
148
ON FRACTURES, xxu.—xxiv.
foot would be useful, especially with a band passed loosely round at the knee to include the splint, as babies are swaddled in their cots. Then if the thigh-bone is distorted upwards (i.e. forwards) or sideways it will thus be more easily controlled by the hollow splint. You should, then, use the hollow splint for the whole limb or not at all.
XXIII. In fractures both of the leg and of the thigh great care should be taken that the point of the heel is in good position. For if the foot is in the air while the leg is supported, the bones at the shin necessarily present a convexity, while if the foot is propped up higher than it should be, and the leg imperfectly supported,! this bone in the shin part has a more hollow appearance than the normal, especially if the heel happens to be large compared with the average in man. So, too, all bones solidify more slowly if not placed in their natural position and kept at rest in the same posture, and the callus is weaker.
XXIV, The above remarks apply to those whose bones are fractured without protrusion or wound of otherkind. In fractures with protrusion, where they are single and not splintered, if reduced on the same or following day, the bones keeping in place, and if there is no reason to expect elimination of splinters, or even cases in which, though there is an external wound, the broken bones do not stick out, nor is the nature of the fracture such that any
1 jmouetéwpos, “rather low.” Adams.
3 npmariouern H- * katauevy Kw.’s conjecture. BM Vomit j. B has xa TO Mev Mh.
149
10
24
10
TMEPI ATMON
ém1d0£ous elvat dvaTroau TOUS TOLOUTOUS ot pev pajre peya ayabov [YTE Weya KaKOV TOLOUVTES, int pevouar TQ ev ErKea Kaba tine TLvi, 2 TLoonpny emiOevres, n Evarwov ») éido TL Ov el@Paor moveiy" érdva oé TOUS olvnpous om Vas ) elpta puTapa émloéovaly 1 aXXo TL TOLOUTOV. éemny b€ Ta EAKea Kabapa yévntar Kai dn cuphvyTar, TOTE Toto d0oviowss auvyvotat Tel- povrar emTLoEly Kal vapOnée xaroplobv. arn pev y} inous arya. Bov Tl Tovel, KaKOV 6€ Ov Meyda. Ta pevToe oatéa oux opoims SUvaTaL iSpverbar és THY EWUT@V XoOpny, avra tive oyenporepa copata Tob Kaipod TadTH yiverau YEvOLTO eS cy Bpaxutepa, ov apudotepa Ta bdctéa Katényev 1) TH YEOS 1) KVHLNS.
XXV."AAXa 8 ad tivés cist of dAoviotct Ta TolavTa intpevouor EvOews Kal évOer pev Kal evOeEv emideover TOLTLD aPoviouat, Kata O€ TO Eos auto Siadetmovan, Kal e@ow ave vx Gar emrelTa emitibéace émh TO &\ KOS Toy Kabaptixay Tt, Kal omAnveow olynpoioe v7) eiploue puTrapoioe epamevovow. avtTn 1) inots Kakn, Kal EtKOS TOUS OUTWS inTpEVOVTAS TA péyLoTA aouUveETEDD, Kal €v Tolow ddroloL KaTHYymaoL Kal ev TolaCL TOLOUTOLOW. peyLar TOV yap | éore TO yiv@a Kel Ka@ omoiov tpotrov xP?) TI apxny pev Banr- AecOat TOD oGoviou, Kat Ka? orrotov pdartota meTriexOat, Kal old Te wheréovtar Hv oplas Tis BarrAnTat THY apyny Kat mieln 7 badtoTa yxpM, Kal ola Bram rovrat iv wn opbas TLS Badrrau poe meetn 1) ” Hadtora XP%s arra evOev kat érOev. eipntat pev ovv Kal ev Tois mpocbev yeypau-
150
ON FRACTURES, xxiv.—xxv.
splinters are likely to come to the surface :—in such cases they do neither much good nor much harm who treat the wound with a cleansing plaster, either pitch cerate, or an application for fresh wounds, or whatever else they commonly use, and bind over it compresses soaked in wine, or uncleansed wool or something of the kind. And after the wounds are cleansed and already united, they attempt to make adjustment with splints and use a number of band- ages. This treatment does some good and no great harm. The bones, however, cannot be so well settled in their proper place, but become somewhat unduly swollen at the point of fracture.t If both bones are broken, either of forearm or leg, there will also be shortening.
XXV. Then there are others who treat such cases at once with bandages, applying them on either side, while they leave a vacancy at the wound itself and let it be exposed. Afterwards, they put one of the cleansing applications on the wound, and treat it with pads steeped in wine, or with crude wool. This treatment is bad, and those who use it probably show the greatest folly in their treatment of other fractures as well as these. For the most important thing is to know the proper way of apply- ing the head of the bandage, and how the chief pressure should be made, also what are the benefits of proper application and of getting the chief pressure in the proper place, and what is the harm of not placing the bandage rightly, and of not making pressure where it should chiefly be, but at one side or the other. Now, the results of each were ex-
1 6oréa for cduara; callus develons.
1 rw nal Ta do0Téa,
51
30
40
45
TIEPI ATMON
pEVOLOLY, omrota ad’ éxaTépov * dmroBatvew pap-
tupel O€ Kal avr ) intpetn: avayKn yep 7 oUT@S emideomevp TO oidos efaciperOa € €s avTO TO &XxKos. Kal yap El Uyins ypws evOev Kal EvOev emdeDein, év péow ¢ Sader Gein, padiora KaTa TH Suddewpru olonoerey av wal ax poino eter: TOS ovy ouxt EXKOS Ye tadTa av wadot ; dvayKatos oov Eyer Aypoov pev Kat extrem hoy pévov 70 Edxos elvat, Saxpuddes Te Kal AVERT UNTOD, oaréa 6€, Kal 1) pedovTA aTroaThvat, ATOTTAT KG, yeve- cau: opuypaces Te Kal Tupaoes TO EXKOS av ein. avayxabovtar 5€ Sta TO oidos émiKaTa- TAdooew? acvupopoy dé Kal TOUTO Totow évOev Kat ev ev émrdeopevolo wv" ax Gos yap avwpenres Tpos TO AAW opuype erriyiveTat. TEAEVTOVTES 88 amodvover Ta emidéo para, omoray ow TaduyKoTh, Kal intpevovat TO oOLTTOY avEU eTL- Sécvos' ovdev 6€ Hacov, Kal HV TL ANrO TPALA TovovTov daBoo, TO AUTO TpoT@ intpevovow ov yap olovTat THY ériSeow THY evdev_ Kal évOer, Kal THV avayyueiy Tov EAKEOS aitinv elvat, ara army Twa aruyinu’ ov pévTOU ye av éypaov TEpl TOUTOV Tooara, el un eU pev noew dovp- popov €ovoav THY emiderw, auxvous 6€ oUTwS int pevovTas, erik alpov dé TO aTouadnpa, pmap- TUpLOV dé Tov op0ds yeypad lar 7a Tm poobev yeypaupeva ElTE [LdALOTA TET TEA TA KATIYMATA LTE HKLOTAs 1 Exarépov.
1 That is, an unhealthy discharge without ‘‘ purification.” 2 Exposure here cannot mean exposure to cold or even bareness—the foolish surgeons cover the wound with wool or
152
ON FRACTURES, xxv.
plained in what has been written above. The treat- ment, too, is itself evidence; for in a patient so bandaged the swelling necessarily arises in the wound itself, since if even healthy tissue were bandaged on this side and that, and a vacancy left in the middle, it would be especially at the vacant part that swelling and decoloration would occur. How then could a wound fail to be affected in this way? For it necessarily follows that the wound is dis- coloured with everted edges, and has a watery discharge devoid of pus,! and as to the bones, even those which were not going to come away do come away. ‘The wound will become heated and throbbing, and they are obliged to put on an ad- ditional plaster because of the swelling; and this too will be harmful to patients bandaged at either side of the wound, for an unprofitable burden is added to the throbbing. They finally take off the dressings, when they find there is aggravation, and treat it for the future without bandaging. Yet none the less, if they get another wound of the same sort, they use the same treatment, for they do not suppose that the outside bandaging and exposure? of the wound is to blame, but some mishap. However, I should not have written so much about this had I not known well the harmfulness of this dressing and that many use it; and that it is of vital importance to unlearn the habit. Besides, it is an evidence of the truth of what was written before on the question whether the greatest or least pressure should come at the fracture.®
pads-—it means absence of due pressure, the proper graduation of which is the main point in Hippocratic bandaging.
a vanronting to Adams this warning was still necessary in is time.
E53
10
20
30
TTEPI ATMON
XXVI. Xpn oé, a os ev Keparaip elpja Oat, olow av uy émibo£os a a) TOV oa Téwy dmoaracts évea Ban, THY aurny int petny int pevew, MOTE ay olow ootéa ev KaTenyora. ein, EXxos O€ py eXovTa: Tas Te yap KaTaTao Las Kal Kkatopbacias TOV OOTEWY TOV AUTOV Tpomov movetoOar, THD TE err (OEeow mapam\joLov TpoTrov. éml wey auto TO €XKOS TmLoonpryy Kyoeo Tp xpicavra, omhiva AemTOv du7rAOOV emdeOjvat,) Ta O€ mepeg KNPOTH AewTH Xptew. Ta be od via Kat Ta aia Tha- TUTepa TW Er xiopeva EaT@, i) el pu) EAKOS elev" Kal @ ap T PWT emudenra, avyve éotw Tod EdKeos TATUTEPOD. Ta yap oTevoTepa TOU EdKeos Socavra éyer TO EdKOS" TO é ov vpn. GNX y) T™ pwr meptBorn oXov KATEXETW TO éX.Kos, Kal UmEpeXeTo 70 ofoveov évOev TE Kal évOev. Barreo bar jev ovv xpn TO d0ov0v Kar avTny TH iéw TOU ErxKE0s, miele Sé Ory jooov ny el pay édKos eiyev, emevéwecOar Sé TH émidécet Gomep Kal _mpoabev elpnTa. Ta b€ ddoma alel bev TOU TpoTrov TOU parBaxov eoTwoay, paddov dé Te? Set ev Totor TOLOUTOLOLY, 7 el 41) EdKcos eiXev. TIO OS dé TOV dOovimy: p21) Xda ow éoTo Tov MpOTEpov eElpnuevwmv, GAAA TIVE Kai TELO. Hy 6€ emoe0n, SoKeiTw TP ET LOEOE EVO Hppoabar® MEV, memLeyOar O€ mr: pate be KATA TO EdKos paduora mppoa Oar, TOUS 5€ Ypovous TOUS avTOUS pev xpr elvae éml 0 paddov Soxeiv npuoc8ar, TOUS avTous O€ émt TO adov doxely yanrav, MOTEP Kal EV TOLCL mpoaOev elpnTaL. peTETLOELY dé Ova Tpltns, TavTa peTtatoeovTa és ToOds TpoToUs TOUS TapaTANGloUS, WaTEp Kal TpdcbeEv 154
ON FRACTURES, xxvi.
XXVI.1 To speak summarily, when there is no likelihood of elimination of bone, one should use the same treatment as in cases of fracture without external wound. The extensions and adjustments of the bones should be made in the same way, and so too with the bandaging. After anointing the wound itself with pitch cerate, bind a thin doubled compress over it, and anoint the sur- rounding parts with a thin layer of cerate. The bandages and other dressings should be torn in rather broader strips than if there was no wound, and the one first used should be a good deal wider than the wound; for bandages narrower than the wound bind it like a girdle, which should be avoided ; rather let the first turn take in the whole wound, and let the bandage extend beyond it on both sides. One should, then, put the bandage just in the line of the wound, make rather less pressure than in cases without a wound, and distribute the dressing as directed above. The bandages should always be of the pliant kind, and more so in these cases than if there was no wound. As to number, let it not be less than those mentioned, before but even a little greater. When the bandaging is finished it should appear to the patient to be firm without pressure, and he should say that the greatest firmness is over the wound. There should be the same periods of a sensation of greater firmness, and greater relaxation as were described in the former cases, Change the dressings every other day, making the changes in similar
1 Proper treatment of compound fractures.
1 émiOeivat 21. 8 jpuacba bis.
40
50
60 61
TEPI ATMON
elpntat, TAHY és TO GUTTA Haoor Tie Tele TabTa 7) éxeiva., Kal 7 Kara oOyov Ta elxora yevnTar, io yvorepov ev aleb evpeOijcerar TO Kara TO &XKOS, to yvov 6€ Kal TO aro Tav TO UTO THS ETLOETLOS KATEXOMEVOV? Kal at Te ExTTUNTLES €sovtat Gaccovs 1 TeV ahos int pevpevev EAKEDD, 6ca TE capKia év TO TPOMATE eweavOn Kal edavataén, Oaocov TeptppryyvuTar Kal €xTitr- TeL eT TAUTN TH intpein y €V THe aro, és @TELAdS TE dagoov opparat TO Ehcos OUTS a7 dds int pevpevov. mavTov 6é TOUT@D aittov Ort iaxvov pev TO Kara TO ENKOS Xeplov yiveTat, laxva dé Ta TeEplexovTa, Ta bev ovv dda TAaVTa TapaT yo lws xen int pevery, @S TA dvev EAKOTLOS OrTéa KATH YVUMEVA™ TOUS be vdpOnxas ov XP? mpoorieva. ota _TovTO Kal Ta oovia xpr TOUTOLOL Tret@ evar iv) Total ETEpoLoLY, OTL TE Ooo mueleTat, Ore TE ol | va pOn Kes Bpadvtepor + mpoorevrac: me pévtToe TOUS vapOnKkas Tpoc- TLORS, [42 Kara THv téEw TOU EdKEos TpoaTEvat, ddrws Te Kal yadapas mpooTiéval, mpopndev- pevos * br ws pndepin ohirytis peyadn éortat aro TOV vapOynKkwv: elpntat dé TobTO Kal év Toiae T™ POTEPOV YEYPALMEVOLT LW. THY pevTor diartav BiRRAReanee gE kal wAelw ypovov xP? moet Oar oiaw é& dpxiis EA Kea, ylvetat Kal oiow oaTéa ei yeu Kal TO oUprray dé eipjaOar, emt totow loxuporaroiat TpeOpacw axptBeorépny Kal Tod Xpove@répyy elva xen THY dlavTav.
XXVIL. ‘Hi auTn intpety TOV EAK ov Kal olow oarea pev KATENYEY, ErKos O€ €& dpxiis pndev 7}, iv be &v TH intpetn EdrKos yévnTat, 7) Tolcw 156
ON FRACTURES, xxvi.—xxvir.
fashion except that, on the whole, the pressure should be less in these cases. If the case takes a natural course according to rule, the part about the wound will be found progressively diminished and all the rest of the limb included in the bandage will be slender. Purification! will take place more rapidly than in wounds treated otherwise, and all fragments of blackened or dead tissue are more rapidly separated and fall off under this treatment than with other methods. The wound, too, advances more quickly to cicatrisation thus than when treated otherwise. The cause of all this is that the wound and the surrounding parts become free from swelling. In all other respects, then, one should treat these cases like fractures without a wound, but splints should not be used.2. This is why the bandages should be more numerous than in the other cases both because there is less pressure and because the splints are applied later. But if you do apply splints, do not put them in the line of the wound; especially apply them loosely, taking care that there is no great compression from the splints. ‘This direc- tion was also given above. Diet, however, should be more strict and kept up longer in cases where there is a wound from the first and where the bones protrude, and on the whole, the greater the injury the more strict and prolonged should be the dieting.
XXVII. The same treatment of the wounds applies also to cases of fracture which are at first without wound, but where one occurs during treat-
1 7.e. discharge of laudable pus. * We must evidently understand ‘‘ so soon.”
1 Bpadurepov. * mpoundevpevars codd. Pq. 157
10
20
30
HEPI ATMON
oOoviorge ardov mex OevTos, * UTr0 vapOnkos w@evedpys, 7) 7 vTro adds TLVOS Tpopacros. yever- OKETAL Lev ouv Ta TOLADTAa, HV EAKos UT, TH TE oouvy Kal TOLL opuypotow Kal TO oldna TO €v TolaL AKpotot OKANPOTEPOY yiryveTaL TOV TOLOUTWY, Kal ef Tov OaKTUAOY eTTayayoLs, TO EpevBos eEaciperas,) arap Kal ables aTrOTpEXEL TAXES. ap ov Tt TOLODTOV vrroTTEUNS, NUoaVTA XPM» Hv bev 7} KUNG [LOS KATA TAS broderuidas y) emi 270 ado TO em sede Levon TLTONpH KNPOTH avTl THs ETEPNS Xphio Pau: Av O€ TOVT@Y bev pndev 7, avro be TO eheea npeOra mévov euploxeTat pédav éml modu 8 axd0aptov, Kal TOV ev capKav EKTUNTOMEVOY, Tay oé€ vevpov T pooeK- TETOUILEVWV, TOUVTOUS OUSEV bet avayyux ew Tavrd- Tac, ovdé TL PoPelabat Tas extrUnoias TavUTAs, > Si a / \ \ ” / , ahr UajiT PECL DimriepLeey arnra mapamAnotov TPOTTOV, @oTrep Kat olaw é& apyis EAKOS eyévero. Tote 5€ dOoviocw dpxecBar xP, émdéovTa, aro TOU 0101) watos Tov év ToloL aK peo. Tavu Narapas, kal érerta émivémecOar tH éemidécer aiel &s TO ” \ / fa) \ 18 a € , fA) 4 be avo, Kal TemTleyOar perv ovdauyn, npwooPar4 dé
, \ N. } kev \ NC] Se. 33 INY Le padXtoTa KaTa TO éXKos, Ta SE AdXrA ETL HogoV. Ta 6€ 0Oovia TA TPOTA, TadTa ev KaDapa EcTw Kal pn oteva: TO b€ TAHOCS TOY BOoviwY éEcTw dcov Tep Kal €v Tolar vapOnkEw, et éTmLdéoLVTO,® 1) 7 bY PRON Sy Dea N SaiGs e \ Odkiyw EXacoov. émi 6€ avTO TO EAKOS iKaVvOY om dqviov TH AevKeh} KNPwTH KEXpLaméevor: Hy TE yap oap& Ty Te veipoy peravOh, MpooeKmer ei Ta’ Ta yap ToLavTa ov Ypn Sptméeouy inTpEevELY, AAA
1 éteipyerat Kw.’s conjecture. Kw.’s note éfefpyera scripsi, @tapelara: B1, ékaciperar B* Pq., efaclparar M V, etaipeeras 158
ON FRACTURES, xxvu.
ment either through too great compression by bandages or the pressure of a splint or some other cause. In such cases the occurrence of ulceration is recognised by pain and throbbing: also the swelling on the extremities gets harder, and if you apply the finger the redness is removed but quickly returns. So, if you suspect anything of this kind you should undo the dressings, if there is irritation below the under bandages, or in the rest of the bandaged part, and use pitch cerate instead of the other plaster. Should there be none of this, but the sore itself is found to be irritated, extensively blackened or foul with tissues about to suppurate and tendons on the way to be thrown off, it is by no means necessary to leave them exposed, or to be in any way alarmed at these suppurations, but treat them for the future in the same manner as cases in which there is a wound from the first. The bandaging should begin from the swelling at the extremities and be quite slack ; then it should be carried right on upwards, avoiding pressure in any place, but giving special support at the wound and decreasing it elsewhere. ‘The first bandages must be clean and not narrow, their number as many as when splints are applied or a little fewer. On the wound itself a compress anointed with white cerate is sufficient; for if flesh or tendon be blackened it will also come away. One should treat such cases not with irritant, but
SE GE ee ers ee. ae Litt., eEaviorara: Wh, 7d e%pevOos etaelparar Galen in cit., etapvata: exkevodra: éxOd (Bera Galen in excgesi. Such is the discord about this word whenever it occurs ; but the meaning seems obvious, * kai omitting %, —® él moAd axd@aprov omitting uéday. 4 jpudoPa. 5 émidéoiro.
159
40
48
10
TEPI ACTMON
mmOaxoiow, Gotep Ta TepixavaTa. peTemdetv 6¢ Sia tpitns, vapOnkas 6é py Tpoartievar atpewe Se eal padrov 1% TO mpdcbev, Kat ddXuyoouTeiy: eidévae Sé ypn eb Te oap&, et Te vedpov TO éxTrecovmevov €oTL, OTE OUTW TOARG [ev focov vé“etar él mAE€lov, TOAD 58 Oaccov éxmreceital, TOAN@ Sé layvoTEepa TA TeEplexXoVTA Zrtat, 7) el tis atodvoas Ta dOovia émiOetn TH tov Kabaptixav happdxwy emi To EXxos. KalToL Kal Av extréon TO éxTUnTdpevor, Oaccov TE cap- KoUTaL exelvas t) ETEpws intpevopevor, Kal Oadaaov @Te\AodTaL. TavTa pap éote TadTa opOas émtdeiv Kal pwetpios erictacba. mpocoupBddretat O€ Kal TA oxrpata Kal ola ypH eivat, Kal 7) ar Sata, Kal TOV dOovimy % émuTNSELoTNS. XXVIII. *Hv 6é dpa éEa7ratnOjs ev Totot VEeoTPWTOLGL, ft) Olopevos daTéwv aTocTATW ZcecOa, Ta & enidvka 4 avaTA@aat, Ov YP) éppwodetvy ToUTOY Tov TpoTOV THs intpeins, ovcev yap adv péya pradpov yévort’ av,’ jv podvov olos Te Ws TH Yelpl Tas eridéotas ayabas Kal dowéas TolicOat. onmetov dé TOde, HY médry dotéwy amoatacw écecOar ev TH TPOT@ TOUTH Ths intpeins: mov yap suXvoY péer ex TOD EXKEOS kal opyav dativetat. muKvoTepov ovY peTeTr- SeicOar2 Sia 1TO wrdSov: érel AANWS TE Kal arvpeto. yivovtat, iy m1 Kapta TueCwvTat UTr0 Tis émidécvos, Kal TO EXKos Kal TA TEpLeXoVTA loxvd: doar pev odv enT@v Wavu ooTEeoy
1 / yevolTo. 2 wereT ely,
160
ON FRACTURES, xxvu.—xxvi.
with mild applications, just like burns. Change the dressing every other day but do not apply splints. Keep the patient at rest and on low diet even more than in the former case. One should know if either flesh and tendon is going to come away that the loss will be much less extensive and will be brought about much quicker, and the surrounding parts will be wnuch less swollen (by this treatment), than if on removing the bandage one applied some detersive plaster to the wound. Besides, when the part that is going to suppurate off does come away, flesh formation and cicatrisation will be more rapid with the former treatment than with any other. The whole point is to know the correct method and due measure in dressing these cases. Correctness of position also contributes to the result, as well as diet and the suitability of the bandages.
XXVIII. If, perchance, you are deceived in fresh cases, and think there will be no elimination of bones, yet they show signs of coming to the sur- face, the use of the above mode of treatment need not cause alarm, for no great damage will be done if only you have sufficient manual skill to apply the dressings well and in a way that will do no harm. The following is a sign of approaching elimination of bone in a case thus treated. A large amount of pus flows from the wound, which appears turgid. So the dressing should be changed more often because of the soaking,! for thus especially they get free from fever, if there is no great compression by the bandages, and the wound and surrounding parts are not engorged. But separa- tions of very small fragments require no great
1 “ Maceration,” ‘‘ abundance of humours.” 161 VOL. IL. G
19
10
20
IIEPI ATMON
bd , > , / a Va aTrooTaales, ovdepins meyarns weTaBorrs SéovTat, > . A , b] lal e \ ’ / GAN 7) YadapwTepa érideiv, @S ft) aTTONaLBavn- fa) / Tat TO Tuvov, GAN EevaTOppuUTOY, 7 Kal TUKVO- lal > a TEpov peTeToely EoT Av aTooTH TO daTéov, Kal vapOnkxas pn mpootévat. € XXIX. ‘Omccoor Sé pelfovos daréov aro- / ~ a lol otacis é7idoFos yévntat, Hv Te EE apYns Tpoyrvas, NY Te Kal EretTa mEeTayV@S, OUK ETL THS avTHS > , a \ intpeins Setrat,) adda Tas pev KaTaTdoLas Kal \ . 4 Tas StopOwa.as otTw ToveicPar BoTEp ElpynTat an \ A lal , \ e omdhvas O€ ypn SuTdods, TAATOS meV HyusoTrlOa- puaiovs, 67 €Adooous (orroiov dé av TL Kal TO a a / a TPO@ua H, Tpos TovTO TexpaipecBar), whKos Se Bpaxvutépous peév drXiyo 7) wate Sis Teptixvetcbar Tepl TO G@ua TO TETPwWpMEVOV, pLaKpoTEpous bé a BN ef ef - a a \ cuxXVe 7 woTe ATaE TeptixvetcOat, TAGs Sé OTocous av cumdépn, Toinodpuevov, TovTOUS év v / ? a / \ > / olive wédave avaoTnp@® Bpéxovta, yp éK pécou > , >’ \ / > lal e apYomevov, ws ato dvo apya@v bTodecpls érr- Seitar, Tepiediocev, KaTELTA TkKETAPVYNOOY Trap- ad\dcoovta Tas apyas adiéval. TAaUTA KaTd TE 3 \ \ la \ \ x. Ao. auto TO €XKos Tolety Kal KaTAa TO évOev Kal EvOev rn C \ / \ / > > iA Tov é€XKeos: Kai TeTLEXOW peV pn, ANN Ooor A na o / éppacuod évexev Tov EdXKeos TpocKetoOw. ert S€ avto TO Edxos émitiOdvar yp} Ticonpyy, H Te TOV evaluwv TL TOV A\AwY hapudKary, 6 TL / “ 2 PJ aA 5 / 3 \ XK A e auvtpopov? éativ [0d] émitéyEe.3 Kai Hv pev 7 apn Oepiyn 7, emiTéyyetv TO Oliv TOUS OTAVAaS , xX \ \ € ov 3 »” \ TuKVa' HY O€ XELpLEpLYH 1 WPN Y, Elpla Toda 162
ON FRACTURES, xxvit.-xxrx.
alteration of treatment beyond either loose bandaging so as not to intercept the pus but allow it to flow away freely; or even more frequent change of dressing till the bone separates, and no application of splints. XXIX. But in cases where separation of a rather large bone is probable, whether you prognosticate it from the first, or recognise it later, the treatment should not be the same, but, while the extensions and adjustments should be done as was directed, the compresses should be double, half a span? in breadth at least—take the nature of the wound as standard for this—and in length a little less than will go twice round the wounded part, but a good deal more than will go once round. Provide as many of these as may suffice, and after soaking them in dark astringent wine, apply them beginning from their middle as is done with a two headed under band- age; enveloping the part and then leaving the ends crossed obliquely, as with the adze-shaped bandage. Put them both over the wound itself and on either side of it, and though there should be no com- pression, they should be applied firmly so as to support the wound. On the wound itself one should put pitch cerate or one of the applications for fresh injuries or any other appropriate remedy which will serve as an embrocation. If it is summer time soak the compresses frequently with wine, but if
1 Adams strangely calls a span a fathom here and else- where.
1 bei,
* civtpopdy, as Galen says, means ‘‘ appropriate,” as in Surgery, XI
8 émréyier Pq. takes as a verb, Kw. apparently takes it as subst., omitting 4.
163
30
TIEPI ATMON
puTrapa vevoTia weve olive Kal edaie : emixetobw. iEadty dé xpn) brorerdaar, kal evaTroppuTa Toveiy, puddooovra TOUS Umoppoous, fe myn) uévov éTL ob TOTOL ovToL, évy Tolct avrotoe oxXnmact TONAL YPOVOY KELMEVOLOL, EXTPLULpLATA OVTaKETTA TOLeovow.
XXX. “Ocous &é py ofov Te émidecer inoacbar Sud Twa TOUTwY Tov elpn Levey TpoTr@y » TOV pnOnoopevor, TOUTOUS mépl TAEOVOS xP? ToL- cio Bau OT aws evdéras TXNTOUTL TO KATENYOS Tob o@paTos Kat’ LOuwpinv, TpooéXovTa Tov voov Kal TO dvarépe bé HarROV TO Katwtépo. et &é TUS MéAXOL KANBS Kal eVXEPOS épyater Oar, aEvov Kal pnXxavorronjcacbat, ¢ dKws KaTratact Stxainy Kal pn Brainy exon 2 +0 KaTenyos TOU TO [LAaTOS"
10 paXdov * oe év Kevin évdéxeTar MX avorrovety.
20
eloe pev ouv TwWeS ol éml mao Totat THs KUNUNS KATHYLATL, Kal Totoe eTLOeomevolat Kal TOLL ) eMLOEOMEVOLT Ly TOV moda aK pov Tpoadeouer ™pos THY KAWHY 7) Tpos ado TL _EvAov mapa Tay KALVnv KaTopvEaVTEsS. oOvTOL pev oy TAvTa KAKA motovow, aya0ov O€ ovdév: OUTE Yap TOU KaTa- Teiver au akos éoTl TO mpoadedca bar TOV 00a, ovdey yap Haaov TO aXXo copa T poo Xopyoer m™pos TOV Toa Kal oUTws OUK ay éTL TelvoLTO: our’ av4 és tip (Ovwpiny ovdey openel, ada Kal Bran ree" orpepopevou yap TOU chou Toua- TOS 7 TH, ) Th ovcey K@AUCEL O dec pos TOV 00a Kal Ta doTéa TA TO Tool TpoanpTnpeva é7TaKo- NovOciy TO ANAM ow@pare: el O€ My) TpooedeseTo, Hooov: av ‘Seer tpépero: ooov yap av éykaTe)el- TeTO €Y TH KLYNTEL TOU AOU GwpaTos. Et O€ 164
ON FRACTURES, xxrx.-xxx.
winter apply plenty of crude wool moistened with wine and oil. A goat’s skin should be spread underneath to make free course for discharges, giving heed to drainage and bearing in mind that these regions (when patients lie a long time in the same posture) develop sores difficult to heal.
XXX. As to cases which cannot be treated by bandaging in one of the ways which have been or will be described, all the more care should be taken that they shall have the fractured limb in good position in accord with its normal lines, seeing to it that the slope is upwards rather than downwards. If one intends to do the work well and skilfully, it is worth while to have recourse to mechanism, that the fractured part may have proper but not violent extension. It is especially convenient to use mechanical treatment for the leg. Now, there are some who in all cases of leg fractures, whether they are bandaged or not, fasten the foot to the bed, or to some post which they fix in the ground by the bed. They do all sorts of harm and no good ; for extension is not ensured by fastening the foot, since the rest of the body will none the less move towards the foot, and thus extension will not be kept up. Nor is it of any use for preserving the normal line, but even harmful. For when the rest of the body is turned this way or that, the ligature in no way pre- vents the foot and the bones connected with it from following the movement: If it were not tied up, there would be less distortion, for it would not be left behind so much in the movement of the rest of the body. Instead of this, one should get two
1 Cf. the good Samaritan. 2 oxnoel. 3 udAwora. 4 airhy.
165
30
40
50
TIEPI ATMON
TUS opaipas dv0 parrattro eK OKUTEOS Aiyutriov TovavTas olas popéovow ot év THot peyaryoe méOnolt moO Xpovov merredn[evor, at oe odaipay eXovev évOev Kai év0ev Xu avas Ta pev Tpos TOU THNwWLATOS Baburépous, Ta O€ Tpos TOY apOpwv Bpaxutépcus, elev 5é€ oyxnpal pev Kal parOaxai, appolovoa: Sé, 7 pev avobev! rav o pupa, a dé KatwOev? Tob yovaros: éx O€ Trains ExaTepns $ dtaoa Exatépober € éyol Tpoa- nNpTnueva 7) atrdoov imavTos 7) SuTroou, Bpaxu- tepa* wotrep ayKdnas, Ta pév TL TOU opupob éxatépober, Ta O€ TL TOU yovaTos: [eat 7 1 avwbev apaipa erepa TOLAUTA Exor] 5 KaTa THY iOvapinv THY auTny. Kamera Kpavaivas paBsous Téooapas AaBov, ioas TO péyelos addy gow €xovoas, maXOs pev Os Saxtudatas, pijKos 6é, @S Keka pévar évappocovoty és Ta aTraLwpHnmata, émLpme- Aopmevos OTs TA Axpa Tov paBdwv pr és Tov XpOra, GX’ és Ta axpa Tov cpatpéwy eynehon. eiva dé Yp7) Fevryea Tpla TOV paBoar, wal THEO, Kat TWwe peakporépas TAS érépas TOY érép@v Kat Tut Kal Bpayutépas kal optxpotépas, ws Kat parrov Scateiverv,® Av BovrAnTaL, Kal Hhoocov: kal éotwoav 6€ ai paBdo. éxdtepar &vOev Kat évOev Tav opupav. TavTa Toivuy el KAAWS Enxavorrounbein, TH TE KataTacw Kal Sexainy av Ta.peXOt wal Omadnv Kara Ty (Ove piny, Kal TO TPOMaTL TOVvOs ovoels av ein? TH yep arom égpuata, ei TL Kal atroTrLéboLTO, Ta prev av és TOV T0oa aT ayouTo, Ta be és TOV penpov" ai TE paBdor evdeTrwrepa, ai pev évOev, ai 6é évOev Ttav aofupav, wate py KwrvecOar thy Oéaw THs 166
ON FRACTURES, xxx.
rounded circlets sewn in Egyptian leather such as are worn by those who are kept a long time shackled in the large fetters. The circlets should have cover- ings on both sides deeper on the side facing the injury and shallower on that facing the joints. They should be large and soft, fitting the one above the ankle, the other below the knee. They should have on each side two attachments of leather thongs, single or double, short like loops, one set at the ankle on either side, the other on either side of the knee (and the upper circlet should have others like them in the same straight line, 2.e. just opposite those below). Then take four rods of cornel wood of equal size, the thickness of a finger ; and of such length as when bent they fit into the appendices, taking care that the ends of the rods do not press upon the skin but on the projecting edges of the circlet. There should be three or more pairs of rods, some longer than the others and some shorter and more slender, so as to exert greater or less tension at pleasure. Let the rods be placed separately on either side of the ankles. This mechanism if well arranged will make the extension both correct and even in accordance with the normal lines, and cause no pain in the wound, for the outward pressure, if there is any, will be diverted partly to the foot and partly to the thigh. The rods are better placed, some on one side and some on the other side of the ankles, so as not to interfere with the position of the
1 rp tvwbev. 2 +@ KaTwber,
3 éxatépn. 4 Boaxéa.
® Kw. omits ; Erm, omits the rest of the sentence also. $ diarelvys,
167
60
70
72
10
TEPI ATMQN
4 an , KUNPNS' TO TE TP@ua evKaTaoKeTTTOV Kal Ev- 1p 3 O\ \ ’ , x bya ws \ Bdaotaxtov: ovdéev yap éutrodwy, el Tes E0éXOL TAS dv0 TOV paBdwv Tas avwtépw avTas pos adr-
/ a)
Anras CedEat, Kal Hv Tus Kovpws BovdrolTO éTL-
/ ee \ 3 if / ? \ Padre, Bote TO ETLBANXAOpEVOY METEWPOY ATO
an , 5 iA lal TOU Tp@paTos cival. EL pev OV ai TE opaipaL Tpoonvees Kal kadal kal padOaxai Kai Katval padeler, cal » évtacis tov paBdwv yxpnoTas évtabein, womep On elpntat, evxpnotov TO enxavnpa: e& S€ Te TovT@Y pm Karas é€eL, Brartot dv padrov 7) wperéor. ypy dé Kal Tas adras pnxXavas 1) Karas pnxXavdcOa, 7) py unxavac0a, aicypov yap Kal ateyvov pnyavo- motéovTa aunyavorroetobat.
XXXI. Todro 8é, of wrelatou THY inTpav Ta KATHY pata Kal TA cov EdKect Kal TA AvEeU EhKéwD, TaS TpwTas TaY HuEepewv intpevovow Eipto.at
a / f pumapoicw: Kal ovdév te atexvov doKxéet TovTO la / nr €lvat. OmdcoL pev ody avayKalovTat UTO TOV ? U avtixa veotpwtwv éovtwv, ox} éyovtes oOova, - elplovat mapackevdcacbat, TovToLoL TélaTy , > \ ” x x 50 / ” avyyvopun ov yap ay Tus Exot avev ofoviwy addro a / > EA > on 2 A ‘s i. TLTONA® BEXTLOV Eipiov emLOHaaL® ToLadTA’ ElvaL a ° / dé vpn TauTodra Kal Tdvu KAADS Elpyacpeva Kal 4 , a \ ~ 7 \ orien ~ 7 Bn TENXéa* TOV yap OAYywV Kal PrXaVpwY OhLYH e bu iA Oe > , x éuv € , Kal » dvUvamts. oor O€ emt pinv nH dvO Nmepas a nr , \ \ elpia émideiv Sixatovot, tpitn S€ Kal TeTapTy / \ / Ooviotaw émideovTes TLélovel, KAL KATATELWOVGL
1 un. 2 emdjoa éxt. 168
ON FRACTURES, xxx.—xxx1.
leg; and the wound is both easy to examine and easy tohandle.! For, if one pleases, there is nothing to prevent the two upper rods from being tied together, so that, if one wants to put something lightly over it, the covering is kept up away from the wound. If then the circlets are supple, of good quality, soft and newly sewn, and the extension 2 by the bent rods suitably regulated as just described, the mechanism is of good use, but if any of these things are not well arranged it will harm rather than help. Other mechanisms also should either be well arranged or not used, for it is shameful and contrary to the art to make a machine and get no mechanical effect.
XXXI. Again, most practitioners treat fractures, whether with or without wounds, by applying un- cleansed wool during the first days, and this appears in no way contrary to the art. Those who because they have no bandages are obliged to get wool for first-aid treatment * are altogether excusable, for in the absence of bandages one would have nothing much better than wool with which to dress such cases; but it should be plentiful, well pulled out and not lumpy; if small in amount and of poor quality its value is also small. Now, those who think it correct to dress with wool for one or two days, and on the third or fourth day use bandages with compression and extension just at this period
1 « Arrange” (Adams), better than ‘‘ maintain” (Littré, Petrequin) ; ‘*sustinere aliquid”’ (Krm.) suits the context— ‘‘easily bears a covering,” but see Herod. II. 125.
2 @vracis perhaps connected with use of word in architecture, ‘slight outward curvature.”
8 Cf Aristoph. Acharn. 12, Vesp. 275, Lysist. 987 on this use of wool.
169
20
30
40
TIEPI ATMON
TOTE padLoTa, OUTOL TOAU TL THS intpiKAs Kal KapTa emixatpov dovveréouct Kora. yap xPn TH TpUTy Heepn n 7H TETAPTN otupeniver mavra Ta TPOLaATA, Os év Keharaiwo eiphobatr Kal pnroouas dé} mags puraccecbar ypn ev TAUTNCL paw mmepyot, Kal Omron ovo arowge TPOLATL ? npebia rat. To évitay yap 1 Tpitn Kal TeTapTy) nwepn ent TOLOL TAELTTOLCL Tov TpOma- TWV TLKTEL Tas TANuyKOTHTLAS, Kal boa és preypovny Kal daxabapoiny oped, Kal dca dp és TUPETOUS in’ Kal para moXNOV a&vov TovTO 76 padnua, eb mép te Kal aAdo Tim yap ovK ETLKOLV@VEL TMV eTLKAaLpoTaTaY ev inTpLKH, ov Kara TH edKea povov, anna Kab KaT adAAa TOAAG vooruara ; 3 él Po TLS noe Kal Tada voopara Edxea eivals exer yap Twa Kal ovTos 0 AOyos emruetKelay" Tohhaxy yap HoEAPLaTAaL TA érepa TOLCL Erépourt. om acon pévror dixacovaw elptovot xphobar, ¢ éoT av émra nwLepat mapehOwow, évrerta KaTaTelvely Te Kal catopbobv Kal oOoviorcw emldety, OUTOL OUK Av acUvETOL Opolws haveter: Kal yap THS dreyLovAS TO émMLKaLpOTAaTOV Trap- ednrvbe, Kal Ta Oo Téa YaXapa [Kal evOeTa]® wera TavTas Tas mpepas av ely. TOAXD HEVTOL jyo- ontat Kal avtn 1 meeTy THIS. e& apxis Totow a0 oviotcww emLoeazos" Kelvos ev yap o TpoTros éBdopatous éovTas apreyudvTous amodekvuat, Kal mapacKevater vapOn€e TEAEWS EmLOELD ovTos 6€ O TpoTros ToNV vVaTEpel, BraBas d5€ Tivas Kal arras exer. anra parpov av ein TavTa ypagew. Cregera dé Ta datéa Katenyota Kal é€- 1 xpn- § rpduara, § Pq. omits, 179
ON FRACTURES, xxx.
are very ignorant of the healing art, and that ona most vital point. For, to speak summarily, the third or fourth day is the very last on which any lesion should be actively interfered with; ard all probings as well as everything else by which wounds are irritated? should be avoided on these days. For, as a rule, the third or fourth day sees the birth of exacerbations in the majority of lesions, both where the tendency is to inflammation and foulness, and in those which turn to fever. And if any instruction is of value this is very much so. For what is there of most vital importance in the healing art to which it does not apply, not only as regards wounds but many other maladies? Unless one calls all maladies wounds, for this doctrine also has reasonableness, since they have affinity one to another in many ways. But those who think it correct to use wool till seven days are completed and then proceed to extension, coaptation and bandaging would appear not so unintelligent, for the most dangerous time for inflammation is past, and the bones after this period will be found loose and easy to put in place. Still, even this treatment is much inferior to the use of bandages from the beginning, for that method results in the patients being without inflammation on the seventh day and ready for complete dressing with splints, while the former one is much slower, and has some other disadvantages ; but it would take long to describe everything.
In cases where the fractured and projecting bones
1 Littré—Adams, “tin wounds attended by irritation,” seems pleonastic (he has said that no wound is to be interfered with). déxdoa tAdAa olow jpéGiora tpsuacw (Petre- quin}, This view is confirmed by Kw,’s reading,
jt
50
70
ITEPI ATMON
icxyovta pn Svvntar és THY EwUTaVY YOpHv cab dpvec@atr, de 7 KaTATT ACLS” - etenpia xp?) TmoteiaOar € és ToDTOV TOV TpoTrOV ouTrep® ot poxnot eXovow, ols ol AaTUTrOL xpéovrat, TO pev Tu TaTUTEPOY, 70 oé TL oTEVvOTE pov" etvat b€ Ypn Kab Tpla Kal €TL WAELW, WS TOLCL par.oTa dppofovet TU Xpycarto:® ETELTa TOUTOLGL xen aya. 7H KATATACEL pox eve vmepBaddovrTa, T pos bev TO KaT@repov * Tob daTéov 70 KATOTEPOV épeldovta, mpos dé TO avetepov® TO av@tEpoV TOD aLonplov, aTrA® be oye, @aomep et ALOov TLS 7) EvNov poxdevou laxupas: Ear dé cevapa Ta ody pia Qs oldv TE, ws pe) Ka“TTNTAL. avTn peyarn Tue@pin, ny TE TA oudrjpea emer oea 7 Kat HoxrevnTal TLS os xen orooa yap dvO pos- TOLOLVY dppeva. peunxarnrar, TavTov iaxupotata éoTt Tpla TavTa, OvoU TE meplaryory?) kat pox Nev ols Kal obnvects: avev 6€ TOUTMD, 0 év0s 6é & TlWoS 7) TaVTwV, Ovdev TOV Epywy TOV iayupo- TaT@V OL avO parrot ém@iTeNCOUTLY. OUKOUY aTL- paoréen arn 7 Hox AevaLS® yap ovTws éurre- ceiTat Ta dared, % ovK GrArAws. Hv 8 apa Tod doTéov TO avw TapndAdXaypEevoy pun émLTHdSELOV éyn évédpny TO pmoyrA@, arAAA Tapokv @ mapapepn,” Tapayuyaca xpH TOD daTtéov evédpyy TO HOXrA® arparéa mouoacbar poynev- ew 6€ xp? Kal TeLvEelv avd nuepa ue devtepaia, TpiTaia O€ pn, TeTaptaia Sé ws Heiota Kal meuTTaia. Kat un é48ddrovta, oyAnocavTe Sé éy TavTnot Thow nuépnot, preymovny av 1 katracrioa used by Asiatic Greeks for ‘‘put in its place.” Galen, X VIII(2). 590. 172
ON FRACTURES, xxx.
cannot be settled into their proper place, the follow- ing is the method of reduction. One must have iron rods made in fashion like the levers used by stone masons, broader at one end and narrower at the other.! There should be three and even more that one may use those most suitable. Then one should use these, while extension is going on, to make leverage, pressing the under side of the iron on the lower bone, and the upper side against the upper bone, in a word just as if one would lever up violently a stone or log. The irons should be as strong as possible so as not to bend. This is a great help, if the irons are suitable and the lever- age used properly ; for of all the apparatus contrived by men these three are the most powerful in action —the wheel and axle, the lever and the wedge. Without some one, indeed, or all of these, men accomplish no work requiring great force. This lever method, then, is not to be despised, for the bones will be reduced thus or not at all. If, per- chance, the upper bone over-riding the other affords no suitable hold for the lever, but being pointed, slips past,? one should cut a notch in the bone to form a secure lodgment for the lever. The lever- age and extension should be done on the first or second day, but not on the third, and least of all on the fourth and fifth. For to cause disturbance without reduction on these days would set up inflam-
* «One rather broader— another narrower,” Adams. > “Presents a point which makes the lever slip,” Pq. “the protruding part is sharp,” Adams.
2 Ovmep. ® apudcovot... xphoera. * KaTwrépw. 5 avwrépw. 6 ré. 7 mdpotuy mapapepy. mdpotu dv Littré.
173
80
90
92
10
13
TIEPI ATMON
J No’ gd s 239\ e \ Toinoele, Kal EewBadddXovTL OVdEeY HaocoV: GTaTMOv v4 2 s Sets lal / bl pévtot €uBadXovts ToAD av wadrov Tronoetev 7 aropyaavTe éuBadrAeLv. TavdTa ev xp eldévat: Kal yap el émiyévotto omacmos éuS8arXorTt, éXrldes ev ov TOANAL GwTNpLNS' AVOLTEAEL OE > , 5] , XN > f > C64 x oTriaw exBadrew 70 ooTeov, et olov Te ety
, dOXNwS. ov yap emt Tote Xahapwreporre Tov Karpov oT ag pol Kal TéTAavoL erruyivovTar, andra éml Tolow évTeTapcvoict paddov. TrEpt OV ovv
, \ an A 0 AOYoS, OV Xp1) EvoYAELY EV THAL TPOELPNMEVNTL nuépnot TavTnol, ANAA perETaY OTwS HKLOTA hreyuwavet TO EXKos Kal pdadioTa éxTUNCEL. > \ \ e \ € / Ls Xx >’ / éemny O€ éemTa uépar Tapewoty 1 orlyo , oe mMNeLous, VY aTUpEeTOS H, Kal pn hrEypAlvy TO e- , e / na ’ , EXKOS, TOTE NOTOV KWAVEL metpijo Oat éwBarnrewv, a > la / Xx be / Ys 5 a , ny érxmitns Kpatyoev, qv O€ wn, ovdev Set waTnv a. ,’ a oyAciy Kal oxreto Oat.
XXXII. “Hy peév ody éuBarrns Ta doréa és hile EwuTav X@pNY, yeypaerae inn ot TpoTrot ows 3 xr iy Tpevely, Wy Te edmilys 0 ooTea arrortiaes Bat nv Te un. ypn oé, Kal any PED exits ooTéa arootyceabat, [ws Epnv, |? To TpdOT@ THY OOoviwy €ml Waal Tolat TOUTOLGL THY ETridecw TroLeia Bat
an ,
€x pécov Tov oOoviov apyYomevov, ws emt TO TOV, ws amo dvo apX@v UTobeo mls emLoelT au: Texpatper Oat d€ Xp7) ™pos THY pophnv ToD ENKEOS, Orrws eo ra aceonpos Kal ex TET ALY MEVOV éotae Tapa Tv émidecwy? Toloe bev yap. em beEva eT LOELV cuvTpopas ® EXEL, Tolot O€ ém@ aplatepa, toiat 6€ aro Svo apyéwn.
1 3.
174
ON FRACTURES, xxx1.-xxxu.
mation, and no less so if there was reduction ; spasm, indeed, would much more likely be caused if reduction succeeded than if it failed. It is well to know this, for if spasm supervenes after reduction there is not much hope of recovery. It is advan- tageous to reproduce the displacement, if it can be done without disturbance, for it is not when parts are more relaxed than usual that spasms and tetanus supervene, but when they are more on the stretch. As regards our subject, then, one should not disturb the parts on the days above mentioned, but study how best to oppose inflammation in the wound and favour suppuration. At the end of seven days, or rather more, if the patient is free from fever and the wound not inflamed, there is less objection to an attempt at reduction, if you expect to succeed; otherwise you should not give the patient and yourself useless trouble.
XXXT'I. The proper modes of treatment after you reduce the bones to their place have already been described, both when you expect bones to come away and when you do not. Even when you expect bones to come away you should use in all such cases the method of separate bandages, as I said, beginning generally with the middle of the bandage as when an under-bandage is applied from two heads. Regu- late the process with a view to the shape of the wound that it may be as little as possible drawn aside or everted by the bandaging: for in some cases it is appropriate to bandage to the right, in others to the left, in others trom two heads.
2 Omit Littré, Erm. 3 guytpépws = oixelws (Galen). Cf. XXIX.
175
10
20
30
TIEPI ATMOQN
XXXII. ‘Omroca 5é katy mopnen ooréa éwre- oely, TavTa [avra] 1 efdévat xen OTL aT OTTHOETAL, Kal doa TENEWS epiroOn TOV capkav. wWtrovTaL dé €viwy péev TO av@ épos, peTe&eTépov dé cuchober aupiOvicKxovow* al capKes’ Kal TOV pev aro Tov apxatou TP@MATOS cecdT pia Tat EVLA TOV OTTEWD, Tay dé ov* Kal Tey bev Mao, Tov 5€ iocov: Kal Ta pev opexpd, Ta OE peyana. dia odv TaUTa TA Elpnuéva OvK EoTLV EVL OVOpaTE evel, Om oTE Ta ooréa aTOTTHTET AL Ta peep yap oa CLK pOTHTA, Ta O€ bua TO eT dxpou éyecOat, Oaacov abiotatau Ta 5é, dua TO pr) apioracbat, arra AemSodaOaL, rataénpavOevra Kal campa yevopeva: Tpos é TOUTOLS, Svagéper Te Kal int petn int pens. @s pev obv TO éimav TaXLoTA TOUT@V ooréa apioratat Ov TaxvoTe fev at EXTTUNTLES, TAXLOTAL 6€ Kat KadaTat ai capxopuiat, Kat yep a Umopuopevar oapKes KATA TO ova. pov avTat petewpivover Ta ooréa os éml TO TONU. OXOS pay 0 KUKNOS TOU OoTéov, ay év TET oapaKovTa mepyoev aTOoTH, Karas amooTHaeTat: eva yap és efnjcovra 7eepas abucveiTar [1) cal wAetous]:3 Ta ev yap apaLoTepa Tov ootéwy Paccov apioratar, Ta be oTEpEW- TEpa, Bpadutepov: Ta 6€ dAXNa TH peo, TONOV evoortepo, aha & ddXas. amomplew dar éov éféyov éml tavde Ta Tpopactov xpn” ay pen Suvytar ep; Sadrewv, puxpod 6€ Twos avTa SoKh det mapenleiv, Kal olov Te 7 mapatpeOivar ap Te adonpov 7 Kal Opadov TL TOV capKior, raul Suvabecinv wapéxXn, Widrov Te TUyXdvN €or, Kal
1 Omit B, Pq. 176
ON FRACTURES, xxx.
XXXIII. As to bones which cannot be reduced, it should be known that just these will come away, as also will those which are completely denuded. In some cases the upper part of the bones are denuded, in others the soft parts surrounding them perish, and the starting point of the necrosis is, in some of the bones, the old wound, in others not. It is more extensive in some and less so in others, and some bones are small, others large. It follows from the above that one cannot make a single statement as to when the bones will come away, for some separate sooner owing to their small size, others because they come at the end (of the fracture) while others do not come away (as wholes) but are exfoliated after desiccation and corruption. Besides this, the treat- ment makes a difference. As a general rule, bones are most quickly eliminated in cases where suppura- tion is quickest, and the growth of new flesh most rapid and good; for it is the growth of new flesh in the lesion that as a rule lifts up the fragments. As to a whole circle of bone, if it comes away in forty days it will be a good separation, for some cases go on to sixty days or even more. The more porous bones come away more quickly, the more solid more slowly; for the rest, the smaller ones take much less time, and so variously. The following are the indications for resection of a protruding bone: if it cannot be reduced, but only some small portion seems to come in the way, and it is possible to remove it; if it is harmful, crushing some of the tissues, and causing wrong position of the part, and if it is denuded, this also should
® wrepiOvyoKovct 3 Kw. Omits.
£77
39
10 11
10
TIEPI ATMQN
TO ToLovTop 1 aatpeiv xpn. Ta bé ddra ovder peya Siabéper, ouTe arom pioat ovre pa) aTro- Mpioat. capéws yap eldévat xP? étt daoTéa, 60a TEAEWS oTepeera TOV capKav Kal éncénpatverat, OTL TavTa Tews drroaTioceTat. boa dé amro- Aerri6ovabar pédret, TabTa ov xp” amor pie Texpaiper Oar éé xpi amo TOV TETAYMEVOY onMEeLwY TA TEEWS aToaTna omeva..
XXXIV. ‘Intpevew dé Tous ToLouTous omh- vert Kal TH olvnpiy nt pely, OOTEP Kal mpoober yéypamTa. é7l TOV AMOg TAO HELD, daTéwy. gurdacea bas dé pn Ty) puxpoicn ® Téyyelw TOV TP@TOV Xpovov' puyeov yap TUPET@OWY xivduvos’ KLYOUVOS bé Kal oT ac may: mpoxanetrar yap oma mov Ta puxpd, moti 6é Kal Eden. eidevar dé vpn OTe avadyen Bpaxvtepa Ta copara. Tavry yivecOat, ov app orepa Ta daréa KaTenyora Kal TapnrrdaypLéva. inTpevnTat, Kal ois GXoS 0 KUKNOS
/ TOU OOTEOU ATECTN.
XXXV. “Ocoor® 6 pnpod daTéov ; Bpaxto- vos eFeoxen, ovToL ov para mepuyivovTat. Ta yap ooréa peydra Kab TONUMUENG, Kal Tora Kal émikaipa Ta cUVTLTpwoKOLEVa Vedpa* Kal pues Kat préBes: Kal hv pev éuBarrdns, oracpuol prréovar emuyiver Oar, [1 euBrDeior dé mupetol o&€es Kal émLxonou Kal Y uryybbecs, wal érripehatvov- Tae" mepuytvourat dé ovY Hocov, olaoe pn €uBrANOn, pon mrevpnOn® éuBarrecOar Ete SE wadrov Tept- yivovTat, oat TO KaTw Epos TOD daTéoU eFéa yer,
1 ro.ovTo.
2 karavuxpoict (BMV). Kw. adopts Ermerins’s sugges- tion Kapta.
178
ON FRACTURES, xxxii.—xxxv.
be removed. In other cases it makes no great difference whether there is resection or not. For one should bear clearly in mind that when bones are entirely deprived of soft parts and dried up they will all come away completely: and one should not resect those bones which are going to be exfoliated. Draw your conclusion as to bones which will come away completely from the symptoms set forth. XXXIV. Treat such cases with compresses and vinous applications as described above in the case of bones about to be eliminated. Take care not to moisten with cold fluids at first, for there is risk of feverish rigors and further risk of spasms, for cold substances provoke spasms and sometimes? ulcera- tions. Bear in mind that there must be shortening of the parts in cases where, when both bones are broken, they are treated while over-lapping, also in cases where the circle of bone is eliminated entire. XXXV. Cases where the bone of the thigh or upper arm protrudes rarely recover ; for the bones are large and contain much marrow, while the cords, muscles and blood vessels which share in the injury are numerous and important. Besides, if you reduce the fracture, convulsions are liable to supervene, while in cases not reduced there are acute bilious fevers with hiccough and mortification. Cases where reduction has not been made or even attempted are no less likely to recover, and recovery is more frequent when the lower than when the upper part 1 This seems the place where wor! means woré as Galen
says in his Lexicon, but wor) «al is an expression peculiar to these treatises and means “ especially.” See Diels, op. cit.
3 “Oowy. 4 kal vevpa. 5 éveBAndn. . . émeiphon.
179
20
26
10
TEPI ATMQN
A e \ ” , 8 A \ ) OlOL TO AV" PUTS payee OLE e av “a olow
eu BA Pein, oTAVLWS YE payD. ped€eTat yap pene- TEWY (Mey Svadépovor, Kal dvaves puoiov TOV TouaT wy és evdopinv. Siagéper éé heya, Kal ny €ow@ TOU Bpaxtovos Kal Tob pnpod Ta daréa eEéyn TodXNal yap Kat émikaipo. KataTtdacues hrAcBav ev THO Ew pEpEeL, MY EVLAL TLTPWOKOMEVAL ohayiat eiow: eioi b€ Kal &v TO &€w péper, nagov O€. €v TolcLW ovY ToOLOVTOLOL TPwuaC~L TOUS pev KLvOUVOUS Ov xen AijGew orroiot TwWés elot, Kal Tpodeyerv Xp TMpos TOUS karpovs. el dé avayxaforo péev éwBadrrewv, ermivors b€ éuSarrev, Kal 7 WOAX) 7 Tapadrakss ein TOU GoTéou, Kal BN cuvdedpapyn cover ol pves— prréover yap ouvbeiv—1 poxrevats Kal TOUTOLCL META THS KATATACLOS ED Av cvANALBavaTo. XXXVI. ‘EuBadrovta Oé, éddEBopov panrOa- KOV Timo ae xP? avOrpepov, ap avén}pepov EuBANIH, el O€ pn, oud eyxerpety XpN. TO be Exxos intpevey xp olot wep Keharrs dotéa KaTenyvins Kal ux por pn dev T poo epeLy, oitiwv O€ oTEphra TEhews* KAL pe peev TLK pOX0- os duce 7, ofuyhucu evades odyov ep vdwp emiaralovTa TOUT@ OtaLTav" my o¢ pa) TLKPOXONOS 7], UOATL TOMaTL ypia Oar Kal ay pev muperaivy TWEXAS, TeccapaKaideca nuépnaot ro exo Tov ovT@ Svactav, 9 ny Oe ambperos ny €TTA nepne ev" emrerTa én Tporayaris kare Royov és pavrny diartav ayew. Kat olow pwn? éuBrO7n Ta ootéa, Kal Thy happakeinv Xp} ToLavTny Troveta Oat, Kai
1 jyuépas bis. 2 dy wh. 180
ON FRACTURES, xxxv.-xxxvi.
of the bone projects. There may be survival even in cases where reduction is made, but it is rare indeed. There are great differences between one way of dealing with the case and another, and between one bodily constitution and another as to power of endurance. It also makes a great difference whether the bone protrudes on the inner or outer side of the arm or thigh, for many important blood vessels stretch along the inner side, and lesions of some of them are fatal ; there are also some on the outside, but fewer. In such injuries, then, one must not overlook the dangers or the nature of some of them, but foretell them as suits the oceasion. If you have to attempt reduction and expect to succeed and there is no great overriding of the bone, and the muscles are not retracted (for they are wont to retract) leverage com- bined with extension would be well employed even in these cases.
XXXVI. After reduction one should give a mild dose of hellebore on the first day, if it is reduced on the first day, otherwise one should not even attempt it. The wound should be treated with the remedies used for the bones of a brokenhead. Apply nothing cold and prescribe entire abstinence from solid food. If he is of a bilious nature give him a little aromatic hydromel ! sprinkled in water, but if not, use water as beverage. And if he is continuously febrile keep him on this regimen for fourteen days at least, but if there is no fever, for seven days, then return by a regular gradation to ordinary diet. In cases where the bones are not reduced, a similar purgation should be made and so with the management of the wounds
1 Decoction of honeycomb in water = amduedr in XI; ef. Galen on its preparation,
181
20
25
10
20
TIEPI ATMON
TOV EXKEWV THY MEAETHVY KAL THY SlatTav’ @CAaVTAS Kal TO aTratwpevpevoyv) Tod Ga@maTos fn) KaTa- Telvelv, GAAA Kal mpoadryew PaXXov, wWoTeE Xahapwrepov Siete TO Kara 76 EXxos. Tov é do TEV atoaTacts * xpovin, Bomep Kal tpocGev — elpnT au. padiora 6 Xp?) ra TOLAUTA diauyely, dpa nv TLs Kary eX Ty atopuyny. ai TE yap EXTLOES ONAL, Kal Ol KivOuvot Toot Kal pn euBadrov drexvos av doKéot eivat, Kal éuBdrdr.wv éyyutépw av tov Gavdtov ayayo 7 cwTnpins.
XXXVII. Ta 6&€ odtcOjpata Ta KaTa Ta youvata Kal Ta Siaxuyuata TOV oaTéwV evn- Géctepa modu TOY KaT ayKava Kn aTov Kal odio Onpatov: TO TE yap pO pov TOU pnpov eVoTAEaTEpoV @s él peyéeber H TO Tob Bpa- xiovos, Kai Stxainy puow podvov éxov, Kal TavTny mepupepea TO O€ TOU Bpaxtovos apOpov peya TE Kal Babpisas Thelovas eXOv. mpos be TOUTOLS, Ta pev HS KU LNS dared TapaTrnowa HAKOS éore Kal o JLUK pov Te ovx a&Lov Aoryou TO éfeo daTeov UMEPEXEL, ovdevos pueryadou _KoAUpa éov, ag’ ov T épuKev 0 cE TEvOV o Tapa TID cyviny: Ta O€ TOU TXEOS doTéa aviod €orW, Kal TO Bpaxutepov TAaXYUTEpOV TUXYD, TO dé Rem oTe- pov 7roNXov UmepBarret Kal UmEpeXel TO apO pov: eEnpTnTar HEVTOL Kal TouTep § TOV VEeVPWV KATA THY Kowny ovppuary TOY ooTéwy" m)etov 66 feépos yeu TAS eEaptijavos TOV vevpav €y TO Bpaxtove TO AeTTOV daTéOV Hep TO TAXD. bev ovv pats ToLtovTOTpoTOsS TOY apOpwyv ToVTwV
} amopeduevor, 2 7 andaracts, 8 rovTo,
182
ON FRACTURES, xxxvi.—xxxvu.
and the regimen. Likewise do not stretch the unreduced part,’ but even bring it more together so that the seat of the wound may be more relaxed. Elimination of the bones takes time, as was said before. One should especially avoid such cases if one has a respectable excuse, for the favourable chances are few, and the risks many. _ Besides, if a man does not reduce the fracture, he will be thought unskilful, while if he does reduce it he will bring the patient nearer to death than to recovery.
XXXVII. Dislocations at the knee and distur- bances of the bones are much milder than displace- ments and dislocations at the elbow; for the articular end of the thigh-bone is more compact in relation to its size than is that of the arm-bone, and it alone has a regular conformation, a rounded one, whereas the articular end of the humerus is extensive, having several cavities. Besides this the leg-bones are about the same size, the outer one overtops the other to some little extent not worth mention,? and opposes no hindrance to any large movement though the external tendon of the ham arises from it. But the bones of the forearm are unequal, and the shorter (radius) much the thicker, while the more slender one (ulna) goes far beyond and overtops the joint. This, however, is attached to the ligaments at the common junction of the bones. The slender bone has a larger share than the thicker one of the attachments of ligaments in the arm. Such then is the disposition of these articulations and of
1 Kw.’s reading is the most suitable.
* A curious error, perhaps due to an effort to make the fibula resemble the ulna as far as possible. (The fibula does not reach the top of the tibia. )
* The ulna is attached to the ligaments of the elbow joint, at the point where it joins the radius, Galen,
183
30
6
HEPI ATMON
Kal TOV doTéwy TOD ayKavos. Kat bia Tov TpoTov THIS puavos Ta KaTa TO youu oar éa, ToAAaKis pev oAdtcOaver, pnidios dé éurimres* preypLovi) dé ov peyadn Tpooyiveat, ove Seo wos Tob apOpov. ora aver dé Ta rela ra és TO éow pépos, éore & OTe és TO &Eo, ToTe O€ al és THY iyvony. TOUT@Y dmavtav at €uBoral ob yarerrat: arha 7a pev é€m Kal éow odaOdvovra, Kab nabat eV Xpx Tov avO pwr ov xapal i) em Napartr) rou TWOS, TO 6€ TKENOS averepo EXEL, wa pev TOANO. KATATACLS be @s €7t 70 TONU per pin dpxel, TH pev KaTtarewew THY KUnuNY, TH Sé avTLTELVELY TOV
npov.4
XXXVIII. Ta 6ée Kara TOV ayKx@va OVXAWOE- oTeEpa core TOV KATA TO youu, wal duceuBoro- Tepa Kal bua THY dreymovnv cat da THY pve, ay pry TLs avTixa éuSarn* ora aver bev Hocov 7) exeiva, duceuBowrepa dé Kal duobeTa@rtepa, Kal eTmipdeypaiver warAXov Kal ev uT@povrat. .
XXXIX.*Eor: 6€ Kal TOUT@Y TretoTa * optKpal eyediores, adore és TO 7 pos TOV 7 N€U- péwy pépos, aAXoTE és TO eo, ou may be TO pO povp peTaBeBnkos, AAA pévov® TO KATA TO KOtAOV
? End of Galen’s Commentary as extant; but later frag- ments are preserved in Orib. XLVI.6, XLVIL. 5, ete.
* jacov opposed to morrdnes above: but not true. Some therefore take it to mean ‘‘ toa less extent.”
3 érimopovrai. 47a wey TAELTTA.
5 udvov B, wévovrt 7d M, pévov te V, nodovov Kw. The reading is important for the writer’s account of elbow dislocations. If uévov, the chapter must refer to dislocation of the radius only and ‘‘inwards” would imply that the writer looked at the arm and hand as hanging back to front with the bend of the elbow turned inwards, the reverse of our position. Petrequin first noticed this, and showed that
184
ON FRACTURES, xxxvi.—xxx1x,
the bones of the elbow. Owing to the way they are disposed the bones at the knee are often dislocated 1 but easily put in, and no great inflamma- tion or fixation of the joint supervenes. Most dislocations are inwards,? but some outwards and some into the knee flexure. Reduction is not difficult in any of these cases: as to external and internal dislocations, the patient should be seated on the ground or something low, and have the leg raised, though not greatly. Moderate extension as a rule suffices ; make extension on the leg and counter- extension on the thigh.
XXXVIII. Dislocations at the elbow are more troublesome than those at the knee, and harder to put in, both because of the inflammation and because of the conformation of the bones, unless one puts them in at once. It is true that they are more rarely ? dislocated than the above, but they are harder to put up, and inflammation and excessive formation of callus 4 is more apt to supervene.
XXXIX. (Dislocation of radius.) The majority of these are small displacements sometimes inwards, towards the side and ribs, sometimes outwards (our “forwards” and “ backwards”). The joint is not dislocated as a whole, but maintaining the con-
1 A strange remark, perhaps includes displacement of the kneecap. Displacements of cartilages are not noticed.
2 Of the thigh-bone.
’ Pq. says he treated ten times more elbow than knee dislocations.
4 Cf. Celsus VIII. 16, ‘‘ callus circumdatur.”
it explains much. dvoy or vorvoy would imply a dislocation of the ulna only, and add another difficulty. It seems clear that the epitomist (M VII, J XVII) read pévov ; but these chapters have puzzled the scribes as well as the surgeons.
185
10
13
10
TIEPI ATMON
a 3 G fr P, ka A A , Tov oatéov ToD Bpaxiovos, f TO Tod THYEOS 3 ta \ “4 n dotéov TO UTEpéxov eye. Ta pev OdV TOLAdTA,
xXx fo) A a ’ , 4 4 > / \ Kav T™ 1 TH OdAMCOn, pyidiov eéuBarreWw, Kal
\ / \ aToxpy 1) KaTaTacls n és TO LOD yLvoméevn KaT nr / \ iOvwpinyv Tov Bpaytovos, Tov wev KATA TOV KapTrOV
6 \ ,
THS KYELpos TElvelv, TOV dé KATA THY pwacxXarnD / \ \ na ¢ / \ XN 2 \
mepiBadXrovta, Tov dé TH éETépn Tpos TO éEeaTEdS
apOpov to Oévap wpocB8arrovtTa @leiv, tH dé
€ , > @ a A 2 > \ lal ” 6
eTepn avTwblew tpoaRaddovta® éyyus TO apOpo. - 7
XL. ’Evaxover 5& od Bpadéws éuBadXropeva
\ a ’ 4 A \ / Ta ToladTa oNCOHpaTa, Hv Tmplw preyuHVH éuBarryn Ts. OdcOdver b€ ws él TO TOAD
4 > \ ” / 3 / De \ b] MaXAOV €S TO ETW Epos, oAtc Pave, b€ Kal és
\ + ” \ a , \ , To é&w, evdnra 66 TO oXHMATL. Kal ToAAAKIS €uMiTMTEL TA TOLADTA, Kal avev loyuphsS KaTa-
\ a \
Tacos’ xp € TOV Eow OALCOaVOYT@Y, TO MED
” > fal > \ /, No X\ lal > \
apOpov atrwlety és Thy pvaw, Tov O€ TiXUY és TO
a \ \
KaTaTpnves adXov pétovta® Tmepiayev. TA MEV TrEloTA AYKOVOS ToLadTAa ONGOnLATA.
XLI. “Hy &€ brep87H 76 dpOpov 4 &vOa H evOa
fal f \
Umép TO oaTéov Tod mrHyeos TO €EéYOY €s TO
a fol / \ >’ / KotAov TOD Bpaxlovos—yiveTat pév OVY OALYAKES
lal e / / TouTo, nv dé yivntat—ovK TL Omoiws 4 KaTa-
/ , a
Tacls 1) és THY (OuMpiny yivomEern éemiTNSEeln TOV s \ A 4
TOLOUT@Y OALGOnuLaTwV* KwAEL yap év TH TOLAVTN lal , ’ ,
KATATATEL TO ATO TOU THYKEOS UTTEPEXOV OTTEOV lel \ , lal
THv UTépBact TOD BpaxXlovos. YpH ToLwuY TotoLW
7
1 étécxev B, Kw., ste i ® xpos Tod mnxeos B, Kw. insert. q: omits, 186
ON FRACTURES, xxxtx.—x11.
nexion with the cavity of the humerus, where the projecting part of the ulna sticks out. Such cases, then, whether dislocation is to one side or the other, are easy to reduce, and direct extension in the line of the upper arm is quite enough, one person may make traction on the wrist, another does so by clasping the arm at the axilla, while a third presses with the palm of one hand on the projecting part and with the other makes counter-pressure near the joint.
XL. Such dislocations yield readily to reduction if one reduces them before they are inflamed ; the dislocation is usually rather inwards (forwards), but may also be outwards, and is easily recognised by the shape. And they are often reduced even with- out vigorous extension. In the case of internal dislocations one should push the joint back into its natural place, and turn the forearm rather towards the prone position. Most dislocations of the elbow are of this kind.+
XLI. (Complete dislocation of the elbow back- wards and forwards). If the articular end of the humerus passes either this way or that? over the part of the ulna which projects into its cavity (the latter? indeed occurs rarely, if it does occur), ex- tension in the line of the limb is no longer equally suitable, for the projecting part of the ulna prevents the passage of the humerus. In patients with these
1 Adamsagrees that XX XIX is ‘‘ dislocation of the radius,” but has to call XL ‘‘ incomplete lateral dislocation of the fore- arm” since the radius alone cannot be dislocated ‘* inwards,” The nature of these lesions is discussed on p. 41] ff.
2 “to either side,” Adams.
8 Refers to “backwards,” which can hardly occur without fracture,
137
10
20
22
10
TIEPI ATMON
oUT«s éxBeByoor THY Katdracty Troveto Oa ToLavTny, oin Tep mpocbev yeypaTrat, emray TUS datéa Bpaxtovos Karenyord émdén, a amo pev Tis pacxadys és TO dive telvecOar, ards Sé Tob aryKkOVOS avroo és TO KaTw avayKate: or yap av parora, 0 Bpaxtoy vrepawpynOein wep THs EwuTod Babpisos, my Oe UTeparwpryOy, pyidtn 2 i as Toll Gévapor TOV YELPOV TO pev eEearteos * TOU Bpaxtovos euBadrovTa weir, TO d€ és TO TOD THYEOS dotéov 70 Tapa TO apOpov euBadrovta cypealiety, TOV auTov T pom ov appa WoOoov wévToL” 1 TOLAVTH KaTaTAGLS TOD TOLOUTOU oda Or} watos Sixauorarn: €uBr» Bein & av Kal ato THS és LOU KaTaTdcvos, OTOV € 7) ovTo. XLII. “Hy &€ és tovumpocdev oricOn 0 Bpa- Niwv, EhLaXlaTaKLS peVv TODTO yiveTal, GANA TL av efarrivys * exTranaus OvUK €uBEXXOL 5 ; Toda yap Kal Tapa THY olKeinv 4 puow exTrITTEL, Kal my peéya Te 7 TO K@ADOD: TaUTn be TH exTadjoet meyer | TL TO Um epBawopevoy TO UTEP TO TAXUTEPOD TOV OTTEWV, KAL TOV vEevpwv ouxy KaTaTacls: Spws 6é 67 Tiow é€emandnoev. onpecov d€ Tolow obTws exTadnoacw: ovdevy yap xXpnua Tod ayk GVOS Kamae Svvavrat, evdnrov ® dé Kal TO apOpov _Wavopevor. VY pev ovv fi) avTiKa éuBrnOn, ioxupat Kat PBiaac breypoval Kal mupeTwoees yivovtat: av 6é 67 avTika Tis , s7 / Tapatvxn evéuBorov, [ypr d€ dAovioy cxAnpor] ®
1 és rd eteoreds.
2 Kw, dudo, hooov pévto . . . He supposes a hiatus, 3 ékamwain. 4 éouxviar. 5 ySnAov. § Kw. omits.
188
ON FRACTURES, xu1.—xu11.
dislocations, extension should be made after the manner which has been described above for putting up a fractured humerus. Make traction upwards from the armpit, and apply pressure downwards at the elbow itself, for this is the most likely way to get the humerus lifted above its own socket, and if it is so raised, replacement by the palms of hands is easy, using pressure with one hand to put in the projecting part of the humerus, and making counter- pressure on the ulna at the joint to put it back. The same method suits both cases. ‘This has, in- deed, less claim to be called the most regular method of extension in such a dislocation and reduction would also be made by direct extension, but less easily.
XLII. (Internal lateral distortion of the forearm, Petrequin’s View). Suppose the humerus to be dis- located forwards. This happens very rarely; but what might not be dislocated by a sudden violent jerk? For many other bones are displaced from their natural position,? though the opposing obstacle may be great. Now, there is a great obstacle to this jerking out, namely the passage over the thicker bone (radius) and the extensive stretching of the ligaments, but nevertheless it is jerked out in some cases, Symptoms in cases of such jerk- ings out. They cannot bend the elbow at all, and palpation of the joint makes it clear. If, then, it is not reduced at once, violent and grave inflam- mation occurs with fever, but if one happens to be on the spot it is easily put in. One should take
1 “Evidently meant as a description of complete lateral dislocation,” Adams. * Kw. ‘‘ beyond what seems natural.”
189
20
30
32
10
TIEPI ATMON
—doviov yap oKAnpov elurypevov apxel, Hn peya, —évbévta TraYyLOV és THY Kary TOU dyKBv0s, éfamivns ouyKapyapar Tov ayKOva Kal ™poo- aryayety @S pada THV xetpa ™ pos TOV @mov. ikavn bev arn uy) enor TOLOLV ovTws éxTrann- cacw'! atap Kal 1 és TO (00 KaTdTacws SUvaTaL evderivery TOUTOV TOV Tpomov TAS enor: TOLCL MEVTOL Gevapor TOV Xeipav Xp}, TOV pev euBdn- AovTa és TO TOU Bpaxtovos éféyvov TO Tapa THY Kapry omiow aTwleiv, Tov O€ Tiva cat ober és TO TOU dry OVOS ov eu BardovTa avTwbety és THY LOvepinv Tov TX EOS pémrovta. dvvarat oe ev TOUT® TO TpoT@ THS Orta O}a Los Kaetun uy) KATATALS n _mpoa dev eyyeypaymevn,” @S xen KaTareivew Ta oaTéa TOU Bpaxiovos KaTenyoTa, ery pEAWoW émideta Oa* ery bé Katatan, ov’Tw xpn Tolar Dévapot Tas tpocBodrds Trot- eta Oar, BOT Ep Kat Tpoobev YeYPUTTAL.
XLIII. “Hv &é és TO OTTiaw Bpaxtov € extréon— ohuyaKes dé TodTO yiverat, em@duvaTarov TE TOUTO TAVT@OV Kal TUPETWOETTATOV, TUVEVEWY TUPETOV Kal axpntoxodrwv, Oavatwodéwy Kal oALynMEpov— Ol TOLOUTOL ExTaVvUELY Ov SUVaVTAaL. iv O€ meV Ov autixa Tapatvyyns, BidcacOar® ypn éxtavucarta TOV ayK@Va, Kal avTOUATOS eMTUT TEL. ny O€ oe pbacn TUPETALV TAS, ovK éTL ypn ew Barrew KATAKTELVELE yap av 1 oduvyn avaryKatopévov. @S & év keparato etpia Bau, ove andro xP” apOpov
ll mrupetatvorvtse éuBarrAaWw, Hxtota O€ ayKova.
1 r@ ToLwvTy. ee Bons yeypaum vn. ta CeoOan.
190
ON FRACTURES, xuiu.—xuut.
a hard bandage (a hard rolled bandage of no great size is sufficient) and put it crosswise in the bend of the elbow, suddenly flex the elbow, and bring the hand as close as possible to the shoulder. This mode of reduction is sufficient for such jerkings out. Direct extension, too, can accomplish this reduction. One must, however, use the palms, putting one on the projecting part of the humerus at the elbow and pushing backwards (our inwards), and with the other making counter-pressure below the point of the elbow, inclining the parts into the line of the ulna! In this form of dislocation, the mode of extension described above as proper to be used in stretching the fractured humerus when it is going to be bandaged is also effective. And when exten- sion is made, application of the palms should be made as described above.
XLIII. (External lateral dislocation of forearm).? If the humerus is dislocated backwards (our “ in- wards’’)—this occurs rarely, and is the most painful of all, most frequently causing continuous fever with vomiting of pure bile, and fatal in a few days—the patients cannot extend the arm. If you happen to be quickly on the spot, you ought to extend the elbow forcibly, and it goes in of its own accord. But if he is feverish when you arrive, do not reduce, for the pain of a violent operation would kill him. It is a general rule not to reduce any joint when the patient has fever, least of all the elbow.
1 Adams. ‘‘Dislocation of ulna and radius backwards,” IL. 500, but II. 549, ‘‘It would seem to be dislocation of the forearm forwards.”
2 So Petrequin. It seems impossible that this should be
dislocation of the forearm backwards, the commonest form, as Adams suggests.
Ig!
10
13
10
TIEPI ATMON
XLIV. "Ears &€ cat ana civea KaT ayKdva oxrodea: TOUTO Lev Yap, TO max UTepov orréov éoTi OTE exiv70n ato TOU ET Epov, Kal ovTE ouyKaprrely OUTE KATATAVUELVY opotes dvvaprtat. djjAov dé yiveat avopevoy KaTa THY ovyKapapl TOU ayKOVOS mapa TH Siac yisa TIS preBos THY avodev TOU [LUVOS Telvouo ay ola S€ TO To.odTo», OUK ETL pyiScov és TV éwuTod how ayayety: ovdé yap addy ovdeminu pnidvoy cuppuada Kownvy Ovo oaTéwD xuvn Geta av és TY apxatyy duow iOpuvOjvat, aNn’ avayen oryKov layew Typ GudoTaow. @s O€ émideiy xpn ev apOpe, év TH KaTa opupov em Oeael el pnTat.
XLV. "Kore 8 otce Kat ayvuTat » TOU TX EOS 76 daréov TO UmorETary Levov TO Bpaxtove, OTe bev TO xovdpades avtTou ag’ ov mépunev 0 Téveov 0 ova Gev Tov Bpaytovos <6éte 5é TA TpdTw KaTA THY apxny THs expvalos TOU mpocbiov Kopwvoi>* Kal, EMV TOOTO Kw7On, TupeT@oes Kal xaxonbes yiverau TO HEVTOL ap0 pov pever év TH €wUTOU Xopn’ Taca yap a) Baous avtoo TavTY umepexet.® otav* 6€ dmayn TavTn Umepéexer » xepam) Tob Bpaxtovos, TavwdéaTe pov TO dpO pov yiverat, ny TAVTAT AGL arroxavMaa Oy. dower Tepa dé, @s ev Keparato eipnadar, TavtTa Ta KaTayVUMEVA TOV doTéwy éoTly 7) OloLY TA eV Oo Téa OV KATAYVUTAL, préBes O€ Kal vedpa émixarpa auduprAGtar év TOUTOLOL TolaL Ywploia: éyyUTéepw yap Javat@
l amayvurat. 2 Omit codd., vulg.; restored by Littré from Galen in Orib. XLVI. 6.
3 bréexet. 4 ay.
192
ON FRACTURES, xtiv.—xtv.
XLIV. (Separation of radius). There are also other troublesome lesions of the elbow. Thus the thicker bone is sometimes separated from the other, and they can neither flex nor extend the joint as before. The lesion is made clear by palpation at the bend of the elbow about the bifurcation of the blood vessel! which passes upwards along the muscle? In such cases it is not easy to bring the bone into its natural place, for no symphysis of two bones when displaced is permanently settled in its old position, but the diastasis (separation) necessarily remains as a swelling. How a joint ought to be bandaged was described in the case of the ankle.
XLV. (Fractures of olecranon), There are cases in which the bone of the forearm (ulna) is fractured where it is subjacent to the humerus, sometimes the cartilaginous part from which the tendon at the back of the arm arises, sometimes the part in front at the origin of the anterior coronoid process, and when this occurs it is complicated with fever and dangerous, though the joint (articular end of hu- merus) remains in its place, for its entire base comes above this bone. But when the fracture is in the place on which the articular head of the humerus rests, the joint becomes more mobile if it is a complete cabbage-stalk fracture (ze. right across), Speaking generally, fractures are always less trouble- some than cases where no bones are broken, but there is extensive contusion of blood vessels and important cords in these parts. For the latter
1 Cephalic vein. 2 Biceps.
3 jmepéxet, swpersedet, ‘*is above,” the articular end of the humerus rests entirely on the olecranon, the arm being bent. ‘‘ Protrudes at this point,” Littré-Adams,
a es VOL. IIL
TTEPI ATMQN
mend ber TavTa 7) éxeiva, ay extrupwOh cuvexel TUpeT eo" Oya ye pyv Ta ToLAdDTa KaTHYypWaTA 18 yivetat.
XLVI. "Eott 5€ 6te adty Kepadryn Tod Bpaxtovos KaTa THY éripvow KaTtayvuTac’ TOUTO d€ dOdKEeov KakooLVwTaTOV éivaL TOAXRD
4 Twi evnOéstepov TMV KaT ayKava clvéwr eoTiV.
XLVI. ‘Os pév oty Exacta Tév OMcOnuaTov appoacer® [éuPdrrgav Kai]? parrota intpever, yéypamtat, Kal OTe mapaxphua euSddrew panr- loTa apOpov ouppéper bua 70 TAXOS Ths prey- povas Tay vevpov. Kal yap iy EKTETOVTA GUTIKA euméon, Opws poret Ta vedpa. ovvTacw moveta Oar, Kal K@AvELW éTtl TOTOV Xpovov TY TE EKTAGL, daonv Tep piret* morncacbat,® THY TE TUyKap LD. intpevery O€ tTdvTa TapaTANnCiws Ta TOLAaAvTA
10 cupdéper cal omora aT ayvuTat, Kal omoaa diictatat, Kal oTOca oda Advert TAVTG yap xen a0oviorcs TOANOICL Kal omjVvErt Kal KnpwTh int pevel, OoTEP Kal Tada KATHY MATA. TO O€ TXAUAa TOD ayK@vos év TOVTOLCL 67) Kal TaVTa- Tact Xp TovwdtTov trovetcOat, olov mep olat Bpaxiwv énedeito Katayels, Kal miyXus* KoLWo- TATOV “ev yap TaoL TOioW OrALCOnpMAGL Kal TOlGL KWIMLAaoL Kal TOOL KATHYMACL TOUTO TO ayHma éotiv: KowoTatov dé pos THY éretta StdoTtacw,®
20 Kal TO éxTavie Exacta Kal ouvyKadpTTeLv* evrebbev yap odol és apporepa Tmapathijovou eVOX@TATOV Kal evavahyTTov avT@ TP KapVOVTE TOUTO TO TXT pa. ere 6€ ™ pos TOUTOLL, el apa KpaTnVein UO TOU TwpwmaTos, EL pev EKTETA-
1 ry. 2 apudoes. 194
ON FRACTURES, xtv.—xtvu.
lesions involve greater risk of death than do the former, if one is seized with continued fever. Still, fractures of this kind rarely occur.
XLVI. Sometimes the actual head of the humerus is fractured at the epiphysis, but this, though ap- parently a very grave lesion, is much milder than injuries of the elbow joint.
XLVII. How, then, each dislocation is most appro- priately [reduced and] treated has been described ; especially the value of immediate reduction owing to the rapid inflammation of the ligaments. For, even when parts that are put out are put in at once, the tendons are apt to become contracted and to hinder for a considerable time the natural amount of flexion and extension. All such lesions, whether avulsions, separations or dislocations, require similar treatment, for they sbould all be treated with a quantity of bandages, compresses and cerate, as with fractures. The position of the elbow should in these cases, too, be the same in all respects as in the bandaging of patients with fractured arm or forearm; for this position is most generally used! for all the disloca- tions, displacements and fractures, and is also most useful as regards the future condition, in respect both of extension and flexion in the several cases, since from it the way is equally open in both directions. This attitude is also most easily kept up or returned to by the patient himself. And besides this, if ankylosis should prevail, an arm ankylosed in the
1 xowdtatov almost = ‘‘ most useful.” 3 Omit B, Kw. 4 wépuKe. 5 woleio Cat, ® diatacw KK.
195
30
10
20
TIEP] ATMQN
pevn 1) XEelp KpaTnOein, Kpécowv av ein py Tpooeovaa, TOP bev yap Koha ein, opehein dé On, el 8 av ovyKeKcaumevn, parhov eVXpN)- ros ay ein, TOARD 6€ evypnatorépy, et TO dua péoov oX ipa éxouea mopwlein [kpécoor].4 ta fev TEpi TOD TYHpmaATOS Towdoe,
XLVIIT. "Exidety 5€ yen tHv Te apxny TOU mpdtov ooviov Barnopevor Kata TO Bradle, ny Te KatTayn, jv te éxoth, Hv te dLacthH, Kal tas tepiBoras Tas mpwtTas KaTa TodTO moveicOar, Kat épnpeicOw pwartata tavTn, évOev dé cal &vOev emi Hacov. tiv dé éridecw Kony moveiaPat x¥pn TOU Te THXEOS Kal TOD Bpaxtovos, Kai éml moAv mA€ov ExadTEpoyv 7) WS Of TAELTTOL mo.eovaw, OTTws eEapvntar? ws uddiaTa ato TOU civeos TO olonua évOev cai &Oev. mpooTepi- BarrécOw 5é xal Td 6E0 Tod TrHYEos, Hv TO aivos KaTa TODTO 7, Hv O€ pH, twa p1) TO oidnpa evravla Trept auta > oudneyn Tat. Tepid evyewv dé xpr év TH emidecel, OTWS LN Kara THY KapTny MoXXOV TOV OOoviov HOpoLapéevov ~aTaL eK TOV Suvatav: meméyOat dé KaTAa TO Givos MS MaNLOTA. Kal Ta ddrKa KaTanraBero avTov mepl Tis TLEELOS Kal THS Nahdovos TaUTa, Kal Kara TOUS avTOUS Xpovous éxaorTa, @OTTEP TOV 6aTéwy TOV Karenyo- Tw ev TH intpety Tm poo bev yéypamtTat Kal ai peT- erridéoves bua TpLTNS gaTwoay: xXarav dé doKeiT@ TH TpLTN, GomEp Kal TOTE’ Kal vapOnkas ™poo- mepiddnew év 7 ieveopeve xpove—ovdev yap aro TpoTrou, Kal ToloL TA dared KaTenyoot, Kab TOoL pn, NV pH WupeTaivn—@s YadapwTatous 6é,
1 Kpésoov or kpéoowy codd. omnes; but many editors omit,
196
ON FRACTURES, xtvu.—xivmt.
extended position would be better away, for it would be a great hindrance and little use. If flexed, on the other hand, it would be more useful, and still more useful if the ankylosis occurred in an attitude of semiflexion.t_ So much concerning the attitude. XLVIII. One should bandage by applying the head of the first roll to the place injured whether it be fractured, dislocated, or separated. The first turns should be made there and the firmest pressure, slackening off towards each side. The bandaging should include both fore and upper arm, and be earried much further each way than most practi- tioners do, that the oedema may be repelled as far as possible from the lesion to either side. Let the point of the elbow be also included in the bandage, whether the lesion be there or not, that the oedema may not be collected about this part. One should take special care in the dressing that, so far as possible, there shall be no great accumulation of bandage in the bend of the elbow, and that the firmest pressure be made at the lesion. For the rest, let him deal with the case as regards pressure and relaxation, in the same way, and according to the same respective periods, as was previously described in the treatment of fractured bones. Let the change of dressings take place every third day, and he should feel them relaxed on the third day, as in the former case. Apply the splints at the proper time —for their use is not unsuitable whether there is fracture or not, if there is no fever—but they should be applied as loosely as possible, those of
Omit «péocor.
® etelpynra Kw. 3 gird,
197
TTEPI ATMON
TOUS meV amo Bpaxtovos KaTaTeTaryMeVvous, TOUS 8e amo Tou TXEOS averpevous® eotwoay dé ju) TAXEES oi va pOnkes avayKatov 6é Kat avicous avTovs etvat AAANAOLTL, TapadAdocel Sé Tap adANAOUS 3077 av cuudhépn, Texpmatpomevov Tpos THY avy- Kapp. aap Kal TOV oT ANVOY THY mpoo bea To“avTny xn movciabat, ob Oo TED Kal TOV vapOnKov elpntat, oyKnpoTépous dé Odiy@D Kara TO oivos mpootibévar. Tovs oé Xpovors | TOUS ano THS preypovts TexpaiperOar ypn Kal ano TaY pod Ber 36 yeypammevov.
1 Reinhold’s emendation, rods uty Kdtw Tetaypevous, Tovs dé yw Keimevous, seems to give the sense most clearly.
ON FRACTURES, xiv.
the arm being under and those of the forearm on the top.1. The splints should not be thick, and must be unequal in length in order to overlap one another where it is convenient, judging by the degree of flexion. So, too, as regards the application of com- presses, one should follow the directions for the splints. They should be rather thicker at the point of lesion. The periods are to be estimated by the inflammation and the directions already given.
Hippocrates had no angular splints, and straight ones applied to the bent arm above and below the elbow had to be so arranged that one set overlapped the other at the sides.
10
20
TIEPI APOPON?
Ti, "Opou dé apOpov é&va TpoTov olda 6Atc Pavop, TOV és THY pacxarny: dv@ O€ ovdémoTe eldor, ovde és TO Eo" ov pévToL StioxupLetn eyorye® él orto Bavor ay H Ov, KalTrep Ex@V Tepl avTov 6 TL A€yw. atap ovdé és TO Eumpocbev ovdéTrw OTwTa 6 Te GO0FE por MALOONKEVAL TOioL péVTOL intpoior Soxet Kapta és TovumpocOev odLoOavelv, Kal padtota éEavatw@vtar év TovTOLoOLY, @Y av Pion KaTarasy Tas odpKas Tas Trepl TO apOpov TE Kal TOV Bpaxtova: paiverat yap €v TOLL TOLOVTOLOL TaVTAaTAaGL 7) xeparn Tob Bpaxiovos eféyouca és Tovumpoobev. Kai éywyé Tote TO TOLOUTOV ov as éexTETTMKEVAL HKOVTA PraAVPwS avo? Tay intpav, bT6 Te TAY Snwotéwy 5La TOUTO TO Tphyua edoKEov yap avToiaw nyvonKévat povvos, of dé adAXOL eyvoxévat, Kal ovK HdvVaLHY avuTous avayvacat, el pry porss,* Ore TOO, éotl Tolovoe’ el TLS TOD Bpaxiovos prrooere pev TOV capKav THY er@pioa, procee dé un 0 pos dvateivel, prrwcere 6é TOV TévovTa Tov KaTa THY pacxadny TE Kal THY KAnioa 7 pos TO aThOos éyovta, paivoito av 1 Kearny ToD Bpaxtovos és Tovpm poo bev eféxovea t ioxupas, KalTrep OUK exTre- TTwKUia: TéepuKE yap és TOUmmMpocOEV TpoTETIS n Kepary) Tod Bpayxiovos’ To 8 adXO daTéov Tod
1 So Apollonius, Galen and most MSS. BM and Kw. add EMBOAH2.
200
ON JOINTS
I. As to the shoulder-joint, I know only one dislocation, that into the armpit. I have never observed either the upward or outward form, but do not wish for my part to be positive as to whether such dislocations occur or not, though I can say something on the subject. Nor have I ever seen anything that seemed to me a dislocation forwards. Practitioners, indeed, think forward dis- location often happens, and they are especially deceived in cases where there is wasting of the flesh about the joint and arm, for in all such the head of the humerus has an obvious projection forwards. In such a case I myself once got into disrepute both with practitioners and the public by denying that this appearance was a dislocation. I seemed to them the only person ignorant of what the others recognised, and found it hardly possible to make them understand that the case was as follows :— Suppose one laid bare the point of the shoulder of the fleshy parts from the arm, and also denuded it at the part where the muscle! is attached, and laid bare the tendon stretching along the armpit and collar-bone to the chest, the head of the humerus would be seen to have a strongly marked projection forwards, though not dislocated. For the head of the humerus is naturally inclined forwards,
1 Deltoid.
2 Kw. omits tw. 3 ind re Pq. 4 udyts. 201
30
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43
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IIEPI APOPOQN
Bpaxtovos és TO &&eo KapT Nov. opened b¢ 0 Bpaxtov T@ KOLAW THS @moTaTNS TAAYLOS, érav Tapa TAS Teupas TAPATET ALEVOS he oTav pévToL és Tovpmpoo Dev extavua OF 7 ovpTaca xetp, TOTE 1) Kepana TOU Bpaxtovos Kata Ty lEw THS OMOTAATNS TO KOLXW yiveTaL Kal ovK ere _eFexew eS rovumpoobev gaiverar. Tept ov obv 0 ovyos, ovderrore eidov ovoe €s ToUppoa Dev cxTred Ov" ov pay io upleto ve ovde mept TOUTOU, el funy ExTrETOL ay ovTwS 2 ov’ Otay ovv exméon 0 Bpaxiwv és THY pacyanrny, TE TOANOLOL EXTITTOVTOS, TodRol émiotavtTas éuBadrec: evmatoevtov b€é €or 70 eldévat mdvTas Tovs TpoToUS, OlawW ot inTpol éuBdrXovat, Kal ws av Tis adTotat Tolar TpoTro.a TOUTOLOL KaANLTTA ay XpeouTo: * xpioOar 5é xen TO Kkpatiare Tov TpOTWY, iy my laxupotarny avayKny opas Kpatiatos 6€ 0 batatos yeypawo- pEVOS.
II. ‘Oxocooe pev ov TUKLVA® exmim ret 0 C1105, ixavol ws él 70 TreloTov 8 avrol opiow avtoiow euBadrewv eloiv" evOevTes Yap THs eTepns VEL POS TOUS kovdvAous € eS Thy pax arny avayKa- Covow a avo TO apO pov, TOV 6é ayKava Tapayouet Tapa TO aThos. TOV auTOV 6é TpoTrov TobTov Kal O int pos av euBarrou, €t aur os bey v0 THY paoXarny eo@repo TOU apOpou TOU ExT ETT O- KOTOS UTTOTELVAaS TOUS daxTvhous arravaryKator a aro TOV TEED, euBarrov THY EWUTOU cepadny és TO dk po psov avrepelovos évexa, Tolar 5€ yovvact mapa TOV ayKnava és Tov Spaxiova éuBdar2r.or, dvr@déot 7 pos TAS TAeupds—aupd epet dé Kap- Tepas Tas xelpas éxew Tov éuBadrAovTa—7) eb 202
ON JOINTS, 1.=1.
while the rest of the bone is curved outwards. The humerus, when extended along the ribs, meets the cavity of the shoulder-blade obliquely, but when the whole arm is extended to the front, then the head of the humerus comes in line with the cavity of the shoulder-blade, and no longer appears to project forwards. To return to our subject, I never saw a dislocation forwards, but do not want to be positive about this either, whether such dislocation occurs or not. When, then, the humerus is displaced into the axilla, many know how to reduce it since it is a common accident, but expertness! includes knowledge of all the methods by which practitioners effect reduction, and the best way of using these methods. You should use the most powerful one when you see the strongest need, and the method that will be described last is the most powerful.
II. Those who have frequent dislocations of the shoulder are usually able to put it in for themselves. For by inserting the fist of the other hand into the armpit they forcibly push up the head of the bone, while they draw the elbow to the chest. And a practitioner would reduce it in the same way if, after putting his fingers under the armpit inside the head of the dislocated bone, he should force it away from the ribs, thrusting his head against the top of the shoulder to get a point of resistance, and with his knees thrusting against the arm at the elbow, should make counter-pressure towards the ribs—it is well for the operator to have strong hands—or, while he
2 «Tis a skilful man’s part” (Liddell and Scott). ‘An easy thing to teach” (Adams).
1 KdAAOTA XpPTO. 3 olow .. . muKva. 3 oad. 203
TIEPI APOPQN
avTos pep THOL Xepat Kal 7H Kepari) 00TH motoin, addrost Sé Tis TOY ayK@va Tapayo. Tapa TO atOos.
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24 apOpov avayKavovow eM TUM TEL.
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10 Kothov THS pacxadns évOeivar oT poryyUhov Tt évappwoacor emiTndelorarar d€ al mavu opKpat opaipar Kal TKANPAl, olar Toda €x TOV oKuTewy * pamrovrar’ HV yap bn Th TOLOUTOV eyxenTat, ov dvvatar 9» mTéEpvn eEtxvetaPar ™ pos THD Keparny TOU Bpaxtovos: KATATELVO{EDNS yap THS xeLpos. KO\NAaLVETAL 1) pasar ot yap TévovTes ol évOev Kat evdev THs paoxadns avtiag iyyouTes évaytiot eiaiv. xpi oé Twa én Oarepa TOU KATATEWOILEVOU Kar) wevov KOT EXEL”
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1 repos. 2 x moAAay cxutéwy moixtAwy Weber. 204
ON JOINTS, m.-11.
uses his hands and head in this way, an assistant might draw the elbow to the chest.
There is also a way of putting in the shoulder by bringing the forearm backwards on to the spine, then with one hand turn upwards the part at the elbow, and with the other make pressure from behind at the joint. This method and the one described above, though not in conformity with nature,! nevertheless, by bringing round the head of the bone, force it into place.
III. Those who attempt to put in the shoulder with the heel, operate in a way nearly conformable with nature. The patient should lie on his back on the ground, and the operator should sit on the ground on whichever side the joint is dislocated. Then grasping the injured arm with both hands he should make extension and exert counter-pressure by putting the heel in the armpit, using the right heel for the right armpit, and the left for the left. In the hollow of the armpit one should put some- thing round fitted to it,—the very small and hard balls such as are commonly sewn up from bits of leather are most suitable. For, unless something of the kind is inserted, the heel cannot reach the head of the humerus, for when extension is made on the arm the axilla becomes hollow and the tendons on either side of it form an obstacle by their con- traction. Someone should be seated on the other side of the patient undergoing extension to fix the sound shoulder so that his body is not drawn round when the injured arm is pulled the other way,
1 «Because without traction,”
Apollon., referring to Fract. I,
205
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IIEPI APOPQN
omevns: emeuTa [[LaVvTOS Harbaxod TAATOS € EXOVTOS ixavov, OTav » ohaipn évteOH es HV HagXahyy, mept THY opaipay me pie Brn evou Tov iuavtos, Kal KATEXOVTOS, AaPouevov auporépov TeV apxéwv TOU imavTos, dvtiKatareivew TWA, UTep THS KEeharns TOV KATATELVOfLEVOU xabrpevor, TO Tool TpooSavra ™pos TOU dxcpopiou TO oaTéov. n O€ ohaipa ws eowTaTo Kal OS. Hakata mpos TOV TAEUPEwY KEelaOw, Kal py ert ™ Kepary Tov Bpaxiovos.
IV. "Korte dé Kal arr ) En B0r}, 7 Katomitovaww* €s opOov: peilw pévToL eivat ¥pn TOV KaT@pivovra, diadaBovra 6¢ Ty yelpa vmoeivar tov wpmov TOV €wuTOU UT Ty pacxarny ody" KaTrELTa Umoorpéeyat, @s av evitnrat Epon, ouT@ oToxac- devov OT ws aul TOV @ ov TOV EwuTOv Kpewdoar Tov av parrov Kara THY pasxadyy autos 6€ éWUTOV ian dorepov ETL TOUTOV TOV @ mov TOLELT@ 4h éml tov erepov' Tob 6€ Kpeuamévou Tov Bpaxtova Tm pos TO EwuTod o7nGos T poo av- ayKaléTo os adioTat év TOUT@ de TO oXnwaTe T poravaceleTo, oTroTay © HeTEwplan TOV avOp- OTrOV, @S av TIPpeT OL TO .AXO copa auTe, avTio TOU Bpaxtovos TOU KATEYOMEVOU" iV 8é aya Kovpos 7 0 avOpwrros, Tpooemixpenac OTe * rovtov émucbév Tes odpos mais. avtar oe euSorat Tacat Kata TadaioTpny eVYpNTTOL 2
1 os katwulCoucw Galen, Kw.
oe > ae 7 oTAaY—avTippeTn. 8 TpovekkpeuacOnrw.
1 This is the common method of reducing the shoulder- joint, and seems to be that chiefly used in Greek gymnasia. Cf. Galen’s account of what happened to him when he dis-
206
ON JOINTS, 111-19.
Take, besides, a fairly broad strap of soft leather, and after the ball is put into the armpit, the strap being put round and fixing it, someone, seated at the head of the patient undergoing traction, should make counter-extension by holding the ends of the strap, and pressing his foot against the top of the shoulder-blade. The ball should be put as far into the armpit and as near the ribs as possible, not under the head of the humerus.
IV. There is another mode of reduction in which they put it right by a shoulder lift? : but he who does the shoulder lift must be the taller. Grasping the patient’s arm, let the operator put the point of his own shoulder under his armpit, then make a turn that it may get seated there, the aim of the manceuvre being to suspend the patient from his shoulder by the armpit. He should hold this shoulder higher than the other, and press in the arm of the suspended patient as far as possible towards his own chest. In this attitude let him proceed to shake the patient when he lifts him up, so that the rest of the body may act as a counterpoise to the arm which is held down. If the patient is very light, a boy of small weight should be suspended to him from behind. All these methods are very useful in the palaestra, since they do not require
located his collar-bone. He rightly remarks that the little ball cannot be put between the ribs and the head of the bone. XVIIT(1), 332.
2 All editors who translate és dp@év make it mean ‘‘stand- ing.” Foées-Erm: ‘‘ in erecti et stantis humerum aeger ex- tollitur ” ; Littré-Adams, ‘‘ performed by the shoulder of a person standing”; Petrequin alone prefers the patient— ‘*sur le malade debout.’’ But after all the expression seems to go best with the verb.
207
19
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ITEPI APOPQN
Elo, OTL ovdev adRot@v apweveov d€éovTa érretcev- exOjvac: XPT ALTO Oe dy TOs Kal arr0O.
: ‘Arap Kat ol mept Ta UTEpa dvaryxalovres eyyus TL TOU KaTa duow éuBaddrovorr. vpn Oé TO joev Urrepov KaTeityOat Tain Twi pwadOakh —iooov yap av itrodta Odvor—brrnvayKdacbat 5é peony TOV TAEUpéwv Kal THS KEehads TOU Bpaxiovos: Kal qv ev Bpaxy } TO Umepov, KabnaGat xen Tov dvOpwmoy emi TLVOS ws Hoss TOV Bpaxtova meptBarrew Svvntas mept TO Umepov" pada ra 6€ €oT@ PakpoTEpoV TO Umepov, @s av ETTEwWs O avO pwrros Kpéeac Oar pix pod den appt T@ EdrO. KATELTO, 0 pev Bpaxtov Kal 0 THXYS TAPATETaMEVOS Tapa To UmEepov éoTw, TO 6é éml Odtepa ToD cHpmaTos KaTavayKaléTw TIS, TepiBadrAwWY KATA TOV avyéva Tapa THY KAHiOa Tas yelpas. avTn » éuBorn Kata duawy emerKéws €oTt Kal euBarrxew Svvatat, hv ypnoT@s oKEVa-
ain TWVTAL AUTHD.
VI. ’Atap nat } 8a Tod KALpaxiov érépy Tis TovavTn, Kal ere Bertiov, OTL aaharer repos av TO c@pma, TO bev Th TO dé TH dvreancobetn peTewpra Bev" mepl yap TO bmepoerdés 6 cos Hv Kab KATaT ET HYN, mepirpadrecbae TO oa p.a. Kivouvos 4) TH 1) TH. Ypn pévtoe Kal emt TH KdpLAKTH pL érrideder bau Te avwbev oTpoyyUNov évdppoacov €s 70 Kothov THS MarXarns, 6 Tm poo diavaryna Ser Thy Keparnv tod Bpaytovos és Thy pvow amtéval.
VII. Kpatiorn pévTOL Tacéov Tov éuBor.ov %) © «TOLNOE Evdov xpi) elvat TRETOS ev @S TEVTEOAKTUAOY, 7) TETPASAKTVAOY TO eTLTA)?, 208
ON JOINTS, 1v.-vn.
further bringing in of apparatus, and one might also use them elsewhere.
V. Again, those who reduce by a forcible move- ment round pestles come fairly near the natural method. The pestle should have a soft band wrapped round it (for this will make it less slippery) and be pressed in between the ribs and the head of the humerus. If the pestle is short the patient should be so seated on something that he can just get his arm over it, but as a rule the pestle should be rather long so that the patient when erect is almost suspended on the post. Then let the arm and forearm be pulled down beside the pestle, while an assistant putting his arms round the patient’s neck at the collar-bone forces the body down on the other side. This method is tolerably natural and able to reduce the dislocation if they arrange it well.
VI. Again there is another similar method with the ladder, which is still better, since the body when lifted up is more safely kept in equilibrium on either side. For with the pestle, though the shoulder may be fixed, there is danger of the body slipping round to one side or the other. But on the ladder-step also something rounded should be fastened on the upper side, which, fitting into the hollow of the armpit, helps to force the head of the humerus back to its natural place,
VII. The most powerful of all methods of redue- tion, however, is the following. There should be a piece of wood about five, or four fingers in breadth
209
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TEPI APOPON
maxos 5é ws Siddxrudov 7) y Kat AemToTEpov, MKOS 6é Oimnxy, oh Kal orto 1 éAac cov. Eore dé emt Oarepa TO ax pov mepipepes Kal oTevoTatov TaUTy Kat AemTOTaTOD" auBnv dé Ex ETO o MLK pay vmEpéxovoay éml TO vaTar@ TOU TEpLpEpEos, év 2 TO Hépel, Bn TO T™ pos TAS meupas, arra TO ™pos THY kepada TOU Bpaxiovos eXOvTL, ws Upappocere TH wacxary Tapa Tas TAEUpPas UO THY xepaniy Tov Bpaxtovos UmoreBémevov: adovin d€ 4) Tawiy parbakn KataKkeKorhia Ow ak pov TO Evhov, OTS _Mpoanvea TEpov nH. emevta XPM UTMcaVTA Ty Kepaday TOU Evhou vTo THY HacXarAnY wS ETwWTATW pEaNYD TOV TAEVPEwD Kal THS Kepadryns Tov Bpayiovos, THY Oé GANV veEtpa Tpos TO Evov kaTateivavTa TpookaTa- ojoat Kara Te TOV | Bpaxiova, Kata Te TOV THXUYs KATA TE TOV KapTov THS XELpOS, @s av aT peu OTe padtoTa: Tepl tmavTos 5€ ypn ToreicOaL, brrws TO axpov tov Evrou as egwTaTo THs paaxarys eoral, brepBeBnxos Thy Kepadny TOU Spaxtovos. éTretTa xp peonyv dvo oTUN@Y oT pwTipa TAA YLOY ev Tpoodjoat, éTrelTa UmepeveyKely THY xetpa ou 7 EvA@ vmep Tob TTPWTHPOS. Oras n bev xelp | ert artepa 7 qs emt Gatepa be TO oO, Kara b€ THD pax arny 0 OTpwTnp’ KaTELTA él jev Oarepa THY xelpa KearavaryK ate ov TO EVA Tepl TOV TTPOTHPA, éml Garepa Sé 7d ddXO coud, Bypos dé é EXOV 0 oTPHTNP mpoadedéabw, WOTE peTéewpov TO ao TOLa elvat er aK pov TOV TOO@V. OUTOS O TPOTTOS Tapa TOAD KpaTic- Tos €uBorHs @pmovs SixaroTaTa pev yap moKreEvEL, iV Kal podvov é€owtépw 9 TO EvVAoV THs KEeparijs 210
ON JOINTS, vit.
as a rule, about two fingers thick or even thinner, and in length two cubits ora little less. Let it be rounded at one end and be thinnest and narrowest there, and at the extremity of the rounded end let it have a slightly projecting rim (ambé) not on the side towards the ribs but on that towards the head of the humerus, so as to fit into the arm- pit when inserted along the ribs under the head of the humerus, and the end of the wood should have linen or a soft band glued over it that it may be more comfortable. One should then insert the tip of the instrument as far as possible under the armpit between the ribs and the head of the humerus, and extending the whole arm along the wood, fasten it down at the upperarm, forearm and wrist, so as to be as immobile as possible. Above all, one should manage to get the tip of the instrument as far into the armpit as possible, up above the head of the humerus. Then a cross-bar should be firmly fastened between two posts and next one should bring the arm with the instrument over the bar, so that the arm is on one side, the body on the other and the cross-bar at the armpit. Then on one side press down the arm with the instrument round the beam, on the other side the rest of the body. The beam should be fastened at such a height that the rest of the body is suspended on tiptoe. This is by far the most powerful method for reducing the shoulder, for it makes the most correct leverage, if only the instrument is well on
1 Omit Kare 2 em.
2rI
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TIEPI APO@PQN
TOU Bpaxtovos: Sixavorarae dé ai avtipporai, aapanees 6¢ TO doTéw TOU Bpaxtovos. Ta pev ov veapa EMTITTEL daccov ) WS av Tes olorTo, T piv uv) Kal KatateTaa bar doKelv drap Kal Ta Tanaa povvn abrn TOY éuBoréwv oin TE eu Br- Baca, av ro) an var xpovou cape pev errernrvOn eal THY KOTUNY, yy oé Keparn Tov Bpaxtovos Bi) TpiBov EwuTH merrornpwern mn ev TO xoplo, va een Mn" ov nv arr éuBardewv yap ror Ooket } Kal ovTe TreTahar@fevov ExT TOW TOU paxtovos—rt yap av Sucain pox Aevals ovxl Kno elev j—pevely pevTor ouK ay ve doxéou KATA XOpnys GA’ orto Gave a ay ws T02 €8os.
To avto 6é motel Kal Trept KMPAKT ipa Kar- avaryeatery TobTov TOV Tporrov oKevdcavTa. Tavu pny LKAVOS exer Kal mept pea. éd0s Berradunor avayKatery, ny veapov 9 TO orc Onua. éo KeuG- cba HEVTOL xp) TO EvAOv ovTwS, @aoTEp elpnT au” aTap Tov avOpomov Kkabioat m)ayvov étl TO Sippe* KaTELTO TOV Bpaxiova ouv To Eide umepBdrrevy vmép TOU avaxhia pov, wal emt bev Oarepa TO cpa katavayKater, emt 5é Oatepa Tov Bpaxtova av t@ EVAW. TO avTO dé TroLEl® kal vmep di«rerdos Avpns avaryxatew" xpnobar dé Yn acel TOUTOLOW, a av TUX Ta.peovTa..
VIII. ElSévae pév ody yp ore vores puotwy
1 &y por Soko. 2 és 7d. 3 troveiv.
1 An old-fashioned straight-backed chair, Galen. Adams is enthusiastic over this method. For the ambé fasten a jack-towel above the patient’s elbow: put your foot in the loop and gradually increase the tension. You will do the
212
ON JOINTS, vit.-viu.
the inner side of the head of the humerus. The counterpoise is also most correct and without risk to the bone of the arm. Indeed, recent cases are reduced more rapidly than one would believe, even before any apparent extension has been made, while, as for old standing cases, this method alone is able to reduce them, unless by lapse of time the tissues have already invaded the articular cavity and the head of the humerus has made a friction eavity for itself in the place to which it has slipped. Nevertheless I think it would reduce even so inveterate a dislocation of the arm—for what would not correct leverage move ?—but I should not suppose it would stay in position, but slip back to its old place. The same result is obtained by pressure round the rung of a ladder, arranging it in the same way. Also the operation is very effectively done on a large Thessalian chair,! if the dislocation is recent. In this case the wooden instrument should be prepared as directed while the patient is seated sideways on the chair. Then put the arm with the instrument over the chair-back, and press down the body on one side, and the arm with the instrument on the other. The same result is obtained by operating over (the lower half of) 2 a double door. One should always make use of what happens to be at hand.
VIII. One should bear in mind that there are
job quickly, safely and almost pleasantly, if the arm and chair top are properly padded.
2 Apollonius strangely illustrates this by an ordinary vertical (folding) double door, As Galen points out, it refers to doors which open in two halves above and below, usually with a cross-bar between.
213
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TIEPI APOPQN
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214
ON JOINTS, vu.
great natural diversities as to the easy reduction of dislocations. There may be some difference in the sockets, one having a rim easy to cross, the other one less so; but the greatest diversity is the attachment of the ligaments, which in some cases is yielding, in others constricted. For the humidity in individuals as regards the joints comes from the disposition of the ligaments which may be slack by nature and easily lend themselves to extensions. In fact one may see many persons of so humid a temperament that when they choose they can dislocate and reduce their joints without pain. The state of the body makes a further difference, for in those who are muscular and have the limb in good condition dislocation is rarer and reduction more difficult, but when they are thinner and less muscular than usual dislocation is more frequent and reduction easier. The following also shows that this is so. In the case of cattle the thigh bones get dislocated from the socket when they are at their thinnest. Now cattle are thinnest at the end of winter, and it is then especially that they have dislocations, if indeed such a matter should be cited in a medical work. And it should be, for Homer has well observed that of all farm beasts cattle suffer most during this season, and among cattle the ploughing oxen because they work in the winter. It is in these, then, that dislocation especially occurs, for they are especially attenuated. For other farm animals can graze on herbage while short, but cattle can hardly do so till it is long, since in the others the projection of the lip is thin,
2 Omit Erm., Kw. 2 &rovéovet. § Omit Erm., Kw.
215
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yvabos: Bot dé maxein bev 1 poor ToD yel- Aeos, mayein S€ Kai GpPreia 7 ave yrabos: ova TavTa UmoBarhew mo TAS Bpaxetas moias ou Svvata. Ta déav povuya TOV Cow, ate aupo- dovta €ovta, dSvvaTat pev aapKater, Svvatau dé vo THY Bpaxetiny Toiny UmoBarrew TOUS odovras, Kal deta TH oUTwS exovon Totn Hadhov H TH Babein: Kal yap TO émitay apelvwr Kal TTEPEWTEPN D) Spaxein Toin THS Babeins mort Kal mpl exKapTrELV Ty Bae einv. dua TovTO ovv émroinaev Moe TUE TA EN—Ds & omoT domd- cLov éap rude Bovolv EEw—OTL dopevoTarn [Totcy]* avtoiow » Badein mroin daiverar, aTap Kal addrws 0 Bows xara pov pucer TO apO pov TOUTO Exel Hadov TOV dANwY Cor: dua TovTO Kal e(Nitrouy 2 gorl waddov TOY adrwv ees Kal pddiota btav AeTTOV? Kal ynpadréov* 7. Sra tabTa TAVTA Kab exmimrer Bot paiara. TELM dé yeypar rat Tept avTov, ore TAVT@Y TOV Tpo- eLpnevoV Tara papTupra eoTLV.
Tlept ov oby 0 ovyos, Toto ¥ dodprovoe peaXdov cxTrim Tet Kal Odooor éumimrter 1) TOLoW Ev cecap- K@PéeVvolTl? Kab hooov emu ey paiver TOLCL Uypotot Kat Tolow aodpKouow a) Toioe oKe- Auppoiae® Kal FETAPKMMEVOLTL, Kal jooov ye dédeTas és TOV évretTa Xpovov: arap Kal el puea Tr€L@vy wmrein TOD petplov pn avy dreEy- povn, Kal ovTws adv dducOnpoy ein, pv&wdéo-
1 Omit Littré, Erm. Kw.
2 eid(rovs: Erm.’s correction which Kw. follows as with
the other adjectives, but they surely go with ¢dov, 3 remTds. 4 yépwv.
216
ON JOINTS, vin.
as is alsothe upper jaw, but in the ox the projection of the lip is thick and the upper jaw thick and blunt, wherefore he cannot grasp the short herbage. But the solid-hoofed animals, having a double row of teeth, can not only browse but can also grasp the short herbage with their teeth, and they prefer this kind to the long grass. In fact the short grass is on the whole better and of more substance than the long, especially when the long is just going to seed. It is in allusion to this that he wrote the following verse :—
« As when the season of spring arrives welcome to crumple-horned cattle,” +
because the long grass appears most welcome to them. Moreover in the ox this joint is generally more lax than in other animals, and for this reason it has a more shambling gait than other animals, especially when it is thin and old. For all these reasons the joint is especially liable to dislocation in the ox, and more has been written about it because these facts testify to all the preceding statements.
To return to the subject, dislocation occurs more easily and is more quickly reduced in emaciated than in muscular persons, and inflammation more rarely supervenes in the moist and thin than in muscular subjects of a dry habit, but the joint is not so firm afterwards. Further, if an excess of mucous substance is engendered without inflamma- tion, this too will make it liable to slip, and, on
1 Not in our Homer.
5 O71 roid. 6 gKAnpoias. 217
70
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TIEPI APOPQN
TEpa yap Toumimay Ta apOpa Toot dodprowoe ) Toto cecapKeopevoraty éoTw" Kal yap avtat at oapKes Tov pn) amo réyvns op0as 4 Aedu- HayXNHEVOY, ai TOV New Tov prEwderrepai eLoev 7 al TOV TAXED, Gootoe mévToL oY preyHovy pea droyiverat, ” preynov?) Snoaca. evet TO apO pov: Ola TovTO ov dda cxmimret Ta vTropmvEa, ExTITTOVTA av, el pn TL 1 TAéov ) ~XaTCOV preymovns Umreryevero,
. Olct pév odv orav” eumeon TO adpOpov Kal 7) emipheyprjvn Ta TEpleXovTa, xphobat Te avwovvas avTixa TO Beep dvuvavTat, odrou pev ovdev vomifovor Seiy EwuT@v eTripedeta Oat intpod pny éoTe KaTapaVTEvoacOat TOV TOLOVTWY" TOICL TOLOUTOLTL yap éxmimte. Kat av0ts paddov 7) oiow av _emepreypnvy Ta veipa. TOUTO Kara mavTa 7a dpOpa obras eXel, Kat padiora Kar’ @uov Kal Kata youu: Kadota yap ovv Kal oAtcOaves TadTa. olor & av emipherypijvy [ra vebpa],? ov Svvavrat xXpioOae TO WM KwAVEL yap ” eddy Kal ) ovVvTacLS THIS preypovijs. TOvS ovv ToLlovtovs inaBat yp KnpwTH Kal omAnvert Kal GOovioigt modXoio. émidéovTa: brotiévat O€ és THY wacyddyy elpiov parOaKov Kabapov cuvetNiacovta exTANPw@ULA TOD KOlrAOU movobyTa iva av TLa TN ply wa. bev TH embéoet UE avaKxoxh o€ TO apOpov- Tov € Bpaxiova vpn és 70 ave pérrovTa. loxew TH TreloTa: ovT@ yap av éxacTaTw ein TOD Ywpiov és 0 wrALTOEV 1 Keparr Tod wpmov' xpn Oé, Stay eridnons Tov
1 Op0ns. 2 ay, Littré’s suggestion. 3 Omit B, Kw,
218
ON JOINTS, vitt.—1x.
the whole, the joints of emaciated persons contain more mucus than those of muscular individuals. One sees, in fact, that these tissues in emaciated persons, who have not been normally reduced according to the principles of the art, have more mucosity than those of stout people. But in those in whom mucus develops along with inflammation, the inflammation keeps the joint firm. This is why the joints do not often get dislocated from a slight excess of mucus, though they would do so were there not more or less inflammation at the bottom of it.
IX. Should, however, no inflammation of the surrounding parts supervene after the reduction of the joint, patients can at once use the shoulder without pain, and these persons think there is no further necessity to take care of themselves. It is, then, the practitioner's business to act the prophet for such, for it is in such that dislocation occurs again, rather than in cases where inflammation of the ligaments may have supervened. This is the case with all joints and especially those at the shoulder and knee, for they are specially liable to dislocation. Those in whom inflammation may have supervened cannot use the shoulder, for the pain and inflammatory tension prevents it. One should treat such cases with cerate, compresses, and plenty of bandages, also put a soft roll of cleansed wool under the armpit, making a plug for the cavity that it may form a fulcrum for the bandage and prop up the head of the bone. The arm should be kept as far as possible pressed upwards, for so the head of the humerus will be furthest from the place into which it was dislocated. After bandaging the shoulder you should proceed to fasten
219
30
36
10
IIEPI APOPQN
pov, érerTa mpooKaradety TOV Bpaxiova ™ pos Tas mAEeuvpas rawvin Tui KUKAD mept TO cua meptBaddovta. vpn 5€ Kal avarpiBew TOV @mov Hovyatos Kal AuTrapas” TONY ETT eupov bei elvat TOV byt pov, aTap &n Kal _avarpinpvos: amo Tob avrod ovomaTOS Ov TwWUTO aTroBaivel: Kal yap av Sijoevev apBpov avaTpipts, Xaraperepov TOU KaLtpod €ov, Kal AUcELeY apOpov oKANpoOTE pov TOD Katpov éov' adda Stopieitar uiv rept avatpiyios €v GAkw OY@. TOV YyodY ToLODTOY @pov uadOaknot Te yepaly avatpiBew cumdéper, Kal Gros mpnéws: TO O€ ApOpov ssaxeveiv, pr) Bin, adda TocovTOV bcov avwhivws KiWHCETAL. Kadiotatas dé TdvTa, TA wey ev TAEOVL XPOVO, TA & év €Xadooov.
X. Diyvocnew dé ef éxmémTwKev 0 | Bpaxtor Toot de xPn Tots onpetoroe TOUTO [MeéD, emerdy ixaLov EXovee TO g@pa oi avOpwrol, Kal Tas xelpas Kal Ta oKédea, mapadetyware xphoPae bet TO wryvet Tos TO Ke bytes, Kal TO [M1 byes mpos TO bytes, Ha Ta adXOTpLA dpOpa ca Sopavta—arhou yap addoov pad dov eEapO por mep UK V—GdNA Tov aurou TOU KAPVOVTOS, my avomo.ov 7 TO UYyltés TH KaduvovTt. Kal TOvUTO elpntar pev op0as, Tapacvveow de ever Tavu TOAAHNY bla Ta TOLavTA, Kal OUK apKEl fpovvoY Aoyo eldévar THvy TéeXVNY TavTHV, GAA Kal Opirin opmtrety’ ToAXOl yap, vo odvVNs, 7) Kal vm’ adroins tpoddctos, ov eEeaTEeWTa@V avToiat TOV apOpwv, buws ov Svvavtat és Ta Gora oXNMAT OL Kkaleatavar és old Ep TO byvaivor ® coma oxXnpaTtiveTar’ Mmpooouvievat ev ovv Kal
220
ON JOINTS, 1x.-x.
the arm to the side with some sort of band, passing it horizontally round the body, and the shoulder should be gently and perseveringly rubbed. The practitioner must be skilled in many things and particularly in friction (massage). Though called . by one name it has not one and the same effect, for friction will make a joint firm when looser than it should be, and relax it when too stiff. But we shall define the rules for friction in another treatise. Now, for such a shoulder the proper friction is that with soft hands, and always gently. Move the joint about, without force, but so far as it can be moved without pain. All symptoms subside,t some in a longer, others in a shorter time.
X. A dislocation of the humerus may be recog- nised by the following signs. First, since men’s bodies are symmetrical as to arms and legs, one should use the sound in comparison with the un- sound, and the unsound with the sound; not observing other people’s joints (for some have more projecting joints than others), but those of the patient himself, to see if the sound one is dissimilar to the one affected. And though this is correct advice there is a good deal of fallacy about it.? This is why it is not enough to know the art in theory only, but by familiar practice. For many persons owing to pain or some other cause, though their joints are not dislocated, cannot hold them- selves in the attitude which the healthy body assumes. One must, therefore, take this also into
1 «* A)] joints re-establish themselves.” Pq.; ‘‘ Things get
restored,” Adams, 2 Kw. punctuates after to.aira.
1 dyinpov.
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TIEPI APOPOQN
évvoetv Kal TO Tovovde oxXhpwa xen. atap kal} év TH paoxXanry n Kepadn Tod Bpaxtovos paivera eyKerpevn TONA@ pfadrOV TOV EKTETT@OKOTOS i) Tov vytéos’ TOTO bé, dvwOev KaTAa THY éTTMOpioa KotXov patveTar TO Ywpliov' Kal TO TOD aKkpwpiou datéov é&éxyov? daivetar, ate UTodeduKdTOS TOU apOpov és TO KadTw TOD Ywpiov—Tapacivecty pay Kal €v TOUT@ eXet TL, arha UorEpov mepl avtou yeyparpera, aes ov yap ypapns éoTi— TOUTO O€, TOU EXTTET TWKOTOS O ay Kov paiverat adectews paddov ato ToOVY TAEUPEWY % TOD er épou" él MEVTOL TLS mpocavaryKatot, Tpoodyerat bev, emu overs be TOvTO O€, a avo THY xelpa dpa evGetav Tapa TO oUvs, éxTeTaweévou TOU aye Bv0S, ov pddra Svvavtat, BoTEep THY yea, ovde mapaye év0a kal évOa opmoiws. Ta TE ovv onueia TaUTa é€oTLVY, @mou éxTETTwWKOTOS* at dé éuBoral ai yeypappévac ai te iatpeias avrat.
XI. ’Emaésov $é 1d paOnua ws xpi intpevew TOUS TUKLVa éxTiTTOVTAS W@moUS: TONXNOL Mev yap 6n aywvins éxwrvOnocav dia tavTny THY cuudopnv, Tadr\’\a TavtTa aktoxpyio. éovTes’ TOOL dé &v TONE LLKOLT LY ax prior éyevovTo kat diepOapnoav bua TavTny THD ocuupopny: dpa te ematvov Kal ova TOTO, ore ovdéva oida opas intpevovra, adda Tous pev pnde éeyyer- péovtas, TOUS be Travavtia TOD cuppéepovtos ppoveovTas Te Kal ToréovTas. guxvol yap 718m intpot éxavoav @movs éexTITTOVTAS, KATA TE THY
1 covT0 wev Apoll. B. Kw. 2 &foxov. 3 Tov€uols &XpEtot, 222
ON JOINTS, x.—x1.
consideration and have such a position in mind. Now, first,! the head of the humerus is much more obvious in the armpit on the injured than on the sound side. Again, towards the top of the shoulder the part appears hollow, while the bone at the shoulder-point (acromion) is seen to project, since the articular end of the humerus has sunk to the lower part of the region. Yet there is some fallacy in this too, but it will be described later, for it merits description. Again the elbow of the dis- located limb obviously stands out more from the ribs than that of the other. If, indeed, one should forcibly adduct it, it yields, but with much pain. Further, the patient is quite unable to raise the arm straight alongside the ear, with the elbow extended, as he does with the sound one, or move it about in the same way. These, then, are the signs of a dislocated shoulder, the modes of reduction are the ones described, and these the methods of treatment.
XI. The proper treatment of those whose shoulders are often being dislocated is a thing worth learning. For many have been debarred from gymnastic con- tests, though well fitted in all other respects, and many have become worthless in warfare and have perished through this misfortune.?, Another reason for its importance is the fact that I know of no one who uses the correct treatment, some not even attempting to take it in hand, while others have theories and practices the reverse of what is ap- propriate. For many practitioners cauterize shoulders
1 Reading rovro wer. ® Cf. Airs Waters, XX. on flabby joints of Scythians and their use of cautery.
223
20
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ITEPI APOPQN
ér@ploa, KaTa TE eum poo Gev, D a Kepany TOU Bpaxtovos eLoyxel, KATA TE TO dria Oev odiryov THS eT@pt0oos. avTar ovv at KAVTELS, el pev és 70 avo, éfémimtev 6 Bpaxior, 9 H és TO eumpoabev i) és TO Oria bev, opbas av éxatov’ vov 6é on, ote és TO KaTw éxmrim rel, éxBadrrovow avbrat ai Kavoels paddov y) Kodvove aTOKXELOVoL yap THS AVM evpux@pins THY cepadnv TOU Bpaxiovos.
X pr O€ woe Kale TavTa: arrokaSovta TOIL OaKkTUoLoL Kara Thy paoxarny TO dépua, apen- KUGaL KAT avTHY THY vg pddora, Kal iy n xepars) TOU Bpaxtovos CXTLTTEL! emerta obTas apeidKuopeévov TO Seppe, diaxadoar € es TO TEpnY. ovdnpiorce dé ypn tadtal Kalew, wn Taxéot, pnde inv paraxpotow, adda T POprjKETt—TAXU- Topwrepa yap — cal Th xeupl errepetoewy" vpn 6€ Kal drapavece Katew, @S Oru TaYLoTa Tmreparwd j KaTa duvapuy Ta yap Tmaxéa Bpadéws mepa.ov- peva TaTUTEpAs Tas exT TOT LAS TOV éaxapéwy Toveitat, Kal xivduvos av eln ouppayivar TAS a@reudds* Kal KAKLOV pev ovdev ay ein, aioxvov dé kal aTEXVOTEpOD. éTav Siaxavons € es TO TEPNY, Tov pev Tela TOV ixavas av exou €v TO KATO pépet TAS éaxapas TavTas povvas. Oeivar’ a be pa) KLVOUVOS paivnrac elvat cuppayivat Tas @rehas, ada TOA TO bia pégou 7; Uma ELT T pov xen Nem TOV Ouepoa bua TOV KAUBATOY, éTL avarenLjLevou TOU S€pparos, ov yap av dddws dvvato Stépoau: emmy € Suépons, apeivac TO dépua, Emerta Meonyd Tav éeaxXapav adrnv
1 + ToLlavTa.
224
ON JOINTS, xt.
liable to dislocation at the top and in front where the head of the humerus forms a_promi- nence, and behind a little away from the top of the shoulder. Now these cauterizations would be properly done if the dislocations of the arm were upwards, forwards or backwards, but, as it is, since the dislocation is downwards, these cauterizations rather bring it about than prevent it, for they shut out the head of the humerus from the space above it.
One should cauterize these cases thus :—Grasp the skin at the armpit between the fingers and draw it in the direction towards which the head of the humerus gets dislocated (¢.e. downwards), then pass the cautery right through the skin thus drawn away. ‘The cautery irons for this operation should not be thick nor very rounded, but elongated (for so they pass through more quickly), and pressure should be made with the hand. They should be white hot, so that the operation may be completed with all possible speed. For thick irons, since they pass through slowly, leave larger eschars to come away, and there is risk of the cicatrices breaking into one another. This indeed is no great evil, but looks rather bad and shows want of skill. When your cautery has gone right through, these two eschars in the part below will in most cases be sufficient by themselves. But if there seems no risk of the cicatrices breaking into one another, and there is a good interval between them, one should pass a thin spatula through the cautery holes, the skin being still held up, for otherwise you could not pass it. After passing it, let go the skin and then make another eschar between the others with a thin 225
1 VOL. IIL.
50
60
70
THEPI AP@PON
eaxdpny euBarrewv AeTTO ordnpio, Kal Svaxadoar aX pls av TO imaneimrpep eyKupoy. omdaov Oé TL XpN TO Sépua TO aro THS waTYarns dmrohap- Rave, ToLoide xp?) Texpatper Bar abdéves Ueto H éXdaoous 7) peifous Taow v0 T HacxXanry, Todhaxy dé wal aXXN TOD TOLATOS. arr ev aro hoy mept adéveov ovhopenins yeypaeran, 6 Tt Té €lot, Kal ola év otovct onpavovat Te Kal Stvavtat. Tos ev obv adéevas ov xP” Tpoa- aTohapBavew, ovo éca ecarépo TOV adeveov: péyas yap o civouvos: Tote yap ETLKALPOTATOLAL TOVvoLoL yetTovevovTat: Ocov Oe efwrépo TOY adévov éml+ mrelotov atodauBavew: acwéa yap. yev@oxery de xen Kal Td06, OTe Hv pv toxXupas TOV Bpayxiova dvareivys, ov Suvnon TOU Séppyatos aToAaBety ovdév Tod Umd TH pacxdrn, 6 Tt Kal aEvov Aoyou" Karavalo povraL yap ev Th avaracet ot oe av TOvOL, ovs ovdemen EnXavy Sef TUTP@O KEL, obToL T pOXELpol ylvovrat Kal KaTa- TETAMEVOL €v TOUTO TO OX pare Hv 8€ opixpov émdpys TOV Bpaxiova, modu mev TOU Seppatos amon ty, ot 6€ Tovor wy bet mpopunbeta bar, & eo Kat T™poow TOU Nerplo patos yivovrat. ap ovv ovK év TAoN Th TEXVN TEPL TAVTOS Xp? mova Oat, TA Sixava oxnuata é&evpioxey ép’ ExdoTo.ce ; Tatra pev TA KATA THD arxarny, Kal ikaval avTar ai Katadyyes, iv op0as teO@ow at eo Xa pat. extog Oey dé THS paoxarns ducoa povvd eotTe Xwpia, Wa ay TUS éoxdpas dein TLuwpEeovaas Tw Tab nate, pelav pev €v TO éuTpoodev peonyv THs Te Keparhs TOU Bpaxtovos
1 ds. 226
ON JOINTS, x1.
cautery, and burn through till you come on to the spatula. The amount of skin that one should take up from the armpit should be estimated thus :—All men have glands, smaller or larger, in the armpit and many other parts of the body.—But the whole structure of glands will be described in another treatise, both what they are, and their signification and function in the parts they occupy.1—The glands, then, must not be caught up with the skin, nor any parts internal to the glands. The danger, indeed, is great, for they lie close to cords of the utmost importance. But take up as much as possible of what is superficial to the glands, for that is not dangerous. One should also know the following, namely that if you stretch the arm strongly upwards you cannot take up any part of the skin under the armpit worth mentioning, for it is used up for the extension. The cords, again, which must by no means be wounded, come close to the surface and are on the stretch in this attitude; but if you raise the arm slightly you can take up a good deal of skin, while the cords which are to be guarded lie within, and far from the field of operation. Ought we not then, in all our practice, to consider it of the highest importance to discover the proper attitudes in each case? So much for the parts about the armpit, and these gathers (lit. interceptions) suffice if the eschars are properly placed. Outside the armpit there are only two places where one. might put eschars efficacious against the malady ; one in front between the head of the humerus and the
1 The extant treatise on glands is an attempt by a later writer to supply this vacancy. Galen XVIII (1), 379.
227
80
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98
TIEPI APOPQN
Kal TOU TEVOVTOS ToD KaTa THY pac arn Kal TaUTD TO S€pyua TENEWS Sraxaier XPN, Badvrepov dé ov xpi" prep te yap maxeln mrAnoin Kal vedpa, ov ovdérepa Oeppavtéa. drrvaBév TE av addy eo xdpny evdexeTat évOeivat avarepo joey TUXYD Tov TévovTos TOU KaTa THY pacyanny, KaTOTEPO dé ddiyo THs epariis Tod Bpaxiovos: Kal TO HEV déppa TEAEwS xen dvaKateww, Babeinv dé pede KapTa TavTNY moveiy" oNepwov yap TO mp vevporow. int pevew pev obdv Yr SLa TaaNS THS iNTpElys Ta ENKEa, pndérore 1 laxXupas avatet- vovta Tov Spa tova, ana METpLOs, 6cov TOV EXKéewY TTL MENELNS elveca: Hooov wey yap av Stapuxorro—oupd éper yap mavra, Ta Katara CKETELY, @S EmeerKeos intpeverv—i oo ov & av éxtAXlacotto: Hocov & av aimoppayoin: acov & dv omacpmos éruyévoito. omotay dé 5) Kabapa yevnra Ta Eden, és @TEthas Te in, TOTE on Kal TavTdmact. “pn atel TOV Bpaxtova ™ pos THow TEUPHTL mpoadedéo bau, Kal vUKTO Kal nwépny™ aap Kal omroray byeea yévntat Ta EdxKea, osolws emt moADy Xpovoy xPn mpoa dew Tov Bpaxiova pos Tas TAEUpas® ouT@ yap av padiora emou- AwOein Kab amohnpbetn evpuvxepin, Kal” iy pddiora ora Oaver o Bpaxiov.
XII. “Ocouvse 8 av @mos Katyn TopnOA éuBrm- Ojvar, nv pev ere ev avenoer EWoU, ouK 0 dew cuvavéer bas TO oaTéov ToD Bpaxiovos o Omoiws TO bye, ara averat pev emi TL, Bpaxvrepov 58 Tov éTépou yiveTau Kal ol KaXovpeEvot OE éx yevens yadidyKkoves, Sta Siccas ouppopas tavtas
2 Os Kal. 228
ON JOINTS, x1.—x11.
tendon at the armpit,! and here the cautery should go right through the skin, but no deeper, for there is a large blood vessel in the neighbourhood, and cords, none of which must be heated. Again, another eschar may be placed behind, well above the tendon at the armpit, but a little below the head of the humerus, Burn through the skin com- pletely but do not make this cauterization very deep either, for fire is hostile tonerves. During the whole treatment, the wounds must be dressed without ever lifting the arm up strongly, but only such moderate distance as the care of the wounds requires. They will thus be less exposed to cold—(it is well to cover all burns if they are to be treated properly)—less drawn apart, less liable to haemorrhage, and spasm will be less likely to supervene. When, finally, the wounds get cleansed and begin to cicatrize, then above all should the arm be kept continually bound to the side both night and day, nay, even when the wounds get healed, one should bind the arm to the side in the same way for a long time; for so would the cavity into which the humerus is mostly displaced be best cicatrized up and cut off.
XII. In cases where reduction of the shoulder has failed, if the patients are still adolescent, the bone of the arm will not grow like the sound one. It grows a little indeed, but gets shorter than the other. As to those who are called congenitally weasel-armed?, they owe this infirmity to two
1 Pectoralis major tendon,
* Strictly weasel-elbowed. Galen in his Lexicon says they have shrivelled upper arms and swollen elbows ‘“‘like the weasels,” but he doubts the derivation. In his Commentary he is still more doubtful, but leaves ‘‘ those who study such matters” to clear it up, which they have not yet done.
229
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30
IIEPI APOPQN
ryivovTal, nv yé TL ToLoODTOY avTovs éEdpOpnya KaTanaBn év TH yaorpl éovTas, dua te dArnYt cuuhopny, mepl as darepov OTE yeyparperas atap kal olow étt vyriotow cobar KaTa THD eparny Tob Bpaxtovos Babetar Kal vmroBpuxvot ex TUN LES yivovrat, Kal ovToL Tavres yanlayKoves yivovrar Kal my TE THNIGoW, Hy we cavdaaw, iy Te GUTOMATOY | opi éxpayn, ev eldévat xP” éTe Tadta oUT@S EXEL. xphcOae peVvTOL TH KeELpl dvvaT@tatot 2 elow ol é€K ryevens yaruaryKoves, ov pny ovde exelvot ye avaTetvat Tapa TO ods TOV Bpaxtova exTavucayTes TOV ayKava dvvavTat, anna TOAU evdecr TEpws 1) ” TY byeéa xetpa. oloe & av dn avipdow € eovow exTréon) 0 @pos Kal a} euBrAnOH, 1) eropis aoapKkorépn yiverat, Kal n &£is NemT1) 1) Kara TodTO 70 pé pos: OTay méevTot oduVMpwevoL TAVTwVTAL, OTOGA meV Set epryalecOat emaipovTas TOV ayKa@va ao THY TAEUpEwY es TO TAraylov, TadTa mev ov Svvavtat aTayTa oOpoiws epydberOar omoga be et epyatecr Car, Tapa- pépovras Tov Spaxiova mapa tas TAevpas, 7 és TOUTLaw 7) és roumm poo ben, Tavta 6¢ ddvayTas épyalecOar: Kal yap av apida éXxvoaev® Kat mplova, Kal Tedexnoalev av, KaL oKdraLev ay, py KapTa avo aipovTes Tov ayKava, Kal TaAXa dca éx TOV ToLOUT OY oXNMATOY épyavovTat. XIII. "“Ocoot & av TO cicp@juLov anoonac Oh, TOUTOLoL paiverat e&éxov TO OGTEOY TO ATED TIAG- pévov: éate b€ TodTO oO avvdeo pos THS KANOOS Kal THS @pmowAaTHS: EtTEpoin yap vous
1 évépny. 8 Suvatarepor, 239
ON JOINTS, x11.—xm1.
separate causes. Either a dislocation of this kind has befallen them in the womb, or another accident which will be described somewhat later ;1 so, too, those in whom deep suppuration bathing the head of the humerus occurs while they are still children all become weasel-armed. And whether they are operated on by the knife or cautery, or the abscess breaks of itself, be sure that this will be the result. Still, those who are congenitally weasel-armed are quite able to use the arm, though they, too, cannot stretch the arm up by the ear with the elbow extended, but to a much less extent than the sound one. In adults, when the shoulder is dislocated and not reduced, its point is less fleshy than usual and this part assumes a lean habit. Still, when they cease to suffer pain, though as regards all such work as requires raising the elbow outwards from the side they are unable to do it as before, any work such as involves moving the arm either backwards or forwards along the side they can execute. For they might work a bow-drill? or saw,—and might use pick or spade without much raising of the elbow, and so with all other works which are done in such attitudes.
XIII. In cases of avulsion of the acromion, the bone torn off makes an obvious projection. This bone is the bond between the clavicle and the shoulder-blade, for man’s structure is here diverse
1 As Galen remarks, if we deduct the dislocation and the disease from the two causes, it is difficult to see what remains,
2 « File” most translators, “auger” Adams, but the dpls was used to work the trephine. See Oribasius, XLVI. ii.
8 éAxtociy . . . meAcKnoeav,, , gKdpeay. Ka,
231
10
20
30
TIEPI APOPQN
, A f avOpimov tavty 7) TOV adrwv Cow of odv intpol padduota éEaTraTavtar év TOUTS TO TPO- X\ / an a pati—ate yap avacyovTos TOD daTéov TOU aTro- / / omacbévtos, éemapis daiverar yapattyryn Kal f ec tad rn a xkolAn—oTe! kal mpopnOeicbar TOV Guwv TOV > , \ ss 3S 2) \ BA CXTETTWKOTWD. TOAXOUS OY Oida LNTPOUS TAA > 4 27 “ A? Sh. BI / ov dAavpous €ovTas, of TONGA HON ENVLNVAVTO, éuBdrrew Tetp@pevor Tov’s TOLOVTOUS BpoUS, , obtws olduevor éexTeTT@Kévat, Kal ov mpoabev x a a mavovtat mpl %) amoyvavat 7 atropicat, d0- lal > \ / ’ \ ’ 4 XX - KOUVTES aUTOL odéas aVTOUS EuBadrELY TOV Bpmoy. TovToLow intpein pév, Hep Kat ToloWw adoLoW Toc TOLOUTOLEL, KNPWT)) Kal oTAHVES Kal dOorA, Kai erisecis ToLavTn. KatavayKxatew pévToL TO imepéyov xpi, Kal Tos omdivas Kata TodTO Tibévat TAEloTOUS, Kal mLéleLY TAUTH padLoTA, Kal tov Bpaxlova mpos That WAevphot Tpoo- f \ B) npTnuévov és TO dvw pépos eye, ovTw yap av pdduota wAnoLdbor TO arreoTracpévov. Tade [EV a > / la \ / ¢ > , ’ eD eldévat py, Kal mpor€éyery ws aodarea, e& UA bya pA ig , \ b) / 7 ddrrws Ores, Ste BrAaBn pev ovdeuin, ovTE opuKph odte pweyaddry, TO @u@ yivetas aro TOUTOV nr \ Uf Tod Tp@patos, alayiov Sé TO xwpiov ovde yap lal 4 ¢€ TodTO TO daTéov és THY apxatny Edpnv Opotws av nS) / ae ’ , 2 ) ? b} / iSpuvOein, womep émiméduxev,” addr avaycn > 7 \ mréov 3) &t\accov oyKnpoTepov elvat és TO avo. bJ \ \ »” ’ / > \ 9 3 \ f ovdé yap AXXO daTéov ovdey és TMUTO KaicTAaTAL 6 Te dv Kowwvéov F éETEp@ doTéw Kal TpoaTEpUKoS le) lel / anooracOn amd THs apxains Pvovos. avaduvor
1 fomwep TAY pws, 3 ws ermepixey
232
ON JOINTS, xm.
from that of animals. Thus practitioners are especi- ally deceived by this injury—since, the detached bone being raised up, the point of the shoulder looks depressed and hollow—-even to the extent of treating the patients for dislocated shoulders.! I know many otherwise excellent practitioners who have done much damage in attempting to reduce shoulders of this kind, which they thought were dislocated : and who did not cease their efforts till they recognised either their error or their impotence if they still supposed they were reducing the shoulder-joint. The treatment in these, as in other like cases, consists of cerate, compresses, bandages and the like mode of dressing. The projecting part however should be forced down, the bulk of the compresses placed over it and strongest pressure made here. Also the arm should be fixed to the ribs and kept up, for so it will best be brought near the part torn off. For the rest, keep well in mind and predict with assurance, if you think proper, that no harm, small or great, happens to the shoulder from this injury, but the part will be deformed. This bone, in fact, cannot be fixed in its old natural position as it was, but there will necessarily be more or less of a tuberosity on the top, Nor, indeed, is any bone brought back to the same place, if, after forming an annex or outgrowth of another bone, it has been torn away from its old natural position.
1 “Looks hollow ” as when the shoulders are dislocated, (Kw.’s reading),
233
35
10
20
IIEPI APOPON
TE TO chk pcb {Lvov év oyna Huépynoe yiverat, hv NPNTTAS €TldénTaL.
XIV. Kris 6 Katearyetaa, Hy eV ATPEKEWS amoxaumad}, evinrorépn éariv: ve dé Tmapapn- KES, dvaurorépn. Tavavria 6 TovToLo Ly eo 7) @S av TLS oloLTO, THY meV yap aT pexéws aToKav- Ava Ocioay MpocavaryKac vey * dy TiS padrAov és Tv vow éeXGetv: Kal yap el mau mpounOn dein, TO dvearépe KATOTEPO av TTrownoese oXHHact TE émriTndelotat Kal em LOEeL appovovan: el O€ pay Te- Aéws iSpuvOein, arn’ ovv TO UT EpeXov ye TOU oatéou ov Kapta 0&0 yiverau ov © av Tapaunnes TO da Téov KATEAYT, LKEXN 1) Tum opr) yiverau TOLo LV oa TéoLa! Toto Ameo Tas MEVOLTL, mepl Ov mpoa Dev yéypar rac: oUTE yap iSpurO jac avTo T pos EwuTO Kapra Genet, 7 i] Te UmepeXovga Ox pus Tov oaTéov o&ein syiverau KapTa. TO bev oy oUTaD, eldévat xpr OTL BraBn ovdepsin TO Ow ovdé TH Ar THMaTe ylverat dua THY natn Ew TIS KAnidos, 7 ay pa) emia paredton’ ouyanes be TobTo yiverat. aiayos ye pay Tpooyiverar qept THY earn Ev THS crni6os, wal TOUTOLOL TO Tp@ToOV aicXtorov, émerta pnv eénl ooo yiverar. cuppverat be TAX EWS crajis Kal Taha TavTa boa xavva ooTéa’ Taxelny yap THY erm @ poow Tovet Tat Ta Toabra,
\ étTav pev ovv veworl KaTEayn, ol TET peOMEVOL omovddtouvat, oto pevot péCov TO KaKOV é€lvaL 4 daov eotiv: of te intpot mpoOvuéovtar dHiOev
1 rpocavayKacot.
1 This is probably dislocation of the clavicle at the outer end. The anatomy of the part was imperfectly understood
234
ON JOINTS, xim.—xrv.
The acromion becomes painless in a few days, if it is properly bandaged.+
XIV. A fractured collar-bone is more easily treated if broken straight across ; but if fractured obliquely, treatment is more difficult. In these cases matters are the reverse of what one would expect. For one will more readily force a collar-bone fractured straight across into its natural position, and by thoroughly careful treatment will succeed in adjust- ing the upper to the lower fragment by appropriate attitudes and suitable bandaging. And should it not be completely reduced, at least the projection of bone will not be very pointed. But those in whom the bone is fractured obliquely suffer an accident like the avulsions of bones described above ; for the fracture hardly lends itself to reduction, and the projecting ridge of bone becomes very sharp. Still, when all is said, one must bear in mind that no harm happens to the shoulder, or body generally, from a fractured collar-bone, unless necrosis supervenes, and_ this rarely happens. Deformity, it is true, accompanies fracture of the clavicle, and this is very marked at first, but afterwards gets less. The collar-bone unites quickly, as do all spongy bones, for with such the formation of callus is rapid. Thus, when the fracture is recent, patients take it seriously, thinking the damage is worse than it is, and practitioners on their side are careful in applying proper treatment ;
even in Galen’s time, some saying that the acromion was a distinct bone found only in man; while others thought there was a third bone or cartilage between the clavicle and acromion. The accident occurred to Galen when 35 years old, and he relates vividly how it was first mistaken for a dislocated shoulder, and how, by forty days’ endurance of tight bandaging, he recovered without any deformity.
235
30
40
50
TIEPI AP@PQN
opAds iho Pac: mpoiovtos 5€ Tod Xpovov ot TeTpw- pévol, ate ovK oduv@pevot ovde K@AVOMEVOL oure odoiTropins oUTE Edwohs, KaTapedéovat of TE av int pot, ate ov Suvdmevot Kana TA Xepia ATrOOELK- vuvat, UratrobiSpdckovat, kal ovK dx Povrat Th apmedein TOV TETPOMEVOD' €v TOUT® TE 1) ETLTO- pois owvTaxvverat.
"Eridéoros ev ody TpOTOS KnabéaTnne mapa- TA1}o-t0s TOloL TAELTTOLL KNPOTH Kal om Avert Kat dOovioice pardaroiaw int pever' Kal Tade del mpoointpevewy, Kal Tade Set Tpocacvviévat Kal padtoTa év TOVT® TO Xetpio pare, ore ToUS TE omhyvas Tela Tous Kata TO 退éyov xP?) TiO évat, Kal Toioe emidéo ovat TAELTTOLTL Kal HadioTa KaTa TovTo xpn mele. etal 5é dy tives, of émecopiaavro non ponusetoy Bapu im poemtKkara- deliv, @s KatavayKxator! to UmepéXov- UVLATL bev ovdv tows ovdé of amAas eTedéovTes: aTap 8) oud oUTOS 0 TpoTros KANtb0s KaTHELOS éoTLV: Ov
yap dvvatov TO UmepeXov catavayKkater bar ovoév 6 tt aELov Noyou. addoe S ad ) Teves elow, olives, Katapal ovres tobTo, bTL abras at err iS€o Les mapapopot eloe Kal ov Kata puow KaTavaryKa- Sovat Ta UmEpexovTa, émrdéovat pev ouv avTous omhnvert Kal ooviorce Npewprevor, Oomep Kal ot adro Cwoavtes 6€ Tov avOpwrov Tain TWi, evlwoToTatos AUTOS EwuTOD éoTiv, OTav émibéwor Tovs omAnvas él Ta Umepéxovra Tob Kariy- patos, éEoyxwoartes ert Ta éfeXovTa, THY apxny Tov dGoviou mpoaednray T pos TO Saou ex TOU eum poo der, Kal obTws emoéovary, emt THY tEw THS KANidos eTiTaVUOVTES, €s TOUTLAVEY ayoVTES* 236
ON JOINTS, xv.
but as time goes on the patients, since they feel no pain and are not hindered either in getting about or eating, neglect the matter, and physicians too, since they cannot make the parts look well, withdraw gradually, and are not displeased by the patients’ carelessness, and meanwhile the callus formation quickly develops.
Now, the established mode of treatment is like that used for most fractures, cerate, compresses, and soft bandages ; also the following extra treatment is required, and it must be kept in mind especially in handling this injury that one should put the bulk of the compresses on the projecting part and apply pressure with most of the bandages, especially at this point. There are some, indeed, who in their wisdom have contrived something further and bind on a heavy piece of lead as well, so as to press down the projec- tion. Perhaps those who use a simple bandage are no wiser, yet after all, this is not a suitable plan for a fractured collar-bone, for the projecting part cannot be pressed down to any extent worth mentioning. Again, there are certain others, who, recognizing a tendency to slip in these dressings and their inability to press down the projecting parts in a natural way, use compresses and bandages like the rest, but gird the patient with a belt at the most suitable part of his body. Then they put compresses on the part of the fracture that sticks up, piling them on to the projection, fix the end of the bandage to the belt in front and apply by stretching it vertically over the collar-bone and bringing it to the back. Then,
1 KatavayKacew.
237
60
70
80
90
TIEPI APOPQON
KATELTA epi Sarroves mepl To Caopa, és TOU Tpoobev ayouat, Kat adfis és tovmicbev. ot b¢ TLVES ovxt Tepl 70 baopa meptBdrdovae To adoviov, anrra mepl TOV mepivarov Te Kal Tap’ avuTny THY eopnv Kal mapa TID axavOay KUKNEU- ovtes TO O0dviov, ovTw mLéLovol TO KaTHYpA. TAUTA YyoUV ameipy fev axovcar paiverat eyyus Te TOU Kara pvaow eivat, NpPEomevep 6é axpnora: ore yap povipa ovoéva Xpovor, ovd € KaTa- K€OLTO TIS—KaLTOL éyyUTaT@ av oUTwS—aAr’ opos, el Kal KAT AKELLEVOS 7 70 oKENOS oUyKapL- vbevev 7) avTos cappdein, mavra av Ta émuoeo- para KLVEOLTO? AAXWS TE AON?) 7 émideous: TE yap éopn aT orNapBaverat, aOpoa ' Te Ta oBova ev TAUTN TH orevox ply yiverac’ Ta Te av mept THY Coovyy meptBardopeva OvxX ows loxupas éwo- Tal, Os OvUK a@ayKkacat és TO avon TV oa émavievat, Kal obtas avayKn av ein yadav? ta émideo ara. ayXuora o ay TLS Soxeou Trotety, KaiTrep ov peyada TOL@V, EL TOLTL fev TLOL TOV dOoviwy rept THY Cwovny meptBarnor, Toiot O€ TrELTTOLTL TOV ddoviey THY dpxainv eridecw émuo€ ou" oUTw yap dv pwartoTa Ta emioéo mata povipa Te ein Kal addyrovge TLpLe peo.
Ta pev ovv TAElaTa ElpnTat, daca KATANGA L- Raver TOUS 7TI)V Krida KATAYVUPEVOUS. 7 poo ouvievatr O€ T06€ XP; ore Krals @s émLTOTONU KaTdyvurat, @OTE TO Mev aro Tov o770eos TepUKOS ooTéov €5 To ave [Epos UMEpEXELY, TO O€ amo THS ck pemins év 78 KAT@ [epee elvat. aitta be TOUT WV rade, OTL TO pev ar Oos ouTE KATOT EPO div TOND OTE avaTEpw YHpPHTELEv? TULKPOS yap O
238
ON JOINTS, x1v.
passing it through the belt, they bring it to the front and again to the back. There are others who pass the bandage, not through a belt, but round the perineum near the fundament itself, and, completing the circle along the spine, thus make pressure on the fracture. To an inexperienced person these methods seem to come near the natural, but to one who uses them useless ; for they have no permanent stability, not even if the patient keeps his bed, though this would come nearest. Yet even if, when recumbent, he bends his leg or curves his body all the bandages will be deranged. Besides the dressing is troublesome, for the fundament is included, and all the bandages accumulate in this narrow part, while, as for those passed through the belt, it is impossible to gird it so tightly as not to yield to the force pulling upwards, and so the bandages will necessarily become lax. One would appear to be most effective, though without effecting much, by making some turns of bandage through the belt while applying most in the old fashion,! for so the bandages would best keep in place and support one another.
Almost all then has been said on the subject of patients with broken collar-bones; but the following should also be borne in mind, namely, that the clavicle as a rule is so fractured that the part arising from the breast-bone is on the top and that from the shoulder- point (acromion) below, The reason of this is as follows: the breast-bone does not move much either downwards or upwards, for the range of the joint at
1 Some make dpxainv erldeow =the under bandage, first applied, but cf. apxain pots = volun, XIII. 33.
1 advta xaday,
439
100
110
120
ITEPI APOPON
KiyKNLG LOS TOD apOpou Tod év TO onde. avTo Te yap éwuTO ouvexés éoTt TO “oTiiOos Kal TH payer ayXioTa pene 7” Kdais POs TO TOU @pov dp pov TOWONS erty vayKacrat yap TUKLVO- Kiyntos evar Oia THY THS akpwpmins ovfevélv. Gddrws Te OTaV TH@OH, hevyet €s TO AVM pépos TO Tpos TO oTNOEL TpoTEXOpmEVOY, KaL OV pada €s TO KAT® LEpOs dvayxater Oat eOéreu wal yap mépuKxe Kovdov,+ Kab 1 evpuxwpin auT@ dve mrelov i) Karo. 0 6€ @pos Kal o Bpaxiov Kal Ta _TpoonpTnpEeva TOUTOLoLY evaTrOAUTa éorw amo TOV TAEupewv cal TOU o710€0s, Kal bua TOUTO OUVaTaL Kal avwTépw TOAD avayerOat Kal KAT@TEPO* Otay ov Kateay i} n KXyis, TO pos > 2 tah 3 TO dno oa Téov és TO KATOTEpO emUppemrer €S TOUTO yap eT LT POX @TE POY avtTo dpa To Op Kal @ Bpaxiovr KATO pepar HaNdov i) és TO avo. onde ovy TavTa TowadTa earl, douveréovaty dco TO Umépexov TOD doréov és TO KAT@ earavary- Kao a olovTae olov Te €ivat. GNAG Oidov 6 OTL Ta KATO ™ pos TO avo 7 pocaktéov éoriv: TOUTO yap exer Kiva, TOUTO yap cor Kal TO amooray amo THS pvaos. ofpNov ovv OTL ddhos pev ovdanas éoTW avayKdoat TovTO—ai TE yap ETLOETLES OUSEV TL WANXDOV Tpooavaryxatovaty a anavayxatovaw—el dé TLs TOV Bpaxiova T™ pos THO’ meupioe copra avayKalot ws Hddora ava, os Oru o€vTaros 0 @L0S paimyrar® elvar, dijAov OTL OUTwS av appoo bein Tpos TO OTTEOV TO dim TOU a7nOeos TEPUKOS, o0ev aneoTaaOn. el ovv TUS TH pev ETLOéTEL YPEOLTO TH Vopimy TOV TAXEWS 1 Aopdov. 240
ON JOINTS, xv.
the sternum is slight and there is continuous con- nexion between the breast-bone and the spine, but the clavicle on the side of its connexion with the shoulder is especially! loose, for it has to have great freedom of movement owing to the acromial junction. Besides, when it is fractured, the part adherent to the breast-bone flies upwards, and can hardly be pressed down, for it is naturally light and there is a larger vacancy for it above than below. But the shoulder, upper arm and parts annexed are easily separated from the ribs and breast-bone and therefore can be moved through a large space up- wards and downwards. Thus, when the collar-bone is broken, the part towards the shoulder sinks down- wards, for with the shoulder and arm it is more readily disposed to move down than upwards. So whenever this state of things occurs, they are un- intelligent who think it possible to press the pro- jecting part of the bone downwards; while it is obvious that one must bring the lower part up, for this is the moveable part, and this too is the one out of its natural place. It is obvious then that other methods are useless in reducing this fracture —for bandagings are no more likely to bring the parts together than to separate them—but if one presses the arm upwards as much as possible, keep- ing it to the side, so that the shoulder appears very pointed, it is clear that the fragment will thus be brought into connexion with the bone arising from the sternum from which it was torn. If, then, one should use the ordinary dressing for the sake of
1 Krotian refers twice to this use of &yx.cra = wdAvora,
* gpalverai, Galen, M, 2Ar
127
10
MEPI APOPQN
ouvarbeab frat elvexa, nyngarto ay Tahna. TavTa pany eiva Tapa TO oxipa TO eipnuévor, opbas Te av ovviol, intpevot Te av TaXLoTa Kal Kan- baw KataKelo Oar pEvTOL TOV avOpwrov péya
ot Svapopov € coTw" Kal nepal iKaVal Tero apeo- Dis ant él aT pepéot, eixooe be mapTorRat.
XV. Et pévtoe tui emi tavavtia 4» KdnIls KaTeayein, 0 OU para yiveTaL, ®oTE TO MeV ATO TOU o71/0¢0s da TEov Umodeduxévar, TO O€ amo Tis axpeoj.ins OoTéov Umepexen wal emoxeto Bat emi TOU ETépou, ovdepens Heyarys intpetns tabra y av déorTo" avros 1ap 0 mos ap ve mevos Kal 0 Bpaxiov tOpvot av ta daréa Tm pos dddona, wal pathy ay TLS émideous apKéor, Kal Odbyas nwépat THS TWPWOLOS yevolar’ av.
XVI. Ei éé pany Katearyein pév obTas, map- orto Aavor be és TO maytov a 7H y Th, és THY puow bev amaryarelv av d€0u, avayayovTa TOV pov avy TO Bpaxton, Gomep Kat mpoabev elpynTae oray ry: itnras és TY apxainv puow, Taxein adv adAN intpetn ein. Ta pev ouv TrELTTA TOY TapadrayuaTov KatopOot avTos oO Bpaxyiwv, avayxalomevos Tpos Ta avw. boa 6é €K TOV aber mapodta Odvovta és 70 maryLov HAOEv, 7) es 70 KATWTEPL, TULTOpavYOL av THD catoplwcw, el 0 pev avOpwrros trios KéoLTo, KaTa O€ TO peonyv Tov @LoTAaTéwv tpndorepov TL OALYO bm oxéouro, @s TEPLPPNOES a TO oTHOos @S pamora Kal TOV Bpaxiova eb avaryou Tes mapa Tas TAeupas TAPATETAMEVOY, o € intpos TH Mev ETEpN vetpl és TI cedar TOU Bpaxiovos euBarwv to Gévap THs yetpos amwOéor, 7H Se 242
ON JOINTS, xtv.—xvi.
getting a quick cure, and should consider everything else of no importance compared with the attitude described, his opinion would be right and his treat- ment most correct and speedy. Still, it makes a great difference if the patient lies down, and fourteen days suffice if he keeps at rest, while twenty are very many.
XV. If, however,a man has his collar-bone broken in the opposite way, which rarely happens—so that the thoracic fragment is underneath and the acromial part projects and overrides the other—no complicated treatment will be required here, for the shoulder and arm left to themselves will bring the fragments together. Any ordinary dressing will suffice, and callus will form in a few days.
XVI. If the fracture is not of this kind, but the displacement is to one side or the other, one must reduce it to its natural position by elevating the shoulder and arm as described before, and when itis set in its old natural plaee the rest of the cure will be rapid. Most lateral displacements are cor- rected by the arm itself when pressed upwards, but in cases where the upper (sternal)! fragment is displaced laterally or downwards adjustment will be favoured by the patient lying flat on his back with some slightly elevated support between the shoulders, so that the chest falls away as much as possible at the sides. Let an assistant push the arm, kept stretched along the side, upwards, while the practitioner with one hand on the head of the humerus presses it back with his palm, and with the other adjusts the
1 So Galen.
Av,
243
30
32
TIEPI APOPOQN
étépn Ta dt Téa TA KaTENnyoTa EvOETi LoL, O'TwS dv uddiata és tiv dvow ayo atap, @oTEp HON eipntat, ev! wadra TO dvwblev ootéov és TO KATH iret UTroduvery. Tolar pev obv TAELTTOLGLW, OTAV éTL0eO@al, TO oxime apnyet, Tap auras Tas meupas TOV ayKova exovra obras és 70 ave TOV @ Lov dvayndber Oat: Eore 6 olox bev TOV @ov avayKabe Sel és TO ava, ws elpyntat, Tov be dyKava ™ pos TO oriOos Tapayew, aixpny 6é THY xetpa Tapa TO AKP@LLOVY TOD Vyréos GjLOV laxeuw. ay fev ovv kataxeiobar TOME, avTl- oT ply jd TL mpoorBevar XP), @S av oO d pos avoTare 7 iy dé mepuin, opevdovny xp” éx TaWins Tept TO o&0 TOU dyKx@vos TOLnoavTa avahauBdvew mept Tov avyéva.
XVII. ’Ayxavos 6é dpO pov mapadrakav peev i) TapapO phar pos mevpHy y} é€o, HEvOvTOS tov o&éos Tob év 7S KOLX@ TOD Bpaxiovos, és evOd KaTaTelvayTa, TO é&éyov aTrwbetv oricw Kal és TO TAAYLOV.
XVIII. Ta be TEREWS éxBavta » &v0a i} eva, KaTdracts bev, év 7 0 Bpaxiov KaTeayels émre- deitat: oltTw yap ay TO KajuT VAOV Tod dye BVOS ov KOT EL. éxmrimrer dé paricta és TO 1 pos m)eupas ° HLEpos. Tas oé Katopbwctas, arayovTa OTL TAELATOY, WS Nn avy THS KopwVvns 7) KEeharn, METEWPOV TepLayel Kal TEpLKaTTELY,® Kal yn és
1 ob Littré, Erm., Kw. 2 qAeuphy. 3 trepicdmpat.
1 Reading od. ed (Galen, Pq, and all MSS.) would accentu- 244
ON JOINTS, xvi.-—xvin.
broken bones; in this way one will best bring them to the natural position; but as was said before the upper (sternal) fragment is not! much wont to be displaced downwards.?_ In most cases, the position after bandaging with the elbow to the side suffices to keep the shoulder up, but in some it is necessary to press the shoulder up as described, bring the elbow towards the chest and fix the hand at the point of the sound shoulder. If, then, the patient brings himself to lie down one should supply a prop to keep the shoulder as far up as possible, but if he goes about one should suspend the part by a sling bandage round the neck to include the point of the elbow.
XVII.3 (Subluxation of the radius.) When there is displacement or subluxation of the elbow-joint towards the side or outwards, the point (olecranon) in the cavity of the humerus retaining its position, make direct extension and push the projecting part obliquely backwards.*
XVIII. Complete dislocations of the elbow in either direction require extension in the position in which a fractured humerus is bandaged ; for so the curved part of the elbow will not get in the way. The usual dislocation is that towards the ribs.4 For adjustment separate the bones as much as possible so that the head (of the humerus) may not hit the coronoid process, keep it up and use movements of circumduction and flexion, and do not force it back ate the statement that the sternal fragment may be dis- placed downwards,
2 Or, following Pq and the MSS., ‘‘the upper fragment may very well be displaced downwards.”
3 For the sources of XVII—X XIX see Introduction, p. 86. 4 = our forearm backwards, cf, Fractures XLI,
245
10
18
TIEPI AP@PQN
evdv BratecOat, apa be adeiv TavavtTla ep’ exdTepa Kal tapwbeiv és xepny’ cuvepedoin av Kat emiatpeyrs dy KOVOS év TOUTOLOLY, éy TO pev és TO imtiov, év TO O€ &s TO Tpnves. ines 5é, TX MATOS pe, drive aveTtépw ccpny THY XEipa Tod ary BVOS EXEL, Bpaxiova Kara m™eupas" obT@ dé Kal aaryyes Kai Oéous: Kal eUpopov Kal puots, Kal xpnow év TO KOW@, nv dpa 1) KAKOS Topo OT: Topovra 8 TAYEWS. ines be dOoviotet KaTa TOV Vopov TOV apOpiTLKOV, kal T0 o&v mpocenoel.
XIX. [Tadeyxotétatov 6é o ary Kooy ) TUpETotT LY, odvvnoL, aowset, aK pnToXOdo, ayKk@vos O& pa- iota TovTicw Sta TO vapK@des, SevTEpov Sé TovupTpocbev. inary dé 7 avTn euBoral Sé, Tod bev OTriow, exTelvavta KaTaTeival. onetov Sé ov yap Svvavtat éxretvew* Tob dé éumpocberv, ov dvvavtTat ouyKauTTeW, TOUT® dé evOdvta Tt TUverNty LEVvOY oKANpor, méept TOTO cuyKaprpaL €€ extaowos éEaidyns.
XX. Avagréawos dé OoTEwY oNpmetoy, KATA THY préBa Thy KaTa Bpayiova aylouérnv dia- spavovtt.
XXI. Tadra 6é TAXES dvar@potrac: ex ye- vens oé Bpaxurepa Ta KATO Tob aiveos dotéa, Tetorov 7a éyyUTaTa Tov T™XEOS" SevTepov xelpos' Tpitov daxTUAwY: Bpayiwy dé Kal @pos,
1 Cf. Fract. XLVIII.
1 ««Kvidently complete lateral luxation of the forearm,” Adams.
2 Our ‘‘external lateral.”
3 Internal lateral, but Adams ‘‘forwards or backwards.’
246
ON JOINTS, xvin.—xx1.
in a straight line, but at the same time press on the two bones in opposite directions and bring them round into place. In these cases turning of the elbow sometimes towards supination, sometimes towards pronation will contribute to success. For after treatment, as regards position, keep the hand rather higher than the elbow, and the arm to the side: this applies both to suspension and fixation. The position is easy and natural and serves for ordinary use, if indeed the ankylosis [stiffening of the joint] is not unfavourable ; but ankylosis comes on quickly. Treatment with bandages according to what is customary with joints; and include the point of the elbow in the bandaging?
X1X. Elbow injury is very liable to exacerbation with fever, pain, nausea and bilious vomiting, especially the dislocation backwards? owing to the numbness [injury of the ulnar nerve], and secondly dislocation forwards. Treatment is the same. Modes of reduction—for backward dislocation, extension and counter-extension : sign—they cannot extend the arm, while in dislocation forward they cannot flex it. In this case, when something rolled up hard has been put in the bend of the elbow, flex the arm suddenly upon it after extension.
XX. Separation of the bones (of the forearm) is recognised by palpation at the point where the blood vessel of the upper arm bifurcates.
XXI. In these cases there is rapid and complete ankylosis, and when it is congenital, the bones below the injury are shortened, those of the forearm nearest the injury most; secondly, those of the hand, third those of the fingers; while the upper arm and shoulder are stronger because they get
247
IIEPI AP@PQN
éyxpatéatepa dua THY Tpopyy: 7 5é érépn xelp
ova Ta epya ere Tei éyxpateo Tépy. pwvdnors
bé TapKav, Et pev eEw e&érecer, €owlev: ef dé pn}, 8 és ToUvaVTLoV 7 efémerev.
XXIL. ‘Aykov be HV OW 7 efo exBh, Kara- Tacis pev ev TX MATL eyyovig TO mH} XEt ™ pos Bpaxiova: TID pev yap pace dy avaraSovtTa Tavin dvaKpepdacat, ayKe@ve dé aK pep vmobevra Tt Tapa 70 apOpov Bdpos, éxxpeudoat, %) xepat KatavayKatery UmreparopnOevtos dé Tob a pO pov, at Taparyaryat Toiot Pévapat @S Ta €v xepotv: émideots €v TOUT® TO oXHmaTL, Kal avadyn ts
9 Kal Oéous.
XX U5, be, oe oma bev, éEaipyns exteivovta dtop0ovv Toit Oévapor apa 6é bel ev TH Su- op0wcet Kal €v TOLGL éTepowaly. ny oe éum poo Bev apdt a0oveov gUVELALYLEéVOV, EVOYKOV TUYyKapTT-
5 TovTa aya dtopOodr.
XXIV. “Hy ETEPOKALVES HR, ev th SiopPece apupotepa dua xp” Tovety. THS O€ _MEnET IS THS Peparreins KOWOD, Kal TO oxXhpa Kal um émidects. dvvatat dé Kab &x THs Stactdo.os Kowh ovpTiz-
5 Teav dtavta.
XXYV. Tév oé éuBorewy, at bev é& omep- aLwpna Los éuSdarrovTat, ai 6é éx KaTaTaa los, ai 8é ék Tepiaparavos® abrat 6é é« TOV mep-
4 Boréwv TOV TXNMATwY } TH TH ov TO Tae.
XXXVI. Xespos 6€ apOpov drucOdver €ow h
éEw, ow O€ Ta TrELTTA. onpeia S€ evonpma:
*XXIi and XXIII are notes partly repeating XVIII and XIX,
248
ON JOINTS, xx1—xxvi.
more nourishment. The other arm is stronger still because of the work it does. Attenuation of the soft parts is on the inner side if the dislocation is outwards, otherwise on the side opposite to the dislocation.
XXII. When the elbow is dislocated inwards or outwards, extension should be made with the fore- arm at right angles to the upper arm. ‘Take up and suspend the armpit by a band, and hang a weight from the point of the elbow near the joint, or press it down with the hands. The articular end of the humerus being lifted up, adjustments are made with the palms, as in dislocations of the hand. Bandaging, suspension, and fixation in this attitude.
XXIII. Backward dislocations, sudden extension and adjustment with the palms of the hands; the actions must be combined as in the other cases. If the dislocation is forwards make combined flexion and adjustment round a large rolled bandage.}
XXIV. If there is deviation to one side, in the adjustment both movements should be combined. Position and bandaging follow the common rule of treatment. It is also possible to put in all these eases by the common method of double extension.?
XXV. Some reductions are brought about by a lifting over, others by extension, others by circum- duction ; and these are by exaggerations of attitude in one direction or another combined with rapidity.
XXVI. The wrist is dislocated inwards or out- wards, but chiefly inwards. The signs are obvious,
2 Partial lateral dislocations (cf. X VII), probably of radius. 3 Partial dislocation of wrist, Celsus VIII. 17.
249
10
10
13
IIEPI APOPON
, \ / b) 7 x \ ouvyKauTTEew TovS SaKTUAOUs ov SivavTat tv Se yy \ > / > \ 4 e \ l4 eEw, wn éxteivev. €or) Sé, brép tpametns Tous daKxTUAOUs éY@V, TOs pev TelVELY, TOds Se > / \ \ > / Xx / KA 4 ee avTiteivelv, TO d€ E£Evov 1) Oévapt mrépvy dpa avobeiv kat @beivy tpocw Kate, KdtwOev Sé Kata TO ETEpov daTéor, OyKov parOaxdv bTrobels, 3 Y / \ a HV pev dvw, KaTaaTperras THY Yelpa, iw S€ KdTo, vurtinv. ina d€ d0ovio.cw. XXVIT."OAn S€é ) Yelp OAucOdver 4 ~ow 4 + AX xX / Nb ” \ oa éEw, 7) €vOa 7) &vOa, warticta b€ gow: éott &€ OTE \ e ’ / > / + > va \ vw kal » emidvors éxivynOy: éatt & Ste TO ETEpov a 4 TOV OoTEwY SLETTH. TOVTOLTL KaTaTAGLS ioxUp) ToLnTen’ Kal TO pev e€éXov amrwbeiv, TO dé EtEpoV avtwOeiv, Svo cidca dua Kal és TovTicw Kal és \ f TO Thaytov, i) Xepoiv emi tparrétns H mrépvn. martycota 6&6 Kal aoxnpova: TH dé xpdve Kpatuvetat €s xphow. inows, d0ovictar civ TH xXelpl Kal TH THXEL Kai vVapOnKas péypL SaKTV- Nov TiOévar’ év vapOnk: S& SeO&vta tadta TuKt- * \ , votepov’ Avew 1) TA KaTHYpaTA Kal KaTayvoeL TrEoML ypHabat. ’ a / XXVIII. "Ex yevehs 5€ Bpayutépn 1 xelp lal , yiveTat Kal puvvOnots capKav padtota Tavartia 3 \ ) 4) TO éxtTopa: nv&npévw 6é, Ta datéa pével. XXIX. Aakrirov dé apOpov, odrtcOov pér,
1 aunvdtepa.
1 “Tn a great measure ideal,” Adams. Seems connected with LXIV, but the epitomist may have seen lost chapters.
* Complete dislocation of wrist. Mochl XVII; cf. Fract. XIII.
250
ON JOINTS, xxvi.—xx1x.
if inwards they cannot flex the fingers, if outwards they cannot extend them. Reduction: placing the fingers on a table, assistants should make extension and counter-extension, while the operator with palm or heel presses the projecting part back, with a downward and forward pressure, having put some- thing thick and soft under the other bone. The hand should be prone if the dislocation is upwards and supine if it is downwards. Treatment with bandages.
XXVII. The hand is completely dislocated, inwards, outwards, or to either side, but chiefly inwards, and the epiphysis is sometimes displaced [fracture of lower end of radius], sometimes one of the bones is separated. In these cases one must make strong extension, Press back the projecting part and make counter-pressure on the other side, the two kinds of moyement backward and lateral being simultaneous, and performed on a table with the hands or heel. These are serious injuries and cause deformity, but in time the joints get strong enough for use. Treatment with bandages to in- clude the hand and forearm, and apply splints reach- ing to the fingers. When put up in splints change more frequently than with fractures and use more copious douching.”
XXVIII. When the dislocation is congenital the hand becomes relatively shorter, and there is at- tenuation of the tissues most pronounced on the side opposite the displacement, but in an adult the bones are unaltered.®
XXIX. Dislocation of a finger-joint is easily
3 Mochl. XVIII. These obscure accounts of elbow and wrist dislocations are discussed, p, 411,
251
10
20
TIEPI APOPQN
eVonuov. éuBur) 64, Katateivavta és (Ov, TO pev éféyov amwleiv, To 5é évaytiov avtwbeiv- inows dé, Tatviovo.y dPoviotow. pn éurecoy 8é, eriT@povtat éEwbev. ex yevens Oe 4 év avénoe eEapOpicavta, Ta datéa BpaxyvveTar Ta KaTw Tov odéaOnuaTos, Kal capKes pLVVOoUGL TavarTia padiota 7) @st TO ExmtT@pa: vEnuévw 6, TA STRAIT 2
GoTéa péver.
XXX. Tvabos S€ briyorow 75n Teréws é&np- Opnoev: oatéov*® te yap TO amd THs dvw yvabov medukos ureluywtar Tpos TH Uo TO ods daTéw TpooTEpuKOTL, OTrEP ATrOKAELEL TAS KEhadas THS KadTw yvalov, THs ev avwtépw éov, THS 8é KATWTEPW TOV KEPAewV: Ta TE AKpEea THS KAaTw yvadou, To wév dia TO phos OvK evrapeiaduToD,® TO 6€ av TO Kopwvoy Te Kal UTEpéxoV Urép TOD fvywmatos: dpa te am’ apudhotépwv TOY axpwv TOUTwY veupwdses TévovTes TepiKacW, eE av eENpTNVTAaL Ol VES Of KpoTaditaL Kal bacnThpes Kadeouevot. Sia Todto S€ Kadéovtar Kal dia ToUTO KivéovTat, OTe evTedOev eEnptyvTar’ év yap TH €0wdn Kal év TH Siad€xTw Kal ev TH AAD XpngEL TOU TTOMATOS, ” juev ave yvabos aT pepel’ ourvnpTyntar yap Th Keparyn Kai ov SinpOpwrar' 9 O€ KaTw yvaos KWeiTat’ amnpOpwrat yap LTO THs ava yvabov Kal ato Ths Keparns. StoTe bev ovv év oTracmolct Te Kal TeTdVOLTL TPMTOV ToUTO TO apOpov éricnpmaive. cvvTEeTapevoy, Kal SuoTe WANyal Kaipio. kal Kapodoat ai Kpotadi- Tubes yivovTat, év AAX@ AOyo EipyoeTat. Tepl
1 F Kw. Mochl. 2 7d doréov Erm., K. 8 crapéxduToy Foés in note, Erm., Kw. ; emapelodurov MSS.
252
ON JOINTS, xxix.—xxx.
recognised. Reduction: while extending in a direct line, press back the projecting part, and make counter-pressure on the opposite side, Treatment with tapes and as (narrow bandages). If not reduced, it gets fixed outside. When the dislo- cation is congenital or during growth, the bones below the laxation are shortened and the tissues waste, especially on the side opposite the displace- ment; but in an adult the bones are unaltered.
XXX. Complete dislocation of the lower jaw rarely occurs, for the bone which arises from the upper jaw forms a yoke! with that which is attached below the ear, and shuts off the heads of the lower jaw, being above the one and below the other. As to these extremities of the lower jaw, one of them is not easily dislocated * because of its length, while the other is the coronoid, and projects above the zygoma. And _ besides, ligamentous tendons arise from both these summits, into which are inserted the muscles called temporals and masseters. ‘They derive their names and functions from being so attached; for in eating, speech, and other uses of the mouth the upper jaw is at rest, being connected with the head directly, not by a joint. But the lower jaw moves, for it is articulated with the upper jaw and the head. Now, the reason why the joint first shows rigidity in spasms and tetanus, and why wounds of the temporal muscles are dangerous and apt to cause coma will be stated in another treatise.4 The above are the
1 The ‘* zygoma.”
2 “ Accessible,” MSS. reading.
3 Or, ‘‘ by synarthrosis, not diarthrosis” (Galen), Some read guvfpOpwrat.
* Pq. thinks this is Wounds in the head, but that seems to
be the older treatise, and is written in a less finished style: also it hardly gives a full account of the matter.
253
40
50
TIEPI APOPQN
8é Tod un Kdpta éEapOpetv, Trade Ta aitia’ aitLov d€ Kal Tode, OTL Ov para KaTarapuBavover TovavTat avayKat Bpwapatov, ooTe TOV avOpwrov Yavetv wélov 4 dcov dvvatar’ éxtrécot 8 av aw ovdevos GANOU TYHnMaATOS it) ad TOD péya YavovTa Tapayayew Thy yévuv ert Odtepa. mpooccup- Badrerar [EVTOL Kal TO0€ T™ pos TO exrrim rely" oT ooa 4p vetpa Kal oT 0G OL pves Tapa aplpa eloly, ) amo a pO pov ab wv cuvdédevTat, TOUT@Y boa év TH Vpnoet T ELT TAKLS dvakiweltat, TAVTA Kal és Tas KataTaatas duvvatwtata émd.d0vat, Gorep Kat Ta déppata Ta evdewyrorata wreiaTny étridoow Exel. TEpl ov Ov oO OYos, extimte. pev yvalos odeyaKis, cyaTat pévTor ToAAaKLS ev Yao HOW, BoTEp Kal adda TOAKAL pvav Tapadrayal Kal vevpwv TodTO TroLéovoL. ofjAov pev ovv é« TOvbe pddord coTW, omrorav EKTETTOKN mpolaxeTae * yap y KaTO yvabos és Troup poo Sev Kal Tapherar TavavTia TOD OALC- Onpatos Kal 70d oareou TO KOp@wVOV ory KN pOTEpoV paiverat mapa | Thy advo yvd0ov Kat yYareTras ovupBarrovor Tas [kato |] 2 yrabous.
Tovroice dé €uBor mpodyros, 7} HTL yivorr’ ay appofovca: xP” yap Tov pep TWA KATEXELVY THY Kehariy TOD TET P@{LEVOU, TOV be meptdaBovTa Tiv KaTo yvabov Kal ~cwOev kai éEwOev Totcr SaxTUNOLTL KATA TO YyévELOV, YaoKOVTOS TOU avOpwrov dcov per piers dvvaTat, Tp@Tov pev Sraxcvety THD [karo] * yvadov Xpovov TWa, TH Kal TH TaparyovTa TH xeupl, Kal aurov TOV v0 porrov KENEVELY Narapny TIV yradov ¢ EVEL, Kal ouuTrap- ayew Kat auvdiovat ws padiota’ émerta éé-
254
ON JOINTS, xxx.
reasons why the dislocation is rare; and one may add this—that the necessities of eating are rarely such as to make a man open his mouth wider than is normally possible, and the dislocation would occur from no other position than that of lateral displace- ment of the chin while widely gaping. Still, the following circumstance also favours dislocation : among the tendons and muscles which surround joints or arise from them and hold them together, those whose functions involve most frequent move- ment are most capable of yielding to extension, just as the best tanned skins have the greatest elasticity. To come then to our subject, the jaw is rarely dis- located, but often makes a side-slip+ in yawning, a thing which changes of position in muscles and tendons also often produce. When dislocation occurs, the following are the most obvious signs: the lower jaw is thrown forward and deviates to the side opposite the dislocation; the coronoid process appears more projecting on the upper jaw, and patients bring the jaws together with difficulty.
The appropriate mode of reduction in these cases is obvious. Someone should hold the patient’s head, while the operator grasping the jaw with his fingers inside and out near the chin—the patient keeping it open as wide as he conveniently can— should move the jaw this way and that with his hand, and bid the patient keep it relaxed and assist the movement by yielding to it as far as possible.
1 oxara, a gymnastic term for a sudden lateral movement, Galen (XVIII (1), 438).
* rpotcxe: Kw. 2 Omit Kw. ® Omit Galen, Erm., etc.
255
60
67
10
15
TIEPI APOPOQN
amrivns oxacat, Tpeat oXnHATL 000 TpooéxovTa TOV voov" xen pev yap mapdyeaOau eK Tis dtactpophs és tiv hvow, Set bé és TovTicw atacbhvat Thy yvabov THy KaTM, Set O€ ErOpEvor ToUTOLoL GULBadrAELY TAS yvaOousS, Kal un YaoKeLD. éuBorn pev ovv avTn, Kal ovK av yevouTo ar aXXwv TXNMAT OD. intpein 5é Bpaxety a apKeret = ot\nva Tpootibévta KeKN pw [EVvOV Xahap@ emt déapw émidetv. aoharéctepor Sé xeupiCeww éeotiv Umtiov Katakdivavta Tov avOpwrov, épeioavTa Thy Kehadny avTov éml axutivov vroKepandatiou as TAIpETTaTOoV, iva @S HKLoTa UmeiKy” TpooKar- éxewv S€ TLVa YpH THY Kcepadny TOU TET P@MEVOU.
XXXI. “Hy 6é apporepar ai yvaba é&- apOpiawa.y, 1) wev inots f) avTy. oupBanrrew 6é TL2 Hocov ovTOL TO oTOMa SvvavTat’ Kal yap MPoTrEeTETTEPAL Al yevUES TOVTOLOL, aoTpaBeEEs SE. TO dé adoTpaBes parsoT av yvoins Tolcw optovat TOD OOOVTWY TOY TE ave Kal TOV KaTwW KaT LELY. TOUTOLOL cup éper Os TaXLo TO eu Barre" éuBo- As Oe TpoTros mpoobev elpyTa. ay Oe LH cuméon, Kivduvos Tept THs Wuyhs 70 TupeT Ov TUvEXewv Kal vob pis Kapwovos—Kapwt €€S yap of pues ovToL, Kal aN oLOUMEVOL Kal EVTELVOMEVOL Tapa puaiw—direl dé ral ” yaornp Umoxwpely TOU- ToLoe Xorwdea dxpyta orLya Kal Mv euewaorr, akpnta éuéovoiv’ ovtTor ovv Kal OvyncKovat
€KaATALOL MaALOTA.
XXXII. “Hy 8 KcateayH 4 KatTw yvabos, Hv Mev 4) AToKavALGOH TavTaTacw, AAR auvexn- TAL TO OaTEOV, eyKeKALpévoy S& H, KaTopOacat ev xpn TO doTéov, TAapd Ye THY yAwooar 256
ON JOINTS, xxx.—xxxu.
Then suddenly do a side-slip, having in mind three positions in the manceuvre. For the deviation must be reduced to the natural direction, the jaw must be pressed backwards, and, following this, the, patient must close his jaws and not gape. This, then, is the reduction, and it will not succeed with other maneeuvres, A short treatment will suffice. Apply a compress with cerate and a loose bandage over it. The safest way of operating is with the patient recumbent, his head being supported on a well- stuffed leather pillow, that it may yield as little as possible ; and someone should also keep the patient’s head fixed.
XXXI. If both lower jaws are dislocated [?.e. both sides of the lower jaw], the treatment is the same. These patients are rather less able to close the mouth, for the chin is more projecting, though without deviation. You will best recognize the absence of deviation by the vertical correspondence of the upper and lower rows of teeth. It is well to reduce these cases as quickly as possible; and the mode of reduction is described above. If not reduced there is risk of death from acute fever and deep coma—for these muscles when displaced or abnormally stretched produce coma—and there are small evacuations of pure bile ; if there is vomiting, it is also unmixed. ‘These patients, then, die about the tenth day.
XXXII In fracture of the lower jaw, if it is not entirely broken across, but the bone preserves its continuity though distorted, one should adjust the bone by making suitable lateral pressure with the
1 apne. ® Sere
257
VOL. Il, K
10
20
10
TLEPI APOPOQN
mrayinv vmetpavra TOUS OAKTUAOUS, TO OE eEwbev avrepelbovra, @s adv cuphépyn? Kai iy bev 61- ETTPAHpEVOL éwouv ob odovTes ol Kara TO TP@La Kal Kexivnpevol, oTroTav} 70 oatéov KaTopOwOh, CedEat Tovds odovTas YP) pos AAANNOUS, fA) povvov Tous Ovo, aAXA Kal TA€oVAaS,? padLtoTA pev 67 ypuciw, éot av KpatuvOn To daréov, et 6€ pun, ALv@" ErrErTA eT LCELY KNPwTH Kal oTAnVETW OXlyorot Kal OGoviotcw orjLlyoloL, pn ayav épeloovta, aAdka Yadapoioiw. €D yap eidévar XPN; aru émideors ofoviow yvab@ kateayeon ® OMLKpa pev ay apenéot, ef XPIITOs €TLOEOLTO, peyara & ap Brarro1, él KAKOS emLO€oiTO. TuKWa € Tapa THY yAMooay éeopaTtetabat ypn, Kal ToXvY xXpovoy avTéyew Totor SaKTUOLCL xkatopOobvta Tod oatéov TO éxxrOév* apictov 5€é. ef alel SUvaito* aX ovY old” Te.
XXXII. “Hy 6€ aroxavrtc6H Tavtatacww TO da Téov—oArydKts b€ TODTO yiveTat—KaTopOody Mev X pr) TO Oa TEéoV OVTW, KAaBaTEp eipnTal. STaV dé Kcatopbacns, Tovs odovtas xen Ceuyvivat, os
poo bev elpnTat: peya yap. av ovrrAauSavor és TIP dr peminy,? Tpooere Kal el TIS ophas Cevger WOTEP XP» Tas apxas payas. aXrXa yap ov pnidvov ev ypagn Yelpoupyiny wacay dinyeto Pat, andra Kal aurov urotometa bar vp) eK TOV YEYPAMMEVOY. eTELTa Xp) Sepparos Kapyn- Soviou: Av ev vaTrL@TE pos * 7 0 Tpodets, apKei TO OTOH Xpiho Oar, ny Oe TENELOTEPOS > avTo@ TO Séppare Tawovra é xp? evpos WS TPpL- Sennen 7) OTws av appotn, vmareiWavra
1 2
258
e , bray. ém) wAelovas. 2 yradov Kateayelons.
ON JOINTS, xxxu.—xxxm.
fingers on the tongue side, and counter-pressure from without. If the teeth at the point of injury are displaced or loosened, when the bone is adjusted fasten them to one another, not merely the two, but several, preferably with the gold wire, but failing that, with thread, till consolidation takes place. Afterwards dress with cerate and a few compresses and bandages, also few, and with no great pressure, but lax. For one should bear in mind that bandaging a fractured jaw will do little good when well done, but will do great harm when it is done badly. One should make frequent palpation on the tongue side, and hold the distorted part of the bone adjusted with the fingers for a long time. It would be best if one could do so throughout ; but that is impossible.
XXXIII. If the jaw is broken right across, which rarely happens, one should adjust it in the manner described. After adjustment you should fasten the teeth together as was described above, for this will contribute greatly to immobility, especially if one joins them up properly and fastens off the ends as they should be. For the rest, it is not easy to give exact and complete details of an operation in writing ; but the reader should form an outline of it from the description, Next, one should take Carthaginian leather; if the patient is more of a child, the outer layer is sufficient, but if he is more adult, use the skin itself. Cut a three-finger breadth, or as much as may be suitable, and, anointing the jaw with
4 eyKrbev, 5 és rd arpepueiv. 8 jrotumeic ba: MSS.: broromeia Gat Erot., Littré. 7 yewrepos.
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KOM pel THY yvadov—ebuevéatepov yap KOXANS—" T POTKONHTAL TH déppuv aiepov ™ pos TO amTro- KeKavALopévov THS yva0ov, atoeimovTAa ws SaKTUNOV ATO TOD eaibjennes 7) OdtyY@ TAEOD. TOUTO wey €S TO KaTw pepos’ eyéT@ OE evTOMIY Kata THV LEW Tov yevelou O (mas, aS augdtBEBHKn appt to 0&0 Tod yeveiov. Etepov b€ (wavTa ToLovToD, 7) oniryep TATUTEPOY, TPOTKONAHOat xpn 7 pos TO ave pEpOS Tis yadou, dmoheimovTa Kal TOUTOV ATO TOU TPOMATOS, og ovmep 0 ETEPOS améNTreV" eo xiabw d€ Kal OUTOS O (pas TH appl TO ovS mepiBacuw. amokees d€ €oTwaay ol imavtes aud thy svvadny: [év0a cvvartecOat TE Kal ouvocia bat és TQ mépara TOV (pavTov ‘p? év O€ TH KONI TEL a) cape TOU oKUvTEDS ™pos TOU XPoTos éaTo, éeKoNNOTE POV yap oT @s. erecta KaTarevavTa XP? | KAU TOUTOV TOV (maura, pardov S€ TL TOV Tept TO yévEeLlovV, WS OTL wadioTA jL1) aTropvrralin > 1) yvdOos, cvvdrpat Tovs iwdavTas KaTa THY KOpUpHv: Kamera TEept TO éT@T OV adovir KATASHT al, Kal car aBrnpa vpn ely al, HoTEp voutCeTal, @S aT pemen Ta deo pa. THY be KATAKALOL Troveta Om em THY byvéa yradon, i) TH yualo Eprpela HEVvOS, anna TH KEpAXN. iay- vaivewv 5é xp?) TO T@pa dx pes 7PEpOV déxa, erreur dvar pepe eu) Bpadéos: y dé év Toe Mporepyat HEPNTL 40) preypnrn, év elkoow mepnow ” yvados KpaToverau TAXES yep emimopovran, @oTep Kal Ta adda Ta dapava datéa, av py emiapaxehioy, Gra yap Tept opaxedio wav TOV oUpTaYTOV ooTéwy AOS MaKPOS oOYos 1 eiuevéartepoy yap KdAAns L. ; «dAAn M.V. 260
ON JOINTS, xxxin.
gum-—-for it is more agreeable than glue—fasten the end of the leather to the broken-off part of the jaw at a finger’s breadth or rather more from the fracture. This is for the lower part; and let the strap have a slit in the line of the chin, so as to include the chin point. Another strap, similar or a little broader, should be gummed to the upper part of the jaw at the same interval from the fracture as the former one; and let it also be split for going round the ear. Let the straps taper off at their junction, where the ends meet and are tied together. In the gumming, let the fleshy side of the leather be towards the skin; for so it adheres more firmly. One should then make traction on the thong, but rather more on the one that goes round the chin, to avoid so far as possible any distortion! of the jaw. Fasten the straps together at the top of the head, and after- wards pass a bandage round the forehead; and there should be the usual outer covering to keep the bands steady. The patient should lie on the side of the sound jaw, the pressure being not on the jaw, but on the head. Keep him on low diet for ten days, and afterwards feed him up without delay ; for if there is no inflammation in the first period, the jaw consolidates in twenty days, since callus forms quickly as in other porous bones, unless necrosis supervenes. Now, necrosis of bones generally remains to be treated at length elsewhere.
1 Erotian s.v.: probably ‘‘snout-like distortion.” ‘In acutum ” (Foés).
2 Omit Kw. and most MSS. 8 Gmrocuiralver Galen (‘‘draw to a point”); amrouvdAdAtyn Krot. (‘‘ be distorted ”’).
261
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IIEPI AP@PQN
Aelwretart
ee A avtTn 7 Sidtacis 1) aTO TOY KOAAN- f > \ PaT@v evens Kal evTapievTos, KaL és TONG \ a » lal Kat Toddayxov SiopAwpmata evypynatos. Tov be > lal e \ / INTP@V OL uy TLV Vow EvyELpes Kal ev ArXOLOL / lal a] TPWUATL TOLOUTOL ELaL Kal ev yva0wy KalnEeow: / na émidéovat yap yvadOov KaTeayeioay Totkinws, Kal KaX@S Kal KAKOS: Taca yap éridects yvabov oUTwS KaTeayelons ExkAlver® TA CoTéa TA &S TO 4 ($5? lal x > \ / ” KATNYMA peTOVTA “aNXAov 7 €5 TV huTW ayel. XXXIV. “Hy 66 ) Katw yrabos Kata THY / a ovpdvow THY KaTa TO yEevecoy SiacTacOnA— (! fol povvn d€ a’Tn 1) auudvots ev TH KATH yvra0e €o7lv, €v O€ TH advw ToAXAaL? aAN ov BovrAopmat b an a 2 Ls \ ” aToT\avay Tov Oyou, év adrOLTL yap Eldect VOONMLATWY TEPL TOUT@Y AEKTEOV—iV OvY SLATTH ] KATA TO yévelov cUudvals, KaTOpO@caL eV N mavTos avdpos éotiv. TO pev yap é€eaTEOs éowleiv ypiy és TO ow pépos, TpocBarovta Tovs / \ ] ” ces > / > \ ” daxTUAous, TO 0 ow pérrov avayew és TO Ew Mépos, evepeicavta Tovs OakTUAOVS. és OtdoTAcW ‘ fal - ° a \ MeVvTOL StaTEeLvadpevoy TADTA Ypr) ToLEtY’ Paov yap ¢ ei x b] / ovTws és tHv hvaow HEE 7% el Tes eyypiuTTOVTA és GAAnXa Ta Ootéa TapavayKatew Teipatat: TOUTO Tapa TavTa Ta To.a’Ta [vTouvypata] > yaptev eldévat. omotav bé KatopOwons, FedEau U » \ bev xp Tovs adovTas TOUS évOev Kal évOev mpos > / iA \ 4 a) ” In fal arrnXOUS, WoTrEp KaL TPOTUEV ELpNTal. Linaolat 1 Cf. LXIX. 2 éynaAtvee B Kw. 8 xarhywara Littré. Erm. omits the whole sentence,
262
ON JOINTS, xxxin.—xxxrv.
This mode of extension by straps gummed on is convenient, easy to manage, and very useful for a variety of adjustments. Practitioners who have manual skill without intelligence show themselves such in fractures of the jaw above all other injuries. They bandage a fractured jaw in a variety of ways, sometimes well, sometimes badly ; but any bandag- ing of a jaw fractured in this way tends to turn the fragments inwards! at the lesion rather than bring them to their natural position.
XXXIV. When the lower jaw is torn apart at the symphysis which is at the chin ?—this is the only symphysis in the lower jaw, while in the upper there are many, but I do not want to digress, for one must discuss these matters in relation to other maladies. When, therefore, the symphysis at the chin is separated, anyone can make the adjustment. For one should thrust the projecting part inwards, making pressure with the fingers, and force out that which inclines inwards, using the fingers for counter- pressure, This, however, must be done while the parts are separated by tension; for they will thus be reduced more easily than if one tries to force the bones into position while they override one another (this is a thing it is well to bear in mind in all such cases’). After adjustment, you shou'd join up the teeth on either side as described above. Treat with
1 Kw.’s reading ; Adams prudently has ‘‘ derange.”
2 The idea that the lower jaw consists of two bones with a symphysis at the chin is corrected in Celsus VIII 1, but repeated by Galen (perhaps out of respect for Hippocrates), though he admits that it is hard to demonstrate,
® Perhaps an insertion, but read by Galen.
263
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TIEPI APOPON
dé yp) KnpwTH Kal omdr}veow antybos Kal oPoviocww. emideow 6¢ Bpaxeiny 7+ TouKidyy padiora TobTo TO Xo plov emidéxerat, eyyus yap TL TOD icoppoTrov eorty, ws 51 un loopporroy éov. Tou 6e oGoviou THY TreptBornv mova Ban xp, Hy ev ” dE yvabos Spite loge emt beEid (ért deEia yap vouifetar eivar, Hv 1 SeEt7) yelp mpo- NynTat Ths émidécios)* Hv be 7 érépn ywabos eco TKN, OS ETEPWOS YP) THY eTlOETLY HyELY. KV pev oO as Tes Katopldanrar Kab (ema peunon Os XPN» Taxein pev 1 anrbeEss, oi be odovTES aaLvees yivovtas ay O€ 11), Xpoviarépn 7 arbeEes, draco rt popiy be isyovawv of ddovTes, Kal otvapol Kal ax petor yivovrat.
XXXV. “Hy 6€ 1) pis Kateayh, Tpdtros pev ovy els éotl KatnEvos* aTap ToOANa pev OH Kal dAa AwPéovtar of yaipovtes THat Kadhow émidécecw dvev voov, év Oé Tolat mepl THY plva padtoTa: émideciwy yap éotiv avtTn mTotkiiwtatTn Kal TA€laTOUS peV oKETdpVoUS EXoVaa, Siappwyas d€ kal diadetias Toikikwtadtas Tod ypwTos popBoeroeas. @s ovV elprTat, ol THY avonTov evxerpinv emUTI/OEVOVTES a Uo LeVol puvos karenyuins emiTuyydvovat, @S emudn twa Ww. poiny pev ovv mypeepav % Ovo dry ddreT at pev 0 int pos, yaiper dé O émudedeMevos” emelTa L TAN EWS ev 0 emLdede LEVOS KopioKeTat, aonpov yap TO popnpa: apKet 0€ TO intp®, émreLon em édevE ev OTL émiaTaTat Trout has
piva émedetv. troved O€ 1 émridects 1) ToLavTn
1 «Rather than”; cf. Surg. XIV, Luke 17. 2. ‘Simple rather than complex”; but cf. Galen, who says that the
264
ON JOINTS, xxxiv.—xxxv.
cerate and a few pads and bandages. A simple dressing rather than a complicated one is specially suited to this part, for it is nearly cylindrical! without actually being so. The bandage should be carried round to the right if the right jaw sticks out (it is said to be “to the right” if the right hand precedes in bandaging”): while if the other jaw projects, make the bandaging the other way. If the bandaging is well done and the patient keeps at rest, as he should, recovery is rapid, and the teeth are not damaged; if not, recovery is slow, and the teeth remain distorted and become damaged and useless.
XXXV. If the nose is broken, which happens in more than one way, those who delight in fine bandaging without judgment do more damage than usual, For this is the most varied of bandagings, having the most adze-like turns and diverse rhomboid intervals and vacancies. Now, as I said, those who devote themselves to a foolish parade of manual skill are especially delighted to find a fractured nose to bandage. The result is that the practitioner rejoices, and the patient is pleased for one or two days; after- wards the patient soon has enough of it, for the burden is tiresome ; and as for the practitioner, he is satisfied with showing that he knows how to apply complicated nasal bandages. But such bandaging
1 ladppotos= *‘ perhaps clearer.
* Le. to the surgeon’s right, but from right to left of the patient’s jaw (Galen).
3 Siaddupias (Kw., Apollon.).
cylindrical” (Galen). ‘‘Semicircular”’ is
lower jaw is the part on which students exercised their skill
in complex forms of bandaging. (XVIII. (1) 462). 265
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ITEPL APOPOQN
TuvTa Taravtia Tov SéovtTos: TOUTS pev yap, oTdgol ctmovvTar Oia THY KaTHEW, SnrOvOTE Et avwbév Tis wadXov Teor, ctu@TEpor Av ETL elev tovTo 6é, dootct Tapactpédetat 7) évOa 7 &Oa
pis, 7) KaTa TOV YovdSpov % avwtépw, SnAOvOTE ovdev avtovs 7 advwbev érridects w@pednoetev,} anra Kal Prarpere ? wadov: ovy 00TH yap eb cuvapporer OTAIVETL TO én Oarepov THS piwos: K@LTOL OVE TOUTO TOLéoUGLY Oi EmrLd€éorTES.
XXXVI. "Ayyiota 5é 1 éridecis por Soxet av TL Tote, €6 KATA péeonv TY piva Kara TO of£v aphid rac Bein 7) oapé Kara TO OG TEA. » el KaTa TO oaréov o [LL pov TL aivos eln,? Kal pn péya: ToloL yap ToLlovToLow emiT@popa laoyet 1) pis, Kal oxpioedertépn Tvl yivetar? adr Opas ovde Tovrotct 5H Tov moddov OyXov SeiTae 1 émidecis, ef 61) Te Kat Cel Encdety. apKet dé éml bev TO hrAdopLa oTAnviov émiTELVaYTA KEKNPw- pévov, ererta ws ato dvo apxéwy émideirat, obras ad cviep és amat mrepiBarrewv. apiatn pEVTOL intpetn TO ANT @, TO onTAVvio, TO TRUT@, yoMoXpo, mepupweven, Oniye, KataT age Ta To.avTa xen b€, 7) me poev €& aryadar 7 7 TOV Tmup@v TO adnrov Kal EVONKLPLOV, TOUT® xpiicOax és mavTa Ta ToLavTa’ Hv dé pr) Wavy SrAKLWOoV 7H, es oAlynv udvunv Vdate oF NecoTaTHY SLevTA. TOVTW pupav TO AXNTOY, 1) KOs TaVY ONYOV waa’TaS player.
XXXVII. ‘Orocorct pév ody pis és TO KaT@
L wpedtoet. 2 Brdwet, 3 Zya, 266
ON JOINTS, xxxv.-xxxvit.
acts in every way contrary to what is proper; for first, in cases where the nose is rendered concave by the fracture, if more pressure is applied from above, it will obviously be more concave, and again in cases where the nose is distorted to either side, whether in the cartilaginous part or higher up, bandaging will obviously be useless in either case, and will rather do harm ; for so one will not arrange the pads well on the other side of the nose, and in fact those who put on bandages omit this.
XXXVI. Bandaging seems to me to be most directly? useful where the soft parts are contused against the bone in the middle of the nose at the ridge, or when, without great damage, there is some small injury at the bone; for in such cases the nose gets a superficial callus and a certain jagged outline. But not even in these cases is there need of very troublesome bandaging, even if it is required at all. It suthces to stretch a small compress soaked in cerate over the contusion and then take one turn of bandage round it, as from a two-headed roller. After all, the best treatment is to use a little fresh flour, worked and kneaded into a glutinous mass, as a plaster for such lesions. If one has wheat flour 2 of good quality forming a ductile paste, one should use it in all such cases; but if it is not very ductile, soak a little frankincense powdered as finely as possible in water, and knead the flour with this, or mix a very little gum in the same way.
XXXVII. In cases where the nose is fractured with
1 Sy xiora = wddiora (Krotian).
? gntdvios may be either summer wheat or a special kind rich in gluten (Galen).
* udvva = powder of frankincense (Dioscorides 1.68).
267
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3 \ \ / fol 3 lal Kal €§ TO olpov péTovea KaTayh, hv mev ex TOD N. \ / éumpoabev pépeos Kata Tov Yovdpov ifnTat, olov Té éoTL Kal evTievar TL Crd pPeo pa és Tovs BURT Hpas: Hv be LN, avopboby bev XPD Tata Ta to.abra, TOUS SaxTudous és TOUS Bui pas évTiOévta, nv evdéxntat, Hv O& py, wayxv bTa- \ \ v fol , AerTTpOP, pL7 es TO EuTrpoaOey THS pivos avayovTa al / ? Se Oe 10/3 ” \ ”~ Tota. OaKTUXOLOL, GAN 7H tdpuTtae CEwbev Sé THs id \ v \ ” f > / lal puwos evOev cat evOev apditauBdvovta Totct UA daxTUAoLoL, TUvavayKalev Te Gua Kal avahépew XN / al és TO dv@. Kal iv pev Tavu év TO Eutrpoabev TO er a KaTyypa 9,1 olov Té TL Kal Eow TOV PUKTH POV évtiOévat, W@aTrep HON elpnTat, 7) axUNnY THY ad’ e / AY 7 nr > ? , ¢. if nuctuBlov 7) addXO TL ToLOUTOY, év BOovi@ Eidta- ta) \ ’ / / covTa, parrov de év Kapynooviw déppatu > / a éppdrparta: oynuaticavta TO dpmoacov axa fal / ED TO Xopto, iva eykeioerar. HV evToe TporwrEepe / > Ba > / 7 70 Karnypa, ovoev oloy Te ow évtiGévau Kal yap et ev TO eum poo Per aonpov TO Popnpa, TOS ve 57) ovK év TO CowTépw ; TO ev OdV TPATOV Kal é&w0ev dvatrdcacbat Kai éowbev ad eLon- \ a TAaVTA Xpy avayayeiy &s THY apxXainv dvaw Kai , / \ ao dvopPecacbat. Kapta yap oin Te pis KaTayeioa , Fy avaT\dcoecOat, parttota pev avOnuepov,? Hv \ / yy ee 5) \ , d€ p47), OAly@ UVoTepov' adda KaTaPNaKxeEvovat of inTpol, Kal aTAaXwTEPwS TO Tp@rov aT TOVTAL a) Os xpn Tapadardovra yap TOUS daxTvdous xen évOev nat &vOev kata thy dtow TIS puvos @S KATWTATW, KATwWOED cuvavayxaterv, Kal o0T@ pariota avopOodcba® civ TH Ecwlev SiopPacet
Left) | Woety. 2 aivOnwepos. 3 gvopdovrvta Kw.
268
ON JOINTS, xxxvi.
depression and tends to become snub, if the depres- sion is in the front part of the cartilage, it is possible to insert some rectifying support into the nostrils. Failing this, one should elevate all such cases, if possible by inserting the finger into the nostrils, but if not, a thick spatula should be inserted, directing it with the fingers, not to the front of the nose, but to the depressed part: then getting a grip on each side of the nose outside with the fingers, combine the two movements of compression and lifting. If the fracture is quite in front, it is possible,as was said, to insert something into the nostrils, either lint from linen or something of the kind, rolling it up in a rag, or better, sewing it up in Carthaginian leather, adapting its shape to fit the part where it will lie. But if the fracture be further in, nothing can be inserted ; for if it is irksome to endure anything in front, how should it not be more so further in? The first thing, then, is to reshape it from outside, and internally to spare no pains in adjusting it and bringing it to its natural position; for it is quite possible for a broken nose to be reshaped, especially on the day of the accident, or, failing that, a little later. But practitioners act feebly, and treat it at first more gently than they should. For one ought to insert! the fingers on each side as far as the conformation of the nose allows, and then force it up from below, thus best combining elevation with the rectification from within. Further, no practi-
1 Editors discuss the obscurity of this passage at great length. The main point is whether the fingers are inserted or applied to the outside of the nose. I follow Ermerins and Petrequin as against Littré-Adams: though there is much to be said on both sides.
269
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TWEPI APOPQN
8 fA) fal 1 4 be > a > \ 28 A [ScopAotvra]+ erecta dé és TadTAa iNTpOS ovOEISs ” I \ a > > s \ lal \ Gdros €oTl ToLwovTos, ef EO€AOL Kai wErETaY Kal TOApay, @s ol OaKTUAOL AUTOD Ob Aexavot: ovTOL \ , , yap kata pvow pdduoTd eiow. TapaBddXovta \ an 7 \ n yap Xp!) TOV SaKTUN@Y EKaTEpOV, Tapa Tacav a € / ¢/ Thy piva épeldorTa, }avyas olTwS EXEL, MAdLTTA wer, et oluv Te Ein, alel, Eat’ av KpatuvOn: é 6€ ¢ lal , un, WS TAElaTOY xpovor, avtTov, @s elpntat eé x a x tal dé pu}, 1) maida i) yuvaixd Tia wadOaxas yap r lal C Tas xelpas Sef elvat: ovTw yap av KaddANoTA > / € , id e\ \ > \ f > ’ > intpevOein oTEw@ 1) pls bn €s TO TKOALOV, AA Es e , , 3 TO KdTw (Opupévn, icdoppoTros ein. éyw pév ovv / va) 5 ¢ ¢ al ovdeuinv mov piva eldov itis ovTw KaTayetoa obx oin te StopOwOhvar adtixa mply TopwOhvar / ’ lol cuvavaykalouevn éyéveto, el tis oplas é0érot \ \ intpeverv* adda yap ot avOpwror aioxpol pev Elva TONAOD ATroTLUM@aL, WEAETaY 5 Gua MEV OVK ¢i an ’ a ériatavtat, dua S€ ov ToApacw, HY pr ddurav- b] tat, 1) Odvatov Sedoixwaw* Kaitou ddvyoxXpovtos a / 4) Topwos THs pivoss év yap Séxa HuEepyoe KpaTvveTal, IV 1H eTLTpaKendton. h , XXXVIII. ‘Omédcoior Sé TO datéov és TO / id € \ ” e > / \ \ TAAYLOV KATAYVUTAL, 1) EV INTLS 1 AUTH THY dé SidpOw@aw Sndovote yp Toteicat ovK LaoppoTrov 5) , ) fan) ’ L 2 wr) A appotépwlerv, aXXA TO TE ExKEKALWLEVOY ~ wl EW és thy dvow, éxtoc0ev avayxafovta Kal éopa- an yy / TeVvomevonv €s TOS MUKTHPAS, Kal Ta Eow pépayTa ra » , io , Siopboby adxvas, éot av KatopOwons, ed eidoTa ¢ 3 , er tL, Wv wh avtixa KaTopOwantat, obX olov TE py ’ \ / \ ca (<4 \ > / ,’ ovxl SueotpapOar Thy pwa. oTav 6€ ayayns €s
i} Galen. Omit most MSS., Littré, ete. 270
ON JOINTS, xxxvi.—xxxvuii.
tioner is so suitable for the job as are the index fingers of the patient himself, if he is willing to be careful and courageous, for these fingers are especially conformable to the nose. He _ should insert the fingers alternately,! making pressure along the whole course of the nose, and keeping it steady ; especially let him continue it, if he can, till consolidation occurs, failing that, as long as possible. As was said, he should do it himself; but if not, a boy or woman must do it, for the hands should be soft. This is the best treatment when the nose is not distorted laterally, but keeps evenly balanced though depressed. Now, I never saw a nose fractured in this way which could not be adjusted by immediate forcible manipulation before consolidation set in, if one chose to treat it properly. But while men will give much to avoid being ugly, they do not know how to combine care with endurance, unless they suffer pain or fear death. Yet the formation of callus in the nose takes little time, for it is con- solidated in ten days, unless necrosis supervenes. XXXVIII. In cases where the bone is fractured with deviation, the treatment is the same. Adjust- ment should obviously not be made evenly on both sides, but press the bent-out part into its natural position by torce from without, and, introducing the finger into the nostrils, boldly rectify the internal deviation till you get it straight, bearing in mind that, if it is not straightened at once, the nose will infallibly be distorted. And when you bring it to
1 This seems the surgical implication of éxdéreporv, Cf. Surg. X.
/ 2 eyKexAtmevov.
271
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IIEPI AP@POQN
Thy gua, TpooBddrovra xpH és TO Xeptov i) TOUS SaxTbhous 7) TOV éva SaKTuAOY, 7 feo xev avakwyetv u) auTov 1) ov Twi, éor av KpatuvO7 TO TPOUA. aTap Kal és TOV MUKTI pa TOV oplKpOV SdnTuAOV aTroléovTa adroTe Kal aNAOTE dtopBoby xP? Ta eyeevra. 6710 ap preypwovns Uroyivnt at ToUTOLGL, O€@ TO GTaLTL xpho@ar tolox pévtoe SaxTUNOLoL TpoaéyeLv € / la) \ b] /
OMOLWS KAL TOU OTALTOS ETTLKELMEVOU.
“Hy 6é mou Kata TOV xovSpov és Ta WAayla KATAY, avayKn TH piva cic pny mapertpaplar. Xp? ovV ToiCL TOLOUTOLOLY és TOV MURTHA cK pov 610 pO pa TL TOV elpnwevaov y} 6 Tt TovToLow €ouKev evreBévan. mTo\dka 6 av Tis evpar ra eTrLT HOE, boa pajre odunv layer, AdXrAwWS TE Kal T poanvea éoriy" éy@ O€ ToTeE mevpovos Tr po- Barov dm Tuna eveOnka,, TOUTO yap Tos TAPETUXEV" OL yap omoyyou évTiOéwevor typao- para O€xovTat. émreTa xen KapxnSoviov bép- patos NoTror, TAT OS @$ TOU peyadov daKTUAOU TETMNHLEVOY, 0) Ooms av ouppepn, T poo Kodhijo ae és TO éxroobev pos Tov HUKTHPA TOV ex KEKE pévov.? KATELTA KATATEVAL Tov iwavra. Tas av ouppepy” MaNey 6€ ody@ TelveLy XP, @oTE” opOiy Kal amapth * THY piva eivar. émerta— pax pos yap eT O (mas—Karober 4 TOD @TOS ayayovTa avTov avayayely mepl tiv Kehbadnu- Kat é€eoTe Mev Kara TO METWTTOV TPOTKOAATC AL THY TedeUTHY TOD imavTos, GEeaTL SE Kal pbaKpO- tepov [ayeuv, érerta] mepediooos 'Ta® Tept THY edad ee TOUTO dua pev OvKainy THY
1 ey KeKAMevor. 2 4 bore. 272
ON JOINTS, xxxvin.
the normal, one or more fingers should be applied at the place where it stuck out, and either the patient or someone else should support it till the lesion is consolidated. One should also insert the little finger from time to time into the nostril and adjust the depressed part. If inflammation arises in these eases, one should use the dough, but keep up the finger application as before, even when the dough is on.
If fracture with deviation occurs in the cartilage, the end of the nose will infallibly be distorted. In such cases, insert one of the internal props men- tioned above, or something of the kind, into the nasal opening. One could find many suitable sub- stances without odour and otherwise comfortable. I once inserted a slice from a sheep's lung which happened to be handy; for when sponges are put in, they absorb moisture. Then one should take the outer layer of Carthaginian leather, cut a strip of a thumb’s breadth, or what is suitable, and gum it to the outer part of the nostril on the bent side. Next, make suitable tension on the strap —one should pull rather more than suffices to make the nose straight and outstanding.t_ Then—the strap should be a long one—bring it under the ear and up round the head. One may gum the end of the strap on to the forehead. One may also carry it further, and after making a turn round the head, fasten it off. This gives an adjustment which is at
1 araprnrhy Kw. arapri Galen, Littré, vulg.
8 > \ 4 \ / amrapTnriy. és Ta KaTaber, ° éwimepteAlcoovra, Littré, Kw., who omit &yew, grecra,
273
47
10
14
HEPI APOPON
SidpOwaw EXEL, aba be evTapievTov, Kal ardor, ap eJedy, Kal hooov THY ayTipporinu TownaeTal » THs pwvos. aTap Kal oTrdc oval és TO ™ayLov u) pis KaTaYVUTAL, Ta pev adra int pevetv xp?) as TpoeipnTat mpoodeirat be Toto TrELoTOLOL Kal TOU imayTos Tos aKpnv THY piva TpocKONArNO Hvar THS ayTeppoTins elveka.
XXXIX. ‘Orrdcouce dé ouv TH Katy Kal éXKea mpooyivetar, ovdev Set TapdccecOar dia TovTO’ GAN érl pev ta EXxea emiTiévar 7h TLioonpyv 1) TOV évaiwwy TL evadr0éa yap TOV TOLOUT@Y Ta TrELGTA EOTLY OMOlwS, KY OaTéa HERA) amvévan. Typ oé Si0pOwow THY Tporny doxves xpr) TovetaOar, pndev emtelTovTa, Kal Tas peg eee TOLL Saxrurouce ev TO émeuTa Xpove > Yahapwreporct pev Npeopevov, _Xpeopevov oé eUTaTTOTATOD yap Te TAaVTOS TOU TwUATOS n pis éotiv. Tadv bé iwdvTwY TH KOAAHTEL Kal Th avTippotin mavtatacw ovdev KwAVEL Xpho- Bat, ovt tw Edxos 7H, oT Hv éripreyunvy: aduTOTaTAaL yap eioL.
XL. “Hy 8€ ots catayh, émidéores pev TacaL Toheutat’ ov yap OUTW TLS YaXapov TrepLBarrAou> ay é parXov mebn, TAE€OV KakOY épyaceTal’ érrel Kal vytes ovs, émidéaes mex Ev, aduvy pov Kal opuypar aces Kat MupeT@oes yiverae. atTap kal Ta émimA\dopata, KaKkioTa pev Ta PBapv- Tata TO éwimay' atap Kat mrEloTa pdavpa Kal aTootatika, Kal pveav Te UToToLE [TAELw],4
1 roijoat. 2 toow . . . xpdvols. 3 mepiBdrAAg * Omit.
274
ON JOINTS, xxxvitt—x..
once normal and easily arranged ; and one can make the counter-deviation of the nose more or less as one chooses. Again, when the [bone of the] nose is fractured with deviation, besides the other treat- ment mentioned, it is Tee necessary in most cases that some of the leather should be gummed on to the tip of the nose to make counter-deviation.1
XXXIX. In cases where the fracture is compli- cated with wounds, there should be no alarm on that account, but one should apply an ointment containing pitch or some other remedy for fresh wounds ; for the majority of such cases heal no less readily, even if bones are going to come away. The first adjustment should be mare without delay and with completeness; the later rectifications with the fingers are to be done more moderately, yet they are to be done, for of all parts of the body the nose is most easily modelled. There is absolutely no objection to the gumming on of straps and counter- deviation, not even if there is a wound or inflam- mation supervening, for the manipulations are quite painless.
XL. If the ear is fractured, all bandaging is harm- ful, for one cannot apply a circular bandage so as to be pity and if one uses more pressure one will do farther damage, for even a sound ear under pressure of a bandage becomes painful, throbbing, and heated. Besides, as to plasters, the heaviest on the whole are the worst; they have also for the most part harmful qualities producing abscess, excessive for- mation of mucus, and afterwards troublesome dis-
? Galen found this gummed leather method very unsatis- factory ; ‘if you pull hard enough to do any good, it comes off” (XVIII (1) 481).
275
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30
TIEPI APOPON
KaTelTa éxTunoias aonpas' TovTwY 6€ IKicTa ovs KaTayév Tpocdeitar: ayyiaTa pnv, el7reEp Xpy, TO YAlaxXpov adnToV, yp? Sé pndé TOTO Bapos éxew. ravew dé ws Kicta cupdéper ayalov yap pappaxov éoti eviote Kal TO under mpoodéperv, Kal mpos TO ovs Kal mpos adAXa TOANA. xen dé Kal Ty emexoipnoy gurdo- cea Bau: TO be copa ioxvatvery, Kal warov o av Kivouvos oy eumvov TO ovs yeveo au: Gl LeLVOV be Kal marddtar THY Kourinu: Wy, bé Kal evneTos } is épely ex Tuppata pod. ny o€ €s eum Un ow ErOy, TAXEWS pev ov Xp?) OTO/LOUY" TOA yep Kal Tov SoKEovTwY éxTVUElcAaL avarriveTat TOTE, KAY penoéev TUS KaTaThaoon. ED oe avayxaa On oTOMAGAL, TAXLOTA pev uyees yiverat, ny tts mepyy draKavon’ eldevau peVTOL xp?) capes OTe KUNNOV éoTat TO ovs, Kal petov TOU eT épou, mp Tépnv dvaxavd}. ay dé KN mepny Kainrat, Tapvely YPN TO peTéwpoy, a) Tavu opLKpHnv Tommy" ola TAX UTEpOU Kal TO TOV evploKeTat 7) ws dv tis doxéot ws 0 ev Keharaiw eitrety,? Kal Tavta TadA\a Ta pvE@dea Kal pv€otoia, ate yAloxpa éovta, vTrodiyyavopeva Suorta Paver TAXES vmod TOUS OakTUous Kal evOa Kal évda: dua To0TO b1a TAX UTEPOU eupiaKouot Ta TOLAUTA Ob intpol ? Os olovTau' érel Kal Tey yayy.wdeay éma, boa av mrabdapa 7H, Kal pvEwdea oapKa éxyn, Toddol atopodaw, oldmevor pevua aveupy- oe és TA TOLaDTa’ 7 ev obvY Yyv@uN TOD inTpOD éEaTratatae T@ O€ TpHyLAaTL TO TOLOVTW OvdSELLA BraBn otopwervte. baa S€ VOaTwdea yYopia 1 evenerys Kw. 2 ciphoba.
276
ON JOINTS, xt.
charges of pus. A fractured ear is far from needing these as well. If need be, the best application is the glutinous flour plaster; but even this should not be heavy. It is well to touch the part as little as possible, for it is a good remedy some- times to use nothing, both in the case of the ear and many others. Care must be taken as to the way of lying. Keep the patient on low diet, the more so if there is danger of an abscess in the ear. It is also good to loosen the bowels, and, if he vomits easily, cause emesis by ‘‘syrmaism.’’! If it comes to suppuration, do not be in a hurry to open the abscess, for in many cases when there seems to be suppuration, it is absorbed, and that without any application. If one is forced to open an abscess, it will heal most quickly by cauterising right through ; but bear well in mind that the ear, if cauterised right through, will be deformed and smaller than the other. If it is not cauterised through, one should make an incision in the swollen part, not very small, for the pus will be found under a thicker covering than one would expect. And, speaking generally, all other parts of a mucous nature, or which secrete mucus, being viscous slip about readily hither and thither when palpated, wherefore practi- tioners find them thicker to penetrate than they expected. Thus, in the case of some ganglionic tumours which are flabby and have mucoid flesh, many open them, thinking to find a flux of humours to such parts. The practitioner is deceived in his opinion; but in practice no harm is done by such a tumour being opened. Now, as to watery parts,
1 An emetic of radishes and salt water (Hrotian): cf. Herod. II. 88.
2717
40
50 51
10
IIEPI APOPOQN
b \ a 4& , \ b] 7 éotly pvEns memdnpopéva, Kai év olotce xwploaw Exacta Odvatov Pépet sTopovpmeva 7% Kal ddXolas BAdBas, wept ToUTMY év AAW AOYO ¢/ \ > yeypapetar. Otay ovy Tdun TIS TO Ovs, TaVT@Y ev KaTaTAaTMATwV, Taons Sé pmoTwaLos aT é- / > 7 \ KA > , nN ”
xecOar xpy intpeve S€ 7) Evaim 7) AAdK@ TH 6 TL prjte Bapos unte Tovoy Tapacxyoe hy yap e iZ ” na \ ig 4
0 xovdpos apEntar Wirodcba, Kal broctdctas iayn [trupwdeas 7) yoNw@deas ],1 0yN@Ses? [ Kai] poy- Onpov: yivetar 5é TodTO bu’ exeivas Tas inowas. TavtTwv 6€ TOY TadLyKOTHTaYTMY 9 Tépyny Sid- KaVOLS AUTAPKETTATOP.
XL. Yaoévdvror b€ of Kata paywy, boorcr pev Uro voonudtwy EdXKxovtar és TO KUdov, TA pev mreloTa advvata AvécPat, ToT Kal boa avwTépw Tov Ppevav THS Tpoapvatos KupovTar. Tav é
/ KaTwTépw pweTeEeTEpA AVOUT KLPTOl yevomevol év Tois oxédeot, madrov & Ete eyytvopevor Kipaol > lol \ ’ / / >A \ 2 év TH KATA iyvunv prEBi: olor S dv Ta KUpwpara
/ / na a AVYTAaL, eyyivovtar bé ev TH Kata BovBava: dn d€ Tiow éAvoeE Kai SucEVTEpin TOAUXpOVLOS YEVO- pévyn. Kat oiaot ev Kupovtac pays Tatoly éodat,
\ a fal » Tpiv 1) TO Opa TEeAELWOHVaL es AVENTLY: TOUTOLGL
\ WY: / fal 20é \ \ a2 \ fev ovde avvavEerbar eOédXer KaTA THY paxLY TO gOua, AAA oKédNEa Mev Kal YElpEes TEAELODYTAL' TavtTa O€ évdeéoTEpa yiverat. Kal Gooow av 7 avaTépw TOV Ppevov TO KDhosS, TOUTOLTL meV al
\ > 9 / ’ \ > \ wv Te TAeupal ovK EVéXovow és TO EVpU av&ecOat, ’ \ > ” X \ a Vee N , adra és Tovptpoaber, TO € atHOos GEV yiveTat, 278
ON JOINTS, xu.—xu1.
or those filled with mucus, and in what parts severally opening brings death or other damage, these matters will be discussed in another treatise. When, then, one incises the ear, all plasters? and all plugging should be avoided. Treat with an application for fresh wounds, or something else neither heavy nor painful. For if the cartilage begins to get denuded and has troublesome abscesses,® it is bad, and this is the result of that treatment [viz. plasters and plugging with tents]. Perforating cautery is most effective by itself for all supervening aggravations.
XLI, When the spinal vertebrae are drawn into a hump by diseases, most eases are incurable, especially when the hump is formed above the attachment of the diaphragm. Some of those lower down are resolved when varicosities form in the legs, and still more when these are in the vein at the back of the knee. In cases where curvatures resolve, varicosities may also arise in the groin; and, in some, prolonged dysentery causes resolution. When hump-back occurs in children before the body has completed its growth, the legs and arms attain full size, but the body will not grow correspondingly at the spine; these parts are defective. And where the hump is above the diaphragm, the ribs do not enlarge in breadth, but forwards, and the chest becomes pointed
1 Not extant. * « Plasters bandaged on”: ef. Wownds in the Heac!
XVII. 3 Kw.’s reading.
1 Littré, Kw. omit. ® 6xAd@beas, Kw The MSS. are very confused.
279
20
TIEPI APOPON
arr’ ov Taty, avrot TE Svomvoor ylvovrat Kal Kepxv@decs: Hosov yap evpuywpinv exovow al Kol- iat au TO medua deyopuevat rah T pore mm ug at. Kal yap 6) Kal dvayeafovTas Kara TOV meyar omovduhov Aopdov wai" avyxéva. EXELY, Os pa) Tpomrern)s a QaUTOLoL 1) Kepany” oTEvoxepiny pev ovy Toy TH papuyye Tapexel Kal TOUTO és TO ow pémov Kat yap Totow opboice puoes dva- mvoway Tapexel TOUTO TO oro€op, my éow pebn, éot av avar vex). dv’ ody TO ToLodTOY oxHwWa eLexeBpoyxou Ol TOLOUTOL TOV av peoTov Han- Rov paivovras jj 7) Ob bysees: pupariat TE WS el TO TOU KATA TOV TrEvmovd elow ob TOLOUTOL oKXN- pav pupatov Kal amen Toy: Kal yap D) Tpopacis TOU KUpwLaros Kab 2) cuvTacts Toil TRelaroUrt ova TOLavTAS ovaTpopas yiverat, How av KOWOY)- TWOLW Ob TOVOL ot ouveyyus. doo dé KAT@TEPO TOV ppevov TO KUpopd EOTL, TOVTOLCL voonuara pev eviourt Tpoayiverat vedprtixa Kal Kata KvoTW" arap Kal dmooTiates EMT UNMATIKAL KaTQ KEVvEaVAS Kal Kata BouvBavas, Xpoved Kal ducan Oées, Kab TOUTOD ovderépy) Aver TA Kupo-
40 Peis toxia 5€ ToLovToLow ert aoapKorepa rylve-
Tat } ToloL dveobev Kupoiow: 7 PEVTOL ovuptTaca paxts pmaxpotépy ToUTOLOW q) Totow dveoder Kupota. Bn dé Kal ryevetov Bpadvtepa Kal dreréorEpa, Kab dryoverepot ovToL TaY dvwbev Kupav. oiat & ap MVEnpevouc On TO Opa 1 Kipoots yevnrat, TovToLoL aTraVTUKpv pev THs vovcou THs TOTE Tapeovons Kpiow Toe 7%
A rdy,
280
ON JOINTS, xu.
instead of broad; the patients also get short of breath and hoarse, for the cavities which receive and send out the breath have smaller capacity. Besides, they are also obliged to hold the neck con- cave at the great vertebra,! that the head may not be thrown forwards. This, then, causes great con- striction in the gullet, since it inclines inwards; for this bone, if it inclines inwards, causes difficult breathing even in undeformed persons, until it is pushed back. In consequence of this attitude, such persons seem to have the larynx more projecting than the healthy. They have also, as a rule, hard and unripened? tubercles in the lungs; for the origin of the curvature and contraction is in most cases due to such gatherings, in which the neigh- bouring ligaments take part. Cases where the curvature is below the diaphragm are sometimes complicated with affections of the kidneys and parts about the bladder, and besides there are purulent abscessions in the lumbar region and about the groins, chronic and hard to cure; and neither of these causes resolution of the curvatures. The hips are still more attenuated in such cases than where the hump is high up; yet the spine as a whole is longer in these than in high curvatures. But the hair on the pubes and chin is later and more defec- tive, and they are less capable of generation than those who have the hump higher up. When curva- ture comes on in persons whose bodily growth is complete, its occurrence produces an apparent ® crisis
1 Axis or second cervical, according to Galen, but perhaps the seventh. Cf. XLV.
2 Unmatured or softened. * Or, ‘‘to begin with”; most translators, ‘‘ obviously.”
281
50
60
10
IIEP! APOPON
KUpwols: ava Ypovov pévToL éTLonuatver TL TOV aUT@V, WoTEp Kal TOLTL vewTépoLaLY,! 7) TAE€OV 7) éXacaov’ Hacov ¢ KakonOws ws TO émitaV mV TolavTa TavtTa éoTiv. moAXol pévtor On Kal evpopws ‘veyxav Kai wvyrervOs? tHv Kvdwor axpt ynpaos, uddiota Sé ovToL, olow av és TO eVoapKoy Kal ThuEd@OES TPOTPATNTAL TO Tapa" oAtyor pnv 4dn Kal TOY ToOLOVTwY UTEp éEENKOVTA érn €Biwoav: of 5é€ mreictor BpayuBiwrtepot elowv. éott © olor Kai és TO TWAAYLOV TKOALODYTAL OTOVSUAOL 7) TH 1) THY TavtTa pry 7H Ta TWrEloTA Ta ToladtTa yivetat S1a cvaTtpodas tas éawlev THS paxtos' mpogovpPBarrETat Sé évioict ov TH vovo@ kal Ta aXiuaTa, ep’ oTTola av eOrcbéwar Kexhio bat. ara mepl ev TOUT@Y ev TOOL Xpoviowwe Kara mAevpova voor} pac elpyjoerae exel yap clolv avT@Y YapléoTaTaL Tpoyvectes mepl TOV medrAOVT@Y éEceaBaL.
XLII. “Ocorsi 8 ék Katamt@cios pays kupovtar, odlya 6) TovT@v éexpatnOn wate €EvOv0 Hvar. TovUTO per yap, al év TH KALiMAKL KA- Taceloves oudeva, TH éiOuvay, Ov Ye yo loa" ypéovtat S€ ob intpot pido avTH Ol émL- Oupéovtes éxXavvody TOV TONY dxdov" Totae yap TOLOUTOLOL tabta Oaupacud eT, nv 4 K ped Levov iSoow 0) _pimreopevor, boa TolcL TolovTotaw €oiKe, Kal Tav’Ta KAnifovew aie, Kal OvKETL avrotor peree omroloy TL aTréBN ATO TOD XErploparos, elite Kaxov elite ayabov. ot BYTE int pol ol Ta Tovar a em iT OEVOVTES oKatol elow, ous Ye eyo eyvor: TO mev yap emivonpua apxaiov, Kal é€taivéw eywye ahodpa Tov mMpeToV eTi- 282
ON JOINTS, xut.-xu11.
in the disease then present. In time, however, some of the same symptoms found in younger patients show themselves to a greater or lesser degree; but in general they are all less malignant. Many patients, too, have borne curvature well and with good health up to old age, especially those whose bodies tend to be fleshy and plump; but few even of these survive sixty years, and the majority are rather short-lived. There are some in whom the vertebrae are curved laterally to one side or the other. All such affections, or most of them, are due to gatherings on the inner side of the spine, while in some cases the positions the patients are accustomed to take in bed are accessory to the malady. But these will be discussed among chronic diseases of the lung; for the most satisfactory prognoses as to their issue come in that department.
XLII. When the hump-back is due to a fall, attempts at straightening rarely succeed. For, to begin with, succussions on a ladder never straightened any case, so far as I know, and the practitioners who use this method are chiefly those who want to make the vulgar herd gape, for to such it seems marvellous to see a man suspended or shaken or treated in such ways ; and they always applaud these performances, never troubling themselves about the result of the operation, whether bad or good. As to the prac- titioners who devote themselves to this kind of thing, those at least whom I have known are in- competent. Yet the contrivance is an ancient one, and for my part | have great admiration for the
1 yéowwt. * dyinpas, 283
20
10
20
ITEPI APOPON
voncavTa Kal TodTO Kal aXXo may 5 tt pnxavnpa Kara pvow émrevon On” ovdev ydp pot WeNTTOV, el Tis Karas oKevacas KArBS KATACELG ELE, Kav eEOvvO hvac € eva. avr os pevTou Katnox uve ny mav- Ta Ta TOLOUTOTpoTra int peveuv otTw, dia TOUTO OTL Tpos aTATEWVOV HadXov of TowodToL TpoToL. XLII. ‘Orocote pev ovv eyyus TOD ax ev0s 2 Kup@aus yiveTa, aegov elds ao pehety Tas KaTaTaovas TavTas Tas émt A ceparajp: o pLLK pov yep TO Bapos y Kepany Kab Ta apap KaTap~ péeTovTa: ara TOUS YE TOLOVTOUS ElKOS él [tTovs]1 wodas KatacercOévtas padrov é€iOur- Ojvar péSwy yap ottws 7 KaTappotin 1 émt TavTa’ dcolot b€ KaTwMTEpwW TO UBwpa, TOUTOLOLW elKos “adXov errl Keharynv KaTacelecOaL. Et odV Tis €OéXot KaTaceEleL, OPOOs av We oKevaloL THY pee KMpaKa XP? OKUTWOLTLD bmoxeparaiowr TrAAYLOLoLY, 1) epiveotar, KaTaaT pacar ev m poo be- depevorow, OnLy @ TEOV Kal é€ml unos Kal évOev Kat évOev, 1) cov dv TO cOpa TOU avOpw@Tov KaTa- oXOe" erreur TOV avO pom ov Umteov KataKhiva emt Tv Kipaka Xpx KarEvTa m poo dijo au jeev TOUS Tooas Tapa Ta o pupa T pos THY KACMAKa py OvaBeBaotas, Seon evOX bev, Harvang € T poo dijoar d€ KATWTEPw éxarepov TOV youvaror Kal avoTép@’ Tpocdhnaar € Kal KaTa TA loxia KaTa 6€ TOvS KEeveavaS Kal KaTa TO aTHOOS Vahaphor tatvinov? mepiBarety obTws, STrwsS Mn Ko\U@oL® THY KaTadTELTW" Tas SE Yelpas Tapa Tas Theupas TapateivayTa TpocKkaTaraPetv TpOs avTO TO c@ma, Kal pr) TmpOS THY KAiwaKa. Stay 2 Omit Erm., Kw. 284
ON JOINTS, xu.—xuit,
man who first invented it, or thought out any other mechanism in accordance with nature; for I think it is not hopeless, if one has proper apparatus and does the succussion properly, that some cases may be straightened out. For myself, however, I felt ashamed to treat all such cases in this way, and that because such methods appertain rather to charlatans.
XLIII. In cases where the curvature is near the neck, extension of this kind with the head downwards is naturally less effective ; for the downward-pulling weight of the head and shoulders is small. Such cases are more likely to be straightened out by succussion with the feet downwards; for the down- ward pull is greater thus than in the former position. Cases where the hump is lower may more appropriately undergo succussion head downwards. If then one desires to do succussion, the following is the proper arrangement. One should cover the ladder with transverse leather or linen pillows, well tied on, to a rather greater length and breadth than the patient’s body will occupy. Next, the patient should be laid on his back upon the ladder; and then his feet should be tied at the ankles to the ladder, without being separated, with a strong but soft band. Fasten besides a band above and below each of the knees, and also at the hips; but the flanks and chest should have bandages passed loosely round them, so as not to interfere with the succussion. Tie also the hands, extended along the sides, to the body itself, and not to the ladder. When you have
* xarapi tal. 3 / K@WAUTEL,
285
30
10
IIEPI APOPQN
dé tadta Katackevdons ovTas, dvehevy THD Kripara 7 Tpos TUpoWw Twa Dandy v7) Tos déro ja oikou' TO 6é @ptov wa Kataceles avTituTov €oTw’ TOUS d€ avTLTElvoYTAas EvTTALOEV- Tous xen elvat, b1rws opmaras [xal cards|” Kal iooppoTms Kal efarrwatas | adycoust, Kal pnTE 7 rina ErepoppoTros ert THY yy apiterar, pente avtol TpomreT ees écovTal. amo [EVTOL TUp- oL0s aves 7 amo io TOU KaTaTrennyOTOS Kap- xo Lov EXOVTOS ete KaNLOV av Tus oKevaoarto, @oTE amo TpOYLArLNS Ta Nahopeva elvat OTAa 7 amo dvov. andes pay Kal paxpodoyety mept TOUTWY’ Guws dé EX TOUTMY AY TOV KATATKEVOV KadrLoT 3 dp Tis KaTaceiaOein.
XLIV. Ei pévtoe xapta advo ein 70 Bona, d€0t O€ KATACELELY TAVYTWS, eT TObAS KaTAaCELELY AvoeTenel, Oop 75% elpnrar* TrEL@Y yap OUTH yiverau 7 Katapporin emt rabra. _fpuacat dé Vp) KaTa bev TO o77Oos pos THY KrpaKa mpoodnoavTa laXUpas, Kata O€ Tov adyéva ws Xarapwrary Tatty, daov ToD catoptovabat elvexa* Kal aQuTiy Ty Kepaniy Kata TO péT@ TOV Tpocdnoar Tpos THY KMBbaKa’ Tas O€ yelpas TapaTavicavTa Tos TO Tama Tpoadijaat, Kal #1) Tpos THY KAlwaKa’ TO péVTOL adrO THpma adeTov elvar Xp; TAY, Ocov Tob Kkatop0ovabat eivexa, GAH Kal AAAY Tawin Xaraph Te pl BeBrHc Oat’ mas dé mr) Kohvoow oUTOL ob Seauol THY KaTadTELOLY, oKOTEVY’ Ta Oé oKédEa 7 pos ev TY KrupaKa Ky poo dedéa Ow, mpos adda dé, ws KaTa TI pax lOupporra 7}. TADTA MEVTOL TOLOUTOTPOT@S ToinTEa, EL TAVTWS
286
ON JOINTS, xvm1—x.iv.
arranged things thus, lift the ladder against some high tower or house-gable. The ground where you do the succussion should be solid, and the assistants who lift well trained, that they may let it down smoothly, neatly, vertically, and at once, so that neither the ladder shall come to the ground unevenly, nor they themselves be pulled forwards. When it is let down from a tower, or from a mast fixed in the ground and provided with a truck, it is a still better arrangement to have lowering tackle from a pulley or wheel and axle. It is truly disagreeable to enlarge on these matters ; but all the same, succussion would be best done by aid of this apparatus.?
XLIV. If the hump is very high up and succus- sion absolutely required, it is advantageous to do it towards the feet, as was said before ; for in this direction the downward impulsion is greater. One should fix the patient by binding him to the ladder firmly at the chest, but at the neck with the loosest possible band sufficient to keep it straight; bind the head itself also to the ladder at the forehead. Extend the arms along, and fasten them to, the body, not to the ladder, The rest of the body should not be tied, except in so far as is requisite to keep it vertical with a loose band round it here and there. But see that these attachments do not hinder the suceussion. Do not fasten the legs to the ladder, but to one another, that they may hang in a straight line with the back. This is the sort of thing that
1 Surgeons will remember that methods no less violent than these and those described below were practised for a time on high authority at the end of last century.
1 karaceloes. 2 Apoll., Galen, but most omit. 8 udAwoTa.
287
10
20
ITEP] APOPON
déou ev Kr paKe catace.o Ojvar alo pov pevTOU Kal év Tacn TEXY Kal ovx iyevora év lar pirh, TONY Oxy rov Kal TONAHY ory Kal TOAUY Noyou Tapacxovra, émerta pn dev opernoat.
XLV. Xp) oe 7 p@Tov pev yev@anery THY puow THS paxeos, oly Tbs eoTUY" és Toda yep vouon- para Tpogbeou ay AUTH. TOUTO pev yap, TO Tpos THY KOLALNV pérov ot omovOunot € €vTOS aprvot elolv ~aAANNOLCL, Kal dédevrat ‘T pos aNd rots deau@ wvEader Kal veupaoet, ato xovdpeov aTro- TepuKore adypt mpos Tov vwtiatov. addot O€ TWES TOVOL veupwdecs dvavraior T™ por purTor Tapa- Tétavta évOev kat évOev adtav. ai dé PreBav Kal apTnplov Kowavia ev Erép@ NOY Sednrw@cor- Tal, boat Te Kal oat, Kal O0ev w@pynpévat, Kat év olotow ola dvvavTat, avTos dé 0 vor ratos olow ENUTPOTAL eXUT pola kal b0ev pynpevorce, Kal orn Kpaivouat Kal olow KOWOVEOUCL, Kal ola duvapévoicw: év b¢ TH étéxewwa ev ApOpoice ye- YLYYAVLOVTAL POS GNAHAOUS Of OTrOVvdUAOL. TOVOL S€ Kowol mapa Taytas Kal év Toiow é&w pwépect kal év toiow éow Tapatétavta atopuais Té éotiv datéou és TO éEw pépos ATO TavT@Y TOV CTOVOUAWY, pia ATO EVOS EXATTOV, ATO TE TOV peCovwr amo Te TOV éX\accdveV: éTL O€ THaLW atopicert TaUTHTL Yovopiwoy éemipvares, KAL ATT’ exelvov vevpwy aTroBAdaTHALS NOEAPLT LEV TOLTLW eLoraro TOVOLOW. meupal oe TpormeprvKcucw, és 70 Eow@ wépos Tas xeparas pemrovaas pGXXov 7) és TO €&w: Kal’ &va b€ ExacTov TaY oTOVSUNOY TpocnpOpwrTar KaumuNwTatat O€ mAEUpal av-
1 ols.
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ON JOINTS, xtiv.-xtv.
must be done if succussion on a ladder is absolutely required; but it is disgraceful in any art, and especially in medicine, to make parade of much trouble, display, and talk, and then do no good. XLV. One should first get a knowledge of the structure of the spine; for this is alsorequisite for many diseases. Now on the side turned towards the body cavity, the vertebrae are fitted evenly to one another and bound together by a mucous and ligamentous connection extending from the cartilages right to the spinal cord.! There are also certain ligamentous cords extending all along, attached on either side of them. The communications of the veins and arteries will be described elsewhere as regards their number, nature, origin, and functions; also the spinal cord itself with its coverings, their origin, endings, connec- tions and functions. Posteriorly, the vertebrae are connected with one another by hinge-like joints. Cords common to them all are stretched along both the inner and outer sides.2 From every vertebra there is an outgrowth (apophysis) of bone pos- teriorly [lit. “to the outer part’’], one from each, both the larger and smaller; upon the apophyses are epiphyses of cartilage, and from these there is an outgrowth of tendons, which are in relation with the outermost cords, The ribs are articulated severally with each of the vertebrae, their heads being disposed rather inwards (forwards) than out- wards (backwards), Man’s ribs are the most curved,
1 Intervertebral cartilage: reference to its mucous centre and cartilaginous anterior layer.
* Both these and those mentioned above seem to be the anterior and posterior common ligaments. ‘‘ Inner” and ‘outer ”” = our “ front” and ‘‘ back.”
289
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30
45
10
IIEPI APOPON
Opwrov etal parBoedéa TpoTov. To dé pernyd TOV TAEVPEWY KAL TOV OT TEWY TOV ATOTEPUKOTOV ato TOV OTOVO’A@Y ATOTANPEOVaLY ExaTépwbev ol pves aro TOU avyevos apEdpevot, ax pt THS Tpoodvatos. avr 6€ 1) paxes Kara HiKcos tOv- TKOALOS éoTLY ATO ev TOD ‘epob oaTéov ax pt TOU peydhov oTOVOUAOU, Tap ov TpoonpTnTaL TOY TKEAEWY 7) n Tpoapuats, a ax pe pev TOUTOU Kur KvOTUS TE yap Kal yoval Kal apxov TO yaNapop év TOUT@EKTLOTAL. ATO O€ TovTOU axpe ppevaov T™pog- apTHO LOS, iOvrop6n Kal Tapapvoras eyvee pve TOUTO “oUVOY TO xeptov eK TOV éo bev pEepar, as 51) KaXovaw Yroas. amo dé TOUTOU aXpL TOU peya- ov crovevArou TOU UTép THY éTMpLLOwY, LOUKIdY: Ets 5€ warXov Soxel 1) Eotiv: 9) yap dxav0a Kata pécov uiyroTatas Tas éexpvovas TOV ooTéwV evel, évdev dé cal (evdev éAdaoous. auto O€ TO apO@pov TO Tov avyevos Aopdov € eat.
XLVI. ‘Orocotct wéev odv cupopata yiverat KaTa Tous amovdvaous, eEwors bev peyady drop- payeioa aro THS ovpdvatos 7) EvOS OTOVOUAOU?) Kal TrEOVOV Ov Hara ToAXotoL yiverat, aXXr OA yout. ovde yap a Tpopara Ta TOLAVTA pridvov yiver Oar: ouTe yap és TO éfo éfwo Ojvar pnid.ov ECTLY, EL LN) EK TOU Eu poober t iaxXup@ Tut Tpwbein O1a THS KoLAins (obT@ om ay amo)ovTo), 4 el Tes ag vynrod Tov xeoplou TET@OV epetoese TotoLy toxion- ow 1 Totow @ Moro w (aAra Kal oUT@S aY aTo- Bavor, Tmapax pha 6€ ovK ay amoOavo) éx 6é TOU drug Oev ov pnid.ov ToLAavT HV éfadow yeveo- Gar és TO Eow, et pa) brepBapv TL axOos € eM ET OU TOV TE yap ooTéwy TaV éxTEepuKOT@V éEw EV 290
ON JOINTS, xtv.-xtv1.
and they are bandy-shaped. As to the part between the ribs and the bony outgrowths (apophyses) of the vertebrae, it is filled on each side by the muscles which begin at the neck and extend to the attach- ment! [of the diaphragm]. The spine itself is curved vertically through its length. From the sacrum to the great vertebra,” near which the origin of the legs is inserted, all this is curved outwards; for the bladder, generative organs, and loose part of the rectum are lodged there. From this point to the attachment of the diaphragm it curves inwards ; and this part only of the inside has attachments of muscles, which they call “ psoai.” From this to the great vertebra ® over the shoulder-blades it is curved outwards, and seems to be more so thanit is; for the ridge has the outgrowths of bone highest here, while above and below they are smaller. The articulation of the neck itself is curved inwards.
XLVI. In cases then of outward curvature at the vertebrae, a great thrusting-out and rupture of the articulation of one or more of them does not very often occur, but is rare. Such injuries, indeed, are hard to produce; nor is it easy for outward thrust- ing to be brought about, unless a man _ were violently wounded from the front through the body cavity—and then he would perish—or if a man falling from a height came down on his buttocks or shoulders—but then he would die also, though he might not die at once. And from behind it would not be easy for such sudden luxation to take place inwards, unless some very heavy weight fell on the spine ; for each of the external bony epiphyses is of
1 “To their attachment ”’ (Petrequin). 2 Fifth lumbar. % Seventh cervical.
291
20
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40
IIEPI APOPON
ExaoTov ToLOvTOY éoTLVY, WaTe Tpdcbev dv avTO Karayhyar mpw i mweyadny pot eo Touno at, TOUS TE owvdérpous Bing dpevoy Kal ra cp Opa. Ta ev ARaypeva. 6 TE aU vateatos Tovoin av, €b é€& OXiyou Ywpiov THY TEPLKALT NY Eyou, TOLAUTHY eEarow eEahdopevov o movOUOU- 6 Te ext ono as amovounros méfor av Tov vwtiaiov, ef pun Kal atroppyeev. miexyOeis 0 av Kal aToXEAappEeVvOS TONN@Y av Kal peydhov Kal émucatpov arovap- KOOL TOLno evev" @aoTe ove dv péroL TO intp@ Oras xpn TOV omovduNOv catopbacat, mToNND Kat Braiwv ddov Kak@v TapeovToy. wate bn ove euBareiy olov Te 7 poor ov TOV TOLODTOV ore KaTaceioes OTE AAW TPOTH OvdEVi, EL pH TLS dvatap@v tov avOpwrov, éreta éopacdpevos és THY KOLAINY, Ex TOD Ecwbev TH yYetpi és TO Ew avtTw0éou Kal TOUTO vEeKpo plev olov Te Trovely, Cavre 6é ov Tayu. dla Ti ovv TadTA ypape ; OTL olovtal TLVES intpeveévar avd pwrrous olow éawbev EVETTETOV OTTOVOUAOL, TENEWS UTEpBavTeEs Ta ap0 pa: Kaitot ye pniotny és To mepryevécOar Tov da- aTpopéwy TavTny éviot vopifovar Kal ovdev detaOat éuBor(Hs, GAA avtopata vytéa yiveoOar Ta TolavTa. ayvogovoe 62) ToAXOL, Kal KEepdaivou- ow OTL ayvoéovot: TeiPovar yap Tovs mehas. éeFavatavta. 6é 61a TOodEe* olovTat yap. THY dkav0ay thy é&éyoucay Kata Tip pay TaUTHnVY TOS aTroVdUAOUS avTovS eEivat, STL oTpoyyvvrov avtav Exactov hatverar Wavopevor, aryvoedvTes éTt Ta ooTéa Tabra éore Ta amo TOY oTOVOUVAWY TEpUKOTAa, TEpl @VY O AOYOS OrjLYO mpoabev elpntat of S€ aTrovdurAaL TOV TpOTw-
292
ON JOINTS, xtv1.
such a nature as to be fractured itself before over- coming the ligaments and interconnecting joints and making a great deviation inwards. The spinal cord, too, would suffer, if the luxation due to jerking out of a vertebra had made so sharp a curve; and the vertebra in springing out would press on the cord, even if it did not break it. The cord, then, being compressed and intercepted, would produce complete narcosis of many large and important parts, so that the physician would not have to trouble about how to adjust the vertebra, in the presence of many other urgent complications. So, then, the impossi- bility of reducing such a dislocation either by succussion or any other method is obvious, unless after cutting open the patient, one inserted the hand into the body cavity and made pressure from within outwards. One might do this with a corpse, but hardly with a living patient. Why then am I writing this? Because some think they have cured patients whose vertebrae had fallen inwards with complete disarticulation; and there are even some also who think this is the easiest distortion to recover from, not even requiring reduction, but that such injuries get well of themselves. There are many ignorant practitioners ; and they profit by their ignorance, for they get credit with their neighbours. Now this is how they are deceived. They think that the projecting ridge along the spine represents the vertebrae themselves, because each of the pro- cesses feels rounded on palpation; not knowing that these bones are the natural outgrowths from the vertebrae which were discussed a little above. But
293
a (=)
60
69
TIEPI APOPON
Téepw ATELTW* oTEVOTATHY yap TaVTwY TaY CowD avOpwros Kotrinv exe, ws eT TH peyébet, ard Tov OTiaev és TO EuTpocOer, ToTl Kal KaTAa TO aTiOos. étav ovv TL TOUTwY TOY dar eo TOV Umepex ovT@y ioxupas KaTayy, qv TE év ny TE TEL, TavTN TATELVOTEPOV TO xepiov ylvetat 7) TO évOev Kal évOev, kal dia TovTo éEaTraTa@vTat, olopevor TOUS amovdurous € éow oixes Bau. Tpoceea- Tard dé é ere avTous Kal TA OXNMATA TOV TETPO- pévavs vy wey yap TeLpavrTat Kam Udrec Oat, oduvarTat, | TEPLTEVEOS yevopevov TavTy ToD 5€p- Ha.T 0S 7 TETPOVTAL, Kai dua Ta OoTéa Ta Karen- yoTa evO pac cet ovT@ [tov TOV XpOTa. uu be Aopdaivocs, paous elaiv: Xahapa@repov yap TO Spy KATA TO TP@ua TAVTY yiverat, Kal Ta daTéa rooov évOpdace’ atap Kal Hv Tes Wavy avT@Vv, KATA TOUTO UTrEetKoVat AOPdoOdVTES, Kal TO Y@piov Keveoy Kal parOaxov wWavomevov TavTn paiverar. tadta mavra, Ta elpnpuéva Tpooega- mara TOUS inTpovs. DryLées be TAKEWS Kal dowees avroparor ol ToLodToL yivovrac: TAXES yap TavTa Ta Tola’Ta odoTéa emiTwpovTal, dca yabva éotw.
XLVIT. Sxoraivetar pev ody paxes cab bytai- vouol KaTa TOANOUS Tpomrous Kal y4p ev TH pucet Kal év TH xpnget oUTws evel’ aTap Kal UT 7 pa.0s Kal vumTo oduynpatov * avvdorLKy eo TU. ai dé 67 KUpoales | at ey TOloL TTOLAT LW os emt TO TOND yivovTat, yh Totow laxtovow epelon *) emt TOUS @mous TET. avaryen yap €&w patverbat év TO Kup@paTte Eva pév TVA VYndOTEpOY TOV omovevrwv, Tous oe evOev Kal évOev emi hocor:
294
ON JOINTS, xtvi—xivi.
the vertebrae are much farther in front ; for man has the narrowest body cavity of all animals relatively to his size and measured from behind forwards, especially in the thoracic region. Whenever, therefore, there is a violent fracture of these projecting processes, either one or more, the part is more depressed there than on either side; and therefore they are deceived, and think the vertebrae have gone inwards. And the attitudes of the patients help to deceive them still more ; for if they try to bend forwards, they suffer pain, the skin being stretched at the level of the injury, while at the same time the fractured bones disturb the flesh more; but if they hollow their backs, they are easier, for thereby the skin gets more relaxed at the wound, and the bones cause less disturbance. Again, if one feels them, they shrink at the part, and bend inwards; and the region appears hollow and soft on palpation. All these things contribute to deceive the physicians, while such patients recover of themselves quickly and without damage; for callus forms rapidly on all bones of this kind, by reason of their being porous. XLVII. Curvature of the spine occurs even in healthy persons in many ways, for such a condition is connected with its nature and use; and besides, there is a giving way in old age, and on account of pain. But the outward curvatures due to falls usually occur when the patient comes down on his buttocks or falls on his shoulders; and, in the curvature, one of the vertebrae necessarily appears to stand out more prominently, and those on either
2 ddivns Kw.
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ITEPI APOPQN
10 ” e SON \ > ry \ Bb] \ a OUKOUYV €lS €ETTL TONU ATOTETTHNONK@S ATO TWY
20
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Gov éeotiv, adda opixpov Exactos auvb.60l, aOpoov dé morAv gaivetat. bia ody TodTO Kal oO V@TLALOS pvedos evpopws péper Tas ToLavTaS Siac popas, Or KUKAMSNS avT@ H Stactpod? ryiveTalt, AXN ov yourwdns.
Xp 6é€ tHv KATA KEUNY Tob Siavayrac pod ToLnvo€ KatacKevdoat. éfeore pev EvXov ¢ tox vpov Kal TATU; evTopayy TapapnKéea EXO; KaToputat eeore dé avi Tob Evhou é ev TOIX eV TOY mapa pnicéa evrapety, 7 TEU avertepe Tov édageos, 7 om@s av peTpios éyn’ émerta olov atvXov Spvivov TETPUywVvov TAAYLOY TapaBdadreELV, aTrONELTOVTA amo ToD Tolyou baov TmapenOety tiva, Hv dén* Kat éml pev TOV oTUNOV éTLaTOpécaL 7) YAaivas 7 G@AXo TL, 6 pwarOaxoyv péev Eorar, UrelEer Sé pH peya: Tov dé dvOpwrov Tupinaat, hw évdéyntat, TOAA® Oepu@ Aovoa’ KaTELTA TPNVEA KaTA- KNival KATATETALEVOY, KAL TAS eV YElpas aUTOD Tapatewvavta Kata vow mpocdijcat mpos TO cua, iwavte 6€ parOake, (kavas TAATE? Te Kal HaKpo, €x Svo Svavtatoy oupBeBAnuéve HEre, Kata péoov dé TO aTHO0s Sis meptBeBrHoOat xp?) @S eyyuTaro TOV pacxareor: érerta TO meplo~ owevov TOV ipavrov KATA THY pacxarny éxaTEpov Treph Tous wpuous TepiBeBAnoOw' Eerrevta ai apxat ™ pos EvAov UmepoeidEs TL TpoadedérOwaay, a apyo- Covcat TO pHKOS TO Evo TO UTOTETAMEV@, TPOS 6 Te mpocBarXrov TO imrepoeidées dvtictypitovra Katateivery. Towvt@ oé Tit étTépw Seau@® yp?) dvw0ev Tov youvatav Syicavta Kal dvebev TOV TTEPVEWY TAS GPXAS TOV iwavT@Y Tpos TOLOUTOV 296
ON JOINTS, xtvu.
side less so. It is not that one has sprung out to a distance from the rest; but each gives way a little, and the displacement taken altogether seems great. This is why the spinal marrow does not suffer from such distortion, because the distortion affecting it is curved and not angular.1
The apparatus for forcible reduction should be arranged as follows. One may fix in the ground a strong broad plank having in it a transverse groove. Or, instead of the plank, one may cut a transverse groove in a wall, a cubit above the ground, or as may be convenient. Then place a sort of quad- rangular oak board parallel with the wall and far enough from it that one may pass between if necessary ; and spread cloaks on the board, or some- thing that shall be soft, but not very yielding. Give the patient a vapour bath if possible, or one with plenty of hot water; then make him lie stretched out in a prone position, and fasten his arms, extending them naturally, to the body. A soft band, sufficiently broad and long, composed of two strands, should be applied at its middle to the middle of the chest, and passed twice round it as near as possible to the armpits; then let what remains of the (two) bands be passed round the shoulders at each side, and the ends be attached to a pestle-shaped pole, adjusting their length to that of the underlying board against which the pestle-shaped pole is put, using it as a fulcrum to make extension. A second similar band should be attached above the knees and above the heels, and the ends of the straps fastened to
1JIn spite of this, the strange contradiction ‘‘ angular curvature” has come to be the technical term for hump-back.
297
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0
TEPI APOPON
tt EvAov mpocdijcat AdAXw 5é iudvTe TATE? Kal parban® Kal duvar@, Tasvioe del, mars ExovTe Kal KOS ixavon, ioXupas mept Tas iEvas KUEN mepidedéaOan a @s eyyuTaTa TOV loyiov: éreta 70 meptacevov Tis TaLvLoeLoeos, A apa aupotépas Tas apxas TOV (MavT@OV, Tpos TO EVOV mpoo Shoat TO T pos Tay Tod@p: KaTELTA KaTareivey € év TOUT TO oxnpate évOa Kal év0a, dua pev icoppoTas, iA \ > ? a b) \ \ XN f \ ic dua o€ és (OU. ovdéy yap av péya KaKkoVv 7 ToLaUTN KaTaTacis TOLNTELEV, EL XpNTTas oKevac- Gein," él yn apa eferirndés Tes BovdouTo cives Oat. Tov dé inTpov yp) 1) adQov, boTLsS iaxXupos wal a) apad ys, emuBevta TO Bévap THS KELPOS emi 76 bPopa, Kal THY ETEpNY YELpa mpocenrévra € emt THY érépny, xatavayxater, T POT TUVLEVTA Ny TE €s 100 és TO KaTW Ted’KN KaTavayKdalerOaL, Hv TE TpPOS THs KEparns, 7 TE Tos TOV loxlov. wal aoweotTaTn Lev abrn 7 avayeny aowes 8% Kal emixabeves Pai Twa emi TO KUpwpa, avTOD apa KATATELWOMLEVOU, Kal évoetoat petewpto Oevra. arap Kal ems Bivau T@® ool Kal oxnOhvat em TO KUPW [LA Hovxos TE evrevocioa oveev K@nvee" TO TOLOUTOV O€ Touoa peTpios éeriTnderos av Tus ely TOV appl Tarator pny ela pevorv. duvat@rTary MEV TOL TOV avaryKéoov éoTiv, el O mev TOLXOS ev TE- TH [LEVOS H TO O€ Evhov TO KATO puyLEvor, 7 evTeTHNTAL, KATWTEPW EN THS paxtos TOU avOpa- mov, oToo@ av Sox HeTpios EXEL avis be prrupivy, Ty) ew77}, évein, ) Kal adAXoU TUvOs EvAou: émerta emi mev 70 bBopa emuTed ein n TPUXLOV Te TONUTTUXOV i) TMLKpOY TL OKUTLVOD UTokepadaioy' ws €AdxXLoTa pv EmixetoOat 298
ON JOINYS, xtivm.
a similar pole. With another soft, strong strap, like a head-band, of sufficient breadth and length, the patient should be bound strongly round the loins, as near as possible to the hips. Then fasten what is over of this band, as well as the ends of both the other straps, to the pole at the foot end; next, make extension in this position towards either end simultaneously, equally and in a straight line. Such extension would do no great harm, if well arranged, unless indeed one deliberately wanted to do harm. The physician, or an assistant who is strong and not untrained, should put the palm of his hand on the hump, and the palm of the other on that, to reduce it forcibly, taking into consider- ation whether the reduction should naturally be made straight downwards, or towards the head, or towards the hips. ‘This reduction method also is very harm- less; indeed, it will do no harm even if one sits on the hump while extension is applied, and makes succussion by raising himself; nay, there is nothing against putting one’s foot on the hump and making gentle succussion by bringing one’s weight upon it. A suitable person to perform such an operation properly would be one of those habituated to the palaestra. But the most powerful method of re- duction is to have the incision in the wall, or that in the post embedded in the ground, at an appro- priate level, rather below that of the patient’s spine, and a not too thin plank of lime or other wood inserted in it. Then let many thicknesses of cloth or a small leather pillow be put on the hump, It is well that
1 oxevacOy.
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IIEPI APOPOQN
cuupéper, povov mpounOeopevov os un a cavis vo oKANPOTNTOS oduvny Tapa Katpov ™poo mapé- xn" Kar’ ‘Ew 6é coro @S padiara Th evTouy TH és TOV TotXov TO UBopa, @s av 7 cats, 7 pddota é&éotynKe, TaAUTN pddiota TLEtn emiTE- Qetoa. Otay 6€ émiteOH, TOV pév TLVa KaTa- vayKately Ypr) TO akpov THS cavidos, Hv Te éva déy mV TE OVO, TOUS OE Kararetvely -! TO oO ja Kara bos, ws Tpoabev elpntas, TOUS pev TN; TOUS bé TM). efeore d€ Kal ovioxoioe THY KaTaTaow moteia0at, 7) TapaxatopvEavta Tapa TO EvXor, 4) Ev AUTO TO EVAW TAs HALAS TOV OvicKwD evTEKTHVA- pevov, iy TE opbas eOerns, éxatépobev Co [LLK pov UmEepexXoveas, y) TE Kara Kopupyy TOU Evdou | evdev Kal évdev. avrar ai avayKat evraplev tot eloe eal és TO iaXuporepov Kal és TO qo o0, Kal iox ov Exouet TOLAUTND, Gore kal el tis én Aven Bovdorro, anna pn él int pet, 6 TOLAUTAS dvayKas ayayelv Kay 2 TOUT® ioxupes dvvacGau: Kal yap av KaTateivoy Kata uAKos podvoy évOev Kal évOev oU Tw Kal AXANV avayKnY ovdELinu Tpoc- TLOeis, Ouws KaTaTEiVELeY av TLIS' GAA pHVY Kal HV pai) KATATELYMY, AUTH Sé podVvOY TH Tavics OUTS irroin Tus, Kal oUT@s av [‘cavdds | 8 KaTavaryKac ever, canal ovv ai ToravTaL laxves elaty, now &&eaTe Kal aabevertépyor Kal loXvporepyat xphoat avuTov Tamlevovta. Kal pev &) Kal Kata pvow ye avayxdtovor ta pev yap eFeate@Ta és TV yopnv avayxater 1 lmwors iévat, TA 5€ TUVENY- AvOOTAa KaTa pvaw KaTaTeivouvct ai KaTa pvow KatTaTao.gs. ovKovy [éyw]4 éy@ TovT@Y avayKas
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ON JOINTS, xivu.
it should be as small as possible, only sufficient to prevent the plank from causing needless additional pain by its hardness. Let the hump come as nearly as possible in line with the groove in the wall, so that the plank, when in place, makes most pressure on the most projecting part. When it is put in place, an assistant, or two if necessary, should press down the extremity of the plank, while others extend the body lengthwise, some at one end, some at the other, as was described above, But it is possible to make extension by wheel and axle, either embedded in the earth by the board, or with the supports of the axle carpentered on to the board itself; either projecting upwards a little, if you like, or on the top of the board at each end.1 This reduction apparatus is easy to regulate as regards greater or less force, and has such power that, if one wanted to use such forcible manceuvres for harm and not for healing, it is able to act strongiy in this way also. For even by making traction lengthwise, only at both ends and without any other additional force, one would produce extension. On the other hand, if, without making traction, one only pressed downwards with the plank in this way, one would get reduction thus also. Such forces, then, are good where it is possible for the operator to regulate their use as to weaker or stronger, and, what is more, they are exerted in accordance with nature; for the pressure forces the protruding parts into place, and the extensions according to nature draw asunder naturally the parts which have come together. For my _ part, then, 1 know no better or more correct modes of
(1) Projecting horizontally,
301
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128
HWEPI APOPON
KadXlous ovde Sixavorépas: u) yap Kat avTny THY axavOav (Ovepin Tis KATATAOLOS caTa@der TE Kal KAT TO lEpov oaTéov KaN€dMEVOv ouK exer emda Bnv | ovdepiny- avolev b€ KaTa TOV avxéva Kal KATA THD Kepaniy émihaBnv peev EXEL; GNX’ EoLOgeLy YE ATpPETIS TAUTH TOL yLVOKEVH 7 Kard- Tacis Kal dadr\as BraBas av 7 pOo TAPE XOU mrcovacbetaa. errerpyjOnv 6é 67) Tote UmTLoV TOV avOpwrov Katatewew, acKov advartov vTobels v0 To UBwpa: KaTErTa AVA® €k Yadkelov és TOV aoKov TOV UrroKelwevor eveevat _puoay: ada. pot ovK eUTrOpEi To" bTE pev yap ev KaTaTelvoupL TOV avOpwrov, nacaTo oO aoKos, KaL OUK NOUVATO pica éoavayxabecbar Kai dddrws EtoOLmov TEpLo- Avo Odvew WV, aTE €5 TO aUTO dvaryKatonevor TO Te TOU avOpwTou bBopa Kal TO Tob aoKoD TAnpoupevou KUPT@ UA. Ore 6 av a) Kapta KATATELVOL LL Tov avOpwmov, 0 jEev do Kos vmod Ths pvens exuptooTo: o 6¢ advOpwiros TavTn maddor ehopbaivero 7 ” a ouvepeper. eypayra dé éitndes ToUTO" Kana yap Kal TadTa Ta Kaipara coTw, & meipnOévta atopnbévta éepavn, kai bd’ adooa 7 TopHnOn
XLVILI. ‘Orodcotcr 8é és TO Eow oKoNaivorvTat of oTOVOUVAGL UTO TT@paTos, 7) Kal éurrecovToS Tivos Papéos, eis pev ovdeis TOV aTrOVdUAwY peya eElotatar KapTa ws éml TO TOA éex TAY adrwv, v O€ exoTH peya ” els 1) TAeloves, @avatov pépovar domep 67 Kat wpoabev eipnrat, KUKAwONS Kal ary Kal ov Yyeoviwdys yiverau y) Tapadrayy. ovpa Mev odVY TOLtoLt ToOLOVTOLGL Kal aTOTAaTOS “adrOv iotaTat 1) Totow éEw Kudotor, 302
ON JOINTS, xtvu.—xivin.
reduction than these. For straight-line extension on the spine itself, from below, at the so-called sacred bone (sacrum), gets no grip; from above, at the neck and head, it gets a grip indeed, but extension made here looks unseemly, and would also cause harm if carried to excess. I once tried to make extension with the patient on his back, and, after putting an unblown-up bag under the hump, then tried to blow air into the bag with a bronze tube. But my attempt was not a success, for when I got the man well stretched, the bag collapsed, and air could not be forced into it; it also kept slipping round at any attempt to bring the patient’s hump and the convexity of the blown-up bag forcibly together; while when J made no great extension of the patient, but got the bag well blown up, the man’s back was hollowed as a whole rather than where it should have been. I relate this on purpose ; for those things also give good instruction which after trial show themselves failures,! and show why they failed.
XLVIII. In cases where the vertebrae are curved inwards from a fall or the impact of some heavy weight, no single vertebra is much displaced from the others as arule; and if there is great displacement of one or more, it brings death. But, as was said before, this dislocation also is in the form of a curve and not angular. In such cases, then, retention of urine and faeces is more frequent than in outward curvatures ;
1 «*On essay show there’s no way” might indicate the play on words.
393
10
20
30
IfEPI APOPON
Kal TOOES Kal OAa TA OKEAECA poxeras padror, Kal Oavarnpopa TaUTa par Nov EXELVOY, Kal ay TepryevovTat &é, pu@dees Ta ovpa parXov oUTOL, Kal Tov oKENEWY axparérrepor Kal vaprabvéa- TEpoL’ Hv dé Kal év To ave [épet parXov 70 Adpdwpa yévnTat, TaVTOS TOD TH LATOS axparées Kab vevapKoLevoe yivovrar. penxaniyy d€ oUK EX ovdeninn eyorye, Omes xpn) TOV ToLovTov €s TO auto KaTATTHOAL, €l Ly Twa a Kara” THS Kr PAKS KaTaoElols apeheiv oin Te éin, y) Kal addy TLS TowavTn inow 1 KaTdTacls, oinrep OMtyw mpocbev eipntar. KatavayKkacw 8 ovv TH KaTaTace ovdeuinv exw, iTLs av yivotTo @oTEp TO KUPOMATL THY KATAaVayKaCW 1 cavis €moleiTo. TaS yap av Tis ék TOD Eutpooev dua THs KOLNINnS avayKxadoat dvvaLTO; ov yap olov Te. GAAA pV ovTEe BYES OUTE TTappol ovdeninv Svvami exovow, WoTE TH KATATACEL TVUYTLU@pElV’ OU pV OVO Everts HvVaNS eveewévyns és THY KOLALnv ovdev av SuvNOEin. Kal pHv at peyarar oixvat tpocBaddAopmevat avaotacLos elvena Onfev TOV éow peTovTwY oTOVdUN@Y peyadn apapTas yvopuns éeotiv: atwbéovar yap padXov 7) avacT@ot" Kat ovd auto TOUTO yeyvoakovar ol 7 poo BaddovTes: bc0@ yap av TLS peSoo mpoo Barry, TOTOUT@ waddov Aopdoby- Tat ob poo Sdn GevTes, cuvavaryrcatopévou avo 70d (S€pparos. TpoTrous Te ddous KaTaTaciwy,” 4 oboe m poo Dev elpnvTat, EX OUpLL av eitely appo- cat® ovs dv tis Ooxéot* TH TaOnpwate addov> aX ov Kdpta Tiatevw avtotat: Sia TovTO Ov ypadw. a0poov 6€ cvviévat yp} TEpl THY ToLOv- 304
ON JOINTS, xuvin.
the feet and lower limbs as a whole more usually lose heat, and these injuries are more generally fatal. Even if they survive, they are more liable to in- continence of urine, and have more weakness and torpor of the legs; while if the incurvation occurs higher up, they have loss of power and complete torpor of the whole body. For my part, I know of no method for reducing such an injury, unless succussion on the ladder may possibly be of use, or other such extension treatment as was described a little above. I have no pressure apparatus com- bined with extension, which might make pressure reduction, as did the plank in the case of hump- back. For how could one use force from the front through the body cavity? It is impossible. Certainly neither coughs nor sneezings have any power to assist extension, nor indeed would inflation of air into the body cavity be able to do anything. Nay more, the application of large cupping instruments, with the idea of drawing out the depressed verte- brae, is a great error of judgment, for they push in rather than draw out; and it is just this which those who apply them fail to see. For the larger the instrument applied, the more the patients hollow their backs, as the skin is drawn together and up- wards. I might mention other modes of extension, besides those related above, which would appear more suitable to the lesion; but I have no great faith in them, and therefore do not describe them, As to cases like those summarily mentioned, one
1 bia. 2 So Erm., Kw. ratraceolwy Littré, Pq. 3 apud ew. 4 &y Soxéortas.
395
50
55
10
TIEPI APOPON
fale ee i, x 7 ¢ \ \ 5) TOV, wy” eV Keparalio ELpNTAL, OTL TH peV ES
70 Nopdov pepavra on€O pid €oTiv Kal owvdpwepa, Ta 6é es 70 xupov acwwéa Gavarou, Kal ovpeov oXErtov Kal dmrovapKoa tov TO emimav: ov yap évTeiver TOUS oxeTous Tous Kara THY KOLrLNY, OvVOE KwWAVEL evpoous elvat n és TO Ew Kopoous” ie 5é Aopdwais TavTa Te Gpuporepa Tovel Kal és Ta GAAa TOANA Tpooryiverat, emel ToL TONU TEoveEs TKENEWY TE Kal XELpa@v dK pares yivovrat, Kal KaTavapKoovTaL TO cOMa, Kat _ovpa loxeTae avtotow oioww av pn exoTH pmev To bPopa Hajre éow pLnTe Eo, cea bewar b¢ loxupas és THY LOvepiny THs paxvos* ola. © dv exoth TO UBwpma, Hocov ToLavTa mao Xova.
XLIX. Tova dé Kal adda év int pict av Tus TowavTa Katidot, @ oy Ta pev toxupa aoéa éath Kal cal éwuTa THY Kplow OXnv hapBavovra Tob VOT 1} LaT OS, Ta 6é@ aobevéatepa owdpopa, Kal aTOTOKOUS voonLat ov Xpovious TOLéovTa Kal KOLW@VEOVTA TO AXAXW GwpaTe el TrEOV. érrel Kal TEU PEDY Karnes ToLobr ov Te mémrov bev" oat pev yap dv KaTayn meupy, 0) pin ) Wéoves, os Totoe Tele TOLTL KATAaYVUTAL, fu [7 diac youTa Ta oaréa és TO éow HEpos pde Wirobévta, odtryou fev On eTUpeTHVaV: aTap ovbe alua TOAXOL HON ETTUTAV, OVOE EUTTVOL TOAAOL yivoVTAL, OVE ELfjLO- TOL OUOE ema haketoves TOV OoTéwV: SiaLTa TE pavran apKet Hy yap pm) TupeTos TUVEXTS émiapL- Bavnrac auTous, Keveary yet KAKLOV TOIL ToLouTOL- ow 7) Ln Keveayyely, Kal émMduVérTepov Kal TrupeE- TwO€aTEpoY Kai BnywhéoTEpov" TO yap TANPwpA
1 os.
306
ON JOINTS, xuvi1-x ix.
must bear in mind generally that inward deviations cause death or grievous injury, while those in the form of a hump are not as a rule injuries which cause death, retention of urine, or loss of sensation ; for external curvature does not stretch the ducts which pass down the body cavity, nor does it hinder free flow, while inward curvature does both these things, and has many other complications. In fact, many more patients get paralysis of legs and arms, loss of sensation in the body, and retention of urine when there is no displacement either inwards or outwards, but a severe concussion in the line of the backbone ; while those who have a hump displacement are less liable to such affections.
XLIX. One may observe in medicine many similar examples of violent lesions which are without harm, and contain in themselves the whole crisis of the malady,’ while slighter injuries are malignant, pro- ducing a chronic progeny of diseases and spreading widely into the rest of the body. Fracture of the ribs is such an affection; for in cases of fractured ribs, whether one or more, as the fracture usually occurs, the bones not being separated and driven inwards or laid bare, we rarely find fever; neither does it come to spitting of blood in many cases, nor do they get empyema or wounds requiring plugs, neither is there necrosis of the bones. An ordinary regimen suffices; for if the patients are not attathed by chronic fever, it is worse to use abstinence in such eases than to avoid it ; and it involves greater liability to pain, fever, and coughing ; for a moderate fullness
1 Le. it is confined to the injury itself, and steady recovery ensues,
397
20
26
10
20
ITEPI APOPON
70 per ptov THS Koonin, 616pA wma TOV mevpewy yivetac’ n O€ KEVOTES KPe[Lao Lov bev THOL Tev- pijoe roves’ o 6é KPEMAT 10S, odvvmy. efwbev Te ad havrAyn éridecis Tolar ToLovTOLoLW apKet’ KnpoTn Kal aomAnvecit Kal oPoviorcw Haovyws épe(Oovta, omadiny thy émiderww TroretcPat Kat epu@o€es Te mpooen Berra. KpaTuveTa dé ™evpyy év eiKoow neepynow” TAXELAL Yap ai ETITMPWOLES TOV TOLOUTWY OaoTéwD.
L. ‘A pgupacbetons bévToL TIS, TapKos aul THO mreuphoy UO TANYAS. %) UI TTO{LATOS 3) UTO avTEpEelatos 7) AAAoU TWVOS ToLOVTOTPOTFOU, ToAXOL On TOA Aiwa &r-TUTAaV" Ol yap GXETOL OF KATA TO AaTTAPOV THs TAEUPHS ExaoTHS TapaTeTa- pévoL, Kal ob Tovor ato TOV emrucalpoTaT ov Tap €év TO TOMATL Tas apopwas Exovow" TOOL ouv non Bnyedees Kal Pupariat Kal EMTUOL eyévovTo Kal EwpoToL, KaL 1) TAEUPH ETeTphaKédLoEV avTOLoW. aTap Kal olow wn dev ToLovTOV T poo eyEeveTo, apdt- pracbeions THS capkos apt THO mevpijaew, Omens be Bpadvrepov oduvepevor TavovTat OVTOL oloww av TEUPH KaTayn, Kal Umoatpopas paddov loxee oduynLaton TO Yaplov ev Tolot TOLOUTOLOL TPWMAGLY 7) TOLTL ETEPOLTLY. pada MEV OVV pETE- EéTepot KaTamedéovow TY ToOLOVTwY aLVEwD, HGXXOV 1) Hv WrEUp}) KaTAYH avUToloW' aTap Kal inotos oKxeOporepys OL ToLovTOL SéovTaL, Eb owdpovotev® TH Te yap Siairy ouppéper oO UVE- aTadhOat, atpewety TE TO TOMATL wS pddLoTA, appodiatwv TE améxeoOat Bpwpatov Te \iTTapav Kal Kepxvw@déwv, Kal ioyupov tmavtov, préBa Te KAT ayKava TéuverOa, ciyav TE MS paddLOTA, 308
ON JOINTS, xuix.-t.
of the body cavity tends to adjust the ribs, while emptiness leaves them suspended, and the suspension causes pain. Externally, a simple dressing suffices in such cases, with cerate, compresses and bandages, applying them smoothly with gentle pressure, adding also a little wool. A rib consolidates in twenty days, for callus forms rapidly in bones of this kind.
L. When, however, the flesh is contused about the ribs, either by a blow, fall, encounter, or some- thing else of the sort, we find that many have con- siderable haemoptysis. For the canals extending along the yielding part of each rib, and the cords,} have their origin in the most important parts of the body. Thus we find that many get coughs, tubercles, and internal abscesses, and require plugging with lint ; also necrosis of the rib is found in these patients. Besides, when nothing of this kind occurs after con- tusion of the flesh about the ribs, still these patients get rid of the pain more slowly than in cases where a rib is broken; and the part is more liable to recurrences of pain after such injuries than in the other cases. It is true that many neglect such injuries, as compared with a broken rib; yet such need the more careful treatment, if they would be prudent. It is well to reduce the diet, keep the body at rest as far as possible, avoid sexual inter- course, rich foods and those which excite coughing, and all strong nourishment; to open a vein at the elbow, observe silence as much as possible, dress
1 Nerves.
3°95
40
50
TMEPI APOPON
émideladai Te TO Xwpiov TO Pracbev omrAnvect LN ToAUTTUYOLoL, gUXVvotat Sé Kal TOAD TAA- TUTEpolat TavTH Tod dAdoMATOS, KNPwTH TE Umoxpiew,! oOovioist te TaTéETL GUY TaLVinoL TraTELnTL Kal parOarior émdety, épelderv Te METPLWS, WOTE 1) Kapta memLeyOau pavat Tov ETLOEOELEVOD, fb? 78 av Xahapov" dpxer 0a d€ Tov émiséovTa KaTa TO hrAdopa, Kal épypete Bar TAUTD Hadar, THv Oé emideouy moveia Oar Os amo dvo dpxéov, émedely TE, iva. p41) TEplppeTres TO O€pua 70 Tept Tas TEUpas Ds aD’ ia opporrov’ emsdety O€ 1) Kal’ Exadotny nuépny 1) Tap érépny. duetvov S€ Kal Koltdinv pwardOdEar Kovd@ Tivi Goov KEvwatos EiveKeY TOU GiToVv, Kal él pev déxa Huépas tayvairew, Ewerta avabpéwat To Toa kal amanovar' TH O€ EmLdecEeL, Eat’ ay bev taxy aivys, épnpero nevy feaAXov xpHeear, o omoray be és Toy amahvo pov AYN emixadapwrépy. Kal Nv mev aipa aToTTUaN KatapXas, TEegoapaKov- Onuepov THv weXeTHv Kal THY éTideclY TroLEiT aL xpn" ay be ta) TTVTN TO aipa, dpKet ev elKoow Hmepnow 7 MENETH WS emt TO TOAU’ TH Loxyvi Sé TOD TP@LATos TOUS Xpovous mporexuatpecOat vey. Gao. 8 ay apedrnowot TOV ToOLOVTaY audipracuatwov, iv Kal adddo pundev avtoiar pravpov péSov yevnrat, Spas TO YE Xeptov dudibracbey puEwderrépny THY odpka ioxet 4 mpooev eiyen, émov 6€ TL ToLODTOV éyKaTa- AeleTa, Kal a) ev eEvmovras 7H ye anbéter, pavrdrepov Mev, Iv Tap’ avTo TO daTéoV eyeara- herhO7 TO puE@oes” ovUTe yap ete 4» aapé OMolws anTETaL TOU OaTéOU, TO TE OOTEOV VOTN- 310
ON JOINTS, t.
the contused part with pads not much folded, but numerous, and extending in every direction a good way beyond the contusion. Anoint first! with cerate, and bandage with broad, soft linen bands, making them suitably firm, so that the patient says there is no great pressure, nor on the other hand is it slack. The dresser should begin at the contusion, and make most pressure there ; and the bandaging should be done as with a two-headed roller, in such a way that the skin may not get in folds at the ribs, but lie evenly. Change the dressing every day or every other day. It is rather a good thing to relax the bowels with something mild, sufficiently to clear out the food, and give low diet for ten days. Then nourish the body and plump it up. During the attenuation period, use rather tighter bandaging, but more relaxed when you come to the plumping up. If there is haemoptysis to begin with, the treatment and bandaging should be kept up for forty days; if there is no haemoptysis a twenty-day course of treatment usually suffices. The forecast as to time should be made from the gravity of the wound. In cases where such contusions are neglected, even if nothing worse happens to them, still the tissues in the contused part contain more mucus than they did before. When anything of this kind is left behind and not well squeezed out by the curative process, it is worse if the mucoid substance is left in the region of the bone itself; for the flesh no longer adheres so closely to the bone, and the
1 Cf, Fract. XXI for broxplo.
1 bmadelpew.
ail
70
79
IIEPI APG@PON
potepov yiverat, opaxeto pot Te Ypovioe oatéov ToNNOloL 7160 aro Tov TOLOUT@Y Tpopacior éryévovTo. aTap Kal iv [Ln mapa TO GaTéOV, GAN avr oy) cape pvtwons 7s ops moa tpopat yivovTat Kal oduvat adoTe kal dAdoTe, ay Tes TO THOMATL TUXN Tovyo as: Kal da TOUTO 7 emidécer yphabat XP» apa pev ayady, apa be éml TOAD Tponkoven, ews av Enpavd7 pev Kal avato0n To eKX UVLO La. TO ev TH pracer eryryev0- pevOv, avénOy dé capKt Dyce TO Xwptov, awntat d€ TOU oaTtéou » oap€. oi 8 av apernBeioe xpovewb Kal GouY@dES TO Xe ptov yevntar, Kal 7 oapk Um opv€os Gi* TOUTOLGL KavGLS inows apiorn. Kal ay pev aut) oapé pvEwons 7; aX pe ToD daTéou watew XPN, Kn pay Srabeppav- Oivat TO daTéov" ny O€ peony TOV TEUPOV 7, émiTronh iis fev Ov0E ovT@ xX pn Katew, guraccerbau pevTOL fiay) Siaxavons TEpNY. ay Oe Tpos TO date So0x7 elvat TO prdoua, kal ere veapov nh» Kal pT we opaxerion TO oaTéoy, HV ev kapta odLyOV 7, out Katey vpn Bom Ep elpnTas ny pevroe Tapa pwnkys 7 O MEeTEWPLA [LOS O Kara TO daTéov, mA€ovas €o yapas euBarrew xen" mepl b€ opakedta pov mAeupiys dua TH TOV €uoT@v int pet elpnoerau. LI. “Hy 6é pnpoo apO pov e& ioxtov exTréo Ns exrrim Tet d€ KaTa Téooapas TpOT ous, és bev TO ow TodU TAELOTAKLS, és 6€ TO EEW TOV AO TRELTTAKLS" és 6€ TO OmicOev Kal TO EuTrpocVev exTrimTet pev, ouyaKes bé. oTog oot bev ovv av éx Bn és TO Evo, fea. poTepov TO okédosS paiveTal, mapaBanrn6uevov Tpos TO EtEpor, ia Siaoas Tpo- 1 B Kw, and most MSS. omit 312
ON JOINTS, u.-..
latter becomes more subject to disease. Chronic necroses of bone are found to arise in many cases from causes like these. Besides, even if the mucoid part is not along the bone, but involves the flesh itself, still relapses occur, and periodical pains, when- ever one happens to have bodily trouble; and there- fore one should use bandaging, both careful and prolonged, for some time, till the exudation formed in the bruise is dried up and consumed, the part filled with healthy flesh, and the flesh firmly attached to the bone. In neglected cases which have become chronic, when the part is painful and the flesh rather mucous, the best treatment is cauterising. If the flesh itself is mucous, one should cauterise down to the bone, but avoid greatly heating the latter. If it is intercostal, the cauterisation should, even so, not be superficial ; yet one should take care not to burn right through. If the contusion appears to have reached the bone, and is still fresh, and the bone not yet necrosed, if it be quite small, one should cauterise as directed; but if there is an elongated tumefaction over the bone, one should make several eschars. Necrosis of a rib will be considered along with the treatment of patients with discharging abscesses.
LI. When tke head of the thigh-bone is dislocated from the hip, it is dislocated in four ways, far most frequently inwards; and of the others the most frequent is outwards. Dislocation backwards and forwards occurs, but is rare. In cases where it is displaced inwards, the leg appears longer when placed beside the other, naturally so, for a double
313
10
20
26
10
IIEPI APOPQN
pacvas el oT MS" emt TE yap TO amo TOD ioxtou mepuKos daTéov, TO avo pepopevov mpos TOV KTéva, Tl TOVTO éTiBacis THS Kehadhs Tov pnpod yivetat, Kal 0 avynv Tod apOpov él THs KOTUANS oxetran éEwbév Te av yNouTOs KOtAOS paiveTat, ATE Eo peyaons THS KEPArS TOU penpov, TO Te av Kara TO youu ToD penpod dixpov avayKateTat é&w pémety, Kat ” Kv TEN Kal O Tous OTAUTOS. aTeE oo e&e _PEToUTOS TOU 060s, OL int pol bv ametpinv TOV uyléa 00a _Tpos TobTov Tpoala Koval, ann ov TOUTOV Tpos Tov vyséa: 61a TOUTO TONY paKpoTEpoyv faivetat TO ciWapov Tov vytéos: ToAdkayn Sé Kal GdAAN Ta TOLAUTA Tapacuverw EXEL. Ov pny ovde CUYKauTTELY dwwavtar KaTa TOV BovBdva opotas TO bryeei arap Kal avopérn y) Kepad? Tov pnpov Kara TOV Teptvaov Um eporyKeovoa Edm AOS € €oTw. Ta pev ovv onpeta TAUTA EoTW, OioLY Av Eow EKTETTOKY 0 punpos.
LI. Ofer pév oy af exTrer OV fn eutréon, adnra KatatropnOn Kat * apern Oy, 4 TE dSoutopin mepipopadny tod ocKéd\eos WaoTEp Tolat Poval ylvetat, Kal 1) OyNoLS TAELTTH aUTOLoW emi TOD Uyléos oKédeds éoTw. Kal avayKkalovtat Kata Tov Kevedva Kal KATA TO ApOpov TO éxTETTTWKOS KOiNOL KaL GKOXLOL Elva’ KaTA O€ TO UyLes és TO é&w 0 yAouTOs avayxdbeTtat Trepipepns elvar: et yap tis €Ew TO TOOL TOU VyLEos TKEEOS Baivot, aTwhéot dv TO G@ua TO AdXO €s TO CIWapoY oKEéXos THY OXNaW TroLeiacbat' TO Sé GLVapoY ovK
1 xal =}. Cf. Thucyd. II. 35, 314
ON JOINTS, u1.-.n.
reason ; for the dislocation of the head of the femur takes place on to the bone arising from the ischium and passing up to the pubes, and its neck is sup- ported against the cotyloid cavity.t Besides, the buttock looks hollow on the outer side, because the head of the femur is turned inwards ; again, the end of the femur at the knee is compelled to turn out- wards, and the leg and the foot likewise. Thus, as the foot inclines outwards, practitioners through inexperience bring the foot of the sound limb to it, instead of bringing it tothe sound one. This makes the damaged limb appear much longer than the sound one; and this sort of thing causes misappre- hension in a variety of other ways. The patients, moreover, cannot bend at the groin so well as one with a sound limb; and for the rest, on palpating the head of the femur, it is manifest as an abnormal prominence at the perineuin.? These then are the signs in cases of internal dislocation of the thigh. LI. In cases where the dislocation is not reduced, but is given up or neglected, progression is accom- plished, as in oxen, by bringing the leg round ; and they throw most of their weight on the sound leg. They are also of necessity curved in and distorted in the region of the loin and the dislocated joint, while on the sound side the buttock is necessarily rounded outwards. For if one were to walk with the foot of the sound leg turned out, he would thrust the body over, and put its weight on the injured leg ;
1 7.¢, lower rim of the acetabulum ; so Littré, Pq. Adams suggests the perforation below the pubic bone (thyroid). As already remarked the frequency and nature of this dislocation are hard to understand.
2 Evidently understood in a wide sense, to include inner part of groin,
345
30
40
IIEPI APOPON
av Suvarto oxety" TOS yap; avaykaberat on oT® KaTa TOD vytéos oKENEOS T TOOL éow Baivew, anrra ry) eco" ovTe yep oxel padiora TO oKENOS To uryees Kal TO éwuTOU [Epos TOU TOMATOS Kal TO Too owapov oKENEOS HEpOS. KOL- Nawopmevot b€ Kara TOV KEve@VA Kal KATA Ta apOpa, cptKxpol paivovrat wat * avrepeider Oar avayKalovTar mharyvot KaTa TO vyees oKéhos® OcovT aL yap QT LKOVTWTLOS TaUTY éml ToUTO yap oi yAouToL péTrovar, Kal TO ax Gos TOU TH LATOS oxetrar” em TOTO. dvayxatovrar bg Kal ET LKUTTELY THY yap xeipa THY KATA TO oKE)Nos TO oLvapov avayKatovrat Kara maryvov TOV penpov épetdew® ou yap dvvatTat TO oivapov oKENOS oxely TO capa ev TH peTadrayy TOV OoKENEWY, ae to) KATEXNTAL 7 pos TY yn mee lo- pevovy. €v TotovTotar® ovv Totoe ox Mae Wy dvayKalovrat eoxnpatiabas, olow av éow éx Bay TO ap pov 1) EMTETN, ov mpoBovrevoavros wee avOpwomou OTrws av pniota eo KNMAT La WEVvOV 4 7, GXX’ avr?) 7) TuLpop) Sudden ex TOV TapeovTov Ta pyiota aipeia an, emel Kal omrogou® éXKos EXOVTES év Tool 7) Kvn ov KapTa dvvavtat émtBaivew T@ OKEXEL, TavTeEs, Kal ob vnT LoL, oUT@S ddovmopobaw" éEw yap Baivover Ta owa- p@ oKéreu’ Kal ouooa Kepoatvovar, duoody yap d€ovTat’ TO TE yap Tama ovK oxetraL omotws emt TOU ef arroPatvopéevov @omep él Tod éow’ ovoe yap KaT iOveopinv auT@ yiveTat TO ax Gos, GNX TOAD Harrop él TOU vroBawopévou" Kat iOvepiny yap avT@ yiverat TO ax Gos, é €v TE auth TH OdolToptn Kal TH peTadrAayH TOV oKEdéwv. 316
ON JOINTS, tt.
and the injured limb could not carry it. How should it? He is thus obliged to walk with the foot of the sound leg turned in and not out; for in this way the sound limb is best able to carry both its own share of the body and that of the injured one. But, owing to the inward curvature at the loin and at the joints, they appear short, and patients have to support themselves laterally on the side of the sound leg with a crutch. They want a prop there, because the buttocks incline that way, and the weight of the body lies in that direction. They are also obliged to stoop; for they have ta press the hand on the side of the injured leg laterally against the thigh, since the injured limb cannot support the body during the change of legs, unless it is kept down on the ground by pressure. Such then are the attitudes which patients are obliged to assume in unreduced internal dislocation of the hip—not as a result of previous deliberation by the patient as to what will be the easiest attitude; but the lesion itself _ teaches him to choose the easiest available. So too those who, when they have a wound on the foot or leg, can hardly use the limbs—all of them, even young children, walk in this way. They turn the injured leg out in walking, and get a double boon to match a double need ; for the body is not borne equally on the limb brought outwards and on that brought in, since the weight is not per- pendicular to it, but comes much more on the limb that is brought under; the weight is perpendicular to the latter both in actual walking and in the
1 tbAm to K. 7g tdAm Littré. Pq. omits. 2 eyKeirat. 3 roUTOLOW, * éoxnpmatiopuevos. ® gc01.
37
50
60
70
IIEPI AP@PQN
€v TOUT@ 7@ oXnwaTL Wiel Site av duvaito U vTro- TiOévar TO vryLes oKERoS, jv TO poe cwap@ efor épw Baivot, TO S& bycéi eTwTEpO. mepl ou ovv oO Aoyos, dryabov evpioxer Oar avTo EwuT@ TO copa és Ta pyniota TOV oXNMATOV. dooce pep oby pyT TETENELO[LEVOLT LY €& avenow eXTET OY ra) eum eon, yurobrat 0 Hnpos cal un KU NEN Kal 0 TOUS’ OUTE yap Ta OoTéa és TO pcos OMOLWS avfetat, adda Bpaxyvtepa yivetat, wariota é TO TOD pNpod, doapKoV Te ATav TO oKédos Kal duvov Kal exteOnrAvaopevov Kal AerTOTEpOV yiveE- Tal, dua pmev Ova THY oTépnow THs Kops TOD ap@pov, dua bé€ Ste advvatov Xphio Pat eo, étt ov Kata puow KelTaL’ yphous yap jeTe- Eerépn preva Tis ayav éxOndvvovos puera bé TL Kal THs el whKOS avavEnaos. KaKoDTaL ev ov partota olow av év yaotpl éodow é€ap- Opyon tovTo TO apOpov, SevTepov Sé olaw av ws UNTLM@TATOLOLY EovaLY, HKLaTAa O€ TOLoL TETEAELW- Hévotolv. Toicl wey OvY TETEAELWpLEVOLOLY ElpNnTaL olin Tis H OdoLTrOpin yiveTat’ olot 8 av vyTOLOL €ovaly 7) cUupop? AUTH YyevNTaL, OL pev TAELOTOL KkataBraxevovar? thv dS10pbwctv Tod awpaTos, anna [kaxas]* elA€ovTat emt TO wryees oKEROS, ™ xerpl pos THY yHVv am epedouevor 7H Kara TO uyles TKEXOS. cataBhaxevovor dé évioe TI és opOdv odoitropiny Kal olow av TeTEeLwpévotce abtn » cupdopy yévntat. omoco. 8 av vyrrtiot €ovTes TaVvTH TH ouupopH KXpyocapevor OpOas Tadayoynbéwar,* TH ev WyLéi oKéreL ypéovTar® és opGov, bmd dé Thy pacyadny Thy KaTa TO
1 2
ei. KaTauBArakevovor bis.
318
ON JOINTS, tn
change of legs. It is in this attitude, with the injured leg rather outwards and the sound one rather inwards, that one can most rapidly put the sound limb under. As regards our subject, then, it is good that the body finds out for itself the easiest posture. When it is in persons who have not yet completed their growth that the hip remains un- reduced after dveinention the thigh is maimed, and the leg and foot also. The bones do not grow to their normal length, but are shorter, especially that of the thigh; while the whole leg is deficient in flesh and muscle, and becomes flaccid and attenuated. This is due at once to the head of the bone being out of place and to the impossibility of using it in its abnormal position; for a certain amount of exercise saves it from excessive flaccidity, and in some degree prevents the defective growth in length. Thus the greatest damage is done to those in whom this joint is dislocated in ulero; next, to those who are very young ; and least to adults. In the case of adults, their mode of walking has been described ; but when this accident occurs in those who are very young
for the most part they lack energy to keep the body up, but they crawl about [miserably] on the sound leg, supporting themselves with the hand on the sound side on the ground. Some even among those to whom this accident happens when adult lack the energy to walk standing up; but when persons are afflicted by this accident in early childhood and are properly trained, they use the sound leg to stand up
3 Kw. omits; also B and the best MSS. 4 Kw.’s correction for ratdaywyndaor codd. ® xpéwvTa Kw.
319
80
83
10
20
TTEPI APOPON
¢ \ lA , / , bytes oKEAOS CKIT@VA TEpLpépovoL, peTEEETEPOL Me fal A Sé kal bm’ auhotépas Tas Yeipas’ TO S€ oLvapov oKéXoS peTéwpov éyovot, Kal Todo’T@ pyiovs v4 3 a calv, dam av avtoisw éaccov TO oKédoS 70 \ > a cwapov 7 TO be bytes ioxver avToiow ovdev > 4 c fooov i) ef Kal ahotepa Uytéa Hv. OnddvovTat lal nr if n 5€ aot Tolat TOLOVTOLGL Ai GapKEs TOV oKE)EDS, ta if 7 Lea Coy } X pearrov S€ Te OndUvovTat at Ex TOV EEW pEpEosS 1} al €k TOD €ow ws ert TON. la) e LITT. MvOoroyotar! Sé tives, 6tt ai’ Apafovi- lal / Ses TO dpoev yévos TO éwuTa@Y a’Tixa VvyTLOV éov >? Q A e \ \ \ 2 , e be é£apOpéovowy, ai wev Kata [Tal youvata, at oé SN G n kata Ta loxta, ws di0ev Yara yivorto, Kat pr €muBovrevot TO dpoev yévos TO Ondevr Yetpwvatw € , dpa TovToLoL ypeovTat,® oTrdca i) aKUTELNS Epya 7} yanrkeins, 7) GAO TL ESpaiov Epyov. el pev ody r ‘s} e adnbéa tadta é€otw, éyw pev ovK olda: Ott Sé b) n / yivorto av Toladta oida, ei Tis eEapOpéot avTixa , \ vijria eovTa. Kata pev odv Ta icxia péfov TO / 4 > ? Nee A Si ? a 4 Sudhopov eat és TO ecw 7) &s TO Ew eEapOpioar \ / » , Kata Sé Ta youvata Siadéper mév TL, EXaccop OE a , tu Staépet. Tpomros d€ ExaTépov TOD Kw@paTos ’ na r Suds €o tiv’ KUANODYTaL 4 ev yap WadXov olaw av > Wo? p) , ’ \ \ ® A és TO &&w eEapOpynon: opbot dé Haocov totayTat 3 ) 4 olow dv és To €ow eEapOpyncn. woavtas bé cal A \ \ \ > / BN \ b) NaS, jy wapa to odupov éEapOpyon, iv pev és TO Ew I, pépos, KUAXOL ev yivovTat, Ectavat Sé Svvavtar* \ » / ty 8é és TO gow pépos, Braicol pev yivovTat, K , hocov 6€ éotavat OUvavTat. Hye wy cuvavEnors nr in) x \ \ TOV doTéwy TOInde yiveTat olot wey AV TO KATA TO 1 MuOodroyéovor Kw. 2 Littré’s insertion, but Galen also has it. 3 xpéwvTa Kw. 4 Erm. Pq. for yuotrvra vulg. 320
ON JOINTS, wun—wiu.
on, but carry a crutch under the armpit on that side, and some of them under both arms. As _ for the injured leg, they keep it off the ground, and do so the more easily, because in them the injured leg is smaller; but their sound leg is as strong as if both were sound, In all such cases the fleshy parts of the leg are flaccid; and, as a general rule, they are more flaccid on the outer than on the inner side.
LIII. Some tell a tale how the Amazons dislocate the joints of their male offspring in early infancy (some at the knees and some at the hips), that they may, so it is said, become lame, and the males be in- capable of plotting against the females. They are supposed to use them as artisans in ali kinds of leather or copper work, or some other sedentary occupation. For my part, I am ignorant whether this is true; but I know that such would be the result of dislocating the joints of young infants. At the hips there is a marked difference between inward and outward dislocation; but at the knees, though there is a certain difference, it is less. In each case there is a special kind of lameness. ‘Those in whom the dislocation [at the knee] is outwards are more bandy-legged, while those in whom it is inwards! are less able to stand erect. Similarly, when the dis- location is at the ankle, if it is outwards, they be- come club-footed,? but are able to stand; while if it is inwards, they become splay-footed, and are less able to stand. As regards growth of the bones, the following is what happens: when the bone of the
1 7,c. the knock-kneed.
2 J.e. leg outwards and foot inwards, and vice versa, The knock-kneed and splay-footed are worse off than the bandy- legged and club-footed.
225 VOL. IIL M
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IIEPI APOPOQN
a pupov oaTtéov TO THs revnuns * EKOTH, TOUTOLTL pev Ta TOU T0008 0 oaTéa Heora ouvavgerat, TavTa yap eyyuTata TOU TPOLATOS: éoTw, Ta € THS KUNENS dare avbera pév, ov odd 6é evdeer- TEPOS, ai HEVTOL odpKes pvvdover. olot & av Kata bev TO a pupov pLevn TO pO pov Kata pvour, Kara dé TO yovu e€eaT ky, TOVTOLGL TO Tis Kv} mans datéov ovK eGérXer cuvavEdverOat opoiws, adrra Bpaxutepov ylveTal, TOUTO yap éyy”’TaTw TOD TPOMATOS cor, TOU pEvToL mo60s Ta OoTéa puvvber pen, arap ovx ojolws, OoTrEp odiyov TL mpoabev elpnTat, ote TO apOpov To Tapa Tov TOba o@ov €oTt. e S€ of ypnoOat nOvvaVTO, woTEp KALT@ KUAXO, ETL av yo cov end0er Ta ToD moos oaTéa TOUTOLO LW. olat & av Kata TO ia xtov a eEdpOpnous yévnTat, TOVTOLOL TOD pnpod TO oar éov ovx éOéder ovvavEaver Oar opoles, TOUTO yap eyyuTato TOD TpwpLaTOos early, arXra Bpaxurepor TOU UryLeos yivera® TA [LeVTOL Tis KV LS oaréa ovx Omolws TOUTOLOLY avav fa ylverat, ovee Ta TOU 70805, oa TovTo 6é, 6 OTe TO Tov pnpod a pO pov TO Tapa THY Kv pny ev TH éourod dvcet pEvel, Kal TO THS KYnLNS TO Tapa TOV Toba: TapKES EVTOL puvvOovet TavTos TOU aKéXEOS TOUTOLOLY. el pévToL Xpielar TO OKENEL ouvarTo, éTe av paddov Ta OoTEA aumbtavero, WS Kal mpoabev elpnTat, miv TOU pnpod, Kay Ho oov acapKa ein, agapKorepa dé TOAD ” eb bryvéa Hv. onpetov dé éTe TadTa Toward eoTiv' OTOGOL yap, TOU Spa- ylovos éxmecdvTos, yahidyKwves éyér0vTO €K ryevens, » Kal ev avénces mpl? TererwOFvat, ovToL TO Mev OoTéoV TOD Bpaylovos Bpaxv iayouat, Tov 322
ON JOINTS, cut.
leg at the ankle is dislocated, the bones of the foot show least growth, for they are nearest the injury, but growth of the leg-bones is not very deficient ; the tissues however are atrophied. In cases where the ankle-joint keeps its natural position while there is dislocation at the knee, the bone of the leg will not grow like the other, but is shortened ; for this is nearest the injury. The bones of the foot are atrophied, but not to the same extent as was noticed a little above, because the joint at the foot is intact ; and should they be able to use the part, as is the case even in club-foot, the bones of the foot in their case would be still less atrophied. When the dislocation occurs at the hip, the thigh-bone will not grow like the other, for it is nearest the injury; but it gets shorter than the sound one; the bones of the leg, however, do not stop growing in the same way, nor do those! of the foot, because the end of the thigh- bone at the knee keeps its natural place, also that of the leg at the foot; but the tissues of the whole leg are atrophied in these cases. But if they were able to use the leg, the bones would correspond in growth to a still greater extent, the thigh excepted, as was said before; and they would be less deficient in flesh, though much more so than if the limb were sound. Here is a proof that these things are so: those who become weasel-armed owing to dislocation of the shoulder either congenitally or during adoles- cence, and before they become adults, have the bone of the upper arm short, but the forearm and
1 This is curious phrasing. Cf. remarks on the astragalus in Introduction and notes on ankle dislocation, Jochl. XXX.
2 kal mply Kw,
323
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TIEP] APOPQN
dé mixyy Kat chepny THY xelpa odiy@ evdceaTépny Tob wyLéos, ovat TAUTAS Tas mpopuctas Tas eipy- pevas, Oru 0 pev Bpaxiov éyyutatw [Tov apO pov] TOU TPO Lat os eoTU, @aoTE OLA TOUTO Bpaxvrepos eyévero" o dé av Thyxus oa TodTO _OvxX opmolws évaKxovet THs cuppopiys, OTL TO ToD Bpaxiovos apOpov * TO Tos Tou TIXEOS év TH dpxain pvoet MEVEL, n Te av xelp aKpn éTe THAOTEPW area tw aD 0 Tixus amo THS ouppopiys. 61a TAUTAS ovv Tas elpnuévas Tpopactas, TOV baTéwY Ta TE pn cuvavéavoueva ov cuvavEdvetal, Ta TE TVVAL- Eavopeva ovvavEdveran. és 6€ TO evoapKov 7H xecpl Kal TO Bpaxtove o) TadauT@ptn THIS XELpos péeya mporwpenel dca yap XeLpav Epya éoTl, Ta TrELoTA TpOOUmEOVTAL Of yadLayKwves épyater Oat TH YElpt TavTyn, doa Tep Kal TH ETEpN SUVaYTAL ovdev évdeerTépws THs aawéos’ ov yap Set Oyeta Oar TO c@pa él TOV YeLpa@V ws etl TOV TKEAEWY, GANA Kodha avToict Ta Epya eotiv. Sta dé THY xXenow ov pvodovow ai oapKes at Kara THY cipa Kal KaTa TOV ThYUY ToloL yadidyKwou" GANA Kal o Bpayior TL Tpoowpeneira és evoap- Kin bua tadra* dray o¢ i io xtov exTAaNes yevnrau és TO éow /Epos éx yevens, ) Kal €TL VNTriO cote, puvddovow at adpKes bua TOvTO HGOV } THS HELPOS; OTL OU duvavTau xpiiaeae T@® KEEL, apTuplov éy3 dé Te évéo rae Kal év Tolow odtyov batepor elpnoomévotct, OTL TAUTA TOLADTA éoTLV. LIV. ‘Ordcotor® & av és TO &Ew 4 TOD pNpodD Kepars xy, TovTOLat BpayvTEpov ev TO TKENOS
1 yavrTyny. 2 Kw. omits. ® Oict.
324
ON JOINTS, wnt-tiv.
hand little inferior to those on the sound side, for the reasons that have been given, viz., that the upper arm is nearest the injury, and on that account is shorter.1 The forearm, on the contrary, is not equally influenced by the lesion, because the end of the humerus which articulates with the ulna retains its old position. And the hand, again, is still further away from the lesion than is the forearm. For the aforesaid reasons, then, the bones which do not grow normally are defective in growth, and those which do grow maintain their growth, Manual exercise contributes greatly to the good flesh-development in hand and arm, In fact, taking all sorts of handiwork, the weasel-armed are ready to do with this one most of what they can do with the other arm, and Jo the work no less efficiently than with the sound limb ; for tt is not necessary for the body weight to be supported on the arms as on the legs, and the work done by them [i.e. the weasel-armed]? is light. Owing to use, the flesh of the hand and forearm is not atrophied in the weasel- armed ; and even the upper arm gains some further development from this. But when the hip is dis- located inwards, either congenitally or in one still a child, there is more atrophy of flesh than in the arm, just because they cannot use the leg. A special piece of evidence that this is the case will be found in what is about to be said a little below.
LIV. In cases where the head of the thigh-bone is dislocated outwards, the leg is seen to be shorter,
1 Kw. puts rod &pepov in brackets. It appears a needless gloss.
* Littré, Adams, Erm. read abrfot and refer it to the hands. But hands and arms may do hard work.
325
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18
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IIEPI APOPOQN
paiveras TapaTelvomerov Tapa TO Erepov, eixoTos" ov yap. eT daréov um emiBaous THS Keparijs ToD pnpow éoTiv, a OTe éow exTr em TOKED, anna map baTéov TapeyKerALmevny Ty pvow ¢ Evov, eV capK dé otnpiferar & oyph Kal wTetxoven’ oud ToUTO pev Bpaxurepov ghaiverar. écwlev é 0 pnpos Tapa THY TALK dba ico ey ye KOLNOTEPOS Kal aoap- KOTEPOS paiverar'* éEwbev O€ 0 yhouTos KUPTOTEPOS, ate €s TO €EwW THs Keparhs TOD uNnpod @dia OnKvins* aTap Kal avwrépw paivetat 0 yAouTOS aTE UTrEL- Eaons TAS. capKosS THS. evTadba 77 TOU pnpod cepari TO 6€ Tapa TO youu TOU pnpod. axpov éow pérov paiverat, Kal 1) Kvn Kal 0 Tous ATAP OVOE GUYKAUTTEL WaTEP TO UyLes TKEAOS Svvavta. Ta pev ovv onucia tavta Tov é&w EKTETTWKOTOS [LN POU Elaiv.
LV. Olon poev ov av | TeTEhEL@mevorgrty non ex Treg ov TO ap 0 pov pay éutréon, TOVTOLCL Bpaxure- pov pev paiveras TO oupTay oKkéXos, ev 6€ TH odolTropin TH ev TTEpVy ov SuvavTaL xabuxveto- Oat [eri]? THs ys, Te Sé€ oryPer Tov Todos Batvovot él tHy yhv: odtyov Oé és TO Ew Epos pémovat Tolat SaxTUNOLTL AKpotowy. OXElv é dvvatat TO copa TO ouvapov oKéhos ToUToLaL TOAD Haddov 0) olow a av és TO éow HEpOS EXTEE- TTOKN, dua fev OTL 1) xepann Tov pnpod Kal 0 avxiy ToD apOpov mAdryLOs pucer TEPUKWS ume TUX péper Tob iaxiov THY vrootacw meToin- Tal, dua é Ott aicpos 0 TOvS OUK és TO Ew pépos avaryKaverat exxexhio bat, ann’ eyys THS iOvmpins THS KATA TO Opa Kal Telver Kal EcWTEPwW. OTAV ovv TpiBov péev Nay TO apOpov ev TH capKt €s iv 326
ON JOINTS, tiv.—tyv.
when put beside the other. Naturally so, for it is no longer on bone that the head of the thigh-bone has its support, as when it was displaced inwards; but it lies along the natural slope of the hip-bone, and is sustained by soft and yielding flesh ; wherefore it is seen to be shorter. The thigh on the inside at what is called the fork appears more hollow and less fleshy, while the buttock is rather more rounded on the outside, since the head of the bone is displaced outwards; besides this, the buttock is seen to be higher, since the flesh at that part gives way before the head of the thigh-bone. But the end of the bone at the knee is seen to turn inwards, and with it the leg and foot; for the rest, they cannot bend it in the same way as the sound leg. These then are the signs of dislocation of the thigh outwards.
LV. In cases of adults, when the joint is not reduced after dislocation, the whole leg is seen to be shorter; and in walking they cannot reach the ground with the heel, but go on the ball of the foot, and turn the toes a little inwards, But the injured leg can bear the weight of the body much better in these cases than where there has been dislocation inwards, partly because the head and neck of the thigh-bone, being naturally oblique, have got a lodging under a large part of the hip, and partly because the foot is not obliged to incline outwards, but is near the vertical line of the body, and even tends rather inwards. As soon, then, as the articular part forms a friction-cavity in the flesh where it is
1 viverau. ? Omit B Kw.
30
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éFexrlOn, » 5é capE yroxpav0j, avedvvov TO Xpove yiverar Stay 5é av@duvoy yévntat, Svvav- Tal ev OdoTropely avev EVO, HY ddAws BovAwD- tat: Svvavtas 6€ oyely TO THma etl TO oLWapov oKédos. 1a ovv THY Yphaw haocov Toict To.ovToLaL exOnAVVOYTAL ai TapKES 7) OloLY OXiYOV mpoabev elpntar: éxOndrvvovtas Oé 7) TAélov éXacoov: wadrdAov bé Te €xOndXvVvovTaL KaTa TO ésw pépos 7) KaTa TO éEw ws él TO TOAV. TO pévToe UTTOOnma peTeEéTEpoL TOVTwY UTrobeia bat ov dvvavtat, dia THY akapTinv Tov oKédeos, ol bé tives Kal OvvavTat. oicw 8 av ey yaorpl €ovow eEapOpyon TOUTO 70 dpO pov, i) ere ev avinoet éovat Bin éxtrecov pa) éuTréon, 7) ral UTO vovcou eEapOpryon TOUTO TO a pOpov Kal exTrahnon—
TON yep TOLAUTA yiverat—Kal evo ev TOV TOLOUTOD aye emiapaxeion 0 pnpos, éuTrunuaTa Xpovea Kal Emporia. yiverat, Kal ooTéwy proates eviota iy opmolws Sé€ Kal olow emia paxe)tler Kal olat pr émiohaxedtver, Tov punpovd TO oatéov TONND Bpaxvrepov yiverat, Kal ouKx eOéXee cuvavéerdau adomep Tod _ Uyeeos: Ta HEVTOL THS KY LNS Bpaxvtepa ev yiverat TA THS ET épys, ONiyw O€, dla Tas avTas Tpopaaras at Kal m™ poo bev elpyy Tac: odour opety TE dvvavrat ob TOLodTOL, ol pév Ties avT@Y TOUTOV TOV TpoTrov MoTEp OloL TEeTEACLWméevoLoW eEETETE Kal ph évétrecev, of S€ Kal Baivovor pev travtl 7 Tool, Stappémovar be év THoe odoumopinaw, avayKa- Coeiot b1a THY Bpaxurnra Too TKENEOS. TavTa d¢€ 1 rovadta yivetat, iv éripedéws peéev Taoayo- ynbéwow? év toicr oxnpace Kal dopOas év oice 328
ON JOINTS, tv.
dislocated, and the flesh gets lubricated, it in time becomes painless; and when it becomes painless, they can walk without a crutch, at least should they wish to do so, and can put the weight of the body on the injured leg. Owing to the exercise, the flesh becomes less flaccid in such cases than in those mentioned just above; yet it does get more or less flaccid; and asarule there is rather greater flaccidity on the inner than on the outer side. Some of these patients are unable to put on a shoe, owing to the stiffness of the leg; but some manage it. In cases where this joint is dislocated before birth, or is forcibly put out and not reduced during adolescence, or when the joint is dislocated and started from its socket by disease—such things often happen—if necrosis of the thigh-bone occurs in some of these eases, chronic abscesses are formed, requiring tents ;+ and in some there is denudation of bone. Likewise, both where there is and where there is not necrosis of the bone, it becomes much shorter, and will not grow correspondingly with the sound one. The bones of the lower leg, however, though shorter than those of the other, are but slightly so, for the same reasons as those given above. These patients can walk, some of them in the aforesaid fashion, like adults who have an unreduced dislocation; while others use the whole foot, but sway from side to side in their gait, being compelled to do so through the shortness of the leg. But such results are only attained if they are carefully instructed in the correct
1 /.e, drainage apparatus.
1 névro Kw. 2 Kw.’s correction.
329
50
60
10
18
IIEPI APOPOQN
Se?, mplv xpaturOfjvar és thy odovtopiny, ért- peNews O€ Kal OpOAs, env KpaTUVO@aLY. TAELTTNS dé emewenetns déovTat olow av VT LOTaTOLTLY éovow airy ” cuppopry yeuntae av yap ded Pact vaymrvoe éovTes, axpniov TAvTaT Act Kal avav&és Gov TO oKédos yiverat. ai dé capKEs TOU dUuTravTOS aKéXEoS pLVvvVOoVGL MaAXoV 7) TOD Dryeos" T avy pev TOG oO COv TOUTOLCL pwvbovar H Olol av éow exTrETTOKN, dia THY YpHow Kal TH TahaiT@piny, olov ev0éws Svvacbat xpho Pat T® KERNEL, @S Kal TpooOev orALyw TreEpl TOY yaday- K@veov elpnTat.
LVI. Eioi 6é tives, av Toto. pméev ex yevens avtixa, Tolae dé ral Umro vovcov dmporépov TOV oKehewv efeorn Ta apo pa és TO é&m pépos. TOUTOLoW ovv Ta pev doTéa Ta’Ta Tabypata TacyYel ai mevTo. cdpKes HKiota €xOndUvovTat Totat TovovToow" evoapKka’ bé Kal Ta oKédrea ylveTat, TANY €l TL Apa KATA TO ~owW Epos édReiTroe” drdiyov. 81a TodTO be evoapKa éoTlv, Ore apporépoiar Toiae TKENETL opotes » XpPHots ylvetat’ opotws yap aanrevovolv év Th odovmopty év0a Kai évda: efexeyAouror dé ovToL ioxupas paivovrar® ola THY exo Taow TOV apOpov. HV O€ bn eTiopaKenton avToior Ta baTéa, pndé KUdol avotépw Tov icxiwv yévevtat—evious yap Kal ToLlavTa KaTadauBaver—hv ovv pn ToOLOUTOY TL yéevntar, ikavas wyinpol Tarra Scapépovtar’ avav&taTepot mevToL TO TAY Toma OvTOL yivov- Tal, may THS Kepanris.
LVII. ’Ocorar & av és Touma bev a) cepary Tov punpov éexmréan—Oorlyooe é éxmimTEt—ouvToL 330
ON JOINTS, tv.-tvu.
attitudes before they have acquired strength for walking, and carefully and rightly guided when they are strong. The greatest care is required in cases where this lesion occurs when they are very young ; for if they are neglected when infants, the whole leg gets altogether useless and atrophied. The flesh is attenuated throughout the leg, compared with the sound one; but the attenuation is much less in these cases than where the dislocation is inwards, owing to use and exercise, since they can use the leg at once, as was said a little before concerning the weasel-armed.
LVI. There are some cases in which the hip- joints of both legs are dislocated outwards, either immediately at birth or from disease. Here the bones are affected in the same way as was described, but there is very little flaccidity of the tissues in such cases; for the legs keep plump, except for some little deficiency on the inner side. The plumpness is due to the fact that both legs get exercised alike ; for they have an even swaying gait to this side and that. These patients show very prominent haunches, because of the displacement of the hip-joints; but if no necrosis of the bones supervenes, and they do not become humped above the hips—for this is an affection which attacks some—if nothing of this sort occurs, they are distinguished by very fair health in other respects. Still, these patients have defective growth of the whole body, except the head.
LVII. In cases where the head of the thigh-bone is dislocated backwards—this is a rare dislocation—
1 Gua yap etioapKa. 2 éadelres. 3 al parBol of unpo.
33
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ITEPI APOPOQN
b) tA b] 7 \ I LA \ \ éexTavvew ov Svvaytat TO oKEéXOS, OUTE KATA TO Yj \ \ N ap0pov TO €xTEcov OUTEe TL KapTAa KaTa THD ’ , ¢ an iyvinv' aAXN HKiotTa TOV exTTAaANTiwY OUTOL lal 1 ’ / \ \ \ \ lal [warXAov]! extavvovet Kai TO KaTAa Tov BovBova N » Kat TO Kara TH iyvony ap pov. _TMporauvievat peév ovv Kal 700€ xXp—evx po Tov yap Kal ToAXOD aEvov €oTl Kal TOUS TAelaTOUS AOer—Ore ove vylaivovtes OUvavTa KaTa THY tyvUNnY éxTaVUeELY \ lj \ 4 ‘
TO apOpov, Hv pn) cUVvEeKTaVUTwoL Kal TO KaTa \ fal ” \ x \ 4 + tov BovBava apOpov, ANY hv pn Tavu avo
BJ 7 \ “ ¢ SY , / aeipwot Tov Toba, OUTW 8 av SvvaLWTO: Ov ToLVUY \ 4 \ \ ovoé auyKxauTte Sivavtat TO KATA THY iyvUnv ” e / ’ \ \ , X\ \ apOpov omotws, AAAA TOAD YareTwTEPOY, HY [LI \ n auyKkapwot kal TO KaTa Tov BouBava apOpov. \ \ \ ” \ \ a / mo\v\a 6€ Kal AANA KATA TO Dua ToLavTAS / 5) \ \ te aderditias EXEL, Kal Kata veupeov ouyTaolas \ a s Kal KATA pUOV TXHUATA, Kal TreloTd TE Kal / TNELT TOU asia ywockes bat OS TU olerat, \ Kal KaTa THv ToD évTépov vow Kal THY THS \ n / ouumdons KoLrins, Kal KaTa Tas TOV VaTépwV \ mravas Kal cuYTadclas AANA Trepl pev TOUTWY CF, ” > / lal r éTEpwOt ROYyos EaTat HOeApiapévos ToloLt VoD € / Aeyouevoiot. epi ov O€ oO AOYyos éoTiv, OUTE exTAVUEW owvavrat, BaTep non elpntat, Bpa- XUTEpov Te TO TKENOS paiverar, 61a diaoas T po- paras: OTL TE OUK exTav vera, ore Te ™ pos THY capka wriaOnxe TV TOD TUyalov: yap ducts rn a \ rob loxtov ToD OaTéov TavTy, H Kab n KEepary Kal o avyny TOU Npod yiverat, oTav O€ eEapO pion, Karadepis Tl _mepuKev emt TOU muryatov TO efeo pépos. ouykaTTew pévtoe OvvavTat, OTaV 442) « ? A / e \ 7 OOUVN KwAUY* Kal H KVYHLN TE Kal O TrOVS OpPa
332
ON JOINTS, tyvu.
the patients cannot extend the leg at the dislocated joint, nor indeed at the ham; in fact, of all dis- placements, those who suffer this one make least extension, both at the groin and at the ham. One should also bear the following in mind—it is a useful and important matter, of which most are ignorant— that not even sound individuals can extend the joint at the ham, if they do not extend that at the groin as well, unless they lift the foot very high; then they could do it. Nor can they as readily flex the joint at the ham, unless they flex that at the groin as well, but only with much greater difficulty. Many parts of the body have affinities of this kind, both as regards contraction of cords and attitudes of muscles; and they are very numerous, and more important to recognise than one would think, both as regards the nature of the intestine and the whole body cavity, also the irregular movements and contractions of the uterus. But these matters will be discussed elsewhere in connection with the present remarks. To return to our subject—as already observed, the patients cannot extend the leg, also it appears shorter, for a double reason; both because it is not extended, and because it has slipped into the flesh of the buttock; for the hip- bone, at the part where the head and neck of the femur lie when dislocated, has a natural slope towards the outer side of the buttock. They can however flex the limb, when pain does not prevent it; and the lower leg and foot appear fairly straight,
2 Omit Galen, Littré, Erm. 333
40
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IIEPI APO@PQN
émieik@s paivetat, Kal ovTEe TH ovTE TH TOND exKEKNLMEVa" KATA be TOV BovBava doKet Te a) cape Aatraporépy etvar ToTl Kal avopevn, are TOU apOpou € és Ta éml Oarepa pépn @daOyKOTOS" KaTa O€ AUTO TO TUYyaloy Statpavopevn 1) KEpary Tob ppov doKel TL eEoyKeiy Kal MadXov. Ta ev ouv onpeta TaiTa €oTW, @ av €> TO OmicOev eKTETT@KN O pps.
LVIII. “Orep fev ouv av TETEAELOLEVD 8m ex Treo OV pa) euTeaN, odormopetv jee Sivarat, 6 otav 0 Xpovos éyyévntat Kal n odvYNn TavanTal, Kal €0ic047 TO apOpov év TH capKl evotpwhacbat. avayxafeta, pevtoe ioyupas ocuyKkaurrte! KATA TOUS BovBavas odortropéwy,” dua Suroas mpopdcvas, dua per ore TONN@ Bpaxvrepov TO TKENOS yiveras dua TA Tpoelpnuéva, Kal Th Hey TTEPVH Kal Tavu TOAXOU Seitat Waverv THS ys? él yap Teipyaatto Kal én’ odrjLyov TOD Todé0sS oxnOivat, pnodevi are avteaTnprtopevos, és TOUTLoW av TédoL' 1 yap porn TONMI) ay ein, TOV ioXi@v émi modu és TovTiow Umepexovtov brép Tob 7060s THs Baotos Kal TIS patxvos és Ta iaxta pemovons. pods 6€ TO ot7OEL TOD Todds Kabixvettat, Kal ovde OUTS, HY [1 Kaun AUTOS EwUTOV KaTa TOUS BouBavas, Kal TO éETEpw oKENEL KaTa THY tyvUny éritvyKau ny. él dé TOUTOLOLY avayKxaleTar WOTE TH YELpl TH KATA TO oLVApOV aKéXos épeidec0ar és TO Avw TOU pnpod ed’ éxaoTn cupBdace. avayKater odv TL Kal TOUTO avTo WoTe KauTTETOaL KaTAa To’s BovBavas: év yap TH meTadrayH TOV oKErAgwV Ev TH OdoLTrOp’n
L ouyKkaumrTov. ® §doimopeiv.
334
ON JOINTS, tvu.-Lvitt.
without much inclination to either side. At the groin the flesh seems rather relaxed, especially on palpation, since the joint! has slipped to the other side; while at the buttock itself the head of the bone seems, on deep palpation, to stick out abnormally. These then are the signs in a case of dislocation of the thigh backwards.
LVIII. When the dislocation occurs in an adult, and is not reduced, the patient can walk, indeed, after an interval, when the pain subsides, and the head of the bone has become accustomed to rotate in the tissues; but he is obliged in walking to flex his body strongly at the groin, for a double reason, both because the leg is much shorter, owing to the causes above mentioned, and is very far from touching the ground with the heel; for if he should try even for a moment to have his weight on the foot with no opposite support, he would fall backwards, as there would be a great inclination that way, the hips coming far beyond the sole of the foot behind, and the spine inclining towards the hips.? He hardly reaches the ground with the ball of the foot, and cannot do this without a simultaneous flexure of the other leg at the ham. Besides, he is forced at every step to make pressure with the hand at the side of the injured leg on the upper part of the thigh. This of itself would compel him to bend the body somewhat at the groin; for at the change of
1 “ Joint”’ here means ‘‘ articular head.”
2 L. and Erm. put the above from ‘‘for if he should try” after ‘‘displaced backwards at the hip.” It gives better sense, but has no authority.
3 Littré, followed by Ermerins, rearranges the text in an arbitrary manner,
335
30
40
50
TEPI APOPOQN
ov dvvarae TO copa dxeioOar enh ToD owapob TKEAEOS, ay 1) a ee TO olvapov ™ pos THY viv vTo Tis XELpos, ovy * Upeotedros Tov apOpou vmod TO ToOpart, an’ es TO Omea0ev éFeoTEMTOS KATA TO Layiov. dvev pev ovv EVO dvvavtat ddouTopeiy of ToL1odtoLr, av addws CicVéwow, Sa TodTO, TL 7» Bais Tod Todos KaTa THY apXainy iOvepinv early, GAN ovK és TO eS EK KEKN EDT ola TODTO ovv ovoéev déovrar Tis AVTLKOVTWMOLOS. OTOL HEVTOL BovrovTat avrl THS TOU Hnpoo emai UTO THY wacyadrnv THY KaTa TO oLvapov ewelbs) UmorOepevor oKiT@va avrTepeloev, eéxetvot, Nv péey paxpoTepov Tov oKita@va vToTOéoLVTO, OpOoTEpoy ev OdoLTOpOvaL, T® O€ TOOL TPOS THY yAV ovK épeldovTat: ei 8 ad Bovrovtat épeidecOar TH Todi, Bpayvtepov pév To EvNov gopntéov, Kata dé Todvs PBovBovas éemisuyxauTtec0ar adv Sdéor avtovs. tav 6¢é capKan ai puvvOnoves KATA NOVO YiyvovTaL Kat ToUTOLOW, Oomep Kal m poo bev elpy tac: TOloL pev yap peTewpov éxouat TO oKédos Kal pndev Tahae- T-opeOust, TOUTOLGL Kal padvara puvvbovow: ob o adv mEloTa XpéovTae TH emiBacet, TOUTOLOLW HKioTa puvvOovar. TO [LévTOL bytes oKENOS OvK @PErELTAL, GAXa parrov? Kal ao XNWoveo TEpov ylveTal, NV XpéwvTat TO owvap@ oKéreu el THv yvs auvuToupyéov yap éxetvw éElicxyov Te amavaykavetat elvat, Kal Kata THv iyviny TVYKALTTELW, HY ye? fr) TpoTKXpenTat TO TiVAap@ érl Tv yi, adda petéwpov exov oKitave avTepelontat, oVTw S€ KapTEpOY yivEeTaL TO LYLEs oKéXos' &y Te yap TH Poe OvaTatar, Kal Ta 336
ON JOINTS, tv.
legs in walking, the body weight cannot be carried by the injured leg unless it be further pressed to the ground by the hand, the articular head not being in line under the body, but displaced back- wards at the hip. Still, such patients can walk without a crutch, at any rate after practice, for this reason, viz., that the sole of the foot keeps its old straight line, and is not inclined outwards; where- fore they have no need for counter-propping. Those who prefer, instead of the grasp on the thigh, to have the support of a crutch under the arm on the side of the injured leg, if they have a rather long crutch, walk more erect ; but they do not press with the foot on the ground. But if they want to make pressure with the foot, a shorter crutch must be earried; and they must also flex the body at the groin. Wasting of the flesh takes place in these cases also according to rule, as was said before; in those who keep the leg off the ground and give it no exercise the wasting is greatest, while in those who use it most in walking it is least. Still, the sound leg gets no benefit, but rather becomes also some- what deformed, if patients use the injured leg on the ground ; for in giving assistance to the latter, it is forced outwards at the hip, and bends at the hain’: but if one does not use the injured leg on the ground as well, but, keeping it suspended, gets support from a crutch, the sound limb thus becomes strong; for it is employed in the natural way, and
1 See previous note.
a
1 dire odx. 2 ei, * Omit, 4 jy de.
337
60
70
80
TEPI APOPON
yupvacia TpooKpativer avTo. hain sev ovov ay tis, é&w intpixhs Ta Tolav’Ta eivary TL yap d7n0ev det mept TOV ON aunKea Tov yeyovor@v ete Tporovveevar ; ; TodoOv 6€ Oe oUTmsS exew’ THS yap aUuTHS yvouns Kat Tabra ovpievat’ ov yap olov TE amrarrot prob iva an aX NOV. def pev yap és Ta akeoTa pnyavdac0al, Stas py avy- KeoTa éoTal, cuMEVTAa OTN AV paddtoTAa KwrUTEA és TO avyKeatov édOeiv: det dé TA avHKETTA ouveevat, @S pn parny Avnatynrae: Ta oé T poppynuata hap pa Kal dy overt ina amo Tob Srayuva@c ney 6m éxag Tov Kal olws Kal omore TENEUTITEL, VY TE €S TO AKETTOY TpaTNTAL, HV Te €> TO avynKesTOV. oTocotar & av &eK yeEveErs ie Kal dArwS TOS év avénoet cotow obT@s oda On TO dO pov OTLT@ Kal yn eumeon, nv TE Bin orioOn, nv Te Kal vo vovoov—moda yap TovadTa eEaplpypyata yiverar éy vovooiow: olac d€ tTwés elow al vodcol, év HoLV éfapOpetrar Ta Toabra, borepov yeypaerar— iv oy exaTav a) éumtéon, TOU pev penpod TO OoTéov Bpaxe yiverat, KaKOUTAL dé Kal may TO oKEéNOS, Kal avav bea tEpov yiveTar Kal acapKorepov TOANO Sua TO pn dev TpoaxphaOar avr eo: KaKxovTar yap TOUVTOLOL Kal TO Kara Thy iyvunv “pO pov: Ta yap vebpa évTeTapeva yiveTae bua Ta mpoa bev, eipn- péva. 610 ov SvvavraL 70 KaTa THY iyvdny dpOpov € exTavvely, oiow av ovTwS ioxiov ex eon, @s yap €v Keparai@ eiphioOar, TavTa Ta év TO Tamar, omoaa €i xpnoet yeyoue, Xpeomevorae peev peTpLa Kal yupwalopevoroty év THoL Tada- Twpinow, ev now éExaota elOtctar, ovTw pev
338
ON JOINTS, tvut.
the exercises strengthen it more. One might say that such matters are outside the healing art. Why, forsooth, trouble one’s mind further about cases which have become incurable? This is far from the right attitude. The investigation of these matters too belongs to the same science; it is impossible to separate them from one another. In curable cases we must contrive ways to prevent their becoming incurable, studying the best means for hindering their advance to incurability ; while one must study incurable cases so as to avoid doing harm by useless efforts. Brilliant and effective forecasts are made by distinguishing the way, manner and time in which each case will end, whether it takes the turn to recovery or to incurability. In cases where such a dislocation backwards occurs and is not reduced, whether congenitally or during the period of growth, and whether the displacement is due to violence or disease—many such dislocations occur in diseases, and the diseases which cause such dislocations will be described later—if, then, the displacement is unreduced, the thigh-bone gets short, and the whole leg deteriorates, and becomes much more undeveloped and devoid of flesh, because it gets no exercise. For in these cases, the joint at the ham is also maimed, since the ligaments get contracted, for the reasons given above; and therefore patients in whom the leg is thus dislocated cannot extend the joint at the ham. Speaking generally, all parts of the body which have a function, if used in moderation and exercised in labours to which each is accustomed, become thereby healthy and well-
339
90
100
10
19
IIEPI APOPQN
dyenpa Kab aveiwa Kal evynpa yiverac: Pay Xpeopevowe 6é, XN’ éAwwvouat, voonporepa ryive- Tat Kat avavkéa Kal Tayvynpa. év € TovTOLCLWW ovx eora Ta apOpa ToUTO mémrovde Kal Ta veupa, Hv pa} TLS avroice Xpenrau KaKovvTat pep ou ola TavTas TAS _Tpopdoras HaNAov TL €v TOUT® T@® TpoT@ Tov dALcOnuaTOS 7) ev Toit aAdovow: Gov yap TO aKéXOs avav&es yiveTat, Kal TH ao TOV OoTéwV PiaEL Ka TH ATO TOV TapKan. ol ovv ToLodToL omroTav dvdpwbdot, feTEWPOV Kal UY KeKapLeEVvOD TO oKEROS loxovaw, emt Oé& Tod éTepou OX eovTat, Kal TO EVM dyteaTnpLtopevor, ot pev évl, of O€ Ovatv.
LIX. Oiot & dv és todvumpocbev % Kepary Tov pnpovd éexTréacn—ortLyotor S€ TOUTO yiveTaL— ovToe éxTavveww ev TO oKEéXOS SUVAaVTAL TEEWS, ouykauTTey O€ HetoTa OvTOL SUVaYTaL Ta KATA tov BovBdva> trovéovat dé, Kal hv Kata THD byvunv avayxatvovtTat ovyKaumtew. pnKos oé TOU oKEAEOS TapaTAnoLov daiveTat, KaTA pmev THY mT épyny Kal Tavu: aK pos dé o Tous Hoo ov TL T POKUTTTELY eOédeu OrNov 6é TO TKENOS eel Ty Ov piny THY KATA puow, Kal ovTE TH OUTE TH perrel. dduvevtar dé avTixa obToL pddiora, kal oupov ia xeTa TO TP@TOV TOUTOLCL HaNAOY TL 4) TOOL ANOLOLWW eFapO pjpaciy: eyKELTAL yap ) xepanrs TOU punpod éyyutaro TovTOLoE TOV TOVWY TOV émuxaipov. Kal KaTa [ev Tov Bov- Bava eEoredv Te Kal KATATETAMEVOY TO Ywpiov paiverat, Kara 6€ TO cmuyaiov oTOMOwdETTEPOY Kal doapkorepov. rabra jev ovv ont €oTL Ta elpnueva, WV dv OUTWS ExTTETTMKN O LNPOS.
340
ON JOINTS, tvmi.-trx.
developed, and age slowly; but if unused and left idle, they become liable to disease, defective in growth, and age quickly. This is especially the case with joints and ligaments, if one does not use them. For these reasons, patients are more troubled by this sort of dislocation than by the other; for the whole leg is atrophied in the natural growth both of bone and flesh. Such patients, then, when they become adults, keep the leg raised and contracted, and walk on the other, supporting themselves, some with one and some with two crutches.
LIX. Those in whom the head of the thigh-bone is dislocated forwards—a rare occurrence— can extend the leg completely, but are least able to flex it at the groin ; and they suffer pain even if they are compelled to bend it at the ham. The length of the leg seems about equal, and quite so at the heel; but there is less power of pointing the foot. The whole leg preserves its natural straight line, inclining neither to one side nor the other. It is in these cases that the immediate pain is greatest, and retention of urine occurs from the first more than in other dislocations; for the head of the femur in these cases lies very close to important cords. The region of the groin appears prominent and tense; but at the buttock it is rather wrinkled and fleshless. The above-mentioned signs, then, occur in patients whose thigh is put out in this way.
1 20éAec = divaiai, says Galen, comparing Jiiad XXI. 366.
341
10
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30
TIEPI APOPON
LX. ‘Orocose pev ov av 718n jvopepéevorct TovTO TO apOpov exTETOV py euméon, ovTOL, OTOTAV avTOLT WW 7) odvyy TavonTat Kal TO a pO pov eOic0n €v TO Yopio TovTw oTpwhacba, iva éEétrecev, ovTor Svvavtar ayedov evOvs? dpOol odorTropeiy dvev EvAov, Kal Tavu pévToL evOées, éml 6€? TO cwapor, ate ovTE KaTAa TOV BovSava EVKAUTTOL EOVTES, OUTE KATA THY lyvUHv: SLa odv TOU BouBdvos TH akautinv ev0utépw Odo TO oKENEL ev 7H osovmopin xpeovrar * a OTE Uytavov. kal cUpoveL é éviore pos Tay vay TOV TOOa, ATE OV pHidlwS TUYKaTTOVTES TA AVW apOpa, kal ate mavtt Baivovtes TO Todt: oddev yap Hocov TH mTéEpyn ovToL Batvoval 1%) Tw éumpoabev: et Sé ye nOvvavTO méya mpoBaivey, Kav Tavu TTEpvOBaTaL Hoa? Kal yap ob VyLat- vovTes, 0ow av wélov mpoBatvovtes ddo.tropéwor, TOTOUT®@ waAXOV TTEpvoBaTat etal, TLHEVTES TOV moa, aipov Tes TOV évavTiov. omocotat Se bn OUTWS EKTET TOKE, Kal ETL panrXrov TH TTEPVY T pooeyX plumT ova 7) 7@ eum poo dev" TO yap éuTpoabev TOU 70605, oT OTaV EKTETOLMEVOV a TO adrX0 oKEXOS, ovx opol@s duvatar €5 TO Tpoow KapmUdr€T Oat, 6 domep oTav Tuy KEKa ppLevoy 7 TO oKEeNOS' OUK av otpwoda bat dvvarat 0 Tous, oTuyKEKappEvor ® TOU oKéXEOS, WS OTAV EKTETA- jévov 7 TO TKEROS. bytaivoved TE ovV y puous ole mpurer, Oomep elpy tae’ Otav O€ éxmecov pe) éuméan TO apOpov, odTws odoumopéovaw @S elpnrar, dua TAS mpopacvas TavtTas Tas elpn- pevas” doapKorepov pEvTOL TO TKEAOS ToD éTépou ylveTal, KaTd Te TO TWvyaiov, KaTad TE THY
342
ON JOINTS, ux.
LX. In cases where this dislocation occurs in those already adult and is not reduced, these patients, when their pain subsides and the head of the bone has got accustomed to turning in the locality where it was displaced, are able to walk almost at once erect without a crutch, and even quite straight up, so far as the injured part is concerned, seeing that it cannot easily bend either at the groin or ham. Thus, owing to the stiffness at the groin, they keep the whole leg straighter in walking than when it was sound. And sometimes they drag the foot along the ground, seeing that they cannot easily flex the upper joints, and that they walk on the whole foot. In fact, they walk as much on the heel as on the front part; and if they could take long strides, they would be purely heel-walkers. For those with sound limbs, the longer the strides they take in walking, the more they go on their heels when putting down one leg and raising the other; but those who have this form of dislocation press upon the heel even more than on the front of the foot. For the front of the foot cannot be so well bent down when the leg is extended as when it is flexed ; nor, on the other hand, can the foot be bent upwards when the leg is flexed so well as when it is extended. This is what happens in the natural sound condition, as was said; but when the joint is dislocated and not reduced, they walk in the way described, for the reasons given above. ‘The leg, however, becomes less fleshy than the other, both
1 Kw. omits. 2 eri ye, ‘ Y / ® xpewvras, $ ouyKexAtpmevou,
343
40
57
IIEPI APOPON
yaar poxynpiny, ral Kara THY drrvaBev i&wv. oloe
av various wy ere éobon TO a pO pov [obrws] oda Pov a) euTreon, uh Kal eK wyevenis oUT@ yevnt ae, Kal ToUTOLOL TO TOU pNpOdD oaoTEéoV MANXOV TE puvvOer 7) Ta THs KYHnuNs Kal TA TOD Todds. Klara py ev TOUT® TO THOT TOV dALCOnUATOS 0 pnpos MELOUTAL. puvvdovar MEVTOL Al odpKes TavTy, paiara. 6€ KaTAa THD druaOev lEwv, a Gomep non Kat wpocbev elpntat. omocor pev odv av TUB yn ewow opIas, ovToe pev dvvayTat 7 poo xpho bar TO oKeher avEavopevol, Bpaxutépo mév TW TOU éépou €ovTt, Gpws dé epevdomevor Evo éml TavTa, 7) TO oLvapov cKéXOS* OV Yap KapTa Svvavtat avev Ths wréEpvns TO otHVEL TOD Todds xpiabat, émuxabiévtes WaTrep ev Erépoiae Ywrev- pact évioe SUvavtat: altioy S€ Tov pr Svvacbat TO OAty@ mMpocbev eipnuévov: Sta ovv TodTO mpocdéovtat EVAov. oTocot 8 av KaTapedrn- Oéwou Kat pn dev Xpewvrar emt THY YY TO TKENEL; Na peTewpov EXCL, TovTOLaL pwober pev Ta oaTéa &€s aveénow HarXOv %) TOloL Xpeomevorou” puvvbovat 5é [Kal] ai odpKes TodkV paddXov 7 TOLL Ypeomévoice’ KaTa bé Ta ApOpa és TO evOu TnpovTat TovToLat TO TKEAOS PAAAOV TL 9) Olat av dddws eKTETTOKN.
LXI. ‘Os pev ody év xeharaiw eipfobar, Ta apOpa Ta éxtimtovta Kal Ta odoOdavovta aQvicws avTa éwvtotaow exTimte Kal OALcOaveL, GNNOTE ev TOAV TAEOV, AAXOTE OE TOAD ElacooV" Kal oiat ev av [{rodv]} ™)éov onria An ) eKTETN, Nader wre pa éuBarrew TO émimav éoTl, Kal iy wn éubiBac0n, péfous Kal émdnroTépas Tas
344
ON JOINTS, wx.-Lx1.
at the buttock and calf and all down the back of it. In those cases too where it is dislocated in childhood and not reduced, or where dislocation occurs con- genitally, the thigh-bone is rather more atrophied than the bones of the leg and foot; but atrophy of the thigh-bone is least in this form of dislocation. The tissues are atrophied in the whole limb, but especially down the back of it, as was said before. Those, then, who are properly cared for are able to use the leg when they grow up, though it is a little shorter than the other; yet they do it by having a support on the side of the injured limb, for they have not much ability to use the ball of the foot without the heel, bringing it down, as some can do in other forms of lameness. ‘The reason of their not being able is that mentioned a little above; and this is why they require a staff. In those who are neglected, and never use the leg to walk with, but keep it in the air, the bones are more atrophied than in those who do use it; and the tissues are much more atrophied than in those who use the leg. As regards the joints, the lesion keeps the leg straighter in these patients than in those who have other forms of dislocation.
LXI. To sum up—dislocations and slipping [separa- tion]! of joints vary among themselves in amount, and are sometimes much greater, sometimes much less. In cases where the slipping or dislocation is greater, it is, in general, harder to reduce; and, if unreduced, the resulting lesions and disabilities are
1 Tt is usual to make dArcobalyw, dAtcOnua refer to “ partial dislocation”; but this hardly suits the context, or the reference to shoulder and hip-joints.
1 Kw. omits,
345
10
20
29
10
IIEPI APOPQN
mnpaacvas Kal KAKWTLAS iaxet Ta Totadra, Kal do Téwv Kat TAaPKOV Kal oXNmaToy dtav 6é petov exTreoy Kal orioOn, pnidzov bey €uBarrew 7a ToLavTa TOV eve pay yiverat* iy or KkataropnOy 7 u) ape eumecety, petous Kal dower Tepae at Typwcves yivovtas TovToLoW y) oloww or poo Gev elpnT a. Ta ev obv dda &pOpa Kal Tavu mONU duahéper es TO OTE fev peiov, oTe be méCov TO OALGOnua TotetcPar’ pnpovd be Kai Bpaxtovos xeparat mapatAnci@tata ddAtcOavou- ol avT?) éEwUTH ExaTépyn’ ate yap oTpoyyvrAat bev ai Keparal eodoa, ary THY oTpOyyVAwWoW kal daraxpnv éxovat, KuxroTepeis 5€ ai Kothiar €ovaat ai dexyopevar Tas Kehards, appokovar bé That Keparnow ba TovUTO OvK EoTLY a’THOL TO Huiov exaoThvar Tod apOpov' ddoOavor yap av dua tHv trepipepeinv, 7) és TO Ew 1) €s TO Eow. TEepl OV OdY O NOYOS, EXTiTTOVGL TEAXEWS HON, ErrEl GNAWS Ye OUK ExTITTOVAL’ Suws Cé Kal TAUTA OTE fev mdelov atoTnda amo THs dvavos, ore Sé éXaccov" pwarrov bé Te unpds TovTo Bpayiovos mérrovOev.
LXII. ’Ezel Gua nai trav ex yevens dALcOn- BaTo@v, iv ptxpov OrLGOn, ola Te és THY vow ayecOat, Kal padtoTa TA Tapa TOD Todos apOpa. OTOgOL ek ryeverns KUAXOL yivoyTal, TA TAELCTA TOUTWY inolud eoTiv, HY pn Wavy peyaryn 1) ExkrLals H, 7) Kal TpoavEéwy yeyovotwy On TOV Taiov cupPH. apioTov pev ody ws TAaXLoTA intpevety Ta TOLAvTA, Tply TavU peyadnY THY évoctay TOV OoTéwY TOY ev TO Tod! yevéoOat, Tpiv TE Tavu peyadny THv evdeiav TOV TAapPKaV 346
ON JOINTS, vxt.-vxt.
greater and more manifest in the bones, the soft parts, and the attitudes. When there is less displacement, either with dislocation or separation, reduction is easier than in other cases ; and if they are not reduced, owing to inability or neglect, the resulting deformities are smaller and less serious than in the cases just mentioned. Joints in general, then, differ very much in having their displacements sometimes less and sometimes greater; but the heads of the thigh and arm-bones each slip out in very similar ways; for the heads, being rounded, have a smooth and regular spherical surface, and the cavities which receive them, being also circular, fit the heads. Wherefore it is impossible for them to be put half out ; for owing to the circular rim, it would slip either out or in. As regards our subject, then, they are put quite out, since otherwise they are not put out at all. Yet even these joints spring away, some- times more, sometimes less, from the natural position. This is more pronounced in the thigh-bone than in the arm.
LXII. There are certain congenital displacements which, when they are slight, can be reduced to their natural position, especially those at the foot-joints. Cases of congenital club-foot are, for the most part, curable, if the deviation is not very great or the children advanced in growth. It is therefore best to treat such cases as soon as possible, before there is any very great deficiency in the bones of the foot, and
347
30
40
IIEPI APOPQN
TOV KATA THY KVYHUNVY Elval. TpPOTrOS pev OdV KUAN@TLOS ovy els, adda Treloves, Ta WA€loTa pay OUK e&npOpnxora Tavranact, arra bv &os TXNMATOS év TUL amroharet TOU T0005 KekuNrw- péva., TpooeXewy dé kal év TH int pety Towoive xpi” an wBeiv bev Kab xaropOooy THS KU LNS TO Kara TO oupov baTéov TO (eEwbev és TO éow HEpOS, avT@betw dé é és TO a0) Hépos TO THS mrépyns TO Kara Thy LEW, br wsS @XyoUs arravr ion Ta dotéa Ta Fic yovTa KaTa pécov TE Kal TAAYLOY Tov T00a* Tovs 6 av daxTUNOUs AOpdovs cdV TO peyarw OaxTUX@ és TO Eow pépos eyKALVEWW Kal mepravayKatery oUTws' émidety bé KnpwTh Eppn- TLVMpPEVN ED, KaL OTANVEDL Kal dOoviotct wadOa- Koiot Ln driyoLot, pnoe dyav miecovTa’ ovT bé Tas Teplayaryas moteta Gat TIS eTLOETLOS, HoTrEp Kal thot xepaty 1) catoplwas 1) nV Tob 70008, 6 Omrws 0 Tous oneyep MarXXOV és TO Bratoor f pém@v paivy- Ta. ixvos 6€ Te xp Trovetabar 7 Sépmatos HA) aryav cK pod, 7 HohvBduvov,» Tpooemoetv oé, BH 7 pos Tov ypaTa TiWévTa, arr OTav 18 TOLTL VITATOLOLVY oboviorce peXdys émidetv: Stav bé 780 emudedepevos 7 n, EvOs TLVOS TOV dboviov XP, olow émidetTat, THY apxXnv Tpoo payrat mMpos Ta KATA TOU 000s emidéo pata Kara TV key ToD px pod daKkTUAOU' emerta és TO av@ Telvovta OTws av doxn pet plas EXE, meptBarhew avwbev Ths yaotpoxynpins, @S HOvuwov 7, KATATETAMEVOV obT ws. ATO dé Oyo, OoTEp KnpoT Aaa TEovTa, xp?) €s THY diow TIV Sicainv ¢ dye Kal TH €KKE- KdLweva Kal TAO GUNTER HSH Tapa THv pvow, 1 poduBdlou. 348
ON JOINTS, vxu.
before the like occurs in the tissues of the leg. Now the mode of club-foot is not one, but manifold; and most cases are not the result of complete dislocation, but are deformities due to the constant retention of the foot in a contracted position.1 The things to bear in mind in treatment are the following: push back and adjust the bone of the leg at the ankle from without inwards, making counter-pressure out- wards on the bone of the heel where it comes in line with the leg, so as to bring together the bones which project at the middle and side of the foot; at the same time, bend inwards and rotate the toes all to- gether, including the bie toe. Dress with cerate well stiffened with resin, pads and soft bandages, sufficiently numerous, but without too much compression. Bring round the turns of the bandaging in a way corre- sponding with the manual adjustment of the foot, so that the latter has an inclination somewhat towards splay-footedness.? A sole should be made of not too stiff leather or of lead, and should be bound on as well, not immediately on to the skin, but just when you are going to apply the last dressings. When the dressing is completed, the end of one of the band- ages used should be sewn on to the under side of the foot-dressings, in a line with the little toe; then, making such tension upwards as may seem suitable, pass it round the calf-muscle at the top, so as to keep it firm and on the stretch.3 In a word, as in wax modelling, one should bring the parts into their true natural position, both those that are twisted and
J.e. ‘an unnatural contraction of the muscles, ligaments and fasciae.”
* I.e, valgus (outward distortion).
® I.e. so as to hold up the outer side of the foot.
349
50
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IIEPI APOPON
Kal THOU xEepow ovuTw StopBodvra, Kal Th éridéoer OTAUTMS, mpoodryetv dé ov Biaiws, adra mapyyo- pleas: mpoopam ret dé Ta Oona, oTrws av cup- péepn Tas avarnyras Toteta0ar’ adda yap adds TOV Yor\wowatov Settar avadyrpios. Vrodnpariov 6€ qoteta Oar 1 poruBdwor, éEwOev ths émidéa.os émrededepevor, olov at Xiau [xpnrides]? pve mov eixov" aX’ ovdev avtod Sei, Hv Tes opbas perv That Yepol Si0pbw@an, opOdas dé Tolcw dOovio.ow > bé b 06 be \ \ ’ Ov , a 3 e émr.dén, OpO@s Sé Kal TAS avadyfias ToLOiTO.2 7 pev ovv inats avn, Kal oUTE Tous OTE Kavowos > \ a a9, a / ovodev (bet, our adhns “Touching: Paaoov yap évakover TA ToLadTa Tis int eins Ws dv Tes oloLto. T pooviKay pevToe xpn TO Xpove, &ws av avéne7 TO o@pma ev Tolct Sucaiouc TX MATL. étav é és Urodnwaros Aoyov in, apBurat € erern- SevoTatat ai mnAoTaTioes KaNEOmEevat: TOvTO yap vumobnudtwy HKioTa Kpateitat UToO Tod U b) \ a nr b] / \ Ne TOO0S, GNXA KpAaTEL maAXOV: emiTHdELoS Sé Kal O Kpntixos tpotros Tov vTodnpdtov.
LXIII. ‘Ordcouoe o av Kynuns ootéa &Eap- Opycavta Kal EXKos ToujoavTa TEAEWS eEiayn KaTa Ta Tapa’ TOV T00a apOpa, elTE eam péwavta, elite wévToe Kal €Ew, Ta ToLavTa pun* éuBarrew, arr édy Tov Bovropevov TOV intpav éuBarrew. cafpéws yap eidévat Yon OTL atroPavettar w@ av ’ t ) , \ oe \ gr 2 , G , euBrAnOévra émpetyn, Kal 1 Con dé OAL} MEPOS TOU- TOL yevnoetat> odiyou yap ay aur ay Tas ema, nuépas vmepBddXolev' oTagmos yap 6 KTELWoV
1 rovetv.
2 kpnmides Galen : omit Kw. and MSS. As Kw. shows, it
is inserted from the Commentary. 3 rownrat, 4 ov xpn. 5 yiverat,
35°
ON JOINTS, vxu.-Lxi.
those that are abnormally contracted, adjusting them in this way both with the hands and by bandaging in like manner; but draw them into position by gentle means, and not violently. Sew on the band- ages so as to give the appropriate support; for different forms of lameness require different kinds of support. <A leaden shoe shaped as the Chian! boots used to be might be made, and fastened on outside the dressing; but this is quite unnecessary if the manual adjustment, the dressing with bandages, and the contrivance for drawing up are properly done. This then is the treatment, and there is no need for incision, cautery, or complicated methods; for such cases yield to treatment more rapidly than one would think. Still, time is required for complete success, till the part has acquired growth in its proper position. When the time has come for footwear, the most suitable are the so-called “ mud-shoes,”’ for this kind of boot yields least to the foot; indeed, the foot rather yields to it. The Cretan form? of footwear is also suitable.®
LXIII. In cases where the leg-bones are dislocated and, making a wound, project right through at the ankle-joint, whether it be towards the inner or outer side, do not reduce such a lesion; but let any practitioner who chooses do so.4 For you may be certain that where there is permanent reduction the patients will die, and life in such cases lasts only a few days. Few go beyond seven days. Spasm
1 Krotian says it was a ‘‘woman’s boot.” In Galen’s time it was quite forgotten.
2 ** Reaching to the middle of the leg.” Galen.
3 “The most wonderful chapter in ancient surgery.” Adams.
* J.e. leave it to anyone reckless enough.
351
IIEPI APOPON
10 €otiv: atap Kal yayypawodo0a ixveitar thy KYnuNY Kal TOV TOOa. TadTa BeBaiws eidévat. Xp oUTwWS eoopmevas Kal OvK av jor SoKEt OSE EAE Bopos. apehjoery * avOnjepov Te do0els Kal aids TLVOMEVOS, dyxicra dé eltrep Te Toobro[ vy]: = ov pévTor ye ovde TovTO OoKéw. iv be py €uBdOn, pce a an apxis pnoels meipnOn euBanr- ew, TepuyivovTat ot TELOTOL QUT OD. xpn 6é Hppor bat ev THY Kv} fa Kat TOV 7 00a oUTWS, WS avtos é€0éreu, podvoy o€ pr) amraveopevpeva, poe
20 Kivevpeva eoTo. int pevev dé miconphy Kal omhjveow olvnpotouw odiyouse, pn ayav pux- potau »>Woyos yap év Totce TOLOUTOLTL omac pov emeKaei Ta. emit noeLa dé Kal purra oevTA@Y v) Byxvov. 7 aXXOU TLVOS TOV TOLOUTwWY év olve pérave avaTnp® jptepOa émiTievra int pevetv él TE TO EXKos ae Te Ta TEepleXovTa, KNPOTH o€ YK ALEpH emexplety * aro TO EAKOS* Av O€ u} @pn Xetrmepevy q, Kal &pia putTrapa olive kal chai KaTappalvovTa YyALtepotaw dvobev emreTéryyelv*
30 caTtadety dé bn dev pir) Oevt,# Hoe Tepim dao ew pdevi ED yap eldévat ypn OTe TieEvs Kal axGo- hopin may KaKOV TOLL TovovToua ty éoruy. emt- THOELA O€ TPOS TA TOLADTA Kal TOV evapo peETeE- Eétepa, boovow avTay Tuppeper épea bé emer e- Oévta, olve emiTeyyovTa, TONY Xpovov éav' Ta dé dduynuepotata TOV evaipav Kat doa pytivy MpockaTarapPaveTat ovy opoiws émritndeva exelvoro ore. xpovin ” Kadapars TOV EAKEOY ryiveTat TOUT@Y" mov yap Xpovov mAadapn yive-
40 Tae: tuvdas 8€ TovTw@Y YpnoTov emideiy. eidévar
L Opedijoas,
352
ON JOINTS, cxut.
(tetanus) is the cause of death; but gangrene of the leg and foot is also a sequel. It should be well known that this will happen; and I do not suppose that even hellebore, given on the day of the accident and repeated, would do good. If anything would help, something of this kind would come nearest ; but I have no confidence even in that. But if there is no reduction or attempt at reduction to begin with, most of them survive. The leg and foot should be disposed as the patient himself wishes, only avoiding an unsupported position or movement. ‘Treat with pitch cerate and a few compresses steeped in wine, not too cold; for cold in such cases evokes spasm. Other suitable applications are leaves of beet or colt’s-foot or something similar, half-boiled in dark astringent wine, and applied both to the wound and the parts around it. Anoint the wound itself with warm cerate, and, if it is winter, apply an upper moist dressing of crude wool, sprinkling it with warm wine and oil; but avoid all bandaging and dressing with plasters, for one must bear well in mind that pressure and weight do nothing but harm in such cases. Some of the applications for fresh wounds are also suitable for these injuries, in cases where they are useful. Cover with wool, moistening it with wine, and leave on a long time. The wound remedies which last a very short time, and those incorporated with resin, are not so suitable for those patients ; for the cleans- ing of these wounds then takes more time, since the flabby moist stage is prolonged. Bandaging is good for some of these cases. Finally, one should bear
2 ro.ovTov Galen. 3 Saroxplew,
* Omit Kw. and many MSS.
353 VOL. Il. N
50
52
10
15
TIEPI APOPQN
peev én Tov cada Ypn ore avaryen TOV dvO pwmov xo ov aia Xpas ryeveo Gar: Kal yap. 0 Tous és 70 avw avéoTacTat TOV TOLOUTWY, Kal Ta ooréa Ta Stoic OncavTa $20) ebexovTa paivetat ovTE yap Wrrovrar TOY TOLOUT OV datéwy ovdev ws émrtTO- modv, ef pr Kata Bpayv Ti, ove agiorarar, ada TEplwmTEthovTat Nem TOW @TELAHTL Kal aadevéot, Kab tabra Hv atpewifwmar modvy ypovov: nv} bé p29}, EAKVO PLOY eycatarerpO hvac KivOuvos avanbes. bums O€, Tept Ov O AOYOS, OUTw pev intpevopevor cw@lovtar, éuBArAnOévtos dé Tov apOpov Kal €upeivavtos, aroOvicKovow.
LXIV. QU7os dé Aoyos obTos, ip Kal Ta Too TXEOS eared Ta Tapa TOV KapTov TIS NELpos éXKOS TonoavTa eEioxn, Wy TE €S TO éow | HEpos THS XELpos, ny Te és TO EEO. capa yap émiorac- Oat xpn 6Tt arroBaveirat év odiynow mepnor TOLOUT@ Oavato, olpmep Kal mpoabev elpnTat, oT@ ay éuBrbévta Ta GoTéa éupevy.” ola Ss av Hi) eu BAO?) pode mrerpnOn éuBarreoBar, ovTot TOU Teloves mepeyivovtTar. intpein be TowavTn TOOL TOLOUTOLOW émiTnoein, oinmep elontau: TO b€ oxTpwa aia pov TOU NOLOLATOS avayKn clvae, Kal TOUS SaxTuhous THs etpos acbevéas Kal axpetous: my pev yap. és TO €ow [uépos odtaOn Ta daTea, ouyKauT Tey ov SuvavTar TOUS SaxtUAous" Hv o€ €s TO Ew pépos, exTavven ov dvvavrae.
LXV. "Ocotot & ay evnpns ooTéor, EAKos TOUT apEvov mapa TO youu, eF@ eEioxn, mv TE és TO €&w pépos, ay Te €S TO éow, TOUTOLOLW ny pév TLS euBary, & eTL ETOLMOTEPOS 0 Ody aos eat HrEep TOlow ETEpoLaly, KalTrEp KAaKElVOLoLY ETOLMLOS
354
ON JOINTS, vxiit.-ixv.
clearly in mind that the patient will necessarily be deformed and lame; for the foot is drawn up, and the projection of the dislocated bones is obvious. There is no denudation of the bones as a rule, except to a slight extent, nor do they come away ; but they get searred over with thin and weak tissue—that is, if the patients keep at rest for a long time; other- wise there is risk of a small incurable ulcer being left. However, to return to our subject, those thus treated are saved; but if the joint is reduced and keeps its place, they die.
LXIV. The same remarks apply to cases where the bones of the forearm make a wound and stick out at the wrist, whether on the inner or outer side of the hand.t_ For one should understand clearly that the patient will die in a few days in the way which was mentioned above, if the bones are reduced and keep in place; but if there is no reduction or aitempt at reduction, the great majority survive, The suitable treatment in such cases is such as was described, but the lesion is necessarily a deformity, and the fingers are weak and useless; for if the bones are displaced inwa:ds, they cannot flex the fingers, if oulwards, they cannot extend them.”
LXV. In cases where a bone of the leg makes a wound at the knee and projects either to the outer or inner side, death is more imminent, if one reduces the dislocation, than in the other cases, though it is
1 Our ‘‘ forwards or backwards.” 2 See note on wrist dislocation.
1 ¢?, 2 dumecivn.
10
15
10
15
TIEPI APOPQN
éov. mp be 1) éuBarov intpevys, énrides pmev coTnpins obTe povers eloiv: Kwovvev[éstepa be Tatra Tov eTEp@v syiverau Kab do aw avorépen Kal dow av loxuporepa 7 Kal amo loxupoTépwr dro Orjxen. ay dé Td daTéov TO TOU pLNpov TO mpos TOU yovaros ENKOS Toad jevov eLoriaOn, éuBrOev | pev Kal éupeivar, éte Braotepov Kai Gacoov Tov Oavatov Toince TOV TpdaOeEV Eipn-
/ 1 \ ? \ \ \ / A pévov'? un euBrAnGev b€ mor KivduVwWoéoTEpOr 7) Ta Tpoabev: buws dé povvyn éXrls avTH cwTNpINS.
LXVI. Ques 6€ Adyos Kal wept THY KaTa TOV ayxava apOpwv, Kal Tepl TaY TOD THYEOS Kal Bpaxtovos: boa yap av TOUT@Y ea plpycavra éEicyn EdKos Tomo aera, mTavTa, nv euPrOn, Oavarov péeper, euBdrnGevta 2 Oé, édmiba oWTN- pins: NOhwoes dé er ot pn Toit TEpuylvouevolcLy. Oavatwdéatepa 6€ Tolou éuBarnopevoraty éort TA avwtépwo Tov apOpwr, atap Kal TOICL pn éuBarropevoret KLVOUYWSETTEPA AUTA TAUTA. eb dé Tie Ta avotata apOpa éEapOpicavta EdKos Toloavta e&icxol, Tadta & av étt Kal éuBar- Aoueva taxyv0avaToTata av ® et Kal [1 euBar- Aomeva ewdvvaderTara intpein O€ Hn elpytat oin THs €wot Sdoxel emitndevoTadtTn eivat TeV TOLOUT@DV.
LXVII. “Ocoor 5é dpOpa SaxtirXw?, 1%) 7o0d0s ~=©6xetpos, eEapOpyjcavta Edxos Toinoapeva
1 4) ra mpdadev eipnucva.
2 €uBarrdueva.
3 Use of double & characteristic. Evena triple &y is found (J. XLVI). Cf. Vul. Cap. IV., Acut. I, Fract. XXVIII, and (for triple &v) Thue. II. 94.—Pq.
356
ON JOINTS, cxv.-Lxvit.
imminent in them too. If you treat it without re- duction, this method, and this only, gives hope of recovery. These cases are the more dangerous, the higher the joint is, and the stronger the dislocated parts and those from which they are dislocated. If the thigh-bone at the knee makes a wound and is dislocated through it, when reduced and kept in place it will cause still more prompt and violent death than in the cases mentioned above; when not reduced, there is far more danger than in the former cases, yet this is the only hope of safety.
LXVI. The same remarks apply to the bones forming the elbow-joints, both those of the forearm and upper arm; for if any one of them is dislocated and projects, making a wound, they all bring a fatal issue if reduced ; but if not reduced, there is hope of recovery, though those who survive are certain to be maimed. More fatal when reduced are com- pound dislocations of the more proximal joints; and they too involve greater danger even when unre- duced. If anyone has the uppermost joints dislocated and projecting through the wound made, it is there that reduction brings swiftest death; and there too is most danger, even without reduction. The kind of treatment which seems to me most suitable in such eases has already been described.
LXVII. When the joints of the fingers or toes are dislocated and project through a wound, the
1 These two sentences seem to be of general application, not confined to the elbow—as in Littré’s and Petrequin’s versions.
357
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IIEPI APOPON
éFéoxe, pn KaTenyoTos Tov odoTéov, aX\dXa KAT’ avTny THY ctUupvow atoaotacbévtos, TOVTOLOW av enBrAnOevra empctvy, eve pév TUS xivduvos CTATLOD, HV LN XPNOTAS intpevovTat: Opas O€ Te d&Lov euBarnew, TPOELTOVTA OTL puhaxis TOANAS Kal pedétns delta. eu Barre MeVTOL priarov Kal duvat@ratoy Kal TEXVLK@TATOV €oTL TO HoxdaKe, BoTep Kal mpoa bev elpnTar ev TOLoL KATAYVUPLEVOLTL Kal eFiaxovor 6 ooTéotow" emeTa at pepetv @S pddiora vp); Kal KaTaketa Oat Kal oduyooeteiv" Gi LeLvOV oe Kal ee es ave KoUpe TWh pappace, TO 0€ EAKos int pevev | wer 1) évainotae Tolo Ww emiTeyKTOLTL n ) TOAVOPEAAuoLG Ly % olaw Keharrs ooréa KaTenyoTa intpeverat, KaT aux pov b€ Kapa pun dev T poo pépew. HixvoTa pev ovv Ta neere apOpa Kwdvvedea éott, Ta b€ €TL avwtépw cw duvad€s TEpa. euBdarrew 6é xp) avOnpepov D TN vaTEpatn, TpLT aig dé ‘ Kat TeTapTaie HKLOTA TeTaptata yap éovra emlonpaiver T Hoe TadwyKoTinat pdadwoTa. olow av ovv pay auTiKa eyryevntat eu Bdrrew, vmEp- Baivew x pn TavTas Tas elpnuevas Tmepas: 6 TL yap av éow déxa 7 LEpecov éuBarrys, orav Kaga- Ant réov. ny O€ apa eu BeBAnpEVO oT AT LOS erruyevnT at, éxBadhew TO dpOpov bef TAXD, Kal Pepu@ Téyryelv @S TET TAKES, Kal TO OXov c@pa Geppas Kai ALTAapHs Kal wadOaKkds évew, wadiora KaTa Ta apOpa: Kexdud bat dé eGdXov 7) éxTeT aa - Oat may TO TOMA YPN. mpoodéxea bau MEVTOL YPN Kara TOUS SaxTvdous Ta apOpa Ta éuBarropneva anocratika écecOar: Ta yap TAEloTa ovTw yivetat, iv Kal OTLODY hrAEYLOVAS UTroyEerNTaL, Ws,
358
ON JOINTS, cxvu.
bone being not fractured, but torn away at the connection, in these cases reduction and fixation involve some danger of spasm, if they are not skil- fully treated ; still, it is worth while to reduce the dislocation, giving warning beforehand as to the necessity for great caution and care. The easiest and most powerful reduction, and that most in accord with art, is that with the small lever, as described before in relation to fractured and protruding bones. Afterwards the patient should keep as quiet as possible, lie down, and take little food. It is rather advantageous to give a mild emetic. Treat the wound either with moist applications for fresh cuts, chamomile,+ or remedies used for head fractures; but do not apply anything very cold. The distal joints, then, are least dangerous, the higher ones more so. One should make reduction on the first or following day, but not on the third or fourth, since the onset of exacerbations occurs mostly on the fourth day. In cases, then, where immediate reduc- tion fails, one should pass over the aforesaid days, Any case you reduce within ten days is liable to spasm. If spasm supervenes after reduction, one ought to dislocate the joint quickly, make frequent warm affusions, and keep the whole body warmly, comfortably and softly at rest, especially at the joints. The whole body should be rather flexed than extended. In any case one must expect the articular ends of the phalanges to come away after reduction ; for this happens in most cases, if there is any amount of inflammation. So, were it not that the surgeon 1 ““Ox-eye.” Galen. St OARS 4) a eR A op ne eigion
2
1 Gepameverr. 2 7a 0’ érdva, 8 wav katadnnrdy Kw. : «dora édardy Reinhold,
88
10
17
IIEPI APOPOQN
ef pn Se” Gpabinv Tav Synwotéwv év aitin ewedrev 0 intpos évea Bau, ovder av TAVTWS oud euBarnrewy ede. TA “ev OV KATA TA apOpa OoTéa éEioxovra éuBarroueva 0TH cy Suvooed € €OTLVY, WS elpnTat.
LXVIII. “Oca &€ cata ta dpOpa ta Kata Tous OakTUNOUS ATTOKOTTETAL TEAEWS, TAUTA acwéa Ta TrEloTAa eoTIV, EL pH TLS ev avTH TH Tpwcer AetToOvpncas BraBein? Kal intpein pavrn apKécet TOV TOLOUT@Y EXKéEwY. aTap Kal doa pn KaTa TA appa, aArAA KaT aAANV TWA LEW TOV OT TEWY ATOKOTTETAL, Kal TADTA aolWéa éoTi, Kal éte evar0éotepa THY ETépwv" Kal boa KaTa Tovs daxTUAOUs Oa Téa KaTEnyoTa! éFia yet WH KATA TO apOpov, Kal TaAUTA aowea early epBarnopera. droKorsles dé TéAELat oa Témy cal KaTa Ta appa Kal & Tool Kal ev xeepl Kal év KUNE, Toto Tapa Ta opupa Kal €v THYEl, TOLoL mapa TOUS KapTovs, TOLL TALaTOLT LW aT OKOTTOLEVOLT LW acwwéa yivetat, boa av pn avtixa NevtroOupin avatpéyrn 7) TeTaptatotaw éovot TupEeTos ouVeE- NS ETUyevHnTal.
LXIX. ’Avocdaxeriotes pevtot capKav, Kat év TPOLACLY ai poppooree syevomevoraey 7 amro- opiyEeow iaxupais, Kal év ootéwv Kariypace Yevouevowae TuexOciot paddov te Tod Karpod, Kal ev aAXoLoL Seg poiae Bratovow, drrornp0evra a ATOTITTEL TOANOLCL, KAL OL TONNOL TeEpLyivovTaL TOV TOLOVTWV, Kal olot pnpod jEpos TL arTro- mintel Kal TOV capKav Kal Tod baTéov, Kal olat Bpaytiovos, hacov4 é mnyyeos TE Kal
1 carayévra. 2 Kw. omits. 8 GaromeAavOevrt. 4 jocdvws,
360
ON JOINTS, vxvit.-.x1x,
is likely to incur blame owing to the ignorance of the vulgar, he should by no means make the reduction. The dangers, then, of reducing bones which project through the skin at the joints are such as have been described.
LXVIII. Cases of complete amputation of fingers or toes at the joints are usually without danger— unless a patient suffers from collapse at the time of injury—and ordinary treatment will suffice for such wounds. Again, where the amputation is not at a joint, but somewhere in the line of the bones, these cases also are not dangerous, and heal even more readily than the former; and if the projection of fractured finger-bones is not at a joint, reduction is without danger in these cases also. Complete ampu- tations even at the joints both of the foot and hand, or of the leg at the ankle, and of the forearm at the wrist, are in most cases without danger, unless syncope overcomes them at once, or continuous fever supervenes on the fourth day.2
LXIX. As for gangrene of the tissues occurring in wounds with supervening haemorrhage, or much strangulation, and in fractures which undergo greater compression than is opportune, and in other cases of tight bandaging, the intercepted 8 parts come away in many cases. The majority of such patients survive, even when a part of the thigh comes away with the soft parts and the bone, also part of the arm, but these less frequently. When the forearm or leg
? Surgeons such as Antyllus and Heliodorus probably erformed amputation or resection in these cases. Even aulus (VI. 121) is surprised at the timidity of Hippocrates, * This chapter seems to refer to cases of injury, not surgical ‘‘resection” as Adams. * Or ‘‘blackened” (&mouedavbévta, Kw.)
361
10
20
30
IIEPI APOPON
KVNLNS aTroTEcovans, Kal éTL evpopwTépws Tept- yivovTat. oict méev odv KaTEayévTOY TMV dbo TéWD arroa piryEtes avtixa éyévovTo Kal pedac uot, TOU- TOLoL fev Taxelat ai mepeppnEtes yivovtat TOU c@uaTos, Kal Ta aromimTovTa TAXEWS am o- mimtel, 0n TOV baTéwy TpoEvdedwKOTwY: olct d€ byiéwy éovToY TOY doTéwWY OL ENACT LOL yivov- TAL, ai mev apKeEs TaYews OvnoKoVat Kal TOUTOLGL, Ta 6€ ootéa Bpadéws adpiotatar, 7 av Ta Spia TOU pera mod yevntae Kal D) Piroos TOU OaTEoU. xp” 6é, dca av KATOTEPO Tob TWAT OS TOV opiwy TOD perao mod ie TauTa, OTav 757, Tautrav TEAK Kal avanyéa n, ad aupely Kara TO apOpov, 7 popnJeonevov Oras ay) Te TpOons" ayy yap dun Oh ATOTAPYOMEVOS Kab uno KUpHon 7 oMua TeOveds TAaUTN 1) ATOTEMVETAL, Kapa. Kly- Suvos bd Ths ddivns AevToOvpHcaL: ai Sé ToL- adTat RettroOvpiar moAXov’s Tapayphua On aT@dcoav. pnpod pev ovv boTéor, Yirwbev éx TOLOUTOU TpoTOV, bySonKOaTAaioV Eldov éyw arro- OTA! 1) MeVTOL KYNLN TOUTO TO AVOpeT@ KaTa TO youu adnpéOn elixoctain, eddxer 5é pou Kat éyyuTépw: ov yap dua, addXN éml To Tpomn- Oéatepov ed0Eé pot Te Trotetv. Kvjpns dé daTéa €K TOLOVTOV pmeAAT HOV, Maa KATA péeoNY THY KUNLNV éovta, éEnxooTaiad mot amémecev, Goa eyrrwoOn auTav. SuvevéryKcoe [ev yap av Tt Kab intpetn int peins és TO Odo cov Te Kal Bpadvrepov Ta OoTéa Wirovpeva aroninterv? duevéyKor ©
1 Kw. édéxer; omit gua and pot. Reinhold’s emendation : ov yap ela pe. . . erate pot.
362
ON JOINTS, wxix.
comes away, they survive still more easily. Now, in cases of fractured bones, when strangulation sets in at once with lividity, lines of demarcation are rapidly developed on the part, and that which is coming away does so quickly, the bones having already yielded ; but in cases where the lividity comes on while the bones are sound, the flesh dies rapidly here also, but the bones separate slowly along the border of the lividity and denudation of the bone. As regards parts of the limb which are below the limit of mortification, when they are quite dead and painless, they should be taken off at the joint, taking care not to wound any live part. For if the patient suffers pain during the amputation, and the limb happens to be not yet dead at the place where it is cut away, there is great risk of collapse from pain ; and collapses of this kind have brought sudden death to many. I have seen a thigh-bone, denuded in this way, separate on the eightieth day. The leg in this patient was removed at the knee on the twentieth day, and I thought it might have been done higher up—not all at once, of course—but I resolved to act rather on the safe side.1. The bones of the leg in a similar case which I had of gangrene just in the middle of the leg came away on the sixtieth day, so far as they were denuded. One or another kind of treatment would make a great difference in the rapidity or slowness with which the denuded bones come away. So too pressure, if
1 Seems to be the sense of a very obscure passage. “Sooner” gives best sense, but is a curious meaning for eyyutépw. ‘* Too early, for it appeared to me that this should be done more guardedly” (Adams, Littré) does violence to
the text. Galen apparently understood ‘‘higher up” ; for he says H. means that it is safer to amputate at a joint.
363
40
TIEPI AP@POQN
av te Kal tmieEts méEvos Kal eml TO io yuporepov Te Kal aolevértepov, Kal és TO Oacoov Te Kal Bpadvrepov aT opehardévra amofaveiv Ta vetpa Kal Tas odpKas Kal Tas aptTnptas Kal Tas brA€éBas* érrel doa pn ioyupas arrohnpbevta@v Ovijoxer, évla TOV TOLOVTMY OVE apixvettat és daTéwy Wireuata, aXX émimoAaotepa exTimter’ évia d€ OVdE és vEevpov irouara adixvettat, arr émTohaLorepa extrimtet. Ola ov TavTas Tas elpnpevas Tpopacias ovK or ev ovvoua ap.0- pod TO xpove OécOa, év omocw Exacta TovTwY
50 KPLVETAL.
60
70
IpoadéyeaOar é Hada xen Toabra inuara’ éodelv yap poBeporepa éotiv Tit 7 intpevew' Kal int pein mpaein apKel Tao TOLOUTOLOLY* avTa yap éwuTa Kpiver pobvov. THs 8é Siaitns | emt perelobar vpn ws KaTa Svvamu aTrUpETOS 7m, Kal év oXNMAct Sixatorae evderifew TO copa" Sixava 5é€ TavTa pndé peTéwpov Trovety, pwnd és TO KaTw pérrov, aXra barrov és 76 ave, mort Kal or” av TEAEWS Tepippayn’ ai wo pparyvewy yap év TOUT® TO Xpovep Kivovvos” 61a TOUTO OU ov xP? Kat ap- porra Ta Tp@LaTa. Tovety, anrra Tavavria. érret Orav rye xpovos eyyevntau TAetov Kab calapa Ta é\Kea yeuntar, ovuK éTt Ta avTa} oxXnpaTA emir decd cor, arr’ uy) evOcia dears, Kal eniore éml TO KaT ap poTov pérrovra ava Xpovov yap éviotat TOUTWY aTooTaoLes TOU yivovTaL, Kal UTodeopmidwyv Séovtar. mpocdéyerOar 8& ypr TOUS ToLovTOUs ava xXpovov UTd SucevTEpins muetecOar' Kal yap emt Tolct pedatvomévoict, Tolot TWrEioTOLOW emUyiveTat OuaEVTEpLN, Kal Emi 364
ON JOINTS, cxix.
stronger or weaker, would make a difference in the rapidity or slowness of the blackening and mortifica- yion of the ligaments, flesh, arteries and veins. For where the parts perish without great strangulation, the denudation sometimes does not extend to the bones, but the more superficial tissues are thrown off; sometimes the denudation does not even extend to the ligaments, but the more superficial parts are thrown off. For the said reasons, then, one cannot fix on one definite time in which each of these cases is determined.
One should be quite ready to treat such cases, for they are more formidable to look at than to cure; and mild treatment is sufficient, for they determine their own process. One must be careful as to diet, so that the patient may be, so far as possible, without fever, and place the limb in a correct attitude. Correct attitudes are neither elevated nor sloping downwards, but rather upwards, especially before the line of demarcation is fully developed; for there is danger of haemorrhage in this period. Wherefore do not keep the injured part dependent, but the reverse. When a considerable time has elapsed, and the wounds are cleansed, the suitable attitude is no longer the same as before, but the horizontal position, and sometimes one sloping downwards ; for in time purulent collections form in some of these cases, and they require under-bandages.!. One must expect such patients to be tnonbleds after a time, with dysentery ; for dysentery supervenes in most cases
1 See Introduction.
l yuUTa.
365
10
TIEPI APOPQN
Thow aipopparyinaw* e& EXKEWD" emuyiverat d€ ws emt TO Tonv KEK PLLEv@V mon TOV pehac- p@v Kal TiS aipopparyins, Kal opmatar pev havpos Kal ioxupas’ drap ouTE TOAUI[LEPOS rylveTas ore Javatwdns” ove Yap para atro- oLTOL yivovTat Ol TOLOVTOL, OVTE AAdws TUpéper Kevenyyelv.
LXX, M npod be dd Onpa Kar’ ioylov woe Xp) euBadrew, Wy és TO éow Mépos odo OnKy” ayadn eV moe Kab Sean Kal KaTa puow n éuBorm, Kal or) TL KAL AYWVLOTLKOV éxouea, OoTLS ye Toioe TOLOUTOLOLY MOETAL Koprpevouevos- Kpeé- pacar xp TOV avOpwrov TOV TOO@Y Tpos pe- coopnv berpL@ duvat@ bev, parOake 6 Kal TETOS éyovTt* TOUS be modas Sue xeuy xP? doov Tésoapas Sax drous aT addirov, ) Kal é\ac- cov yp dé Kal émdva bev Tov emuyouvidey ee eee es aa TraTel imavre Kal parlance, avaretvovTe és? Hp peo oOpny™ TO 0€ akédOS TO owapov evteT aa Jaw xen @S duo daxTUANOUS par Aov Tov étépov' amo TIS, ris TH xeparny aTre- XET@ ws dv0 THYEAS, 1) oni yep TOV Y éXNacoov" Tas O€ yelpas TApAaTeTapEvas Tapa Tas m™Neupas 7 poo OE0EHLEVOS éoTo pardane Tit TavTa 6é TavTa UTTiO KATAKELLEVD KatacKevacdnra, @S OTL éeddyuotov Xpovov K PéunrTat. éray dé Kpe- pac, avopa xen evTaloevTov Kal pn aabevéa, éveipayTa TOV ™HYUY peony TOV pnpaor, elta Oéc0au Tov TAX UY peonyd Tov TE mepwatov Kal THs Keparijs ToD Hnpod Tis eLearn cvins, & emetta ouvdpavra THv éTépny yelpa ™ pos THY Sump wevny, Tapactavta opGov Tapa TO c@ma Tod Kpema-
366
ON JOINTS, vxrx.-.xx.
of mortification, and in haemorrhage from wounds. It comes on as a rule when the mortification or haemorrhage has been determined, and is copious and violent at the start, but neither lasts long nor is dangerous to life. The patients in such cases do not lose their appetite much, nor is there any advantage in a restricted diet.
LXX. Dislocation of the thigh at the hip should be reduced as follows, if it is dislocated inwards. It is a good and correct method, and in accord with nature, and one too that has something striking about it, which pleases a dilettante in such matters. One should suspend the patient by his feet from a cross-beam with a band, strong, but soft, and of good breadth. The feet should be about four fingers apart, or even less. He should also be bound round above the knee-caps with a broad, soft band stretch- ing up to the beam; and the injured leg should be extended about two fingers’ breadth further than the other. Let the head be about two cubits, more or less, from the ground. The patient should have his arms extended along the sides and fastened with something soft. Let all these preparations be made while he is lying on his back, that the period of suspension may be as short as possible. When he is suspended, let an assistant who is skilful and no weakling insert his forearm between the patient's thighs, and bring it down between the perineum and the head of the dislocated bone. Then, clasping the inserted hand with the other, while standing erect beside the suspended patient, let him suddenly
1 roiat aivoppayicacw. 2 ampbds.
30
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IIEPI APOPQN
peévou, éEarivns exxpepacbévta pet éwpov aiwpn- Ofvac @S iooppoT@rarov. abTn b€ 1) euBonrn mapéxerar TAaVvTa boa Vpn Kara puow" avTO TE yap TO capa K pec jLevov T@® EwvuTOU Baper Kat a- TAC ovetrat, 6 TE éxxpepac Gels ama bev TH KATATAGEL avayKater breparwpeia Par Thy xepa- My TOU Enpod UTep THS KOTUNIS, dua o€ TO doTE@ Tob TNX EOS ATO [LOX AEVEL Kal dvarydter és Tv apxainv dvow odaPavew. ypn 6é TayKadrws pev Toior dSecpolow éaxevacbat, gppovéovta 5é kat ws icyupotatov! tov éEaiw-
/ a povpevov eivat.
LXXI. ‘Os pév ody Kai mpdcbev eipnta, péya TO Siadépoy éoti Tay huciwy Toit avOparoow és TO evemPrnTa elvat Kal SuoeuPryra [ra appa): 2 Kal dL0Te péya Sad éper, elpyTau mpoaev év Toiat Tepl wpou. evioiat yap. 0 pn pos eum Tel aT ovdepuijs Tapac Kerns, GX’ orLyNS MeV KATATAOLOS, Gaov THOL Yepat KaTLOvVAL, Bpaxeins bé KUyKMC LOS" TOXOLTL 6é ouyKkapapact TO oKEéXOS KATA TO ApOpov évérrecev, HON audhiapar- oLv TOLNTamEvovV. GAA Yap TA TOAD TAELW OUK évakovel THS TUXOvVaNS TapacKeuts’ La TOUTO émiaTac bau pe Xp Ta KpaTioTa mepl éxdoTou év mdon TH TEXYY’ xpijoOas 6e olow av 60&y ExdoTOTE, elpynvrar pev odv TpoT ot Katatacioy Kal €v Totow eumpooOev YEYpappevoow, doe xphoba. TovTwyv doTis av TapaTuyn. Set yap
1 According to Littré and Petrequin, the patient is meant; but Littré emends to éxuveétarov. The rai favours reference to the assistant; as in the Latin interpreters and Ermerins.
2 Omit Galen, Littré,
368
ON JOINTS, vxx.-Lxx1.
suspend himself from him, and keep himself in the air as evenly balanced as possible. This mode of reduction provides everything requisite according to nature, for the body itself when suspended makes extension by its own weight; the assistant who is suspended, while making extension, forces the head of the bone to a position above the socket, and at the same time levers it out with the bone of his forearm, and makes it slip into its old natural place. But the bandages must be perfectly arranged, and care taken that the suspended assistant is the strongest available.!
LXXI. Now, as was said before, there is a great difference in the constitution of individuals, as regards ease and difficulty in reducing their dislocated joints; and the reason of this great difference was given before in the part about the shoulder. Thus in some, the thigh is put in without any apparatus, by the aid of slight extension, such as can be managed with the hands, and a little jerking ; while in many, flexion of the leg at the joint and makinga movement of circumduction is found to reduce it. But the great majority do not yield to ordinary apparatus; wherefore one should know the most powerful methods which the whole art provides for each case, and use them severally where they seem appropriate. Now methods of extension have been described in previous chapters, so that one may use any one of them which happens to be available.?
1 Pq. renders, “the patient very strongly suspended,” so also Littré; but there are surely two injunctions. Adams, ‘*the person suspended along with the patient [should] have a sufficiently strong hold.” Littré’s éxupsrarov applied to the assistant.
2 Cf. VEL 369
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IIEPI APOPON
avTixatateTadcOar iaxupas, érl Oatepa wev Tod oxédeos, emt Gatepa S€ TOU GwMpaTos: ivy yap ev catatabh, dTepatwpnO cera a ceparn TOU pnpov brrép THS apyaiyns ens Kal nv wey vIreEp- aveopn Oh obTws, ovoe Kohdoat ere pyidcov iteo Bar aut ny és TV EwuTiis Edpnv, WATE ON mace apnel poxevats Te Kal KaTopOwats: adda yap édXel- TOvoLV ev TH KaTATao eu" dua TOUTO oY OV TAeLeo Tapexet 1) 7 €uBorn. xp1) ovv+ ov podvov Tapa TOV mooa TQ deo pa efnornatan, anrra kal avwblev tod youvaros, Omras * [in KATA TO TOD youvatos apO pov év Th Tavucel a emidoars ® a Hadov 7 Kara TO TOU iaxtou apO pov. oUT@ Mev obv Vp} THY KaTAaTA- ow THY T pos” 70 TOD Todos mépos eo nevada Bae: arap ral THY émrl Oarepa KaTaTacw, ji) odvo éx THS Tept TO oTHOOS Kal Tas pacxadas TepeBorns avrireived Bat, arra Kal ipadyre paxp®, OuTTUYXO, ioxup®, m™ poonvel, Tapa Tov mepivarov BeBdn- pEV@, TapaTeTapevo, él pev TA OnLcOev Tapa THV pay, él é Ta eum poo bev Tapa THY KAnioa, TPOTNPTN HEV oD Tpos THY apynv THY avTiKaTa- TelvovcaY, OUTW dvavaryxaterbar, Tolct bev évOa Sratewapévorot, Toll be évOa, 6 o7rws o€ 0 fmas 0 mapa TOV T€plvavov pa) TEpl T2V Kepargy TOU penpov TAPATETAPLEVOS eo rat, anrra peanyy Tis Kepanriys Kal TOU mepwatov, év Oé 7H KATAT AGEL KaTa _pev THY Kepadyy TOU pnpod épeioas THY muypny és To &&w wbeireo. jy Oe petewpitntar EAKOMEVOS, duepoas THY xetpa Kal emo vvanyas Th éTépn XELpl Gua TuyKaTaTeLVETo, aa dé € és 70 ef cvvavayKxaléTw: adAos O€ TLS TO Tapa TO youu TOU LNpPOD I}TVX@S Es TO Zow Epos KaTOPOOUTM. 370
ON JOINTS, vxxi.
There must be strong extension both ways, of the leg in one direction, and of the body in the other; for if good extension is made, the head of the thigh- bone will be lifted over its old seat, and when so brought up, it becomes difficult even to prevent it from settling into its position, so that any leverage and adjustment suffices ; but it is in extension that operators fail, and that is why the reduction gives more trouble. One should attach the bands, not only at the foot, but also above the knee, so that, in stretching, the giving way may not occur at the knee-joint rather than at the hip. This then is how the extension towards the foot end should be arranged ; but there should be also counter-extension in the other direction, not only from a band round the chest and under the armpits, but also from a long double strap, strong and soft, passed round the perineum and stretched behind along the spine, and in front by the collar-bone attached to the source of the counter-extension. With the cords so arranged, some are stretched in one direction, some in the other, taking care that the strap at the perineum is not stretched over the head of the thigh-bone but be- tween it and the perineum. During extension, let the fist be pressed against the head of the thigh-bone and thrust it outwards. If the pulling lifts up the patient, insert one hand between the thighs and, clasping it with the other, combine extension with pressure outwards. Let another person make adjustment by pushing the knee end of the bone gently inwards.
1 58, 2 Wa, 3 énideos Littré, Petrequin, and codd., except B. émfSoars B, Erm., Kw.
371
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30
MEPI APOPQN
LXXII. Hipnras 6&€ xal mpdcbev dn Ott émakiov, daotis év mode TodvavO pare int pever, EvNov KexTha Bas TET pury@vov Os Earn, y) oriy@ méCov, epos dé @s dimnyxy, ™aX0S 66 a apxet on apiaior: érretta Kata BiyKos bev &vOev Kai évOev evTopay exew XPM» @S [1) bYynrorépn TOU Karpov a) pnxdrnous 7 eTeLTa Pras Bpaxetas, ioxupas Kal iaxXupas evn por méevas, oviaKov Exel éxatépwlev: Ererta dpxet pev év TO pion TOU Evrou—ovédev b€ xorver Kal 61a TavTds—éevTe- tuncOat ws Katrétous paxpas trévte 7) €E, dradrer- Tovaas at adAnov ws Tégoapas SaKTUAOUS, avtas 6& apKet elpos TpLdaxTUAOUS eElvat Kal Babos ottws. exe b€ Kata wécov TO EVAOV Kal Katayrupiy xpn Badutépny, emt TeTpdywvor, ws Tpiov SaxTUAwy: Kal és pev THY KaTayrudiy TavTny, OTav do0xh mpocdety, Evrov éumnyvvvar évappofov TH Katayhupy, TO O€ dvw oTpoyyUrov: éumrnyvuvae 5€, ery Tote OoKH cupdépev, weonyv TOU Tepivatiou Kal THs Kehadis ToD npovd. TOTO TO EvAov ECTEOS Kove THY éTrloogLV emLdudova TO oO ja. Totce T pos TOOWV EdKove tw évioTe yap apKkel avTo TO Evov TOUTO aVTL THS dvodev a avTL- KaTatao.os: éviote 6€ Kal KaTaTELvom“évouv Tod aKxéXeos évOev Kai evdev, aro TO Evhov TobTO, Narapov eycelmevov ) TH 1) TH, EK HOX NEVE €7rL- 77 S€Lov av ein THY Kepahny Tob pnpod és TO é&w [EpOS. Oud TobTo yap Kal at KATETOL eVTETMEATAL, as Kal” omoiny av avtéwy dppoon, eu Bardopevos EVALvOS Hoxros poxdevor, i?) Tapa Tas Keparas Tov apOpwv, i i) Kara Kepahas TehEws epeldouevos aa TH KaTaTdcel, iy TE &s TO CEw pcpos cuuhépy 372
ON JOINTS, vxxn.
LXXII1. It was said before ! that it is worth while for one who practises in a populous city to get a quadrangular plank, six cubits long or rather more, and about two cubits broad ; while for thickness a span is sufficient. Next, it ehoard have an incision at either end of the long sides, that the mechanism may not be higher than is suitable? Then let there be short strong supports, firmly fitted in, and having a windlass at each end. It suffices, next, to cut out five or six long grooves about four fingers’ breadth apart; it will be enough if they are three fingers broad and the same in depth, occupying half the plank, though there is no objection to their extending the whole. length. The plank should also have a deeper hole cut aes in the middle, about three fingers’ breadth square; and into this hole insert, when requisite, a post, fitted to it, but rounded in the upper part. Insert it, whenever it seems useful, between the perineum and the head of the thigh- bone. This post, when fixed, prevents the body from yielding when traction is made towards the feet; in fact, sometimes the post of itself is a substitute for counter-extension upwards. Some- times also, when the leg is extended in both direc- tions, this same post, so placed as to have free play to either side, would be suitable for levering the head of the thigh-bone outwards. It is for this purpose, too, that the grooves are cut, that a wooden lever may be inserted into whichever may suit, and brought to bear either at the side of the joint-heads or right upon them, making pressure simultaneously with the extension, whether the leverage is required
1 Fract. XIU. The Scamnum or ‘‘ Bench” of Hippocrates. ® J.¢e. the supports should be *‘ let in,” not fixed on the top.
373
43
10
TEPI APOPQN
> A ” > \ oo» Ni Loh, ex poyrevecOat, Av TE €5 TO ow, Kal HY TE OTPOY- 4 \ \ / 3 A 2 yuXov Tov soyAov cUULpepn Elval, NY TE TAATOS ” ” \ ” a 7 e , éyovTa’ adios yap GdA\w TOV apOpev appoter. evxpnotos O€ éotiy él Tavrav Tov apOper >’ a an \ \ / 4 e , euBorgrs TOV KaTa TA TKENEA AUTH 1 MOXEVOLS OU TH KaTaTacE. TEpPl OV OY O AOYOS éoTI, , ¢ r ¢ X 5 i a L oTpoyyvNros dppoter O Hoxros eivae TO MEVTOL ” > > ig > é&m exTreTTT@KOTL ApPpw mAaTUS apmogeL ElvaL. lal / aTO TOUT@Y TOV pnYavéwy Kal avayKéwy ovdSéV dpOpov por Soxel olov te Elva atropnOhvatr éeu- TECELD. ¢i ’ / LXXIII. Evtpot & adv tis Kat adrXovs TpoTrovs / la) x” ’ a ’ \ \ A \ TovTov Tov apOpov éuBorNs: et yap TO EVrOV TO lol » , péya ToUTO Evol KaTa pécov Kal é« TAaYLoV / ¢ [4 prtas dvo ws trodsatas,’ trpos bé brrws av Soxéor , \ \ M4 \ be ” Fal 22 ovupdeperv, THY pev evOev, Thy O€ &vOev* erreta 7 , she ’ A aA e EvXov TAGYLOV Eveln EV THAL PALNTLW wS KALMAK- / ec aA THpP, eTELTAa SLéepaar” TO UYyLEes TKEXOS PETNYY TOV grLéwv, TO S€ oivapoyv av@bev TOD KALMAKTHpOS Nye \ éxeww ? évapwolov araptt mpos TO Uyos Kal wpos \ ” Q e@ 2 / o She iS Sa \74 TO apOpov, éxmémta@xev’ pnidiov dé [xp] € \ SN n e , appofew'’ Tov yap KrALwaKTHpa UrnNOTEpoOV TLVL a a , Tie pn Tovety TOD peTplov, Kal iwaTLoV TONUTTUXOD, , / \ a @s av appLoon, UToTEiVELY UTO TO TOua. ETELTA vpn EvAov Exov TO TAATOS péTpLOV, Kal pHKOS an lo) XN \ aXpt TOU apupod UToTeTapévov, UTO TO aKEXOS ELVAL, LKVEVJLEVOY ETEKELVA THS KEPAATS TOU pNpov l rodds uijxos Paulus VI. 118. 2 ¢i diepociey Kw., epeloere Apoll, 3 Exot. 4 Omit.
374
ON JOINTS, vxxt.—ixxm.
outwards or inwards, and whether the lever should be rounded or broad, for one form suits one joint, another another. This leverage, combined with ex- tension, is very efficacious in all reductions of the leg-joints. As regards our present subject, it is proper that the lever be rounded; but for an external dislocation of the joint, a flat one will be suitable. It seems to me that no joint is incapable of reduction with these mechanical forces.
LXXIII. One might find other ways of reducing this joint. This big plank might have two props at the middle and to the sides,! about a foot long —height as may seem suitable—one on one side, the other on the other; then a crossbar of wood should be inserted in the props like a ladder-step. One might then insert? the sound leg between the props, and have the injured one on the top of the bar, fitting exactly to its height and to the joint where it isdislocated. This is easily arranged ; for the crossbar should be put somewhat higher than is sufficient, and a folded garment spread under the patient, so that it fits. Then a piece of wood of suitable breadth and of alength sufficient to reach to the ankle should be extended under the leg, going
up as far as possible beyond the head of the thigh-
1 These props seem to have been removable and at the sides of the hole for the perineal post, which was rata wéoor ; not fixtures at the sides of the ‘‘ bench,” as usually figured. See the description in Paulus (VI 118). ‘The wooden cross- piece must have been either very thick or much shorter than three feet, to stand the pressure required, It could be put either at the top, when the whole resembled the letter pi, or lower down, when it resembled éta (A), This also shows that the arrangement was not very wide.
2 Si€poeev surely implies that the props were not far apart.
375
20
30
33
10
TEPI APOPOQN
as olov te mpockatabedésOat S€ yp mpos TO oKéXOS, OT wS dv peTpios ENN. KATELTA KaTATEL- vojévou TOD okéeos, ElTE Evo Ur epoetdel, ele TOVT@V Tih TOV Katatactov, 0 ood pt) caTavay- ater bat TO TKENOS Tept TOV KALWLAKTHpA és TO KATW [Epos oop TO EU TO poo dedenever’ TOV b€ Tiva Kat exe Tov dv porrov avorepo Too apO pov Kara To ioxiov. Kal yap ovTws dma perv a) Katara Umepaiporto * TH Keparny TOD penpov vmrép TS KOTUNNS, apa oe 7 box reverts atwOéou TH Kepadny ToD pnpod és THY apxainv puow. aUTaL TAaTAL ai el pywevar avayKat boxy- pal Kal Tacat Kpéacous THs cuumophs, Hv Tes oplas xal Kadk@s oKevaty.2 woTrep O€ Kal TpOdC- Gev On eipntat, Torv TL ato acbevertépwr KaTaTaclwy Kal pavroTépns KaATATKEUHS Toot mretoow § éurinte.
LXXIV. “Hy d€ és 1O &&w Keharr pnpod OAcOy, Tas ev KaTaTactas évVOa Kal évOa ovTw xen moteta Oat BoTrep elpnTat, 1 TOLOUTOT POTTS" THY dé poxhevow TATOS & EXOVTL [Loxr@ Poxrevew xp dua TH KATAT AGEL, €x Too eco pépous és TO ero avaryKalovra, Kata ve avrTov TOV yAouTov Te Oépevov TOV Hox ov Kal onriryep avatépw’ él TO wryees iaxtov Kara TOV yhouTov dvrearn pileron Tus THOL YEpaly WS fun) UTELKN TO TOA, 1) ETEPW TLVL TOLOUT® [LOXAMD UTOBadrAwV Kal épelaas, ex 4 TOV KATET OV THY appofovoay dV TUKATEXETO" Tov oé€ penpod Tod en pOpnKoros TO Tapa TO youu Eo wbev é&w TapayéTw novyws. 1 S€ Kpé“acis ovX
¥ Smrepaiwpeo: by,
376
ON JOINTS, vxxit.—-vxxrv.
bone ; it should be attached to the leg in a suitable manner. Then, while the leg is being extended either by a pestle-shaped rod or any of the above modes of extension, one should simultaneously force the leg with the wood attached to it downwards over the crossbar; while an assistant holds down the patient at the hip above the joint. For thus the extension will raise the head of the thigh-bone over its socket, while the leverage will thrust it back into its natural place.! All these forcible methods of reduction are strong, and all are able to overcome the lesion, if one makes a proper and good applica- tion of them; but, as was said before, in the majority of cases the joint is put in with much weaker extensions and more ordinary apparatus.
LXXIV. When a thigh-bone head slips outwards, extension should be made in both directions as described, or in similar fashion. The leverage should be done with a broad lever simultaneously with the extension, forcing it from without inwards, the lever being applied to the buttock itself and a little above it. Let someone give counter-support to the hip on the sound side at the buttock with his hands, that the body may not yield, or make counter- pressure by slipping a similar lever under the joint, using a suitable groove as fulerum. Let the bone of the dislocated thigh be gently brought from within outwards at the knee. The suspension method will
1 An imitation of the method of reducing the shoulder- joint (VII).
2 «kevd(nrat, as Apollonius. 3 aAelorototy. * és for é« Kw., following Erm.’s conjecture,
377
20
22
10
19
IIEPI APOPON
apmocet TOVTM TO TpOTw THS OrALCOHCLOS TOD apOpov' 0 yap THYUS TOD exKpEepapéevou atrwbéor } cw THD Kepadny TOU penpov amo THS KOTUANS. THY pévtot our TO EUXo TO UTOTELVOMEVO HoXdevowy pnxavyoatr av Tis MaoTE appotew Kal TOUT@ TO TpOT® Tod orto Onuatos, &EwOev 7 pocapTewy. ara Ti al det [mrelw Aéyevy] 5 2 Dy yap opbds bev Kal ev KataTevnral, opbas d€ woydevnTtar, TL OvUK ay eu ET OL apO pov ouTws EXTETTOKOS 5 ;
LXXY, “Hy d€ és ToUTLaOev BE pOS EKTETTOKY O pNpos, TAS meV KaTaTao Las Kal dvriTaotas ovUTw det moveia Oat, cadamep * elpnTae’ emia Topécavta dé éml 70 gvdov f (atvov TOUT TUXO, @S panda- KWTATOV %, Tpnved KaTakNivavtTa TOY avOpamov, oUTw KaTaTeively’ apa dé Th KaTataces xPH TH oavior KatavayKate TOV avTov TpoT ov Os 7a vB@uata, KAT i€uv Tov muyaiov Tounadwevov TH caviba, Kal Haddov és TO KATO pEpos y) és TO ave TOV ioxiov" Kal ” evToun ” év TO TOLYY TH cavioe BN evOcia ear, arn’ Odtyov caTadepys Tos TO TOV TOOOY HE pos. arn 7 éuBonry KATA puow TE pddiora T@ TPO TOUT@ Tob orto Or}pa- TOs éore Kal dua ioXupoTarn. apkécee © ay laws avtl THS cavidos ral ee Fowevor Twa, 7) THOL yvepatv Epelo devon y éemiBavra eEamivns opmolws emaropnOjvar aa TH KaTaTacel. arn dé ovdenin éuBorn TOV m pia bev ELPNMEVOV KATA dvaw €oTt TO TpoT@ TOUT® TOD OALCONnMLATOS.
LXXVI. “Hy de és TO éum poo bev onriaOn, TOV pep Katratac tov 0 autos TpOTOS TouNT Eos” dvdpa dé vpn ws taXupoTatov amo TOV Xelpav Kal as evTadevTOTaTor, evepeicavTa TO Oérap THs YEtpos 378
ON JOINTS, txxtv.—Lxxvi.
not suit this form of dislocation, for the forearm of the person who hangs himself on would push the head of the thigh-bone away from its socket; but one might arrange the leverage with the board at- tached so as to suit this form of dislocation also, fitting it to the outside. But what need is there [to say more]? Forif the extension is correct and good, and the leverage correct, what dislocation of this kind would not be reduced?
LXXV. If the thigh is dislocated backwards, extension and counter-extension should be made in the way described. Spreading a folded cloak on the plank, so that it may be as soft as possible, with the patient lying prone, one should make extension thus, and simultaneously make downward pressure with the plank, as in cases of hump-back, putting the board in a line with the buttock, and rather below than above the hip. Let the groove in the wall for the board be not level, but sloping a little down towards the feet. This mode of reduction is most naturally in accord with this form of dislocation, and at the same time very powerful. Instead of the board it would, perhaps, suffice for someone to sit on the part, or make pressure with his hands or with the foot, in each case bringing his weight suddenly to bear at the moment of extension. None of the other modes of reduction mentioned above is in natural conformity with this dislocation.
LXXVI. In dislocation forwards, the same exten- sions are to be used; and the strongest-handed and best-trained assistant available should make pressure
1 arwoin. 2 Omit Kw. and a few MSS. 3 « as.
379
10
14
10
TEPI APOPQN
Tis ETEpNS Tapa tov BovBova, Kat TH erépy xetpl THY EwUTOD Xetpa mpooxataraBorra, & dpa peev és TO KAT obeiv TO orcOnua, & dpa déeé és TO eum poo- Oev Tov yovaros fépos. ovTos yap o TPOTOS THS é€uBorNs Hadora kara prow TOUT@ TO odo Onwart eo TW. aTap Kal 0 K pe Lao Mos eyyus TL Tob KaTa pvow def pevtToe Tov EK PELE MEVOY EUTTELpOV Elva, WS pay exwox edn TO THYEL 70 dpO pov, aNd TEpl péov TOV mepivacov Kal KATA TO lepov OaTEéoV THY exK PEAT TOinTal. LXXVII. Evcoxepet 5é€ 62) Kal [o me pabeis|* aoKe TOUTO TO a0 pov EuBarreo Bar: Kal 8M peév TLvas eLoov oireves vmod pavdornTos Kal Ta é&w excekhipeva Kal Ta omiabev acK@ éeip@vTo euBarrey, ov ylyv@oKovTes OTt é€eBadov avToO pea dov ») éveBaddov 0 mévTOL TPA@TOS eTrivonaas djAov OTL T pos Ta €OW orig Onkora dox@ eu Badrew eTEL pr} TATO. éemiatacbat ev ovy Xp?) @s Xpneteov aoK®, el déoL xpi Par: drayweoke, € xp” OTL érepa TONG aoKov Kpéoow early. vpn O€ TOV meV do Kov KaTa- Deivar > és TOUS penpovs adpvantov cova, @s av dvvatTo aV@TATW TPOS TOV TEpivaLov ay dyouTa amo 6€ TOY émruyouvidcv apEdpevor, Tain 7 pos adda NOUS TOUS pnpovs Katadhoat _axpl TOU Hptoeos TOV pnpov: ErEerTa és é&va TOV TrodMD,! TOV NEAULEVOP, évOevta avhov eK Xarxelov, Pdoay écavayKavew és Tov doKov" TOV dé av 0 pwmov mrayiov cataKeta Oar, TO owapov oKEROS em l- Tons EyovtTa. pev ovv TapacKert) avTn
1 Omit Kw. and most MSS. 2 bet. 380
ON JOINTS, txxvi.—Lxxvu.
at the groin with the palm of one hand, grasping it with the other, and pushing the dislocated part downwards, while at the same time the part at the knee is brought forwards. This mode of reduction is in most natural accord with this dislocation. For the rest, suspension rather approaches the natural method; but the man who hangs himself on must be experienced, so as not to lever out the joint with his arm, but make the suspension weight act at the middle of the perineum, and over the sacrum. LXXVII. Finally, there is an approved method of reducing this joint also with a bag;? and I have seen some who, through incompetence, kept trying to reduce even external and posterior dislocations with a bag, not knowing that they were putting it out rather than putting it in. The first inventor of the method, however, obviously used the bag in trying to reduce inward dislocations. One ought, therefore, to know how to use it, if required, while bearing in mind that many other methods are more effective. The bag should be applied to the thighs uninflated, and brought up as close as possible to the perineum. Bind the thighs to one another with a band extending from above the knee-caps half-way up the thighs; then, inserting a brass tube into one of the feet? which has been untied, force air into the bag. The patient should lie on his side with the injured leg on top. This, then, is the arrangement ;
1 Tn the ‘‘ Apollonius” illustration he makes pressure with one hand on top of the other.
2 /,e. wine-skin. Cf, use for spine (XLVII).
2 Of the wine-skin.
Se ee
3 evdetvat, 4 rodchHvwy Weber, Kw.
381
30
40
42
10
TIEPI APOPON
éoriv" oKevdSovrat dé KaKLoV ot TreiaTou 77 os eyo elpnKea ov yap KaTtadéovat TOUS Nnpovs eT oUXvoV, ara povvoy Ta yovara,, ovee KaTA- Tetvouat xp? 5é Kal T poo KkaTaretvely™ dues € 78n Ties evéSadov pyidiov T PNY HAT OS eT LTU- NOvTES. evpopws be ov mavu EVEL Sravarynaler- Bas OUTS" 6 Te yap aoKos EupuT @ pEv0s ov Ta oyKnpoTara autod éxer mpos TO apbpm Tis Keparijs, 7) nv bet padiora éxpoxdevoar bar, anna cad EwuToV avTos peas Kal TOV Mapa iows 7) KATA TO péo ov i) ETL KAT@TEPW* of Te av pnpot puoer yavool TepvKcac iy, avobev yap capKadeés Te Kal oULENpOL, és 6€ TO KATO Drroknpor, aore kal 1) TOV npav puous emravaryxd et Tov ao Kov amo TOU eT LKaLpoTaTOU xe@ptov. el TE oby Tes o MLK pov evOrjoer TOV ACKOD, TpLLK pn n Loyus éotoa aov- vaTos éoTau dvaryeabew TO apOpov. ef d€ det aoK@ xphrbat, él TOD oi pnpol cuvderéot 7 pos adrrhous, Kal apa 7H KATATACEL Tot TOLATOS 0 doKos puantéos Ta 6é oKEehed ap porepa oou cal kaTadely €y TOUT® TO TPOT@ THS éuBorns emi THY TEAEUT IV.
LXXVIII. Xpn dé mepl mrelaTou pev TrOLela- Bai év maon Th TEXYN OTWS bya TOONS TOD vooeovTa: ei Sé moAXoior TpOTrOLoL olov te én vyvéa moet, TOV doxoTraTov xp? _aipsio bar Kal yap avdparyabixwrepov ToUTO Kal TEX PLO TEpOD, BoTes 1) em Oupet 61 1oeLdéos KuBondins. mepl ov ovv o oryos earl, ToLaioe av TUVES KATOLKLOLOL KATATAOLES elev TOU oo@partos, OOTE ex Tov Tapeov Tov TO eUTopov eupio Kew" ToUTO pev ef ta Seopa Ta ipavtwa pi) Tapeln Ta 382
ON JOINTS, wxxvit.-Lxxvin.
but most operators make less suitable preparation than that which I have described. They do not fasten the thighs together over a good space, but only at the knees; nor do they make extension, though there should be extension as well. Still, some are found to have made reduction, chancing upon an easy case. But the forcible separation is by no means lightly accomplished thus; for the inflated bag does not present its largest part at the articular head of the bone, which it is especially requisite to get levered out, but at its own middle, and perhaps at the middle of the thighs, or still lower down. The thighs, too, have a natural curve; for at the top they are fleshy and close together, but taper off downwards, so that the natural disposition of the thighs also forces the bag away from the most opportune place. If one inserts a small bag, its power being small, it will be unable to reduce the joint. So, if one must use a bag, the thighs are to be bound together over a large space, and the bag inflated simultaneously with the extension of the body ; also tie both legs together at their extremity, in this form of reduction.
LXXVIII. What you should put first in all the practice of our art is how to make the patient well ; and if he can be made well in many ways, one should choose the least troublesome. ‘This is more honourable and more in accord with the art for anyone who is not covetous of the false coin of popular ad- vertisement. To return to our subject—there are certain homely means of making extension, such as might readily be found among things at hand. First, supposing no soft supple leather holdfasts are
383
20
30
TEPI APOPOQN
parbana Kal T™ poonvea, GX i) o1drpea * a Oma i) oxowia, Tawinot xen » expyypwace JTpuxiov epuvewy TEPLEALT ELV TavTn padiora 7 pédree Ta deca cadet, Kal éte éml TEOY" émerTa oT ely oie! Sea potow" TovTO 56, éxl «Artvns xn Ts taxyupoTtaTn Kal peylarn TOV Tapeou- oéwv Kataretaa bar Kaas Tov av pwmov' Tis dé Kcrivns TOUS Todas, 7) TOUS T pos Kwepanrijs y) TOUS TpOS OOD, épnpetabas Tpos TOV ovdon, ét te €EwOev cupdéper, ef Te EcwOev: Tapa S€ Tos éTépous Todas trapeuBeBrARcOar EVAOv TeTpAaya- vov TAY, duiov amo Too TOOOS Tpos TOV mooa, Kal Hy pev KewTOV 7 TO Evnov, poo dedéa Fw mMpos TOUS mobas Tis KrWNS, yy dé mayv uP ponder? émerta Tas apxas Xen Tav Serwav Kab TOV TpOS Ths Kebarijs Kal TOV Tpos TOV ToO@v T poo Oioat éxaT epas pos bmepov ) pos aro Te ToLobTov" 0 be deo 410s eXeT@ iOvepinv KaTa TO cHua 7 Kal NT dvarEpo, TULMET PWS é extetaa Ow ™ pos Ta UTEPA, OS, opla éoTewTa, TO ev Tapa Tov ovdov épeldntat, TO O€ Tapa To EvNov TO TapaBeBrnuévov' KaTELTA OvTw Ta Umepa dvakhovra xP??, THY kaTatacw movel, apket 6€ Kat Krinak ioxupovs éxovea TOUS KALMAKTI PAS, Uroreramevn vTO THY Kdivny, avrl Tob ovd0b TE kal Evdou TOU TApareTapmevov, as Ta wU7epa, pos TOV KALLAKTH POV TOUS appd- fovtas évOev Kal evdev T poo epn pera eva, ava- KAw@peva, OUT THY KATaTATW TroLnTaL TOV eT MOV.
"EuBarretar dé pnpod apOpov Kal tovde Tov
1 ceipad.
384
ON JOINTS, -uxxvin.
available, one might still wrap up iron chains, ship's tackle, or cords, in scarves, or torn woollen rags, especially at the part where they are fastened on, and somewhat further, and then proceed to bind them on as holdfasts. Again, one should use a bed, the strongest and largest available, for making good extension ;1 the legs of the bed either at the head or foot should press against the threshold, outside or inside, as is opportune, and a quadrangular plank should be laid crosswise against the other legs, reaching from one to the other. _ If the plank is thin, let it be fastened to the legs of the bed; but if thick, this is unnecessary, Next, one should tie the ends of the bands, both those at the head and those at the feet respectively, to a pestle, or some other such piece of wood. Let the bands be in line with the body, or slanting a little upwards, and evenly stretched to the pestles, so that, when they are vertical, one is pressed against the threshold, the other against the plank laid across; and then one should make the extension by drawing back the pestles thus arranged. A ladder with strong crossbars stretched under the bed is a good substitute for the threshold and cross- beam, so arranged that the pestles may get their fulera at either end against suitable crossbars, and, when drawn back, may thus make extension on the bands.
The thigh-joint is also reduced in the following
1 Littré and Petrequin render katarerdoOa simply “coucher”; but the word is used throughout for surgical ‘‘extension,” Adams: ‘‘the patient should be comfortably laid.”
@ od def (Kw.’s conjecture from otdtyv of BMV).
385
VOL, III, Oo
50
58
10
TIEPI APOPON
, BN b] AWS. b] @ / Weare S ®, TpoTroy, Hv €s TO Ecw @ALAOHKY Kal €s TO EwTrpo- Oev' Kripaka yap ypi KatopiEavta émixabicat Tov avOpwrrov, Ererta TO pev UYyLEs TKENOS Hov- Xos KaTaTeivavTa Tpocdhoat, OTov av apLoon' éx € TOU cwwapod és Kepapiov Vdwp éyyéas Ex-
, xX ’ / / > f , 4 Kpepaoal, i) €s apupioa \iPovs éuSarev. €TEpos TpoTros éuBorHs, Hv €s TO ow @ALAO)KN’ oTpPw-
n \ lal \ / f ef ue XxPN KATAONCAL peraty d0M oTUAMY oyros EXOT aL o Ui eT pov" TMPoeXer@ dé TOU OTpeTipos KaTa TO &p Hépos oTocov TO Tuyatov'} trepi- Snaas 6€ Tepl TO aTHOOS TOV GvOpwrou iwaTuor, éruxabica Tov avOpwrov éTi TO TpoexXov TOU oTpwThpos eita TpoodaBetv TO oTHVos mpos Tov
r an / \ NN oTUAOY TAaTEL TLV’ ErEerTAa TO eV VYLES TKENOS
\ a KATEXETM TLS, @S Li) TEPiapadArAnTaL’ ex O€ TOD n o / awvapod éxxpeudoat Bdpos, dcov av appmoly, ws Kal mpoabev Hon elpntar. LXXIX. [pérov peév ody Set efdévat OTe TaVvT@V fal b / € vd ? e > \ \ ¢ TOV OTTEM@V Al GUUPoOAaL ELoLY @S ETL TOAD 1 \ Vio fie Yj yt) 2 Uk \ VO € , Kepary Kal 1) KoTUAn é€f av bé Kal » Yw@pa / a KOTUAOELONS Kal éripmaKkpos’ Eat 6 TOV yYwpéwy yAnvoerdées eioiv. cael d€ euParrew det TavtTa Ta extimtovTa apOpa, wadoTa pev evOvs Tapa- a an / Vphpua étt Oepua@v eovtwv: et O€ py, WS TaXLOTA’ Kal yap TO éwBarXovte pyitepov Kal Cdaoov b > } / \ an > / \ bd éotiy €uBarrew, Kal TH agOevéovtTs TOAD aTro- s ea \ (2 \ ta ? , A \ votépn 1 éuBorn 7) ply dtoidety eotiv. Set &€
1 an xvatoy Littré; wuypatoy Pq.; muvyaiov vulg., Kw. x ’ K 9 BUY 5»
356
ON JOINTS, -txxvitt.—-L_xxrx.
manner, if it is dislocated inwards or forwards, One should fix a ladder in the ground, and seat the patient upon it; then, gently extending the sound leg, fasten it at a suitable point, and from the injured limb suspend a jar and pour in water, or a basket and put in stones, Another way of reducing it, if dislocated inwards :— Fasten a crossbar between two props at a moderate height, and let one end of it project a buttock’s length.t After passing a cloak round the patient’s chest, seat him on the projecting crossbar, and then fasten his chest to the upright with a broad band. Let an assistant hold the sound leg, to prevent him from slipping round, and hang a suitable weight from the injured one, as has already been described.”
LXXIX. One must know, to begin with, that the connections between all bones are as a rule the head and the socket. In some, the cavity is large and cup-shaped; but in others, the cavities are shallowly concave. One must always reduce any dislocated joint, preferably at once, and while the parts are still warm ; failing that, as soon as possible, for reduction before swelling sets in is accomplished much more easily and quickly by the operator, and is much less painful for the patient. When you are
1 “What a measure!” says Petrequin, and suggests muypyacov. Littré reads mnxvaiov, ‘‘a cubit.” The reading of the MSS. is supported by Apollonius (both text and illustration), though it is hard to see why the patient should not sit between the posts.
2 According to Galen, the treatise ended here. The rest is a sort of appendix of fragments, some of them (¢.g. LX XX) perhaps genuine parts which were lost and subsequently rediscovered. Most is from Mochlicon, as explained in the Introduction.
387
17
10
20
TiEPI APOPOQN
ael TravtTa Ta apOpa, oT OTAaV éEAATS enBdrnewv, mpoavaparatat Kat Sraxvyedioat paov yap eOérex euBarrE0 Oa. Tapa maoas 6€ Tas TeV apOpov eu Boras loxvatvery def TOV dvOpwroy, paMora pev rept Ta meyeota dpOpa Kal vane- Torara éwBarrea Gat, tkicTa Oe Tepi Ta eXayioTa Kat pyidia.
LX XX. Aaktidov 5é Hv exTEon apOpov tT TaV Tis XEtpos, iy Te TO TP@TOV, HV TE TO SevTEpor, 7) mY TE TO TplTov, @UTOS [Kat toos|? TpoTros THS éuBorjs* yaneTarTepa PEVTOL ael Ta MeyLaTe TOV apOpwy euBadrewv. cx im TEL bé KaTa Téooapas TpoTous, aVO ) KATO. ) és TO Taytov exatépober, pua- Arora pev és TO Avo, HKLoTa Oé €s Ta Taya, év 7@ opodpa Kivelabas, Exarepoabev be TIS xepns, ov éx BEBnxev, aomep duBn éotiv. ay bev ovv és TO ave éxTéon 1 €s TO KATw Ota TO NELOTEOHY elvar TAVTHVY THY YOpHy, ) ek TOV TrAYioY, Kal dma MiKpHsS €ovans THS UmepBda.os, wv petacTH To apO pov, pnidioy éotw éuBdrrEwWw. TpoTos dé THs euBorns Ode TepiediEar Tov SadxTuNOV AKpov 1 émidéo mart TLL 1) adap TpoTe@ TOLOUT@ rv, Sms, oToTay Kararetvns akpov aBopevos, ft) atonabavn Otay oé mrepiehtEys, TOY [ev Tuva dvara Bérbar avwlev Tod Kapmo THS Xetpos, TOD 6é Tob KATELNILLEVOV™ 2 erevta Karareivery 7 pos E@UTOV apporépous ev pada, Kal dua at@cal TO éfeornKos apOpov és TH Nopny. a be és 7a maya EKTETN, THS MEV KATATATLOS WUTOS Tpo- Tos" ane dé On SoxH coe UrepBeBynKevar Thy ypapmay,9 ja xpr) KaTarelvavTas aT OT AL es Thy xopny evIus, Erepov 5é Tia €K TOD ETépou 358
ON JOINTS, vxxix.—ixxx.
going to put in any joint, you must always first make it supple and move it about, for it will thus be more easily reduced. In all cases of reduction, the patient must be put on restricted diet, especially when the joints are very large and very difficult to put in, and least so when they are very small and easy.
LXXX. If any of the finger-joints, whether first, second, or third, is dislocated, the mode of reduction is identically the same, though the largest joints are always the hardest to put in. Dislocation takes place in four ways, up or down! or to either side; chiefly upwards, most rarely to the sides, in some violent movement. Oneach side of the part whence it is displaced there is a sort of rim. Thus, if the displacement is upwards or downwards, it is easier to reduce, because this part is smoother than that at the sides, and the obstacle to get over is small, if the joint is dislocated. The mode of reduction is as follows:—Wrap a bandage or something of the kind round the end of the finger, in such a way that it will not slip off when you grasp the end and make extension. When it is applied, let one person take hold of the wrist from above, the other of the part wrapped up. Next, let each make vigorous exten- sion in his own direction, and at the same time push back the projecting joint into place. In case of lateral dislocation, the mode of extension is the same. When you think it has passed over the line of the joint, push it at once into place, while keeping up the extension ; an assistant should keep guard over
1 Or ‘‘ backwards” or ‘‘ forwards,”
1 Omit B, Kw. 2 KaretAvuévou Weber. * GuBnv (Kw.’s conjecture).
389
30
40
43
TIEPI APOPON
/ A a pépeos TOD SaxTUXNoV duAdooEW Kal avwOHetr, Omws pn mari éxeiOev aroricOn. éuBddrovat
\ / a) lal dé émierkéws Kal ai cadpar ai ex TOV howixwv TAEKOMEVAL, NY KaTaTelYns evOev Kal evOev Tor
/ , A n SdxTuAOY, AaBopmevos TH pev ETépN THS cavpns, Th O€ €Tépn TOD KapToD THs yYeupos. Stray é euParrAns, émidety Sef oOoviotcw @s TdyLoTA, NETTOTATOLOL KEKNPWLEVOLTL KNPWTH pHTE ALNV
a / la nr > \ / b] 4 pardakyn wnTe Ainv oKANPY, GAA pETPLWS EYOUGN. € \ \ \ b) , by \ a fs nH ev Yap oKANPH apeaTHnKev ATO TOU SaKTVAOD, € \ € AY NEGe. \ / \ ’ ,
n O€ aman) Kal Uyp} StaTHKETAL KaL aTrOhAUTAL, f a / , \ oo» Peppatvouevov ToD daKTUAOV. Ave 5é apOpov a 3 na \ ¢ SaKxTUAoVU TpiTatoy 1) TeTapTaiov' TO Sé Grov, Hv
\ / / ‘A x \ 4 > / bev hreyunvy, TUKVOTEPOV AVELV, HV OE LH, ApaLo- Tepov’ KaTa TavTwy O€ TaV apOpwv TadTa éyo.
/ \ a / A ” Kkalictatat 5€ Tov SaxTUNOV TO apOpov TeEc- cal \ / capeckaloeKkataiov. o autos 5€ éott OepaTreins , TpoTros OaKkTUA@Y yelpos TE Kal Todds. = a ”
LXXXI. Ilapa wacas 8 tas tev apOpwy éuBoras Set coyvaivey Kal Nymayxovety Kai »” € , 5 NO Bs , , axpe éBdouns’ Kal ef rEeymatvol, TuKVOTEpOV
, ) \ / > / ig , \ al Ave, ef O€ fH, apaLoTepov' ouxinv é dei ” 3 e\ \ / ” \ e / éverv ael TO Toveoy apOpov, Kal ws KadAALoTA eoxynuatiopévoy Keto bat.
a \
LXXXIL Tovu && etnbéotepov ayxa@vos dia
\ > / \ \ > oh \ \ > , THY evaTarinv Kal THv evpuiny, S10 Kal ExTrimrer
a 4 Kal éuTimter pdov' exmimre: O€ TAELTTAKLS Evw, by Id lo] atap Kai é&w kal dmicbev. éuBorai bé, ex Tod 399
ON JOINTS, vxxx.-Lxxxu.
the other side of the finger and make counter- pressure, to prevent another dislocation to that side. The “lizards”’ + woven out of palm tissue are satis- factory means of reduction, if you make extension of the finger both ways, grasping the “lizard” at one end and the wrist at the other. After reduction you must apply at once very light bandages soaked in cerate, neither too soft nor too hard, but of medium consistency; for the hard gets detached from the finger, while the soft and moist is melted and disappears as the finger gets warm. Change the dressing of a finger-joint on the third or fourth day; in general, if there is inflammation, change it oftener; if not, more rarely. I apply this rule to all joints. A finger-joint is healed in fourteen days. The mode of treatment is the same for fingers and toes.
LXXXI.? In all reductions of joints, the patient should have attenuating and starvation diet up to the seventh day; if there is inflammation, change the dressing oftener; if not, more rarely. The injured joint should be kept always at rest, and be placed in the best possible attitude.
LXXXII.? The knee is more favourable for treat- ment than the elbow, because of its compact and regular form, whence it is both dislocated and reduced more easily. It is most often dislocated inwards, but also externally and backwards. Modes
1 Hollow cylinders of plaited material which contract on being pulled out, Once a well-known toy. Also mentioned by Diocles, who calls them ‘‘the lizards which the children plait.” Aristotle (P.A. IV. 9) calls them mAeyudria, and compares them with the suckers of cuttle-fish.
* An insertion repeated from §§ LX XIX (end) and LXXX,
3 From Fract. XX XVIII and Jochl, XX VI
391
IIEPI APOPON
x / ’
ovyKkecaupbat exdaxticar o&éws, 7) cuvenri€as Tawins oyKov, év TH iyvin Geis, audl Todrtov > , > ” bd / \ na / eEaipuns €s OxKNacW adléevat TO Goma. SuvaTaL \ \ , 7
6€ Kal KaTATELVOMEVOY pETPiwWsS, WoTTEp ayKaV, b / Nv 237; 'e \ No, NS i, b éumintew ta dmicOev' ta dé évOa Kal évOa, éx
a BY /
10 Tod cuyxexdupOar 7) éxrNaKTicat, aTap Kal éx / le
KaTaTdoLos peTtpins. Su0opOwots Atract Kou.
ay O€ (L) €uTréon Tolot wey OTLaOev, ovyKawTTEW
5 ; TL 2O\ . ” t ov dvvavTalt, aTap ovdé Tolat AdXOLOL TavV. puvvder Sé€ ponpod Kal Kyyuns Tovpmrpocber’ Av
\ > \ by4 f tA \ ’ »” dé és TO ow, BAratootepor, pivvder Sé Ta &Eo. EN ‘ 9 \ » , \ \ & nv oe €s TO é€w, yavoortepot, ywrol Sé Haocov:
\ s / a KaTa yap TO TayYUTEpoy daTéov Oyel, puviber OE
NY: > a be Ned > le \ ,
Ta ow. €&k yevens € Kal ev av&joes KATA AOYoV 19 Tov wpoabev. \ \ \
LXXXIII. Ta &6¢ cata ta chupada Katatacuos > a o XN a \ Ey A / iaxupnhs Settat, i) THae YEepoly %} addoLat ToLOv-
, > ToLol,! KaTopOwatos 5é aya audotepa troLeovans: 4 xolvov S€ TOUTO aTacLD. \ LXXXIV. Ta dé év modi ws Kal ra ev Yeept 2 vyiees.”
LXXXY. Ta 6 THs Kvjpns cuyKowwvéovta Kal éxTecovta® éx yevens, 7) Kal év av&joee b] / > \ a \ > ,
3 €EapOpicavta, TavTa & Kal ev XELpt. ”
LXXXVI. ‘Oxocor 6€ mndycavtes avober
9
1 toto. 2 byin Mochi. 3 uh eumecdyvta Mochi.
392
ON JOINTS, vxxxu.—Lxxxvi.
of reduction: by flexion or a sharp kick upwards ! (? jerking the leg upwards), or placing a rolled bandage in the ham, on which the patient brings the weight of his body by crouching suddenly. Suitable extension can reduce backward dislocations, as with the elbow. Those to one or the other side are put in by flexion or leg-jerking, and also by suitable extension, Adjustment? is the same for all. If there is no reduction, in posterior cases patients cannot flex the limb, but they can hardly do so in the others; there is atrophy of the thigh and leg in front. If inwards, they are more knock- kneed, and there is atrophy of the outer side; if outwards, they are more bandy, but not so lame, for the weight comes on the larger bone; the inner side atrophies. Cases which occur congenitally or during adolescence follow the rule given above.
LXXXIIL.% Dislocations at the ankle require strong extension, either with the hands or other such means, and a rectification involving the two 4 combined. This is common to all.
LXXXIV. Dislocations in the foot heal in the same way as those in the hand.
LXXXV. The bones connecting the foot with the leg, whether dislocated from birth or put out during adolescence, follow the same course as those in the hand.
LXXXVI. Those who in leaping from a height
1In Hippocrates Coacae Prenotiones 108 it is applied to involuntary “jerking of the legs.”
2 The slight variation in Moch?. XXVI seems to favour Pq.’s rendering. ‘‘ This (.e. extension) is common to all cases,”
3 Partly repeated in § LXXXVII.
4 Extension and counter-extension? Extension and adjustment? It seems an obscure summary of Fracl, XIII.
393
10
20
28
TTEPI APOPON
bd , a 4 4 a \ eoTnpi—avto TH WTépvn, Wate SiacThHvat Ta > , \ / > F n \ a b) doTéa Kal PréBas exXvpwO Hvar Kal vedpa apdr- a e pracbivat, orotav yévntat ola Ta Seva, Kiv- / \ a duvos péev ohakerioavta Tov aid@va Tpyypata TapacyelV potwon mév Ta OaTéa, TA bé vEvDPA / / AXXAHAOLTL KOWOVEOVTA, érrel Kal olow ay pa Mora Kataryetoly ) brd TpwmaToOS i év KUL) H év HNpe, ») vEvpov aToAvGeyT@Y A KoLVwVeEL TOUT@V, 7) €K KATAKALTLOS apeEréos, euedavOn 1 mrépyy, Kal TOUTOLoL Ta TadwyKoTeov Ta eK TOV TOLOUTOY. éorw OTE Kal TPOS TO opaKkehiopo yivovTat mupeto. o&ées uypodées, yvouns atr- TOMEVOL, TaxvOavarot, Kal ért preSav almop- potéwv TENLWT LES. onpeta b€ TOY TaNXLyKOTN- TaVTOV, IV TA ExYUMOMATA Kal TA wEeXdopATA Kat Ta Tepl TadTa UmoacKAnpa Kal brépvOpa'! El 6e \ , 8 a / 8 ny 6€ ovv oKdnpYopaTe TEN OVwWOH, KivduVOS a DY \ G s > x \ Li peravOyjvar: jv dé vmoméka 7, Kal TédLa ¢ \ , / D7 Xx c / § \ Mara Kal EXXUPMOpLEVA,” 1) VTOXAWPA Kal wada- Ka, TavTa éml Taot Toiat TolovToOLoW ayadd. d \ a a ¢ L MWR \ , (nals, VY ev aTrUpETOS H, EAEBopov" Hv Sé my, Pas \ \ Ie/ ) L a 2 X en adXra ToTev oFUyXUKY, ef Séot. €rridecis Oé ” c , \ \ / lal a / apOpwv" emi 6€ Tadvta, “adXov Tolar dXAdopacw, dPoviotct rEtoot Kal parOakxwtépooiw iekts Hooov’ mpoomepiBarrew O€ TA TAELTTA TH TTEP- a « / \ vn. TO oX HMA, Orep 1 émidecus, as py es THY TTEpVHY aTroTrLeCnT aL vapOn€e dé BH xpijobar. LXXXVII. Otic. S ay €xBH 0 Tovs 7 auros H ov Th éemipvoet, exmimter wev padXov €s TO / gow: iv O€ wn euéon, NETTVVETAL ava YXpovoY
1 Srépv0pa 7 Moché. 394
ON JOINTS, vxxxvi.-Lxxxvil.
come down on the heel, so that the bones are separated, and there is extravasation of blood and contusion of ligaments—when grave injuries such as these occur, there is danger of necrosis and life- long trouble ; for the bones slip easily, and the liga- ments are in connection with one another. Further, when in cases of fracture especially, or a wound either of leg or thigh, or when the ligaments joining up with these parts are torn away, or from careless- ness as to position in bed, mortification of the heel has set in, in these patients also such causes give rise to exacerbations. Sometimes acute fevers follow the necrosis, with hiccoughs, affecting the mind and rapidly fatal; there are also lividities from haemorrhage. Signs of exacerbation are ecchymoses, blackenings of the skin with some induration and redness of the surrounding parts. If the lividity is accompanied with hardness, there is danger of mortification; but if the part is sublivid or even very livid after ecchymosis, or greenish yellow and soft, these are good signs in all such cases. Treat- ment: if there is no fever, hellebore, otherwise not, but let him drink oxymel, if required. Bandaging : that used for joints; over all, especially in con- tusions, use plenty of soft bandages; pressure, rather slight ; additional bandaging, especially round the heel. Attitude: the same object as in bandaging, so as to avoid pressure on the heel. Do not use splints.
LXXXVII. In cases where the foot is dislocated, either by itself or with the epiphysis, it is usually displaced inwards; and if not reduced, the hip,
2 ekicexuuwpera.
395
IIEPI APOPQN
TO TE taxtov Kal 0 unpos, Kal KUN LNS TO dvttov Tov oAtcOnuaTtos. éuBorn 6é (aXAN,” Homep Kaptov, Katataoi dé loxupy inas 8é, Popos apOpwv. TadvyKoTel, Nooov oe KapTov, HV Hovxdowaty. diavTa petcov" edwvovet. TO 6€
9 &x yevens %) ev av&yoet, KATA NOYOV TOV TpPOTEpOD.
1 Se GAAW Omit Mochi. und translators, except Pq.
396
ON JOINTS, vxxxvu.
thigh and leg become in time attenuated on the side opposed to the dislocation. Reduction in other respects as for the wrist; but strong extension is required. Treatment: that customary for joints. Exacerbation occurs, but less than in wrist cases, if the patients keep at rest. Diet more reduced ; they do no work. Congenital and adolescent cases follow the rule given before.!
1 See notes on these chapters in Jochlicon, pp. 425-428.
397
10
20
MOXAIKON#
> an \ I. ‘Ooréwv vot: Saxtikwv pev aTrAa Kat oatéa Kal apOpa, yerpos b€ Kai todos ToAXa, ” > / 1 hig de L \ y arra ahdovws ournpl pwpeva beytota O€ Ta aver aro. mréepyns dé é év, olov efeo paiverat, T™ pos d€ avTny ob orria Avot TEVOVTES Tetvovotn. KV LNS 6€ dvo, dvwev Kai Kdtobey cvveyomeva, KaTa / SS / / ‘ae Ni NN pécon | d€ Ovéyovta opLKpOV" TO éEwOev, KaTa TOV o uLK pov Oak TUAOV AemTOTEPOV Bpaxel, eto Tov 6é TavTy Stexovon Kal opLKpOTEpy porn Kara youu, Kal o Tévwov €& avTod TEPUKED, 0 mapa TH iryvony eo. éxouer 66 KaTw@Oey KoLWnV emigvow T pos Hv 0 Tovs KivelTae adqv dé avobev eXovow enipuow, €v 7 TO TOD penpod: apO pov KWweital, amoov Kal evaoTares ws emt BNKEL \ \ eidos KovdvdA@bes, EYov ETLpvALOa> avdTos 6é eyKUPTOS Ea Kat eum poo bey ” dé ceparn emipvats €oTL oT poyyvry, é& Hs TO vedpov TO év TH KOTUAN TOV Layiov TépuKev’ UToTAaYLOV Oé Kal TOUTO TpoonpTyTal, aoov bé Bpaxiovos. \ Nod. / / \ an / TO 0€ LaXLoV TpociayeTaL POS TO pheyaXw oTov- Be atoy mpoolayerat aby ni heen ae S5UAM TO Tapa TO lepov oaTéov YovdSpoveupwoer deo uO. 1 MOXAIKOS Littré; and the word is used as a synonym for soxAlowos in XLII.: but MOXAIKON is supported by the
MSS., and by the analogy of MPOTNQSTIKON and TPOP- PHTIKON. Cf. also Galen XVIII.(2) 327.
398
INSTRUMENTS OF REDUCTION
I. Nature of bones. In the fingers and _ toes, both bones and joints are simple; but in hand and foot they are diverse and diversely articulated, the uppermost being largest. The heel has a single bone which appears as a projection, and the hind tendons pull upon it, There are two leg-bones joined together above and below, but. slightly separated in the middle. The outer one, towards the little toe, is rather more slender, most so in the separated part, and in the smaller inclination at the knee; and the tendon on the outer side of the ham has its origin from it. They have below a common epiphysis on which the foot moves ; and above they have another epiphysis, in which the articular end of the thigh-bone moves. This is simple and com- pact, considering the length of the bone; it is knuckle-shaped, and has a knee-cap. The bone itself is curved outwards and forwards; its head is a spherical epiphysis, from which the ligament arises which has its attachment in the cavity? of the hip_ this (tendon) ® is inserted rather obliquely, but less so than that of the arm.4 The hip-bone is attached to the great vertebra ® next the sacrum by a fibro- cartilaginous ligament.
1 Or, ‘‘with the greatest deviation (from the vertical) at this point, and less at the knee”; but the passage is obscure.
2 Acetabulum. ® Ligamentum teres, 4 Long head of the biceps. ® Fifth lumbar,
399
30
40
60
MOXAIKON
, Nap \ \ Irv na» / , a Pays € aro pév Tod iepov datéov péxpL TOD peyaXou omovevrov Kudy. KUaTIS Te Kal youn Kal apyov TO éyKexAtmévoy ev TovT@. ard é / ” a > e077 \ € TovTov aype ppevav AGev H LOVNOpCos, Kal at / nm an an oat cata ToUTO: évTedOev b€ dypL TOD peyddov omovovrkov TOD UTép TOV ETTMOpLOwY (OUKUdHS* ” \ lal Q a yf 3 -} € \ ov a étt O€ WAaNXOY OoKeEl 7) EoTLV’ ai yap Omicbev TAY / > / , G , H \ oToVvovA@Y aTopUates TAUTH wynAcTaTaL’ TO dé Tod avyévos apOpov Aopddv. amdvdurou Sé BA ” \ > / 3 \ \ lal vy éo wOev apTLoL Tpos aXddous, aro dé trav éEwbev xovdpeov veup@ TUVEXOMEVOL 1) be cvvapOpwats auTay év TO OTL OEv Tob votiatoy’ omicbev dé éyouct expuow delay éyouc av eripuow xove- podea évOev vevpwv aTrOp vats KaTaepys, @oTep Kal ol pues TapanepiKacw aTO avxévos és da pur, ™AnpoovTes bé Teupecov Kal axavOns TO pécov. meupat dé KaTa Tas Siapvowas TOY TTOVOUAMY Vveuvpim TpoaTEpUKAacL am _ aux Eev0s és oarpov éowber, emimpoo Gev dé Kare TO ot005 yadvov Kat parOaxov TO Gkpov éxoveae’ eldos patBoewdérraTov TOY Soap: OTEVOTATOS yap AUT!) o advOpmwmos em’ dyxov' 4 Oé j1 Trevpat elow, éxhvals mrayin, Bpaxeta Kal TRaTela ep’ EXATTO TTOVSUAM veuplip TpoomepvKacw. StHO0s Se TUVEXES avTo EwuT@, dia vavas éyov Trayias, % TAEUPAl TPOTHPTHVTAL, Nadvov dé Kal xovd paves. KANIOES éé Tepupepees és ToupT poo Oer, exovoat TOs pev TO oTHOos Bpaxetas KIVoLas, ™ pos d€ 70 cic p@ Lov ouxvo- Tépas. QK Pw pLLov de €& @ oT harewv TEPUKED, avopoiws 8& Tolar TreloToiol. wpoTAdtn 6é
4 « The ensemble of the articulations.” Pg.
A400
INSTRUMENTS OF REDUCTION, 1.
The spine from the end of the sacrum to the great vertebra is convex backwards. The bladder, genera- tive organs, and inclined portion of the rectum are in this part.. From here to the diaphragm it ascends in a forward curve, and there are the psoa-muscles ; but thence up to the great vertebra above the shoulders it rises in a curve backwards, and seems more convex than it is, for the backward processes of the vertebrae are here at their highest. The neck-joint! is concave behind. The vertebrae on the inside are fitted to one another, being held together by a ligament from the outer side of the cartilages ; but their jointing (synarthrosis) is behind the spinal cord, and they have posteriorly a sharp process with a cartilaginous epiphysis. Hence arise the ligaments which pass downwards, just as muscles also are disposed at the side from neck to loins, filling up the part between the ribs and the spinal ridge. The ribs are attached by a ligament at the intervals between the vertebrae from neck to loins behind, but in front to the breast-bone, having the termination spongy and soft. In shape they are the most curved of any animal; for man is flattest here in proportion to his size. Where there are no ribs, there is a short and broad lateral process ; they are connected with each vertebra by a small ligament.
The sternum is a continuous bone, having lateral interstices where the ribs are inserted ; it is spongy and cartilaginous. ‘The collar-bones are rounded in front, having slight movements at the sternal end, but more extensive ones at the acromion, The acromion has its origin from the shoulder-blades in a different way from that in most animals.? The
2 See notes on Joints XIII.
Aor
60
67
10
12
MOXAIKON
xovdpodns TO ™pos pax, TO & &AXo xavvn, TO dv @pwarov é&w éyovaa, avxeva dé Kal KoTUhay éxoura xovdpwdea, e€ As at mevpal KLUnoLD Exoue, evaTrouTos covca daTéwV, TAHV Bpa- xvlovos. TtouTov bé ék THs KOTUNNS veupio 1) Keparn eEnpTntar, xovdpou Vavvou Te pupepy) emiguaw éXouca* auTos & éyxuptos &&w Kal éuTpoobev mrAYLOS, OVK OPOdS pds KOTUAHY® TO 6€ Tpos ayx@va avTov mMraTD Kal KOVvdUA@SES Kal BarB0ades Kal oTEpEOY, eryKowdov omic Bev, ev @ u] Kop@vn uw) €x TOU 71) XE0S, oTav éxtady 7 xelps EVETTLY’ ES TOUTO Kal TO vapKddes vevpov,
01 é« THS Siapuoros TOV Tov TNXEOS OTTEWD, EK prov EK TEPUKE KAL Téepaverat.
II. ‘Pis dé Karearyeiod avaTAdacecOat oin TE avd wpov. Ki pev ovv o yxovdpos, évtiOecOar? axyny o0oviov, evaTrodéovTa AoTO Kapyndovie, ) €v AXX@ 0 py épeOces’ TO hora 5€ Tas Tapan- NdEvas TapakoNrav Kal ‘avadapPBdveww" TavTa O€ émidecis KAKA TroLel.? inous addy dua 5€ TO oupBaneiy ouY pavvn * ) Oclo avy KNPOTH avtixa dvaTAdocely, errevTa AVAKOX TED, TOloL axTUroLaL ETMATEVOMEVOY Kal mapagrpepovra: Kal TO Kapxndoviov" TwpoiTo av Kal Hp Edxos én Kal av oatéa aT UV aL MéAAN—OvV yap TANYKOTOTATA—OUTW TOLNTEA.
i 7d, 2 evridevar Littré, Kw.
3 karamoe codd.; kakorot M marg.; xaka morger Lit. conj. 4 GAnT@ ov mavyn.
? Long tendon of the biceps.
2 Galen U.P. II. 14. Our ‘‘olecranon.” Both processes of the ulna were called xopwydv, because of their semicircular shape.
402
INSTRUMENTS OF REDUCTION, 1-11.
shoulder-blade is cartilaginous in the part towards the spine, and spongy elsewhere ; it has an irregular shape on the outer side, and the neck and articular cavity are cartilaginous. Its disposition allows free movement to the ribs, since it is not closely con- nected with the bones, except that of the upper arm. The head of this bone is attached to its socket by a small ligament,! and has a rounded epiphysis of spongy cartilage. The bone itself is convex out- wards and oblique in front, and does not meet the cavity at right angles. Its elbow end is broad, knuckle-shaped, and grooved; it is also solid, and has a hollow at the back, in which the coronoid process? of the ulna is lodged when the arm is extended. Here too the cord which stupefies,® arising from the interstice between the bones of the forearm, has its issue and termination.
If. A fractured nose is a thing to be adjusted at once. If the cartilage is the part affected, introduce lint, rolling it up in thin Carthaginian leather, or in some other non-irritant substance. Glue strips of the leather to the distorted parts, and raise them up. Bandaging does harm 4 in these cases. Another treatment: while bringing the parts together, apply frankincense or sulphur with cerate ; adjust at once. Afterwards keep it up by inserting the fingers, feeling for and reducing the deviation; also the Carthaginian leather. It will consolidate, even though there be a wound; and if bones are going to come away—for there are no very grave exacerba- tions—this is the treatment to use.
8 Surely our ulnar nerve (funny-bone), though Foés and others call it ‘‘a ligament void of sensation.”
4 Pq. renders ‘‘ depresses,” reading katamoei, as opposed to avaTAaooelv.
403
10 11
10
MOXAIKON
9 \ a \ Ill. Ods xateayev pH éridetv, pndé Kkata- 7 ara , , ¢ U € / Tacoew* iv Sé Te én, OS KOUPOTATOD, 1) KNPwWT’ \ / a * Nii 37. NG 1 eg DY kai Getw Kataxod\rygGv. ov 5€ éumrva Ta @Ta bia / , X , \ Taxéos evptoxetat, Tavta dé Ta UTropvEa Kal ne a \ / 3 ine > \ , ™) VYpH capKl TWAnpEa e€aTraTa’ ov pr BrAaABn / n V4 Ni [yevntat]! oropwlév To TovodTOv’ éoTL yap ” \ ig / 7 Leet ete? \ \ aoapka Kat vdaT@dea, wvENS mrEa* STrov Sé Kal @ / / 7 ola €ovta Oavatwded é€ott, TwapeOévta.” wTwv a , / Ne {e A \ ny: \ Kavos TEpnV, TaxioTa vytater* KUANOY O€ Kal a ts \ a XK \ peetov yiveTat TO ods, Hv wépnv KavOn. iv Se A , a oTopwln, Kovpeo évaipo denoet ypnabat. IV. Vvador 6é katact@vtas péev ToNAAKLS Kal Bi. b / be ’ 4 / Kkabiotavtar' éxtimtovot O€ ddLyaKLS, padiaTAa \ \ s A / Mev Yaopwpmevotol’ ov yap ExTiTTEL, HY pH TLS \ , , , a E Yavev wéya twapayayou éxtimter Sé padXov, OTL \ a ? / \ / _ Ta vevpa év TAAYiM Kal AedAvYLopeva ouVb.dol. A aA , , onela: mpoiaxer 1) KaTW yvaOoS Kal TapécTpaT- TAL Tavavtia ToD éxTT@maTos' TUUSaddreLy Ov / 3 v. a dvvavtat’ Hv € audotepat, mpolaxovot waddXovr, e tal \ \ auuSdrrAovew Hooov, actpaBées: Snrol dé Ta cy n an ’ bpia TOV OddvT@Y Ta dvwW TOlaL KaTw@ KaT LEL>D. x a \ > qv ovv appotepar éxTrecovcal pr) AUTLKa Eep- / a mécwat, OvioKkovat Sexatatot ovTOL padtoTa an an a / € \ n TUPET@ TuvEeXet vwOpH TE KapwceEL’ ol yap mes a an / / OUTOL TOLODTOL. YyaoTHp émLTAapdaoeETAaL OYA an / > axpyta: Kal ip éuéwor, Toradta éuéovaw: 7» 6 ems, ) f > \ NSte StLN Go , E ETEDN aAolvEeaTEpN. eo SE 1 AUTH aupoTepav LA 3 n ? , a KaTaKelmevou 7 KaOnuévov Tov avOpwrov, THS 1 Kw. omits. 2Cf. Art. XL. wapetrat.
404
INSTRUMENTS OF REDUCTION, u1.-1v.
Ill. Do not bandage a broken ear, and do not apply a plaster. If one is required, let it be cerate plaster as light as possible, and agglutinate with sulphur. When there is suppuration of the ears, it is found at a depth; for all pulpy tissues and those full of moisture are deceptive. There is certainly no harm in opening such an abscess, for the parts are fleshless and watery, full of mucus; but the position and nature of abscesses which cause death are not mentioned. Perforating cautery of the ears cures a case very quickly; but the ear becomes mutilated and smaller if it is burnt through. If an abscess is opened, a light wound application must be used.
IV. The jaw is often partially displaced, and reduces itself. It is rarely put out, and that chiefly when yawning; for it is not put out unless it is drawn to one side during a wide yawn; and dis- location occurs the more because the ligaments, being oblique and twisted, give way. Symptoms: the lower jaw projects and deviates to the side opposite the dislocation; patients cannot close the mouth. If both sides are dislocated, the projection is greater, ability to close the mouth less, no devia- tion; this is shown by the upper row of teeth corresponding in line with the lower. If, then, bilateral dislocation is not reduced immediately, these patients usually die in ten days with con- tinuous fever, stupor and coma; for such is the influence of the muscles in this region. The bowels are affected, and there are scanty, undigested motions; if there is vomiting, it is of a similar nature. One-sided dislocation is less harmful, Reduction is the same in both eases; the patient being either
4°95
20
23
10
20
MOXAIKON
Kepaniys eXOpEvor, meptraBovra TAS _yrabous apporépas aphorépy at Nepoly Eo wb ev Kal éEwOev, Tpla apa Tour ac aoar és opbov Kal és TobTisw, Kal cvoxelv TO oTOma. inaows' pardypact Kal oXnwace Kal avadirer yevetov' Tovodat TadTa? TH €uBor7.
V. *OQpos 8€ éexmimte Kato’ adAn 6€é ovTw nKOVGa. OOKEL ev yap és TovmmTpoTOev éxtTriT- TELV, WY Al GapKES al TEpL TO ApOpov pemlvvOn- kact Sta tHY POicw,” olov Kal totar Bovot Verwa@vos paivetar Sia NeTTTOTHTA. Kal éxTiTTE MadXov Tolat O€ NeTrTOLaW 7) taxvoiow } Enpotar Kal Tolow wvypacpata mepl ta apOpa EXovow dvev preyuovns’ attn yap aude of S€ Kai Bovolv euBadrovtes Kal arom E pov aVTES é€apap- Tdvovet, Kal OTL Ota THY Xpioev, OS YpHTae Bods Keel, ArjGer, Kal OTL KOLWOV Kal avOparr@ ovTws éYovTe TO oxXhwa TOUTO’ TO TE ‘Opnpevov" Kal dL0Te AeTTOTATOL Boes THVLKADT A. 60a Te TOV TH XUV TAAYyLov ato TEevpéwVy apavTes pact, ov wavy dvvaytat dpav, oiow av pn éeuTréon. olot mev oy ex TLTTEL pddora, Kal @s EXouvawr, elpyntat. olor b€ € éKx yevens, Ta eyyutata peaddov Bpaxtverar 6 daTéa, olov év TOUT@ ot yaridyKeves: maxus 5€ jooon, xelp o€ é ere Hacov, Ta 8 avwbev ovoev’ Kal aoapkotata éyyus’ wivvGer Sé wartota
1 rauTa.
2 Littré’s correction. gvaw MSS. would give sense, but the writer is evidently copying Joints I.
1 The safety-pin was a very ancient instrument. Cf, Iliad XIV.180, It is strange that there is no other mention
406
INSTRUMENTS OF REDUCTION, w.-v.
lying down or seated, his head fixed, take hold of both sides of the jaw with both hands, inside and out, and perform three actions at once—get it straight, thrust it back,and shut the mouth. ‘Treat- ment: with emollients, position, and support of the chin; these things co-operate in the reduction.
V. The shoulder is dislocated downwards. I have no knowledge of any other direction. It appears indeed to be dislocated forwards in cases where the tissues about the joint have diminished through wasting disease, as one observes also with cattle in winter, because of their leanness. Dislocation occurs preferably in thin and slight subjects, or those of dry habit; also those who have the region of the joints charged with moisture without inflammation, for this braces them up. Those who use reductions and fixations with fibulae! in oxen are in error, and forget that the appearance is due to the way the ox uses its leg, and that this attitude is common also to man in the same condition—also the Homeric quotation, and the reason why oxen are very thin at that time. Actions requiring lateral elevation of the arm from the ribs are quite impossible for patients in whom the joint is not reduced. The subjects, then, most liable to dislocation, and their condition, have been described. In congenital cases, the proximal bones are shortened most, as is the case with the weasel-armed ; the forearm less than the arm, the hand still less, and parts above the lesion not at all; the most fleshless parts are near the lesion. Atrophy occurs especially on the side
of it in the Hippocratic surgical works. That it was then
in surgical use for closing wounds seems indicated by Eur. Bacchae 97.
407
39
40
MOXATKON
Ns. £9) , la) > f \ \ ’ 3 / Ta éevartia TOV OMaGOnuaTwr, Kal Ta év avEnoe, Hooov 6€ Tie TOV ex yevens. Kal ‘ra Tapatun- \ > / , bs pata, Ta Kat apOpov Babéa, veoyevéot fuddicta Tap @uwov yiveTalt, Kal ToOUTOLTLY WoTEp TA b / a X \ > / \ \ eEapOpncavta trovet. iv o€ nuEnpwévoict, TA pev daTéa ov pelovTat, OvSE yap EXEL H adra OD ovvavEetat omolws, at O€ pivuOnotes TOV CAaPKOP. TovTO yap Kal’ jucpny Kai avfeTar Kal peodTat, / e Kal Kal’ HALKias. Kal a StvaTalt oXyHpmaTA, Kal 5 nm NG av onpeloy TO Tapa TO AKpwpuLoOV KaTED TAG LEVOV kal KotAov, Ou0Te 6Tav TO akpwmlov atoaoTacby Kal KotNov 7, olovtat TOY BpaXiova éexTemToxKévar' Keparn o€ Tov Bpaxiovos év TH pacxyary haive- tat’ aipew [yap]* od duvavrat, oddé Tapayew év0a kal &v0a opciws' 0 érepos @mos penvver. > \ , aren \ \ \ ele , éuBoral O€ avdTos pev THY TUYMIY UTO pacXaXny € \ \ \ b tal \ \ a UmoGels Thy Kehariy avwleiv, tiv sé yelpa 2 , aN \ a ” a ed émimapayew éml To otHOos. adXAN’ és TOVTICM TeplavayKdcal, ws audiopary. adn? KEepanrn \ X Mev TPOS TO AKPwpLov, Yepal Oé UTO bacKXarny, Kepariy wvrayew Bpaxiovos, youvac. 6€ ayxava a 3 a lal \ atvobeiv, 3) avtl TOY youvatev TOY ayKava TOV érepov Tapdye ws TO TPOTEpoV" 7) KAT @sLoU a c \ a , \ 5 SEK An iecOat, vrobels TH pacyadn TOV @pov' 4 TH / , fol / a mrépyyn evOédvta exTAnpwopata TH pacyarn, dekh deEvov' 7) mepl Uirepov: 7 Tepl KALaKTHpa’ 1) a an cal / meptooos auv To EVLwW TO UTO YEipa TELVOMEVO. inows’ TO oXAwa, mpos mAeuvpyot Bpaxtwv, xeip 408
INSTRUMENTS OF REDUCTION, v.
opposite to the dislocations, and when they occur during adolescence, but is somewhat less than in congenital cases. Deep suppurations at a joint occur in infants, especially at the shoulder, and have the same effect as dislocations. In adults there is no shortening, for there is no opportunity for one bone to have less growth than another; but there is atrophy of the tissues; for in the young there is increase and decrease, both daily and according to age. [Consider] too the effect of attitudes, and also what is indicated by the hollow at the point of the shoulder, due to avulsion ; for when the acromion is torn away and there is a hollow, people think the humerus has been dislocated. If so, the head of the humerus is found in the armpit, the patients cannot lift the arm, nor move it to either side equally ;+ the other shoulder is an index. Modes of reduction: let the patient put his fist in the armpit, push up the head of the bone, and bring the arm tothe chest. Another method: force the arm backwards, so as to make a movement of circumduction. Another: with the head against the point of the shoulder, and the hands under the armpit, lift the head of the humerus, and push back the elbow with the knees, or, instead of using the knees, let the assistant bring the elbow to the side, as above; or suspend the patient on the shoulder, putting it under the armpit, or with the heel, putting plugs into the armpit, using the right heel for the right shoulder, or on a pestle or ladder ; or make a circular movement with the wood (lever) fixed under the arm. Treatment; position; arm to
1 Or, ‘‘as before.”
1 Omit, 4°09
50
10
17
MOXAIKON
dxpy ave, @ Los dive" ovTwS émidects, avarnrpes. My O€ 2) EuTréeon, AKP@pLov TpooAeMTUVETAL,
VI. "Ax pomvov arosmacben, TO ev eldos patvetat olov rep @pov EKTETOVTOS, OTEplTKETAL 6é ovoevos, € és 6é TO avTo ov cabiorarat. OX Awa TO avTo ©! Kal eKTETOUTL, év émidéaet Kal ava- Ayer: éridects Kal @s vopos.
VII. “AyKOvos , apPpov maparrabav pev? v7) mpos mAeupny i) €&@, évovtos Tov o&€os Tov év 7 KoLA@ TOD Bpaxiauas, és (003 Katateivovta, Ta éféyovta avlety * oricw Kal és TO TAaYLOD.
VIll. a 6€ Teréws éxBavta 7 &vOa 1) evOas KATATACLS ies év 7 0 Bpaxiwy® émidetrar oUTw yap TO KauTUAOY TOV ayKaVOS OV KWATCEL. exTrimtet O€ padtota és TO Tpos Teupéa ® wépos. Tas 6€ KaTopOHctas, aTayovta STL TAELTTOV, WS pn rravon THS Koperns 1 Kehads, meTéwpoy bé mepiayery Kal teptkapryat, Kal pn és (O07 BidtecOar, dua dé w0civ TavavTia ep’ EKATEPA, Kal mapobety és Keopny. ouvadenoin om ay cal éemiotpewes dye Ov0S év TovToLoW, éy TO pev €s TO UTTLOV, EV T@ O€ €S TO TPNVES. éuBorr dé8 TX MLATOS pev oAtyov ® dverepo ae Yvetpa ary KOv os 1° évew, Bpaylova dé kata Tas} * wheupas: ouUTw O€ 7 Y dvds, ® Kab eUpopor, Kal KPIS ép TO KOU, yy apa ideal KAKOS Topol meopovrar Sé Traxéws. inows:!® oBoviorst Kata TOV vOMOV TOV apOpitixov, Kat TO O£U mpoceTLoeiv.
IX. [ladiyxotétatov O€ aya 4 auperotct, GET lal: aah : P Aas a coy advvn,)® aawbel, AKPNTOKXOAM: AyKaVOS Sé -wadioTa oma dia TO vapKa@bes, SevTEpoyv TO euTpoaler. inots 9 avtTyn® éuBoral dé Tod pev oTicw éx- 410
14
INSTRUMENTS OF REDUCTION, v.-1x.
ribs, hand elevated, shoulder elevated ; bandaging and support in this attitude. If not reduced, the point of the shoulder atrophies as well.
VI. Avulsion of the acromion (process of the shoulder-blade), appears in form like a dislocation of the shoulder, but there is no loss of function ; yet it does not stay in place when reduced. Position as regards bandaging and support the same as in a case of dislocation; the bandaging follows the customary rule,
VII-XIX. Mochlicon VII-XIX corresponds verbally (except a few “various readings” such as occur in different MSS.) ! with Joints XVLI-XXIX. Instead of repeating the translation, we may, therefore, attempt a few explanatory notes; for dislocation of the elbow has always been an obscure subject, owing to the complicated form of the joint, and the presence of three bones.
All the chief surgical commentators, Apollonius, Adams, Petrequin, agree that VII represents disloca- tion of the radius only, in directions which we call « forwards” and “ backwards” ; though Galen says that Fractures XX XVIII, of which it is an epitome, refers to partial lateral dislocations of the ulna, “ Diastasis””’ (X) can hardly mean anything else than dislocation of the radius in the other possible direction—outwards, or away from the ulna,
1 These are given in the notes.
1%, 2 Add 4 mapapOpicav. 3 evOd.
4 Grabeiv. 5 Add ratayels. 8 wAeupas.
7 vod. 8 Yas 5€ (So Kw, here). °° ddAtyy. 10 Tod ayKGvos. 11 Omit tas. 12 Add ka) Oéots. 8 inots 5é. 14 § dyicoy. 19 O50vyat.
18 nats 5& alti.
Att
MOXAIKON
retvovta! katateivar. onmetov dé* ov yap Suvav-
Tat éxreiverv’ Tov dé éumpocbev ov SdvuvavTat cuyKcauTtew. TtovT@ Oe évOévTa te aKkXNpOV CUVELALYMEVOV, TEPL TOUTO GvyKapat EF ExTACLOS éEaifyns.
. Avacrdavos é daTéwv onpetov KATA THD prea THY KaTa& Tov Bpayiova oyilopwévyny dtawpavovTt.
XI. Tatra 6é TAX EOS SvaTrwpodrau® éx evens oé, Bpaxutepa Ta Karo ooTéa TOU oiveos,” mela Tov Ta éyyvTata 7 XE0S; OevTepov NELPOS, TpiTov OaxTUANOD. Bpaxtov 6 Kal os eyKpa- TéoTEpa bua THY Tpopypy" 7) o ETépn yelp ota Ta épya mhebw ere éyKpatea rep. gue stake é€ TapKaV, ét qev é&m e&érecev, Ecw'? ef dé pun), &s TovvavTiov %) 4 é&émecev.
XII.4 ’Ayxov S€ fv pev® goo Ew exh,
an rn
KaTaTacts peeve OX NATE eyyoviw, KoLV@ TO TXEt T pos Bpaxtova- Kab Hac any dvanaBov e Tawty avakpemdoat, dy Ove dé dxpo brrobets * TL mapa TO apOpov Bdpos éxxpeuacat, 1) yvepat KaTravayKacat. UTepatwpyGEvTos é TOU apOpov, ai Tapayoryal Toot Gevapow, @s Ta ép xepoly. ETLOETLS EV TOUTM TO TXNMATL, KAL avadAy Wis Kat Gécrs.
XIIL.8 Ta 6éé oma Gev, eEaibvns éxTelvovTa dtopGobv Toicr Gévapow apa be be. ev TH Svop- Owcer, Kal ToloLW ETEPOLT WW. ny O€ mpocber, audi 60oviov cuverdiypévov, evoyKoV, GUYKapT-
5 Tovta dpa SvopPovaba.®
2 ~ > / Tov otveos 60Téa,
3 gcwler.
l éxrelvayta.
412
INSTRUMENTS OF REDUCTION, tx.-xin
As regards complete dislocations, Littré and Adams refer those in VIII to lateral cases, and those in IX to dislocation forwards and backwards; while Petrequin, turning the bend of the elbow inwards, takes the opposite view. The most frequent and mildest form of complete dislocation is that of the forearm backwards (or the humerus forwards), and the Hippocratic writers can only be got to agree with this by assuming the Petrequin attitude ; for they evidently describe this form as a dislocation of the humerus inwards (ef. Fract. XL, XLI). The dislocation “backwards” which specially affects the ulnar nerve would thus be our external lateral dislo- cation of the forearm.
Still, the accounts remain obscure and often diffi- cult to accommodate with facts; nor do we get much help from the existence of a sort of double epitome, XII and XIII repeating VIII and IX from a more practical standpoint, while XIV refers to the radius dislocations noticed above in VII and X.
The account of wrist dislocation (XVI, XVI1) com- bines theoretic clearness with even greater practical obscurity. As Adams says, “in the wrist, nothing is more common than fracture, and nothing more rare than dislocation.” Yet the epitomist gives us a neat schematic arrangement of dislocation in all four directions, and says nothing of fracture, unless we take “with the epiphysis” to imply this. The original account is lost ; but its essence is doubtless contained in Joimts LXV, on compound dislocations of the wrist.
4 Variant of VIII. 5 Omit wey. ® dvadaPdvra, 7 Srodevra. S.Ct, LX. 9 S1opBody.
413
10
10
12
MOXAIKON
XIV.1 “Hy 6é ETEpoKNivEeS 7, EV 77 SiopB acer duporepa xP» Tote’ THS Sé medeTNS 2 KoLvOY Kal TO ox Ta Kal y) érrideots" duvatar yap? é« ths
LATA LOS KOLVH oupminrely mavra.
XV. Tar 88 éuBonréwv ai pev €€ UTreparwprjatos > / ‘9 \ 9 / € \ > €uBadrovtat, ai O€ éx Katardotos, ai Oé ex TeEpt- aharotos' attar 5é €x TaV vTEepBor€av TaV TXNMATOV 1) TH 1) TH OVY TO TAYEL.
XVI. Xevpos dé apOpov dea diver y) Eco ul éfo, éow dé Ta TreloTAa. onucia 8 evonua’ Hv pev éow, cvyxdunTtew br(ws opav® tovs daxtvXAouS
5) , JAA Yo» 5) / ) \ ie ov SvvavTa’ av be eo, EKTELVELY. eu Body 6€ Umep Tpametns robs daxTvdouS EX@Y, Tous pev reve, Tous O€ avTLTEtvet" TO b€ eFEXov 7] 7 Oévape HTTEpyn dua amwdeiv® mpdow Kai Katwbev," Kata TO Etepov datéov dyKkov Te® wadOaxov Utro-
3 0 D A i r Deis, rijy ® pep avo, Kataot peas THY KXElpa, HV Yj 6€ Kato, UTtinv. inats,)© dOoviocw.
XVII."OAn Sé yelp drdicPdver Eow 7 Eo,
/ be ” xX wv x ” 11 ” } v4 ¢ pariaota bé é€w, 7) &v0a ) Oa" gore S Ste H > / 12 > / . ” Pe ef \ av a Errihvals exev On gore & bre TO Erepoy Toy da Témy dean. TOUTOLOL KATUTAGLS ioxupn. ToUuN- Tén, Kal TO pev efeXov anwetv, 70 dé Erepov avTwOeir, 80 eldea Gi dpa Kal és ToUTiC@ Kal és TO TAAYLOY, 7) Xepow emt Tpametns 7] HWTEpYN. Tadtly- KoTa dé Kal doXn}wova, TO xorg O€ KpaTuveTat és Xphow. inos, doviore avy TH Kept Kab 7 myxer’ Kal vapOnkas pEX pl daxTUdwy rebevac” €v va ponte dé teOévta ® Ta vTa TUKVOTEPOV Ave 7) TA KATHYMATA, Kal KaTAXVOEL TEOVL YpHoPaL.
1 Cf. VII. 2 Add rijs Oepamelns. 3 Add rat. 4 Gmrayre.
4%4
INSTRUMENTS OF REDUCTION, xiv.-xvu.
Here the writer evidently describes dislocation of the bones of the forearm from the wrist ; while the epitomist (unless, with Littré and Petrequin, we put some strain on the Greek) speaks of dislocation of the hand, but follows Hippocrates in saying that “when the dislocation is inwards (our ‘ forwards’), they cannot flex the fingers, when outwards, they cannot extend them.”
This is the view of Celsus (VIII. 17), and is most in accordance with modern experience—when the hand is dislocated backwards, the flexor tendons are on the stretch and the fingers cannot be extended, and vice versa, though exceptions have been observed, and the accidents are too rare and complicated for the establishment of neat rules. The typical “ dis- location” of the wrist is the fracture of the end of the radius, known as Colles’s fracture.
The brief account of congenital dislocation (XVIII) may have been added to complete the picture. The results described are those of all congenital disloca- tions, as frequently given in Joints, Perhaps, how- ever, “nothing can show more remarkably the attention which our author must have paid to the subject than his being acquainted with a case of such rarity ” (Adams).}
1 Littré treats these subjects at length in his Introductions, and Petrequin at still greater length in his Notes and Excursus. They confirm the observation of Adams that a full discussion would lead to no conclusion, and would be tedious even to professional readers.
5 Omit bAws oar. ® Add ka) weir.
7 apdow xatw, KérwOer. 8 Be. > Hy, 10 Ynois Be. AL 4) tv0a }) &v9a, udrAwora O€ Eow. 2 kal i) enlpuois. 18 Sedévta,
415
10
10
MOXAIKON
XVIII. Exe yevens Oé, Bpaxutepn a) xelp ryt- vera, Kal ky * pwvdnous oapKov paduora Tavav- tia 1) @s* TO éxmT@pa’ nvEnuévw O€ Ta doTéa pevet.
XIX. Aakrvrouv 6é dpOpov odio Ody ev evon- pov [ov bet ypadey].® "&uBons d€ avTod noes KaTaTteWwavTa és /00 TO (Bev ee Xov atwbeiv, TO dé évavtiov avtwleiv. inais 6€ 1) TpoanKovaa,® Toiot OOoviotcr® éridecis.” pn éumrecov yap émt- T@povTaL efwbev. €x yevens O€ 7) év avéjoe éEapOpncavta Ta oatéa Bpayvvetat Karo * Tov oa OnpaTos® no oapKes puvvOovar Tavavtia pariota 1) w@s® TO éxmT@pa: HvEnpevo be Ta OOTEM [eével.
XX. Mypob dpOpov éxmimter Kata TpoTrous Tésoapas: éow TreloTa, é&w SevTepov, Ta 6é dda OMolws. onpeta* KOWOV pev TO érepov oKENOS* idtov S€ TOD mev ow. mapa Tov mepiva.ov 10 Wrave- Tal 1 Kepans ovyKdpmToucl ovx opotws, bo- ret O€ pax porEpov AL ro TKENOS, Kal TORY, iy pH?) és MEcov duporepa you Taparelvys* Kal yap ovr &&w o mous Kal TO vyovu pémer. Hv pen. ovv éx ryevens 1) ev avEnoes extréon, BpaxuTepos oO -npos, Haocoy b€ KY LN, KaTAa NOyor Sé6 TaAXA’ pLVvVOOVEL 56 gapKes, pddtota O€ Ew. ovTOL KaTOKVEéOVa LV oplovabat, Kai ethéovtar él TO bytés* Fv dé avay- Kalovra, oKiMTOvE évl y) dvaly odovmopéouct, 70 dé oKehos aipovaw: da yap peciov, Tow padov. hv Oé nvénuévorer, TA pev ooTéa péver, ai
1 Omit 7. 7} F. 3 Omit (‘ probably a gloss.” Kw.). 4 Omit me: noe. 5 Omit 7 mpoonkovca.
416
INSTRUMENTS OF REDUCTION, xvi.—xx.
The problem of the knee (XXV1) seems insoluble. All writers, from the author of Mochlicon to Ambroise Paré, copy the statement of Hippocrates (Fract. XXXVII) that dislocation is frequent and of slight severity. We know that it is rare and requires great violence which usually has serious results. Suggestions such as confusion with “internal de- rangement,” or displacement of the knee-cap, seem unsatisfactory. The existence of some peculiar grip in wrestling which dislocated the knee without further injury seems the most probable explanation. One of the modern causes—being dragged in the stirrup by a runaway horse—was absent in antiquity.
XX. The thigh-joint is dislocated in four ways, most frequently inwards, secondly outwards, in the other directions equally. Symptoms: in general, comparison with the other leg. Peculiar to internal dislocation: the head of the thigh-bone is felt towards the perineum; they do not flex the thigh as on the other side; the leg appears longer, especi- ally if you do not bring both legs to the middle line for comparison, for the foot and knee incline out- wards. If then the dislocation is congenital, or oceurs during adolescence, the thigh is shortened, the lower leg less so, and the rest in proportion, There is atrophy of the tissues, especially on the outer side, These patients shrink from standing erect, and wriggle along on the sound leg. If they have to stand up, they walk with a crutch or two, and keep the leg up, which they do more easily the smaller it is. In adults the bones are unaltered, but
6 rawloio d0ovioiws 7 Omit éerldecis, 8 ra KaTw 9 udAtora, 7) A : Sens 10 ; ToS j meplveov. TOAY pakpdrepov.
417 VOL. Ill. P
20
26
10
MOXAIKON
dé capKes puviOovel, @s mpoeipntat. odot- Topéovat 6é meptat popaony, as Boes, &v Oe KEVEOVL 2 KapmvroL, emt TO vytes eFioxvot € éovTes* TO pev yap avayKn UToBatvew ws oxh, Ae € amroBaiveuw (oo yap dvvatat oxeiv), woTrEp ot EV Tool Ed«cos EXOVTES. KaTa O€ TO Dyves, Tayvov * Eth TO TOpate avTikovToval, TO bé o1vapov TH Yelpl Umrép Tov yovaTos KaTavayKalovat ws oxelV év Th petaBace TO c@pa’ toxiwm Katabev* e€ xphAtat, kadtoOev® jaocov piwvder Kal TA OoTéa, BadXov O€ odpxes.
XXI. Tod & é&@ tavavtia Kai Ta onpeia Kal ai otdoves’ Kat TO yoru Kal o Trovs é&w pérer Bpaxv. Totcr oé ev avenoet i) ex ryevens taQovoL
’ ¢ , \ pee < , OUX opolws ouvavgerat ° Kata Tov avtov door" loXlov dveatépw Tivt, oUX Opolws. otaL dé TuKWa exmimTter &s TO €EW avev preypovis, iryporépep TO oKédet Xpavrae, @aTep O peeyas THS XEtpos dxtunos" padiora bé ovTos cxrrimrel pucer’ ois fev éxtrimrer padrov #) Hooov, Kal ois wey éxTritr- TEL NANETTE POY 3 7) priov, Kal olow érxTrls Oao cov éuteceivy, Kal ola ovK as) TOUTOU, Kal olot TOANGKLS EXTITTEL, inols TOUTOU. €K EVENS OE 7) em avénoer » €v vovow (uddiaTa yap ex vovcov) éore pe [ovy] 7 olaow emiahaxentCer To oaTéov, aap Kat oiat pn, TUTXEL [eV maya, Hooov dé 7) TO €oW, HV XPNTT HS emriped nO@aw, Bate Kal 6X Baivovtas Tt Todt Siappimtew dia perérns
u Te KEVEDVL. 276. 2 rAdyior, 4 ioxiwy KaTwrépw. 5 KaTw Te. 6 Kw. puts colon after cuvattera. 7 Omit.
1 Cio J. LIV.
418
INSTRUMENTS OF REDUCTION, xx.-xxi.
there is atrophy of the tissues in the way described. They walk with shambling gait, like oxen, bent in at the loin and projecting at the hip on the sound side; for they have to bring the leg under to serve as sup- port, and keep the other leg out (for it cannot give support), like people with a wound on the foot. On the sound side they use a staff as a lateral prop, and press down the injured limb with the hand above the knee, so as to support the body in the change of step. If the part below the hip is used, there is less atrophy of the bones (below). It occurs more in the tissues.
XXI. In outward dislocation, both symptoms and attitudes are the reverse. Knee and foot. incline slightly inwards, In adolescent or congenital patients there is inequality of growth, in the same proportion (as with inward dislocation), Hip some- what elevated, not corresponding.t Those in whom outward dislocation is frequent without inflammation have the limb more charged with humours, as is the case with the thumb; for this is by its nature most liable to dislocation. In some the dislocation is more or less complete; in some it takes place with more or less difficulty; in some there is hope of speedy reduction: in some there is no cure for the condition ; in cases of frequent dislocation there is a treatment. In congenital and adolescent cases, and those due to disease (for disease is the principal cause), in some cases there is necrosis of bone, but in others not. They have all the affections above mentioned, but to a less degree than those with internal dislocation, if they are well cared for, so as to balance themselves and walk on the whole foot. The youngest require the greatest care. Left to
419
20
10
MOXAIKON
TAELOTHS ToloLYNTIMTaTOLOW: €adévTa KaKovTaL, emripednGévta 6 @pereitats Tolow droLow, HoTov dé Te, puvdOovet.
XXII. Oict 8 av audotepa obtas éxtrécn, TOV doTéwy TavTa mabijpara’ eVoapKot per, TID érabev, ebexeyRovror, p potxol fen por, ay BN émiapa- Kedion. el Kudol Ta aveober i io Xiov ryevOLvTO, UyLN- pol mév, avav&ées 68 70 cOpma, TANY Keparfs.
XXII. Ofou dé dria Oev, onpela” éumpoa bev AaTrapwreEpor, oma Oev eS€xov, Tous op0os' cuy- KaUTT EW ov SvvavTat, el 1) LET advvys, exretvew HKLoTa’ TOUVTOLTL OKEAOS BpayYUTEpOV. aTap ovd’ extTavvely OvvavTai Kat iyvunv )} Kata BouvBova, QV [LN WAVY AipwoLY, OVSE TUYKAUTTELV. HryElTas é€v Toiot TAELTTOLTL TO ave cip@ pov TO 7 p@Tov" KoWwov TOUTO apOporot, vevpolor, poly, evTEpotoly, varepyaoty, aANOLOL" TOUTOLS Tov laylov TO OoTéov Kara eperar els Tov yNouTOV" 61a TOTO Bpaxy, Kal OTL exrelvely ov dvvayTat. oapKes TAVTOS TOU TKENEOS ke Taot puvdBovowr eg olat éé padiora, Kal ol,” elpntar Ta épya Ta EwuTod Exao Tov TOU TO [LATOS épyasopevov pen _loxvet, dpyeov O€ KakovTal, TAY KOTrOU, TUpETOD, prEy- povns. Kal TO ef, 6Tt €s odpKa Umetkovcay, Bpaxurepov" TO Oe & eo, OTe ém” OoTéov TPoEXor,
MaKpOoTEpov. av pev ody nvEnuévoioe pn euTery, éml BovBdot kaput OdotTopéovar, Kal 7 ETEPH
14 = ‘and not” (cf. Surg. XIV); but Kw. reads Civ ph, from J. LVIL. 2 Te. ‘to what extent” (?) ; but Kw. (M) has 7.
1 Hardly intelligible without reference to J. LVIL. 420
INSTRUMENTS OF REDUCTION, xxr-xxu.
itself, the lesion gets worse ; if cared for, it improves. There is atrophy of all the parts, but somewhat less (than in dislocation inwards).
XXII. When both hips are thus dislocated, the bones are similarly affected. The patients have well-nourished tissues, except on the outer side; they have prominent buttocks, and arched thighs, unless there is also necrosis of the bone. If they become hump-backed above the hips, they retain health ; but the body ceases to grow, except the head.
XXIII. Symptoms of posterior dislocation: an- terior region rather hollow, posterior projecting, foot straight ; they cannot flex the thigh without pain, nor extend it at all; the limb is shorter in these cases. Note also that people cannot do extension at the knee and not at the groin unless they lift it quite high, nor can they flex.! In most cases the proximal joint takes precedence (in function) ; this applies to the joints, ligaments, muscles, intestines, uterus, and other organs.2 In these dislocations, the hip-bone is carried to the buttock, which causes the shortening and inability to extend the joint. In all cases there is atrophy of the tissues through- out the leg; in which cases this occurs most, and where, has been explained. Each part of the body which performs its proper function gets strong ; but when idle, it deteriorates, unless the inaction is due to fatigue, fever, or inflammation. External dis- location, because it is into yielding tissue, produces shortening : internal, because it is on to projecting bone, lengthening. If then it is unreduced in adults, they walk in a bent attitude at the groins,
? /.e. movements, including contractions, start from above.
421
20
30 31
10
MOXAIKON
iyvin Kapmtetar atiGeor por) Kabixvetrar? yewpl TO oKEROS caTarauBavet, avev EvXov, ay ehwow: VY pev yap waxpoTepov 7H, ov Byoetar: 7 dé Baivy, Beaxy. puvvOnaots dé capKar, oice TOVOL, KaL 1) igus Eumpoa bev, Kal TO vyLet Kata Adyor" olar Se ex yevens 4) adLouevoicr H bd vovcov évoonce kal é&apOpa éyéveto (év als, ElpnoeTal), OUTOL UaGALTTA KAKODVTAL OLA THY TOV vevpov kat apOpwy apyinv' Kat TO yovu La Ta elpnuéva ouyKaKOvYTAL. avyKEeKampéevov oOUTOL éxovTes OdouTropéovowy él EvAov, évos 7) SO" TO 5é Uyés, eVoapKoy 1a YpHow.
XXIV. Olas és Tovpm poo ber, onpeta Tavav- Tia: oma Bev Aamapor, cum poader € ef éXov" HKLOTA ouyKaumrTove Ww oUTOL TO okéXos, padiara dé éxtetvovat’ opOos aovs, oKédos icov, TTEépva’ Bpayet dxpas avéotartat. [%)]* movéovore pans- ora OUTOL auTixa, Kal Ovpov iaYETaL adLoTa eV ToUTOLOL TOLOLW eFapOpypacwy™ év yap Tovotow eyKerTa Tolow émikaipoiow. Ta éumpocber Kkatatétata [avavkéa, voowoea, Taxvynpa|: 4 ra oreo Gey oTooadees" olow vEnwevovrw, odouTro- péovae opbot, TTEPVN Haiddov Batvovres: el O€ NOUVAVTO eye mpoBaivew, kav mavy cvpouce 6é. puvvbes dé Hevota, TovToor b€ 4 Yphows aitia’ paricta O€ Omicbev' S1a TavTds TOU oKéXdeEOS, opOdtepor Tod petpiov, EVAov SdéovTar KaTa TO
1 udyis.
2 «iwetrat codd.; ixvetra Littré.
8 Kw. deletes. Perhaps 4 emphatic.
4 Words from J. LVIII referring to effects of disuse, evidently out of place here.
422
INSTRUMENTS OF REDUCTION, xxiu.—xxiv.
and the sound knee is flexed. The ball of the foot barely reaches the ground; they hold the leg with the hand if they choose to walk without a crutch. A crutch for walking should be short; if too long, he will not use the foot, There is wasting of the flesh in painful cases+ down the front, and on the sound side in proportion. In congenital and adoles- cent patients, or where the dislocation follows disease (what the diseases are will be explained), these cases especially go to the bad through disuse of the sinews and joints ; and the knee shares in the deterioration, for the reasons given. They walk with the leg flexed, on one or two crutches; but the sound limb is well nourished, because it is used.
XXIV. In cases of dislocation forwards the symptoms are reversed; hind region depressed, front projecting. These patients are least able to flex the leg, but have most power to extend it. The foot is straight, and the leg equal to the other, if measured to the heel; the foot is a little drawn up at the tip. Now these patients suffer especially at first, and there is a special liability to retention of urine in these dislocations ; for the bone lies upon cords of vital importance. The parts in front are stretched [cease to grow, and are liable to disease and premature age]; the hinder parts are wrinkled. In the case of adults, they walk erect, chiefly on the heel,and, if they could take long strides, would do so entirely ; but they drag the leg. There is very little atrophy in these cases on account of the exercise, and it is chiefly in the hinder parts. Because the whole leg is straighter than it should be, they require a crutch
1 Pq. renders ‘‘in those who exercise the limb ”’ (!) ; surely the sense is, ‘‘ where it is too painful to use.”
423
20 21
10
15
MOXAIKON
aivapov. olat dé éx yevets ) advEopévorct, ypn- TTHS mev eTimENnGEiowy 1 XpHows, OoTEp Tolow nvEnucvoiciy’ apedrneiot 5é Bpayd, éxteTapévor’ Tmopovtat! yap TovTotot, wadtota 6é és (OU Ta apOpa’ ai d& Tav doTéwy petmaotes Kal ai TOY capkav piwvOnoves KATA NOYOD.
XXV. Mnpod 6€ xatdtacis pév ioyvpy Kal m SvopOwots KoLvy, } XEepoly 7 cavids 7) poxXrO, Ta pev ow atpoyyvA@, Ta bé é&w mTraTel, pardtata b€ Ta éEw. Kal Ta pev Erw aoxotow axecdpevov és TO vToENpov Tov pNnpov, KaTa- Tdotos O€ Kal ovvdéctos oKedéwv' KpEe“acat dtaXelTrovTa oMLKpOV TOUS TrOOaS, eTELTA TAEEAYTA éxxpepacOnvat tia, év TH StopPece appotepa dua ToredvTa. Kal TO éutrpocbev TodTO ixavov Kal Tolow étéporow, heiota 5é TH Ew. 4 TOU EvAov Uroctacts,2 O@oTEp WUw, VITO THY YXelpa, ols éow* Tolat yap a\XNOLTW Hooov KaTavay- Kacey 6€ peTa OlaTacios, padtoTa Tov éumpoobev 7) dricbev, 7 Todt ) Xewpl epilecOat caviol.
XXVI. Tovu 8 ednbéctepov ayxavos 81a THv evotarinv Kal evdvinv, 6.0 Kal éxmimter Kat éumrimree pgov. EKTUTTEL 6€ mhevar anes Evo, atap Kat é&w Kal dmicbev. éuBorai dé 7 &x Tov cuyKxexaudOat, 1) éxraxticar o&éws, 7) cuve- ALEas Tawins dyKov, év iyviyn Oels, adi TodTOY éEaipyns és bkraow adgeivar To coma, [wadota
1 rnpovra, perhaps the correct reading, asin/. LX. Foés, Littré, Kw.
2 badtacis.
424
INSTRUMENTS OF REDUCTION, xxiv.-xxvi.
on the injured side. In congenital and adolescent cases, if exercise is well managed, they get on like adults ; but in neglected patients, the leg is short and extended. Ankylosis occurs in these cases, with the joints usually in an extended position. The shortening of the bones and atrophy of the tissues are according to rule.
XXV. For the thigh strong extension is required, and the adjustment in all cases is with the hands or a board or lever, rounded for internal, flat for ex- ternal dislocations. The external cases want it most. As to internal cases, there is a treatment with bags to the tapering part of the thigh, with extension and binding together of the legs. Suspend the patient with his legs slightly parted ; then let some- one be suspended from him, twisting [his arms between the patient’s legs],1 performing both acts of adjustment at once (extension and leverage out- wards). ‘This suffices in anterior dislocation and the rest, but is no good in the external form. The plan with wood beneath the limb, as under the arm in shoulder dislocation, suits internal cases, but is not so good in the others; you will sueceed in reducing anterior and posterior cases especially by double ex- tension, using foot or hand or a plank to make pressure from above.
XXVI-XXXI. In these chapters we have an epi- tome of an obscure subject already given verbally (with a few various readings) in Joints LXXXII- LXXXVII. Instead of repeating the English ver- sion, we may therefore attempt some explanation of the diffienities:2 The chief of these are :—Why is there no mention of the astragalus in ankle dis-
1 Cf. J. LXX. ? For note on § XXVI, see p. 417. 425
10
20
10
MOXAIKON
évy tH Tov dicbev:'|! Sivatar Sé Kal KaTa- TELVOMEva pet plas, domep ayKon, éumintew Ta Omri Gey" Ta be év0a 7) eva, éx TOU ovyKekapdbar a éxXaKTiaas 1) [ev] KATATAEL, [maora é avr ® TO drvaber]. aTap Kal ex KaTATAOLOS pet pins, n d10p0aars c aTace Koti. hy O€ pr éutréon, Totct fev OrriaOev cuyKauTTely ov SUVaYTAaL, aTap OSE Totaw ardovow mavu TL. juvuder d€ ponpov Kai Kv} UNS TO eum por bev, ay Oe és TO eo, Brat- coTEpol, puvuder d€ Ta Ew iy O€ és 70 ef, yavaorepot, X@rol 5€ focov. Kata yap TO TAX UTEpOV oaTéov ayer’ puvv0er SE Ta ow. eK yevens dé } év av&noe, KaTa NOYoV TOV éuTpoobev. XXVIII. Ta 6€ cata ogupa Kkatatdcios ic- xupis Oettat, 1) That Yepoly 7) dANoLoL TOLOVTOLCL, KaTopOw@atos 5é dua aupoTepa Tovevons KOLVOV 6€ maou. XXVIII. Ta dé é €v mobi, os Ta év xeLpl, oyun. XXIX. Ta dé év 7H KU NLD cuyKowweveovTa Kal jn e€utrecovta, ék yevens Kal év av&noer eEapOpricavta, TavTa & Kal év YeLpi. XXX."Oco. 8€ andncavtes dvwOev éatn- ptEavto TH 1Tépvn, dare OlaoThvat Ta ooTéa Kal pr Bas x xupodivar Kal vevpa appiprac Oivat, oTav yéuntar ola Ta dewoTaTa, KivOuvos pev opakeNicavtTa TOV ai@va TpHywaTa TapacyeiV Kal potxwdn*® wey ta batéa, Ta 5é vetpa ad- Ayrowre KOW@VEOYTA. érel kal olow ay KaTea- yetouw Uo TPOpLATOS, ola ép KvnpLy, 0) pnp, vEevpov aToAvOévtTwy & KoWWavel TovToLoW, i) €& ddAns KATAKNM.LOS ceheos ewehavOn 4 y} TTEPVN, Kal TOUTOiCL TAN YKOTA EK TOLOUTWY. EaTW OTE
420
INSTRUMENTS OF REDUCTION, xxvi.-xxx.
locations? and, What is meant by the epiphysis of the foot and leg?
We are told (Fract. XII, Mochi. 1) that the leg- bones towards the foot have “a common epiphysis” against which (pds jv) the foot moves. The bones may be dislocated with the epiphysis, or the epiphy- sis only may be displaced (Fract. XIII). In the epitome, however, the epiphysis is considered part of the foot, which may be dislocated either with or without it. Littré discusses the subject at great length,! and concludes, somewhat doubtfully, that the epiphysis is “la réunion des deux malléoles considérées comme une seule piece.” Its dislocation is the separation of the two bones. But Hippocrates has a special word for each of these, cvpduds for the union and éracracts for the separation ; and he uses neither here. Adams,? following a suggestion by Gardeil, confines the term to the lower end of the fibula; dislocation of the epiphysis is fracture or displacement of the fibula. He admits, however, that a full discussion would be futile and tedious even to the professional reader. The chief argu- ment in favour of this view is that fracture of the lower end of the fibula frequently accompanies ankle dislocation. On the other hand Fract. XIII seems to distinguish clearly between the epiphysis and either of the leg-bones,
A third view, hardly bolder than that of Adams,
1 ir. 393 ff. ; 1v. 45 ff. Petrequin agrees with Littré. 2 11. 522, also 504.
’ J, LUXXXII omits here and below. 3 airy. ® boiwdea, 4 pedavip.
427
20
30
MOXAIKON
mpos shaKxeriopo yivovTat TupeTol bmepoeees, Avyyooecs, Tpomeodees, 'y yvoeuns aTrTOpeVOL, TAaXv- Odvatot, Kal ét PreEBOV aismoppowy TerAL@aLES Kal yayypawecces. onpcia Tov maniykorna dvT@v: Hv Td EKX UO MATE Kal Ta perdo para Kal Ta Tepl TavTa UTOoKANnpAa Kal UTrépvOpa n° Hv yap ovv oxrnpvopate TEALWOH, KivduvOS pedXavOjvat’ ay 6é UmoméALa uE KAL TEALG para Kal Kexupeva," ?) UToXAwpa Kal parbana, tabTa ev maoL TOLGL ToLovTOLOW ayada. ino 6é ap pev Grr pero wow, EAreBopivew'> hv S€ ux}, wn? ANA TroTOY Siddvar OFVyAvEKU, eb Séot. errideais O€ 7 ApOpav avvOecis’ étt 6€4 mavtTa parrov roice prac- pace Kat ddoviorct TrEoot Kal parOakwréporae xphaFar meus ooo" Bdwp ™heov"? T™pooTept- Badrew Ta mretora TH mr epyy TO ONT pO OTrep 7 érideors, os pny es THY TTEpYNY amromeEntar’ avotépw youvatos éotw ev0etos’ vapOn&. py xpicacba.®
XXXI."’Orav 6&é exorh 0 TOUS, 7) pobvos ” ij ouv 7. emipvoet, EKTTLTTTEL paddov és TO Ero" et & dé pay eumeon, Nem TUVETAL ava x povov loylov Kat pnpovd Kat KY NEMS TO ay Tiov TOU ducOnpwaros. éuBor2, @S 7 KapTOU, KaTAaTAGLS be io Xvporepn. inats, v0 [108 apOpwv’ TaruyKoTet ooov KapTod, Vv HovXaon. Siaura pela, éduvdovar yap. Ta dé é ex yevens ev i) ev avénoe, KaTa Oyo TOV TpOTepov.
XXXII. "Evel Ta opixpov @d«oOnKOTAa éx yevefs, via old te Si0pOotcAa. pddtota dé 1 ekkexumwmeva- 2 én.
3 ambpetos f, EAAEBopov.
428
INSTRUMENTS OF REDUCTION, xxx.-xxxu.
is that the epiphysis is our astragalus, looked upon either as an annex to the leg-bones or an epiphysis of the foot. This would explain much, e.g., the fact that Hippocrates speaks of dislocation of the leg from the foot (Fract. XIII, Joints LIII, LXIII); for, with the astragalus, the leg-bones would have a convex end; so too the foot is said to move on (xpés) not mm this joint. We may also note that the epitomist, taking the epiphysis as part of the foot, adopts the modern view, dislocating the foot from the leg, yet retains the language of his original (Fract. XIV) in saying that the commonest disloca- tion is inwards. The commonest dislocation is that of the leg inwards and the foot outwards, so we can only make him correct by a bold translation such as that of Gardeil, who renders 6 rots ékrimre: wGAXov és 7O éow, “la partie supérieure de l’astragale se place communément en dedans.”’
The other Hippocratic account of the ankle-joint (Loc. Hom, V1) says, “‘towards the foot the leg has a joint at the ankles and another below the ankles.”’ The part between is the astragalus; and it is left doubtful whether this belongs to the foot or the leg.t
XXXII. Among slight congenital dislocations, some can be put straight, and especially club-foot.?
1 So, too, in Joints LIII, we hear of a ‘‘bone of the leg at the ankle” which seems distinct from the leg-bones proper, and more closely connected with those of the foot.
* An almost ludicrous epitome of J. LXII.
© énideois 5€, UpOpwy atydecis: emidetv Kw. 5 Omit. 6 ypiobat. 7 abrds. 8 hy.
429
10
20
MOXAIKON
Too0s KVAAWOLS' KUAA@LOS yap ovy els €aTi tTpoTos. 1 6€ inaovws TovToOV, KnpoTacTEtY KNpwTH pyntiv@dns,t o0oma ouxvd, H TwéeApa 7) pohuBsvov T pooeT Loeiy, fe) Xpwri avaryn is, Ta TE TXNLATA oporoyeiTor,
XXXII. “Hy 6é efapOpicavta Erxos Tmoun- cdapeva €€icyn, ew@peva GMElvo, Gore 62) 1) dmrasmpela Oat pnd anavaryKater bar. inaw 6é meaonpi) i) OT VET olvnpotor Oeppotow—anace yap TovTOLCL TO Wuxpov Kaxov—Kal purrovou" XELL@VvOS 66, elplouee pepuT@pévoise THS oKEeTNS elveka’ pn KaTaTAdTOEW, Nd emidety? diatTa
Newer)" poxos; axOos Tov, Ties, avayKn, -
TX NLATOS Tak" eloévat ev ody TAaUTa TavTa oneO pta. per pics dé Ocparrevdevtes, X@Aoi aicXpas’ mv yap mapa mooas yevnras, mous avacraTat, Kal HV TH addy, Kara NOyov. baTéa ov dra afpiotatar’ piKpa yep Worrovrat, TrEPLW- TELNOUTAL AeTTT OS. TOUT@Y Ta Heyora cwovve- déoraTa, Kal Ta avoTatw. édris bé povrvn cwTnNpins, edy pa) ELBaND, TAHY TA Kata daxTuhous Kal Xetpa aiepny" TavTa 6é Tpoelmeren : TOvs KLVOUVOUS. ey Netpety émBarreuv 3) TH Tpaern nT] devTepn, ny o€ Mn, T pos Ta O€ka’ HKLOTA TeTapTaia. eu Bors b¢, OL poxXrcKot. noes €, os Kepanis oat éwv, Kat Oepun EAXreBopw 6é Kal autika émeta® toto euBardopevoror BéXt10v xpno Gar. Ta adda ev eldévat bet Srv euBanr- Nopevovy Oavator Ta péytoTa Kal TA avwTaTw
1 Knpwri elle A ® rpoeimdyTo 3 al éreita,
430
INSTRUMENTS OF REDUCTION, xxxu.—xxxun.
Now there is more than one kind of club-foot. Here is the treatment of it: moulding, resined cerate, plenty of bandages, a sandal or sheet of lead bound in with the bandaging, not directly on the flesh ; let the slinging up and attitude of the foot be in accordance,
XXXII. If dislocated bones make a wound and project, they are best let alone, seeing, of course, that they are not left unsupported or subject to violence. Treatment with pitch cerate, or com- presses soaked in warm wine (for cold is bad in all these cases), also leaves, and, in winter, crude wool as a protection ; do not use a plaster application or bandaging; low diet; cold, heavy weight, constric- tion, violence, a forcibly ordered attitude—bear in mind that all these are pernicious. Suitably treated, they survive badly maimed; for if the lesion is near the foot, the foot is drawn up; and if anywhere else, there is a corresponding deformity. Bones do not usually come away, for only small surfaces are denuded, and a thin scar forms. In these cases there is greatest danger with the largest and proximal joints. The only hope of safety is not to reduce them, except the fingers and bones of the hand. In these cases let the surgeon explain the risks beforehand. Perform reduction on the first or second day; failing that, about the tenth; by no means on the fourth. Reduction: the small levers. Treatment: as for bones of the head; warmth; it is rather a good thing to give a dose of hellebore to the patients immediately after reduction. As to other bones, one must bear well in mind that their reduction means death, the quicker and more certain the larger and higher up they are. In the
431
10
MOXAIKON
/ \ / \ \ > / lA paddioTa Kal TdyloTa. Tovs bé éxBds, oTAaTpMOS, \ 3 yayypaiva’ Kal yap nv éuBrAnOévte erruyévyntat Te 7 b] / > / v ” ’ / > 3 TOUTWY, EXPadrAovTe EAXTIS, EF TLS apa é€XTTis* ov \ , para a , c , ’ Tog) sate yap avo TOV YAaAN@VT@V Ol OTAaTMOL, AAN aTro TOV €VTELVOVTOD. XXXIV. Ati 6é arwoxotral év dpOpe@ } Kata Nia re \ ” ? ey \ n Se \ TA OOTEA, [L)) AVM, GAN 7) Tapa TO Todt Tapa TH NEetpl eyyvs TWepuyivovTar, nv fy adtixa para * / fol NerTroPupin aTrodhwvTat. inots, ws KEepandns, / Beppu. ’ nr XXXV. ’Arocdaxeniotos pévtot capKav, Kal €v Tpwmact aipoppoots atroadiyyOév, Kal év doTéwy KaTHnypwacr TLEXOEV, Kal ev Secpois amro- peravbév, Kai olov unpod pépos atrotmimte Kal Bpaxiovos, dotéa te Kal oapKes amtorimtovct, \ J e r ” > , TOXNNOL TEPLYLVOVTAL, WS TA ye AXXa EvhopwTEpa* S / e s olot pev odV KaTEAyeEVTMY OTTEWV, Al [EV TEPLp- pnétes tayeia, ai 5€ TOY dotéwy ATOTTMCLES, >) oY, lal , , H dv TA Spta THs WiAOaLOS Hh, TAUTH ATroTTTOVAL, Bpaddtepov dé. det? 5€ Ta KaTwTépw TOU Tpa- lal lal , fal / patos Tpocadarpety Kal TOV G@paTOS TOD UYLEoS / —tmpobvycxe. yadp—puracocopevor"? nan) yap NecroOupin OvncKovow. penpov datéov arre- i: val \ la AVON éx ToLlovTOV GySonKocTaiov, 1 Sé KYHnmH ? / \ / adnpéOn eixoatain Kvnuns S€ oaTéa KaTa péonv o \ \ éEnxootaia amedvOn. ék TOLOVT@Y TAaXU Kal
? / iv4 oovvn ama
1 Gua. 2 xp) Kw. 432
INSTRUMENTS OF REDUCTION, xxxut.—xxxv.
case of a (compound) dislocation of the foot, spasm and gangrene (are to be expected). If anything of this kind supervenes on reduction, there is hope from dislocation, if indeed there is hope at all; for spasms do not come from relaxation of parts, but from their tension.
XXXIV. Amputations at a joint or in the length of the bones, if not high up, but either near the foot or near the hand, usually+ result in recovery, unless the patients perish at once from collapse. Treatment: as for the head; warmth.
XXXV. (Causes) of gangrene of the tissues are: constriction in wounds with haemorrhage, compres- sion in fractures of bones, and mortification from bandages.2. Even in cases where part of the thigh or arm falls off and bones and flesh come away, many survive; and in other respects this is rather well borne. In cases of fractured bones, lines of demarcation form quickly ; but the falling off of the bones (it is where the limit of the denudation occurs that they fall off) occurs more slowly. One must % intervene to remove the parts below the lesion and the sound part of the body (for these parts die first), and be careful;4 for patients die from pain and collapse combined, A thigh-bone separated in such a case on the eightieth day, but the leg was removed on the twentieth; leg-bones separated at the middle on the sixtieth day. In such cases the compression __ 1 éyyts corresponds to ois mAciarow, J. LXVIIL; but it Is &@ curious use,
2 J, LXIX. 8 « Should” (Kw.). 4 « Avoid pain”—Kw.’s punctuation.
3 pvdacodnevov absolute: cf. Head Wounds XVIII. Kw. follows a conjecture of Foés and reads puAacadpevoy ddvvny,
433
MOXAIKON
Bpadeas, ai mue€ Les at int pica. Ta o a\Xa Ooa jovxaiws, Ta pev OoTéa OvK atroTimTe: Ovde TAaPKaV prrovran, an’ émumohatorepov.| T po - 20 dexeo Bau tabTa Xpy Ta yap TrELoTA PofEepwrepa 1) KAKLO. y) inous Tpacia, Jepph diaity ax piBet Kivuvos aipoppayiav, Wuxeos: oXNMaTa d€ ws pev avapporra, € eTelTa UrogTaavos ™vov elveca ef igov %) doa oupdéper. él Totat ToLrovTotce Kal ETL TOLTL MEAAT MOLLY, aipwoppayiat, SuaeEvTEptat, Tept Kplow, Aavpot pév, OALyHmEpor O€. OvK amoatTor 6€ TWavu ovoe TupeT@oces, OVSE TL 28 KEvEayyNTEéov.
XXXVI."TBwots, 7 bev gow ériOavatos, ovpwv oXéclos, aTrovapKwatos’? Ta be Ew, TOUTw@Y aowéa Ta TAE€iaTa, TOAD MaAdOV 7 baa ceLC- Oévta pn é&éotn. atta peév éwutoiat Kpiow Tonodueva, Kelva O€ emt TAEOY TO ToOpaTL ETLOLOOVTA, Kal ev émLKaipols eovTa.
Olov mdevpal Kateayeloar pév, OXLyaL Tupe- T@dees Kal aiwatos mMTUaLOS Kat ohaKEdto pod, Hv Te pula, mv Te TAElous pry KaTayH ecw é%
10 kai inows havrAH, wn KEevEeayyoUVTA, IV ATrUPETOS
>
uE ETLOETLS WS YOpos" 1. d€ me@pwals év elkooLy mEpNTW, xabvor yap. iy ro aupipracby, pu- patiat, cal Bnxobecs, Kal E[pLorot, Kal Teupas éopakéoav™ mapa yap mAeupny éExaoTHY aro
15 Wavtwv Tovot eiaiv.
XXXVII. Ta 6€ amo Katarteclos Hooov
1 érimoAadtepa. 2 elvera understood. 3 uh Kkatayetoa 5é. . . Kw. He suspects a mutilation in the text.
1 «Which have been gently constricted.” Littré (Adams). 434
INSTRUMENTS OF REDUCTION, xxxv.-xxxvu.
used during treatment makes it quick or slow. For the rest, in cases of mild character! the bones do not come away, nor are they denuded of flesh; but the mortification is more superficial. One should take on these cases, for they are most of them more terrifying than dangerous. Treatment: gentle, with warmth and strict diet; dangers: haemorrhage, chill; attitudes rather elevated; afterwards, be- cause of collection of pus, on a level, or whatever suits. Haemorrhage supervenes in such cases, also in mortification, and dysentery at the crisis, copious, but of short duration. Patients do not lose their appetites much, nor are they feverish; and there is no reason why one should starve them.
XXXVI. Spinal curvature: inwards it is fatal, from retention of urine and loss of sensation; ex- ternal curvatures are most of them without serious lesions, much more so than cases of concussion without displacement, for they make their own crisis; but the latter have a greater effect on the body and on parts of vital importance.
So, too, fractured ribs rarely give rise to fever, spitting of blood, or necrosis, where there is one or more fractured, if it is not broken inwards ;? and the treatment is simple, without starvation diet, if there is no fever. Bandaging as customary. Callus forms in twenty days, for the bone is spongy. But if there is great contusion, tubercles, chronic coughs and suppurating wounds supervene, with necrosis of the ribs; for along each rib there are cords coming from all parts.
XXXVII. Curvatures due to a fall are less sus-
2 Or, ‘‘if not splintered,” Littré (Adams); ‘‘if they are not broken (but contused),” Kw.
435
20
MOXAIKON
dvvatat é&OvvecOat' yarerrotepa S& Ta avw ppevav éEiOvvecOat. olat b€ Taticiv, ov ovur- avéetal, ANN 4) oKEXNH Kal xelpes Kat cepary vEnpévoory bBoous, Tapaxphya poe oS vouoou puerar, ava xpovov o emvonmatverar yi aumep Kal Toice VEWTEpOLOLY, hooov be Kaxonbos. etal 5é of evpopws HveyKay, olaw av és evoapKoy Kal TlMENWOES TPaTHTAL OALyoL Sé TOvTwY Trepl éEjxovta étea €Biwoav. atdap Kal és ta Taya lacTpéupmata yivetat’ auvaitia bé€ Kal ta oxnpata é€v olow av KatakéwvTar' Kal é&xeL ;
Tpoyvad as.
Tlorrol be Kat alive értucav Kab EMTrVOL éyéVvOVTO. a dé _MedETH, inots, emideots ws vojLos* Suairns Ta Tpara aTpeKéws, errerTa am anvvew" nouxin, ouyy oXnpara, Kou, ap podiora. ardp ols dvatma, ér@ouverepa TOV KATAYVULEVOY Kal puruTootpopwrepa Xpovoraty’ oboe dé Katahelme- Tal pvE@oes, UTOML LY IT KEL év QUOLO Wy, inows: cadvaus, Toioe pev ar doréou, EX pes ® ooréou, py) auto 6é Hy bé peTako, py (Téepyy, anode ére- TONS" opaKehia pos. Kal Ta empora metpac Gar: elpnoeTar avavTa Ta em ETLOVT A. opaTa, NOyots 8 ov pan} Bpopara, TOMATO, dadros, Woxos, OX Toa’ or Kal pdppaxa, TQ [bev Enpa, Ta O€ bypas Ta 6€ muppa, Ta 6é péhava, Ta O€ NEUKA, Ta 6¢€ otpugva, émt édxn, oUTw Kal diarTas.
XXXVIIT. Nopos euBorHs Kat dv0pAdctos: dV0S, LOXACS, oPnvicKos, imos: dvos wev avayeLy, MoxrOs O€ Tapayev. Ta dé éuBAnTéa % SzLop-
1 emionmclverat rt (asin J. XLI), 2 wexp. Tov. 436
{INSTRUMENTS OF REDUCTION, xxxvi.-xxxviut.
ceptible to rectification; and those above the dia- phragm are the more difficult to straighten. In the cease of children, there is cessation of growth, except in the legs, arms, and head. Curvature in adults delivers from the disease at the moment; but in time the same symptoms appear as in younger patients, but in less malignant form. There are some who bear the affection well, those in whom there is a tendency to fulness of flesh and fat; but few of these reach sixty years. Lateral distortions also are produced, and the positions in which patients lie are accessory causes; they also serve for prognosis.
Many patients spit blood, and get an abscess.! Care and treatment; bandaging as usual. Diet: at first strict, then feed him up; repose and silence, position, the bowels, sexual matters. But where there is no show of blood, the parts are more painful than in fractured cases, and there is more tendency to relapse later. Where the tissue is left in a mucous state, there is a return of pains. Treatment: cautery, where bone is involved, down to the bone, but not of the bone itself; if between the ribs, not right through, yet not superficial, Necrosis: try also the treatment with tents; all that concerns this will be described. Things are to be seen—don’t trust to words; food, drink, warmth, cold, attitude. As to drugs also, some are dry, some moist, some ruddy, some black, some white, some astringent, used for wounds; so too (various) diets.
XXXVIII. Usage for reduction and adjustment : windlass, lever, wedge, press; windlass for stretch- ing, lever for bringing into place. Parts to be
1 This passage seems out of place here, and Littré boldly joins it on to XXXVI; but we now have to do with odd notes.
437
MOXAIKON
/ a , Owréa Stavayxacar Set éxtetvovta, év & dv éxaoTa oxXnmaTe médAry UtreparwpnOnaecOat: TO & b) / 1 € \ 4 60 > / lal O€ ex Bay,” vmep TovTou obey eFeBn. TovTO OE, 0 xepoy 7) Kpe“wacL@ y} dvovow }) Tepl Tt. xepat \ pev ouv op0as KaTa épea: KapTov be Kal ayKava amoxpn Sravaynatew, KapTrov bev els 10 iOv aryKOVOS, ayK ava 6é eyryoutov pos _Bpa- xlova eXovTa, oiov mapa TO Bpaxiovt TO v0 THY KXelpa UTroTewopmevov. é€v olat de SaKTUAOD, U , a To0O0S, KELPOS, KAaPTTOD, UB@paTos TO éEw,” duavay- Kdoat det Kal KATAVAY KAO aL, Ta pev adra uo xeupav ai SravayKnaaves ixavat, KaTavayKac ar dé Ta UmEpEXOVTA és Spy mrépyvn 1) Oévape ert Tivos’ waoTe KaTa ev TO é&éyov wtToKElabaL OyKov ovppeTpoy warOaKov: Kata bé TO ErEpov [unotwpal & av? ypn abet oricw Kal Kato, x Nh, x NY ay, > , Ni \ > 20 Hv O€ ow Hy Oé Ew exTreTT@KY Ta O€ ex TAA- \ lal al ylov, Ta pev am@beiv, ta 5é€ avtwbeivy oricw apporepa Kara TO ErEpov. Ta 6€ bBopuara, Ta pev éow, oUTE TTAPLO OuTE Bnxt, ove pvons ever el, OUTE oR vn” def O€ Tl, KaTaoTacLs: 1 5€ amdtn, Ott olov Té* mote KateayévTMVY TOV t \ \ , \ \ ’ tb oTrovdUhov Kal Ta Aopd@para ova THY oduyiy doxel Eow wAtoOnkévar’ Tavdra be Taxupua Kal pacia. Ta dé ew, KaTaTacts, Ta bev ava emt 7Oda6, Ta O0€ KaTwW Tavavtia’ KaTtavayKacts &é \ s Ave: x \ A , \ ’ 30 ody Katatdce, 7 &dpyn 7) Todt 7 cavidsu. Ta 8 1 éuBav Ap. : 9 és 7d tw Ap. . 5 unotwp (= ‘‘skilled assistant”) 8 &y vulg. ; wh orope-
cavta Lit. ; unoropa dua Kw. 4 ofovra Kw., Littré.
1 [e. hand-power is strong enough.
438
INSTRUMENTS OF REDUCTION, xxxvmi.
reduced or adjusted must be separated by extension, till each comes into an attitude of sufficient eleva- tion, the dislocated part above that from which it was dislocated; this is done with the hands, or suspension, or a windlass, or round something. Proper use of the hands varies with the part; in the case of the wrist and ankle, it suffices! to separate the parts, the wrist being in line with the elbow, but the elbow at right angles to the upper arm, as when the forearm is in a sling. In the case of finger or toe, foot, hand, wrist, humpback, double extension and forcing down the projection are re- quired; in the other cases, separation by hand- power is enough, but one must force projecting parts into position with the heel or palm over some- thing, taking care that a suitable soft pad is placed under the projection. On the other side, a skilled assistant should simultaneously press backwards and downwards, if the dislocation is either inwards or outwards; in lateral cases, press one side away and the other side back to meet it, bringing both together. As to curvatures, internal ones are not (reducible) by sneezing, coughing, injection of air, or a cupping instrument; a mode of restoration is wanting.? The deception people fall into when vertebrae are frac- tured, and incurvings due to pain simulate dislocation inwards; these heal quickly, and are not serious. Outward curvatures: extension,® towards the feet if the lesion is high up, if low down, the reverse ; forcing into place, simultaneously with extension, by sitting on it, or by using the foot or a plank.
2 Or ‘‘If anything, extension,” reading xarataois, as Littré
(Adams). 3 katdoewis, ‘‘succussion,” Littré,
439
40
BO
MOXAIKON
év0a 7 7 év0a, el TIS KaTaTAaGLS, Kal éTt TA oXN- pata ev TH Otairy.
Ta (appeva TavrTa eivat wratéa, Tpoonvéa, ioyupa, el én’ pay® det paxeor mpoxareiix Gat. éoxevacbat 7m ply 7) ev THOW avayenow mavra, TULLE sLET PN] LEVOS Ta pajKea Kal byrea Kal evpea. d1atacts, otov pnpod, TO Tapa opupov dedéo Pau Kal avo Tov youvaros, Tatra pev és TO auto TelvovTa” Tapa dé cEvi? Kat Tept Hacx das, Kal KATA _Tepivarov: Kal pnpor, tas peTagy THS apXASs TO wey ert o7i0os, TO 6€ él v@TOV Telvovta, TavTa 6 és TO avTO dmavta* TeélvorTa, mpocdebévta %) mpos viepoerdéa 7) mpos Ovov. él ev ouv KALYNS TOLEOVTL, ToUTo pep TOV TOOMY T pos ovdor xpn) Epetcat, Tpos 6€ TO erepov, Evrov ioxyupov mhaytov TrapapeBrnabar, Ta 6€ vrepOev Urrepoeidea Tpos TavTa ayteatnpivovta diateive, 1) TAHUVaS KaTopvEavTa, 7 KNimaKa diabevra, dudporépwbev obeiv. To d€ Kowor, cavis eEdTrNXUS, €UpOS dimnxus, TAXOS on apis, éXovoa OVOUS dvo Tatewvovs évOev Kat evden, éxovga de Kata pécov oTUhic KOUS _TULMLETPOUS, cE ° a @V WS HKRMAKTHP éméaTau és THv UTOcTacW TO EVAM, OoTEP TH KAT Bmov' KaTaydUdous bé @oTEp ANVOUS elas EXEL, TETPASAKTUAOUS EvPOS kat Baos, cai diadtrety TocodToOY Gcov avTH Th poxrevaer és SidpPwow' ev péow O€ TeTpa- yovov KatayAudyy doTEe oTUALTKOY éveElval, OS Tapa TEplvaLoy EwY TepLPpeTELY TE KMAVTEL Ew ei de un, Littré’s conjecture, Kew... C8 Us LXX VILL.
t
vy. 3 unpwy Td.
1 2 4 és ra Grevavtia, 5 ep’.
440
INSTRUMENTS OF REDUCTION, xxxvin.
Curvatures to this side or that; one may use some extension, also postures with regimen.
The tackle should all be broad, soft, and strong, otherwise ! they must be previously wrapped in rags ; all should be suitably prepared as to length, height, and breadth before use in the reductions. In double extension of the thigh, for example, make attach- ments at the ankle and above the knee, drawing these in the same direction; at the loin and round the armpits; also at the perineum and between the thighs,? drawing one end over the chest, the other over the back, but bringing these in the opposite direction ;? they should be fixed either to a pestle- pole or toa windlass. If one operates on a patient in bed, its legs at one end should press against the threshold, and a strong plank should be laid across the other end; then, using these as fulcra, draw back the pestle-like poles from above; or fix wheel- naves in the ground; or lay a ladder along, and apply force at both ends. For all cases: a nine- foot plank, three feet broad, a span thick, having two windlasses set low down at each end, and also having at the middle suitable props, on which is placed a sort of crossbar to act as fulcrum for the board, like that used for the shoulder.4 It should have fossae like smooth troughs, four fingers broad and deep, with sufficient intervals between for ad- justment by actual leverage. In the middle (there should be) a quadrangular excavation for a prop to fit into, which, when it is at the perineum, will prevent the patient from slipping, and when it is
1 Reading «i d¢ uh. ‘* Sufliciently strong ; it should not be necessary to wrap” (Pq.’s reatte ering: of the text).
* Kw.’s reading. ® Kw.’s reading. * Le. the ambé; cf. J. LXXIII.
441
64
G
=
10
MOXAIKON
e / e 4 \ \ a TE UTOXAAApPoOs UTOmOXrEVTEL. Vp7 O€ THs ca- 7. xX an / a vidos, 7) €V TO TOLXw TO AKpoV KaTayeyNUpLpLéevov / a S \ Yj Te éyovons, ToD EVNOV @aat TO aKpov, emt 4é / / Odtepa KatavayKxalew, vroTiOévtTa paOaKka Tiva 4 TUMLMLET PA. / \ , nr XXXIX. Olow oatéov ao vrepwons amHre, / iv ¢ e\ f € \ , péon ifer pls TovToowv. of O€ PrAwpeEVvoL KeE- \ / ry 3 , By paras avev ENKEOS, y) TETOVTOS 1) kat d&aytos y] TLETAVTOS, TOUT@D €VioLol TA Opimea EpXeTae ato Kepaniys KATA Tas papuyyas, cal amo TPOLATOS ev TH kepanr} Kal és TO Trap Kal €s Tov pnpov. XL. Snpeta Tapadrr\$aymaTov Kal éxTT@pda- ¢ « Yh fal \ Tov’ Kali Kal O7ws Kal dcov diadéper TAVTA TpPOS ” a . \ ® € / , \ a adrAnra’ Kal Ololy KOTVAN TrAapEayEe, KaL olot veupiov atrecTiaOn, Kai oloe éripuats atréaye, \ \ id Ne x / e f > / 5 > \ Kal olot Kal ws, Kal Ev 7 SUO, MY SVO éoTtiv" él , / TOUTOLOL KIVOUVOL, EATTLOES Olalt KaKal, Kal OTE , , , Kaxwotes Oavatou, vyteins, acpanretins. Kal a bd / XN Ld N Over ATA XN XX & wv, euBrnTéa 7) KXetpiatéa Kal OTE, Kal A ov 1% OTE Ov , , e : éml tovtorow édmides, KivouvoL ola Kal OTE XEL- fol » \ piatéa, kal Ta ex yevens EEapOpa, Ta avEavopmeva, Ta v&npeva, KaL O TL Oaccov, Kal 0 Tl Bpadure- pov, Kal O TL NOOV, Kal os Kal ov’ Kal bio Tu Kat 0 Te puvdijcet, Kal 7 Kal ws Kal olaw haocov Kal OTL Ta KaTayevTa Qaacov kal Bpadvtepov A , puopeva, 7 al diac tpopat Kal TIT WPOLES a té , ylvovTal, Kal akn TOUT@V. olow EdXKEa aUTIKa
1 This is condensed from J. XLVII and LXXYV, on pressing down a hump by bringing a plank across it, one end being in a groove in a post or wall. The translation makes the epitomiser say this; but in the Greek he seems to confuse the plank with the ambé, which had a sort of excavation at its end. Littré omits 4) and the first 7d &Kpov.
442
INSTRUMENTS OF REDUCTION, xxxvu—xt,
rather loose will serve as a lever. Use of the plank : one should push it in at one end; the end should occupy an excavation in a post or in a wall;* press down at the other end, putting some suitable soft substance underneath.
XXXIX. In cases where a bone comes away from the roof of the mouth, the nose falls in in the middle.2 Patients with contused heads without a wound, due to a fall, fracture, or compression ; some of them have a flow of acrid humour from the head down to the fauces, and from the lesion in the head to both liver and thigh.®
XL. Symptoms of subluxations and dislocations : their difference from one another in position, nature, and extent, where the socket is fractured, where a small ligament is torn away, where the epiphysis is broken off. In what cases and how either one or two bones (are broken), when there are two ; dangers and expectations in these cases; in which cases they are bad, and when injuries are mortal, or when there is more hope of recovery. Also what cases are to be reduced or treated surgically, and when, and which not, and when not; the expectations and dangers in these cases. In what cases and at what time one should treat congenital dislocations or those occurring during and after adolescence. Which case is quicker and which slower to recover where a patient is (permanently) lame, and how, and when not; and why, and in what cases, there is atrophy ; on which side, and how, and the cases in which it is less; and that fractured bones are quicker or slower to consolidate, where distortions and accumu- lation of callus occur, and the cure for these. Cases
2 pid. IV. 1.9, VIL. & 8 Epid. II. 5. 4. 443
10
20
MOXAIKON
BoTtepov yivovrae’ oiot Kal datéa KaTaryetoe petw, olay ov’ vice KATAYEVT A éféoxev, Kal 7 éEioyvet waddov' oiow éxBdvta. 9p 1) apOpa eEloxua aratavrat cal dv a ev olow opaaty, év olow dvavoedvTat, appl Ta TAaOnpata, aul Ta Oepa- TevwaTa.
XLI. Nopovoe TOLoL vouiporcr TeEpl emedéotos” TApacKevy, mapetts, KaTATAGLS, OopOwars, ava- Tpuves, érideots, avaryyrs, Oéaus, OX TMA, Xpo- vol, dlavTa. Ta Nauvorara TAXLTTA pueras, Ta dé évaytia, evavTios® Siac tpodat, 7 «KUpTOL doapKou, dveupot. TO eumer ov @S Tpocwrarw® i) To exTreg Ov éoTae 70d Xeptov ov eémecen vevpov, ra poev év Kejoey Kal ev mado, emr- Sorta’ Ta O€ 11), ooo’ dpiarov a) ay EKTETN, el é€u7réoot Taxtora™ TupeTaivovTe 77) eu Bar- Aew, pnde TeTapraia, memTrata, ieeora ayKava. Kat Ta vapro@ved mavra, OS TaXLo Te apiora, H THY prey povyy Tapera, Ta ATO T@MEVA, ) vedpa 1) Xovdpia 7) éeripvares, 1) Stiotdeva KaTA cupupusias, advvata omouwd rae diaTrwpovTar TAX EWS Toto MELT TOLOLY™ 7” be Xphees ombverar, éxBavrov, Ta éxara, paov Ta paota éxtecovta aor prcypaiver’ Ta O€ iewora Geppaivovta, Kal py emepaTevO evra, padora avdts ex Ti -
@
TTEL. KATATELVELD ev TX MATL TOLOUTO, év @
1 @ amatavrat Kw. 2 ExaoTaTw.
3 Obscure; seems to be taken from J. IX. 41Cf. JP LX XIX
1 Apparently ‘‘intervals” between changes of dressing and the like.
444
INSTRUMENTS OF REDUCTION, xu.-xut
where wounds occur at once or later; where the fractured bones are shortened, and where they are not. In what cases fractured bones project, and at what part they chiefly do this. The confusion between dislocations and prominent joints, causes of deception in what men see, and conjecture concerning maladies and treatments.
XLI. Recognised usages as regards bandaging: preparation, presentation, extension, adjustment, friction, bandaging, suspension, putting up, attitude, periods, diets. The most spongy bones consolidate quickest, and vice versa; distortions on the side towards which they curve; atrophy of fiesh and sinews. The reduced bone shall be (kept) as far as possible from the place where it was dislocated.” Of ligaments, those in mobile and moist parts are yielding ; those which are not are less so. Wherever a dislocation may be, prompt reduction is best. Do not reduce when a patient has fever, or on the fourth or fifth days, least of all in an elbow case. All cases with loss of sensation, the quicker the better; or wait till inflammation has subsided. Parts torn away : ligaments, cartilages, epiphyses or separa- tions at symphyses cannot be made the same as before; in most cases there is rapid ankylosis, but the use of the limb is preserved. Of dislocated joints, the most distal are the more easily (put out ?);* those most easily put out suffer least in- flammation ; but where there is least heat and no after-treatment, there is greatest liability to another dislocation. Make extension in such a posture that
2 “Force used in reduction to be applied at as great a distance as possible” (Adams). 3 Or ‘‘treated” ; but it seems best to follow the context.
445
30
10
MOXAIKON
bddoTa UTEpalwmpynOycetal, TKETTOMEVOY es THY puow Kal TOV TOTov 7 €&€Bn. d10pOwors* éTiaw és 6pOov Kal és maryeov mapodeiv Ta dé Taxes dvtigmdcavra avTLOT aT aL TAX EWS 1) 67 é ex Trepiaryoryys” Ta O€ TrELTTAKLS exTrimTOvTa pgov cperimrel’ aitvov vevats 7 vevpov OOTEWD. vevpov bev LHKOS 7) erridoats* oo Téwy dé, KoTUANS opmadorns, Kepanrigs paraxporns® TO €005 TpiBov mot aitin kal oxéows Kal &Eis Kal 7)ALKin. TO uTouvEov addéypavtov.
XLII. Oicw &\xea éyéveto, ) adtixa } daTéwv evo YovT@r, 1) ErEetta, 7) KYNTMOV 7) TENXVTMOY, TavTa pev iv aid0h, evOdws AVcas, TLcaNpHDY €ml TO Edxos emlets, €TLOElY wS ETL TO Edxos T™pa@rov THD apxny Bardopevos, Kal Tada @S ou TAUT) Tov oiveos eovTOS" otro yap avTo Te loxvoratov Kal éxmunoet TaXLoTa Kal Teptp- pnterar, Kal Kabapbevra TaxLoTa pucetar. vdp- Onxas be pajre Kar avo TOUTO ™ poo ayer pynte mele" Kal @v ootéa pr peydd\a arelow, wv 6e peyaha, oUT@ TroLety:) TONNI} yap epTrunors Kal TAUT OUK ETL odTws, arn aveypuKTar TOV Uroatacioy elvenad. TO 6é Towaira oTroaa éfe- ove, Kalb el te €uBrNOH ev TE pn, erridects perv ovK émitndecov, Sidtacts 5€. aohaipat ton- Ocicar olar médats, 7) perv Tapa odupov, 4 Oé
1 Littré joins oftw moeiy to &reiw and adds ov after peydAa, de suo: &meow woattws* Gv de weydda SjAov, Kw. M.
1 Second # perhaps added for sake of symmetry ; thereare only two classes of wounds, ‘‘ immediate” and ‘‘later.”
2 Adopting Kw.’s reading, which has some support from the MSS.
440
INSTRUMENTS OF REDUCTION, xi1—xuit.
the (dislocated bone) will be best lifted above (the socket), having regard to its conformation and the place where it is dislocated. Adjustment: push backwards, either straight or obliquely ; where there has been a rapid twist, make a rapid twist (back- wards), or at any rate by circumduction. Often repeated dislocations are more easily reduced ; they are due to the disposition of the ligaments or bones— in the former, to Jength or yielding character; in the latter, to flatness of the socket and rounded shape of the head. Use makes a friction-joint ; it depends on the state of the patient, his constitution and age. Rather mucous tissue does not get inflamed.
XLII. In cases where wounds occur either at once, with projection of the bones,' or afterwards, from irritation or roughnesses, when you recognise these latter, at once remove the dressing, and apply pitch cerate to the wound. Bandage, putting the beginning of the roll first on the wound, and the rest as though there were no lesion there, for so there will be least swelling at the part; suppuration and separation will be most prompt, and the cleansed parts heal up most rapidly. As to splints, do not apply them to this part, and do not make pressure. This treatment applies to cases where small pieces of bone come away; when large it is clear? (what to do), for there is much pus formation, and this treatment is no longer suitable, but the wound is left open because of the accumulations. But in all such cases as have bones projecting, whether they are reduced or not, bandaging is not suit- able; what is required is stretching. Rounds are made like fetters, one at the ankle, the other
447
MOXAIKON
mapa youu, és KV} NV mraTelal, Tpoonvess, ioxupai, KpiKoUs EXovoar paoor TE TULpeTpoL Kpavins Kal [eiKos Kal TAYOS, WATE Sareivew 20 iuavtia 5€ &€& axpwv apdhotépwbey éyovta és Tovs Kpikous évdedécbar, ws Ta Akpa és Tas odatpas evo Tnpicojeva dvavayxaty. inow 66, mronpn Peppy” oXmaTa. Kal Todos béas Kal iaxiou" Siaira ATPEKNS. eu Baddew Ta OoTéa Ta Umeptaxovta avOnpepa 7) devtepaia TeTap- taia 5é 7 meuT Tala, 1), ANN’ emmy ioXva H. 1) 6€ €uBorn Tolar moxALtKolatv* %) TO éBarropevov TOD dotéov, Hv py eXn atoortnpiEw, aToTpicar TOV KwWUVOVT@Y’ aTap Kal a TA WihwbévTa aTro- 30 weceitat, Kal BpayvTepa Ta médEQ.
XLIIIY Ta ‘dé apOpa, Ta pev Wréov, Ta O€ jeetov ohio Odver’ Kal Ta pev Hetov eu Pddrew pacsov Ta O€ pétous Moves Tas KaK@olas Kal baTéwy Kal veupov Kal apO pov Kal TapKav Kal oXnuatov. pnpos dé xal Bpaxiwy oportata
6 €xmlTTOVCLD.
1 monph Sepup.
448
INSTRUMENTS OF REDUCTION, xiu.—xum1.
at the knee, flattened on the leg side, soft and strong, provided with rings; rods of cornel-wood, suitable in length and thickness, to keep the limb stretched ; leather thongs adapted at each end to the extremities (of the rods) are fastened to the rings, so that the ends of the rods, being fixed to the rounds, make extension both ways. Treatment: warm pitch cerate, attitude, position of foot and hip, strict diet. Reduce projecting bones on the first or second day, not on the fourth or fifth, but when swelling has gone down. The reduction with small levers: if the fragment to be reduced does not afford a fulcrum, saw off what is in the way. For the rest, shortening of the limbs is proportional to the denuded bone which comes away.
XLIII. Joints are dislocated, some to a greater, some to a less extent; and the less are easy to reduce, but the greater produce more serious lesions of bones, ligaments, joints, flesh, and attitudes. The thigh and upper arm are very similar in their manner of dislocation.*
1 Je. completely, or not at all. See J. LXI.
449 VOL. Tl. HIPP Q
OUR OTE TO. i gly gt a taerlate comms babusob Sid od
Lance ee
a |. : - nar 0%
v ’ —e py) ee) No lake
APPENDIX NOTES ON JOINTS LXXX
We have seen that, according to Galen, Chapter LX XVIII is the #oratos Adyos, or ‘‘ final discourse,” of Joints. His commentary ends rather abruptly in the middle of it, but he has already intimated that he is not going to say much, and he can hardly have gone beyond, though some manuscripts contain the rest of the Hippocratic treatise. Of this appendix the most interesting part is Chapter LAX X. It looks like, and has always been considered, the original Hippocratic account of finger-joint dislocation, which somehow got dis- placed and replaced by the very poor substitute, Chapter XXIX, identical with Mochlicon XIX.
But there are difficulties in this view. No ancient writer, till we get back to Diocles, early in the fourth century B.c., seems aware of its existence. Galen excludes it from Joints, but had he known that Hippocrates anywhere mentioned ‘‘ lizards” as surgical instruments he would surely not have left them to puzzle succeeding generations till Diels happened to visit a toy shop. He would have explained it in his Hippocratic Glossary. Even Erotian, who tells us twice over that ceipd in Hippocrates means ivds (strap), would hardly have left cadpa unexplained. The analogous but less peculiar use of t’pous (Joints XLIII) is explained twice over both by Erotian and Galen.
Apollonius obviously knew nothing about it. He apolo- gises for the poverty of XXIX, and supplements it by an extract from Diocles, but seems quite unaware that this extract is an abbreviation of the genuine Hippocratic account. Apollonius was the chief Alexandrian surgeon of his day (first century B.c.), so we may safely conclude that the chapter was not in the Alexandrian edition of Hippocrates.
45!
APPENDIX
One would hardly add a poor account of a matter to a treatise which already contained a good one; it is therefore improbable that Joints contained Chapter LX XX when it got separated from Fractures, and had its more glaring omissions made up by insertions from Mochlicon. We thus get back to the author of Mochlicon. Did he abbreviate his Chapter XIX (XXIX J.) from LXXX? Able editors such as Littré, Adams, Petrequin say he did. I venture to think that the reader will find no evidence of this, but will discover without much trouble that XXIX is practically made up of stock phrases taken from the three previous chapters, one of them (‘the flesh wastes chiefly on the side opposite to the dis- location”) being dragged in rather absurdly. Unusual words, etonpov avrweiy Exrtwma erimwpovtat, are all absent from LXXX, but have been just used or seen by the epi- tomist (ém:mwpotta: F. XX XVIII which he has just abridged), while the peculiar words and expressions of LX XX are all absent.
Coming to the Diocles quotation we find a great contrast. The correspondence of words and phrases is so close, that, though the hand is looked at from a different position, it seems almost certain that the two passages are connected. The natural view is that Diocles is copying Hippocrates, and this seems confirmed by Galen’s assertion that he para- phrased other parts of Joints. On the other side there is the ignorance of Apollonius; the difficulty in believing that Chapter LXXX could have been so entirely lost and so entirely recovered after many centuries, and another fact which perhaps turns the balance against the accepted theory. Besides cavp2 the writer uses another word in a peculiar sense, xaépa = ‘‘joint socket.” This occurs no less than six times in the two chapters LXXIX-LXXX, which is strong evidence that they are by the same author, and against the view that he is identical with the author of Fractures-Joints ; for though the old writer uses xépa} occa- sionally, it always has its natural sense of ‘‘ place,” whereas in LXXIX-LXXX the ‘‘natural” and sometimes necessary sense is ‘‘socket.” The remaining Chapter (LXXXI) is made up largely of passages taken from the two previous
1 Usually with éwvrod, cf. FIX, XIV. In J. LXXIX- LXXX this word is omitted in all six cases.
452
APPENDIX
ones, with the highly un-Hippocratic addition that all dis- location patients should be starved for seven days(!). Even if we soften this down by inserting «al (‘‘even for seven days”) as do some manuscripts, it is still inconsistent with the rules given by the author of Fractwres-Joints. We conclude there- fore that these three chapters are probably a late addition, Perhaps a surgeon who had read the apology and supplement of Apollonius, and believed, as we do, that the latter is really taken from Hippocrates, thought it no forgery to try to rewrite the latter in an expanded form and in Hippo- cratic style. While he was about it, he might also wish to remedy another defect in Joints, which, as he justly observes, should first tell us what joints are. He therefore composed Chapters LXXIX-LXXX and probably LXXXI which became firmly attached to the end of the treatise.
THE DIOCLES SUPPLEMENT TO XXIX
AaxtbrAov uty &pOpov By Te wodds tv Te xXeipds exméoy, TE- tpaxas éxmlmret, } evtds h exrds 7) cis Ta TAdyia. Saws 0 bv exméon, padiov yvavat pis Td dudvuuoy cal Td byes OewpovyTa. eubdrdAew 5& Karatelvovtra evOy amd xelpav, TepieAitas De dmws uh eodicOdvy. aoreiov de Kal ras cavpas, &s of maides mACKOUTI, mepidevta wep) uxpov toy Sdxrvadoyv Katatelvew, éx 5& tod em Odrepa Tats xepaly.
A joint either of a toe or finger may be put out. It is put out in four ways, inwards, outwards, or to the sides. The way it is put out is easy to distinguish by comparing it with the sound and corresponding joint. Put it in by making extension in a straight line with the hands, but wrap a band round it that it may not slip away. It is also ingenious to put the lizards, which children plait, round the end of the finger and make extension, pulling in the opposite direction with the hands.
THE HIPPOCRATIC BENCH
Though we have three complete accounts of the Hippo- eratic Bench, by ‘‘ Hippocrates,” + Rufus (or Heliodorus),*
Joints LX XII-LX XIII. 2 Oribasius XLIX. 26 ff. 453
APPENDIX
and Paulus Ajgineta?! respectively, attempts at restoration have been unfortunate. ‘Till the time of Littré they were based on that of Vidus Vidius (1544), who read pixpas for pakpds in Joints LX XII and produced a bench with a row of square holes down the middle. He represented the perineal peg as angular and pointed, and made the corner supports so high that the patient would be lifted as well as stretched.
Littré pointed out that the «dwero: were long grooves parallel to one another. He also reduced the height of the corner posts, and was on the point of making them project horizontally lengthways, so sunk into the bench that the axles would come below its surface.2 This view, which seems admitted as an alternative in Joints XLVII, is still supported by Schone.
On the whole, however, Littré’s figure, including the un- comfortable form of perineal peg which he retained, is still generally accepted: but there are serious doubts as to the intermediate supports. Littré like his predecessors repre- sented them as fixtures at the sides of the bench, though Scultetus had suggested that they were movable, a view adopted by Petrequin, who, however, still keeps them well to the sides. The chief object of this note is to suggest that they were not only movable, but were inserted when required into the grooves not more than a foot apart.
Paulus in his renovated text is clear as to the first point.* “¢ As a last resort in internal dislocation of the thigh, let the perineal peg be removed and let two other pieces of wood be inserted on either side of its position ”—eé« mAayiou Tis TovTOU Oécews Exatépwhev erepa Svo EvAa memnxXOw. This seems in- tended for a paraphrase of the Hippocratic cata méoov Kat ex maaylwy,4 for kata wéoov has just been used to describe the position of the peg. A cross-piece is then inserted “so that the shape of the three resembles the letter pi (M), or eta (H) if the cross-piece is a little below the top. Then, with the patient lying on his sound side, we may bring (ayaywuer) the sound leg between these supports.”
In Rufus the apparatus is apparently in one piece, a pi-shaped prop.® It is noticed first merely as ‘‘ another
1 VI. 118. 2 1V. 46. Se Vile S so: 4 EX TE. 5 qioctd)s pAid.
454
THe Hriprocratic BENCH OR SCAMNUM
i. According to Vidius. 1544
ii. According to Littré. 1844
ie DCU DI Eg renee A. Plank. BB. Corner Supports. C. Axle. DD. Grooves. Kf. Perineal Peg. I’. Intermediate Supports. G. Crossbar.
To face p. ADA.
or » - - i) ' /
APPENDIX
central contrivance besides the perineal peg.” ! In describing the use of the bench for thigh dislocation he adds that it was especially contrived for the internal form ; ‘‘ the perineal peg is taken out, the patient laid on his sound side, and the sound leg is arranged (té0cera) under the prop.” It isalso called a awiyua or framework, and perhaps could stand on the bench wivnout being inserted. Anyhow, it can hardly have been a fixture occupying the breadth of the bench, for it would then not have been very pi-shaped, would have been in the way on all other occasions, and the patient could not lie on the bench without having his legs beneath it.
This fact seems alone sufficient to prove our points—that the props were not only movable, but, when inserted, were so close as just to admit one leg.
The terms used by Hippocrates are the strongest of the three, whether we read d:€pca: ueonyd (‘‘ insert between”), a term just employed for inserting an arm between the thighs,? or épeioese peony (‘‘ press between”), as read by Apollonius. Even the mildest of the expressions used for bringing the sound leg between the props would surely be absurd if they were so far apart that the patient could not lie on the bench without having it there already !
This view enables us to give wod:alas* its natural meaning : the supports were ‘‘a foot long” in order to stand firmly in the grooves. So, too, the wooden cross-bar, instead of being three feet long and expected to resist immense pressure at its middle, was only about a foot in length and the pressure distributed throughout.
The illustrations of Apollonius are disappointing ; the one thing we learn from them is that the groovessometimes went the whole length of the bench. The wheel and axle arrange- ments at the ends are apparently separate from it, and there is no trace of any intermediate supports, though the perineal peg is represented. The Wellman Museum of Medical History contains an interesting example of the Vidian restoration, though the supports had been cut down when it was discovered.
1 Spamonds. 2 DXKI, Oni i-0. 4000
455
ae ono dicshe
orld to deoyacria old ois axtorooggii ed Bi a m9eniad byogiet **) togyrnan, ana. sat aw is * sdgidt ads asswied nrie ae pdiiseant 19 aninollogA yd baat a& {“ noswdodt aon ad? gettyiixd vol beat acoineriqas out youd Hi hinede.ad glonva: blew ota a arty
Hopod ada so oil Jost Dilires bn d oe
: spain agen fertun si, eer, oui Zirh ee al vot: Btalaot tebrio at” yuol toot a sea ‘ats yitiad Io Beotent “reel-enord staboow aild oot (ot 1 tgs miberasin ge imeruid deiess oF hodsegxe Baw 3 hes Haart’
woresig ads has dtyaet at soot a diode. us sas tecdeoa
Asal
ado old; gaidimionqeaih ote auitvollogh to paiva: Jnew eeniientog asvooty adh. dad) eb cred) nto ais vagtens alxe bia loodir edt donad-ont to dignats qisd! his dt ctont stetsqos Yann. one abet. {noaiaag odd dauodd eoqqra stuihsarsial you.
les nihalt to ssa M ssolleW ed? che yeibiY odt to alormexs . giridesrodith ha ‘anipd wed? nwob duo teed bad etsoqque sdb bartints
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Tacitus: Histories AND AnnAts. C. H. Moore and J. Jackson. 4 Vols.
TERENCE. John Sargeaunt. 2 Vols.
TERTULLIAN: APOLOGIA AND De Specracutis. T. R. Glover; Minucius Freurx. G. H. Rendall.
VaLeRius Fracous. J. H. Mozley.
Varro: Dr Linaua Latina. R.G. Kent. 2 Vols.
VELLEIUS PateRcuLUS and Res GEstTAE Divi AuGUSTI. F. W. Shipley.
Vireit. H.R. Fairclough. 2 Vols.
Vitruvius: Dre ArcuirEctuRA. F. Granger 2 Vols.
GREEK AUTHORS
ACHILLES Tatius. S. Gaselee.
AELIAN: ON THE NATURE oF AnrMALsS. 3 Vols. Vols. I. II. and III, A. F. Scholfield.
AENEAS Tacitus, ASCLEPIODOTUS AND ONASANDER. The Illinois Greek Club.
AESCHINES. C. D. Adams.
Axrscuytus. H. Weir Smyth. 2 Vols.
ALCIPHRON, AELIAN AND PHILOSTRATUS: LETTERS. A. R. Benner and F. H. Fobes.
ApoLttoporus. Sir James G. Frazer. 2 Vols.
APOLLONIUS RuHoptus. R. C. Seaton.
Tue Apostotic FatHEerRS. Kirsopp Lake. 2 Vols.
Apptian’s Roman History. Horace White. 4 Vols.
Aratus. Cf. CALLIMACHUS.
ARISTOPHANES. Benjamin Bickley Rogers. 3 Vols. Verse trans.
AristotLE: Art or Ruetoric. J. H. Freese.
ARISTOTLE: ATHENIAN CONSTITUTION, HUDEMIAN ETHICs, VirRTUES AND Vices. H. Rackham.
ARISTOTLE: GENERATION oF ANIMALS. A. L. Peck.
ARISTOTLE: Mretapuysics. H. Tredennick. 2 Vols.
ARIstoTLE: Mrtrroronoaica. H. D. P. Lee.
ARISTOTLE: Mrnor Works. W.S. Hett. ““On Colours”’, “On Things Heard”, ‘“‘Physiognomics’’, “On Plants’, “On Marvellous Things Heard’’, ‘Mechanical Problems’’, “On Indivisible Lines”, “‘Situations and Names of Winds”, “On Melissus, Xenophanes, and Gorgias’.
ARISTOTLE: NICOMACHEAN ErHics. H. Rackham.
4
THE LOEB CLASSICAL LIBRARY
ARISTOTLE: OkrcoNomica and Magna Moratia. G. C. Armstrong. (With Metaphysics, Vol. II.)
ARISTOTLE: ON THE HEAVENS. W. K. C. Guthrie.
ARISTOTLE: ON THE SOUL, Parva NATURALIA, ON BREATH. W.S. Hett.
ARISTOTLE: ORGANON—CATEGORIES, ON INTERPRETA- TION, Priork ANaAtytTics. H. P. Cooke and H. Tredennick.
ARISTOTLE: ORGANON—PosTERIOR ANALYTICS, TOPICS. H. Tredennick and E. S. Forster.
ARISTOTLE: ORGANON—ON SOpHISTICAL REFUTATIONS, On COMING TO BE AND Passtna Away, ON THE Cosmos. E. 8. Forster and D. J. Furley.
ARISTOTLE: Parts or Antmats. A. L. Peck; Motion AND PROGRESSION OF Anrmats. E. S. Forster.
ARISTOTLE: Puysics. Rev. P. Wicksteed and F M. Cornford. 2 Vols.
ARISTOTLE: PortTics and Loneinus. W. Hamilton Fyfe; DEMETRIUS ON STYLE. W. Rhys Roberts.
ARISTOTLE: Poxrtics. H. Rackham.
ARISTOTLE: PrRoBLEMS. W.S. Hett. 2 Vols.
ARISTOTLE: RHETORICA AD ALEXANDRUM. H. Rackham. (With Problems. Vol. IT.)
ARRIAN: History oF ALEXANDER AND INDICA. Rev. E. Tliffe Robson. 2 Vols.
ATHENAEUS: DEIPNOSOPHISTAE. OC. B. Gulick. 7 Vols.
St. Bastz: Lerrers. R. J. Deferrari. 4 Vols.
CaLLimacHus: Fracments. C. A. Trypanis.
CALLIMACHUS and LycorpHron. A. W. Mair; ARaTUS. G. R. Mair.
CLEMENT OF ALEXANDRIA. Rev. G. W. Butterworth.
Cottutuus. Cf. OPPIAN.
DaruHNis AND CHLOE. Cf. Loncus.
DrMOsSTHENES I: OLYNTHIACS, PHILIPPICS AND MINOR Orations. I.-XVII. and XX. J. H. Vince.
DEMOSTHENES II: Dr Corona and Dr FALsA LEGATIONE. C. A. Vince and J. H. Vince.
DrMOSTHENES III: Mrrpras, ANDROTION, ARISTOCRATES, TIMOCRATES, ARISTOGEITON. J. H. Vince.
DemostHrnes IV-VI: Private ORATIONS AND IN NeaErAm. A. T. Murray.
DremostHENFsS VII: FunrerAL Sprrcu, Eroric Essay, Exorpia AND LetTrERS. N. W. and N. J. DeWitt.
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THE LOEB CLASSICAL LIBRARY
Dio Cassius: Roman History. E.Cary. 9 Vols.
Dio Curysostom. J. W. Cohoon and H. Lamar Crosby. 5 Vols.
Dioporvus Sr1cutus. 12 Vols. Vols. I.-VI. C. H. Oldfather. Vol. VII. C. L. Sherman. Vols. IX. and X. R. M. Geer. Vol. XI. F. Walton.
DiocEnes LaErtTIus. R. D. Hicks. 2 Vols
Dionysius oF HanicARNASSUS: ROMAN ANTIQUITIES. Spelman’s translation revised by E. Cary. 7 Vols.
Erictetus. W. A. Oldfather. 2 Vols.
Euripipes. A. 8. Way. 4 Vols. Verse trans.
Evsesius: Ecciesiasticat History. Kirsopp Lake and J. BH. L. Oulton. 2 Vols.
GaLEN: On THE NATURAL Facuttizs. A. J. Brock.
Tur Greek AntHotocy. W.R. Paton. 5 Vols.
THE Greek Buco.ic Ports (THEOcRITUS, Bion, MoscuHus). J. M. Edmonds.
GREEK ELEGY AND IAMBUS WITH THE ANACREONTEA. J. M. Edmonds. 2 Vols.
GrEEK MatHEMATICAL Works. Ivor Thomas. 2 Vols.
Heropes. Cf. THEOPHRASTUS: CHARACTERS.
Heroporus. A.D. Godley. 4 Vols.
HesiopD AND THE Homeric Hymns. H. G. Evelyn White.
Hrprocratss and the FRAGMENTS OF HERACLEITUS. W. H. S. Jones and E. T. Withington. 4 Vols.
Homer: Intap. A. T: Murray. 2 Vols.
Homer: Opyssrey. A. T. Murray. 2 Vols.
Isanus. E. S. Forster.
TsooratTEs. George Norlin and LaRue Van Hook. 3 Vols.
St. JoHN DAMASCENE: BARLAAM AND IoOASAPH. Rev. G. R. Woodward and Harold Mattingly.
JosEpuus. H. St. J. Thackeray and Ralph Marcus. 9 Vols. Vols. I.-VII.
Jutian. Wilmer Cave Wright. 3 Vols.
Loneus: DapHnis AND CHLOE. Thornley’s translation revised by J. M. Edmonds; and ParrHentvs. 8S. Gaselee.
Lucran. Vols. 1I.-V. A.M.Harmon; Vol. VI. K. Kilburn. Vol. VII, M. D. Macleod. 8 Vols.
LycopHRON. Cf. CALLIMACHUS.
Lyra GraEca. J. M. Edmonds. Vols.
Lysras. W. R. M. Lamb.
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THE LOEB CLASSICAL LIBRARY
Manetruo. W. G. Waddell: Protemy: TETRABIBLOS. F. E. Robbins.
Marcus Auretius. C. R. Haines.
MENANDER. F. G. Allinson.
Minor Artic Orators. K. J. Maidment and J. O. Burtt. 2 Vols.
Nonnos: Dionystaca. W.H.D. Rouse. 3 Vols.
Oprian, CoLLutHuUS, TRyPHIoDORUS. A. W. Mair.
Papyri. 5 Vols. Non-Liverary SELECTIONS. A. 8. Hunt and C. C. Edgar. 2 Vols. Lirmrary SeLections Vol. I. (Poetry). D. L. Page.
ParTHENIvus. Cf. Lonaus.
PavuSsANIvus: DESCRIPTION OF GREECE. W.H.S. Jones. 5 Vols. and Companion Vol. arranged by R. E. Wycherley.
Puito. 10 Vols. Vols. I.-V. F. H. Colson and Rev. G. H. Whitaker; Vols. VI.-IX. F. H. Colson.
Puno. 2 supplementary Vols. (Translation only.) Vols. f. and II. R. Marcus.
Puiwostratus: THE Lire or APoLLonius or TYANA. F.C. Coneybeare. 2 Vols.
PuHILOsTRATUS: IMAGINES; CALLISTRATUS: DESCRIPTIONS. A. Fairbanks.
PuitostratTus and Eunapius: Lives or THE SOPHISTS. Wilmer Cave Wright.
Pinpar. Sir J. E. Sandys.
Prato: CHARMIDES, ALcIBIADES, Hipparcuus, THE Lovers, THEAGES, Mrnos and Eprnomts. W. R. M. Lamb.
Prato: CRATYLUS, PARMENIDES, GREATER HIPPIAS, Lesser Hippras. H. N. Fowler.
Piaro: Euruypxro, Apotoay, Criro, PHAEDO, PHAED- rus. H.N. Fowler.
Prato: Lacwres, Proracoras, Meno, EuraypEmMus. W. R. M. Lamb.
Puato: Laws. Rev. R. G. Bury. 2 Vols.
Prato: Lysis, Sympostum, Goreras. W. R. M. Lamb.
Prato: Rerusiic. Paul Shorey. 2 Vols.
Prato: StTaresMAN, Puitesus. H. N. Fowler; Ion. W. R. M. Lamb.
Prato: THEAETETUS AND Sopuist. H. N. Fowler.
Prato: Timaxnus, Crirras, CLriropHo, MENEXENUS, EPIs- TULAE. Rev. R. G. Bury.
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THE LOEB CLASSICAL LIBRARY
Prurarcn: Moraria. 14 Vols. Vols. I.-V. F. C. Babbitt; Vol. VI. W. C. Helmbold; Vol. VII. P. H. De Lacy and B. Einarson; Vol. 1X. E. L. Minar, Jr., F. H. Sandbach, W.C. Helmbold; Vol. X. H. N. Fowler; Vol. XII. H. Cherniss and W. C. Helmbold.
PLuTARCH: THE PARALLEL Lives. B. Perrin. 11 Vols.
Potysius. W.R. Paton. 6 Vols.
Procopius: History or THE Wars. H.B.Dewing. 7 Vols.
ProLtemy: TETRABIBLOS. Cf. MANETHO.
QuinTUS SMyRNAEUS. A. 8S. Way. Verse trans.
SExTus Empiricus. Rev. R. G. Bury. 4 Vols.
SopHocLes. F. Storr. 2 Vols. Verse trans.
StrRABO: Geography. Horace L. Jones. 8 Vols.
THEOPHRASTUS: CHARACTERS. J. M. Edmonds. Hrropes, ete. A. D. Knox.
THEOPHRASTUS: ENQUIRY INTO PLants. Sir Arthur Hort. 2 Vols.
Tuucypiprs. C. F. Smith. 4 Vols.
TryPHIODORUS. Cf. OPPIAN.
XENOPHON: CYROPAEDIA. Walter Milia. 2 Vols.
XENOPHON: HELLENICA, ANABASIS, APOLOGY, and Sym- posium. C. L. Brownson and O. J. Todd. 3 Vols.
XENOPHON: MEMORABILIA and OErconomicus. I. Marchant.
XENOPHON: Scripta Minora. EE. C. Marchant.
VOLUMES IN PREPARATION
GREEK AUTHORS
ARISTOTLE: History oF ANIMALS. A. L. Peck. Piotinus. A. H. Armstrong.
LATIN AUTHORS
St. AUGUSTINE: CITY OF Gop. BaBprivs AND PHAEDRUS. B. E. Perry.
DESCRIPTIVE PROSPECTUS ON APPLICATION
LONDON WILLIAM HEINEMANN LTD. CAMBRIDGE, MASS. HARVARD UNIVERSITY PRESS
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