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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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