on fractures-第7章

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which　require　great　force。　Wherefore；　reduction　with　the　lever　is
not　to　be　despised；　for　the　bones　will　be　reduced　in　this　way；　or
not　at　all。　But　if　the　upper　fragment　which　rides　over　the　other
does　not　furnish　a　suitable　point　of　support　a　suitable　point　of
support　for　the　lever；　but　the　protruding　part　is　sharp；　you　must
scoop　out　of　the　bone　what　will　furnish　a　proper　place　for　the　lever
to　rest　on。　The　lever；　along　with　extension；　may　be　had　recourse　to　on
the　day　of　the　accident；　or　the　accident；　or　next　day；　but　by　no　means
on　the　third；　the　fourth；　and　the　fifth。　For　if　the　limb　is
disturbed　on　these　days；　and　yet　the　fractured　bones　not　reduced；
inflammation　will　be　excited；　and　this　no　less　if　they　are　reduced；
for　convulsions　are　more　apt　to　occur　if　reduction　take　place；　than　if
the　attempt　should　fail。　These　facts　should　be　well　known；　for　if
convulsions　should　come　on　when　reduction　is　effected；　there　effected；
there　is　little　hope　of　recovery；　but　it　is　of　use　to　displace　the
bones　again　if　this　can　be　done　with　out　trouble。　For　it　is　not　at　the
time　when　the　parts　are　in　a　particularly　relaxed　condition　that
convulsions　and　tetanus　are　apt　to　supervene；　but　when　they　are　more
than　usually　tense。　In　the　case　we　are　now　treating　of；　we　should
not　disturb　the　limb　on　the　aforesaid　days；　but　strive　to　keep　the
wound　as　free　from　inflammation　as　possible；　and　especially
encourage　suppuration　in　it。　But　when　seven　days　have　elapsed；　or
rather　more；　if　there　be　no　fever；　and　if　the　wound　be　not　inflamed；
then　there　will　be　less　to　prevent　an　attempt　at　reduction；　if　you
hope　to　succeed；　but　otherwise　you　need　not　take　and　give　trouble　in
vain。
　　32。　When　you　have　reduced　the　bones　to　their　place；　the　modes　of
treatment；　whether　you　expect　the　bones　to　exfoliate　or　not；　have　been
already　described。　All　those　cases　in　which　an　exfoliation　of　bone
is　expected；　should　be　treated　by　the　method　of　bandaging　with　cloths；
beginning　for　the　most　part　at　the　middle　of　the　bandage；　as　is　done
with　the　double…headed　bandage；　but　particular　attention　should　be
paid　to　the　shape　of　the　wound；　so　that　its　lips　may　gape　or　be
distorted　as　little　as　possible　under　the　bandage。　Sometimes　the　turns
of　the　bandage　have　to　be　made　to　the　right；　and　sometimes　to　the
left；　and　sometimes　a　double…headed　bandage　is　to　be　used。
　　33。　It　should　be　known　that　bones；　which　it　has　been　found
impossible　to　reduce；　as　well　as　those　which　are　wholly　denuded　of
flesh；　will　become　detached。　In　some　cases　the　upper　part　of　the
bone　is　laid　bare；　and　in　others　the　flesh　dies　all　around；　and；
from　a　sore　of　long　standing；　certain　of　the　bones　become　carious；　and
some　not；　some　more；　and　some　less；　and　in　some　the　small；　and　in
others　the　large　bones。　From　what　has　been　said　it　will　be　seen；
that　it　is　impossible　to　tell　in　one　word　when　the　bones　will
separate。　Some　come　away　more　quickly；　owing　to　their　smallness；　and
some　from　being　merely　fixed　at　the　point；　and　some；　from　pieces　not
separating；　but　merely　exfoliating；　become　dried　up　and　putrid；　and
besides；　different　modes　of　treatment　have　different　effects。　For
the　most　part；　the　bones　separate　most　quickly　in　those　cases　in　which
suppuration　takes　place　most　quickly；　and　when　new　flesh　is　most
quickly　formed；　and　is　particularly　sound；　for　the　flesh　which　grows
up　below　in　the　wound　generally　elevates　the　pieces　of　bone。　It　will
be　well　if　the　whole　circle　of　the　bone　separate　in　forty　days；　for　in
some　cases　it　is　protracted　to　sixty　days；　and　in　some　to　more；　for
the　more　porous　pieces　of　bone　separate　more　quickly；　but　the　more
solid　come　away　more　slowly；　but　the　other　smaller　splinters　in　much
less　time；　and　others　otherwise。　A　portion　of　bone　which　protrudes
should　be　sawn　off　for　the　following　reasons：　if　it　cannot　be　reduced；
and　if　it　appears　sons：　that　only　a　small　piece　is　required　in　order
that　it　may　get　back　into　its　place；　and　if　it　be　such　that　it　can
be　taken　out；　and　if　it　occasions　inconvenience　and　irritates　any　part
of　the　flesh；　and　prevents　the　limb　from　being　properly　laid；　and
if；　moreover；　it　be　denuded　of　flesh；　such　a　piece　of　bone　should　be
taken　off。　With　regard　to　the　others；　it　is　not　of　much　consequence
whether　they　be　sawed　off　or　not。　For　it　should　be　known　for
certain；　that　such　bones　as　are　completely　deprived　of　flesh；　and　have
become　dried；　all　separate　completely。　Those　which　are　about　to
exfollate　should　not　be　sawn　off。　Those　that　will　separate
completely　must　be　judged　of　from　the　symptoms　that　have　been　laid
down。
　　34。　Such　cases　are　to　be　treated　with　compresses　and　vinous
applications；　as　formerly　laid　down　regarding　bones　which　will
separate。　We　must　avoid　wetting　it　at　the　beginning　with　anything
cold；　for　there　is　danger　of　febrile　rigors；　and　also　of
convulsions；　for　convulsions　are　induced　by　cold　things；　and　also
sometimes　by　wounds。　It　is　proper　to　know　that　the　members　are
necessarily　shortened　in　those　cases　in　which　the　bones　have　been
broken；　and　have　healed　the　one　across　the　other；　and　in　those　cases
in　which　the　whole　circle　of　the　bone　has　become　detached。
　　35。　Those　cases　in　which　the　bone　of　the　thigh；　or　of　the　arm；
protrudes；　do　not　easily　recover。　For　the　bones　are　large；　and　contain
much　marrow；　and　many　important　nerves；　muscles；　and　veins　are　wounded
at　the　same　time。　And　if　you　reduce　them；　convulsions　usually
supervene；　and；　if　not　reduced；　acute　bilious　fevers　come　on；　with
singultus　and　mortification。　The　chances　of　recovery　are　not　fewer
in　those　cases　in　which　the　parts　have　not　been　reduced；　nor　any
attempts　made　at　reduction。　Still　more　recover　in　those　cases　in　which
the　lower；　than　those　in　which　the　upper　part　of　the　bone　protrudes；
and　some　will　recover　when　reduction　has　been　made；　but　very　rarely
indeed。　For　modes　of　treatment　and　peculiarity　of　constitution　make
a　great　difference　as　to　the　capability　of　enduring　such　an　injury。
And　it　makes　a　great　difference　if　the　bones　of　the　arm　and　of　the
thigh　protrude　to　the　inside；　for　there　are　many　and　important　vessels
situated　there；　some　of　which；　if　wounded；　will　prove　fatal；　there　are
such　also　on　the　outside；　but　of　less　importance。　In　wounds　of　this
sort；　then；　one　ought　not　to　be　ignorant　of　the　dangers；　and　should
prognosticate　them　in　due　time。　But　if　you　are　compelled　to　have
recourse　to　reduction；　and　hope　to　succeed；　and　if　the　bones　do　not
cross　one　another　much；　and　if　the　muscles　are　not　contracted　（for
they　usually　are　contracted）；　the　lever　in　such　cases　may　be
advantageously　employed。
　　36。　Having　effected　the　reduction；　you　must　give　an　emollient
draught　of　hellebore　the　same　day；　provided　it　has　been　reduced　on　the
day　of　the　accident；　but　otherwise　it　should　not　be　attempted。　The
wound　should　be　treated　with　the　same　things　as　are　used　in
fractures　of　the　bones　of　the　head；　and　nothing　cold　should　be
applied；　the　patient　should　be　restricted　from　food　altogether；　and　if
naturally　of　a　bilious　constitution；　he　should　have　for　a　diet　a
little　fragrant　oxyglyky　sprinkled　on　water；　but　if　he　is　not　bilious；
he　should　have　water　for　drink；　and　if　fever　of　the　continual　type
come　on；　he　is　to　be　confined　to　this　regimen　for　fourteen　days　at
least；　but　if　he　be　free　of　fever；　for　only　seven　days；　and　then　you
must　bring　him　back　by　degrees　to　a　common　diet。　To　those　cases　in
which　the　bones　have　not　been　reduced；　a　similar　course　of　medicine
should　be　administered；　along　with　the　same　treatment　of　the　sores　and
regimen；　and　in　like　manner　the　suspended　part　of　the　body　should
not　be　stretched；　but　should　rather　be　contracted；　so　as　to　relax
the　parts　about　the　wound。　The　separation　of　the　bones　is
protracted；　as　also　was　formerly　stated。　But　one　should　try　to
escape　from　such　cases；　provided　one　can　do　so　honourably；　for　the
hopes　of　recovery　are　small；　and　the　dangers　many；　and　if　the
physician　do　not　reduce　the　fractured　bones　he　will　be　looked　upon
as　upon　as　unskillful；　while　by　reducing　them　he　will　bring　the
patient　nearer　to　death　than　to　recovery。
　　37。　Luxations　and　subluxations　at　the　knee　are　much　milder　accidents
than　subluxations　and　luxations　at　the　elbow。　For　the　knee…joint；　in
proportion　to　its　size；　is　more　compact　than　that　of　the　arm；　and
has　a　more　even　conformation；　and　is　rounded；　while　the　joint　of　the
arm　is　large；　and　has　many　cavities。　And　in　addition；　the　bones　of　the
leg　are　nearly　of　the　same　length；　for　the　external　one　overtops　the
other　to　so　small　an　extent　as　hardly　to　deserve　being　mentioned；
and　therefore　affords　no　great　resistance；　although　the　external　nerve
（ligament？）　at　the　ham　arises　from　it；　but　the　bones　of　the　fore…arm
are　unequal；　and　the　shorter　is　considerably　thicker　than　the　other；
and　the　more　slender　（ulna？）　protrudes；　and　passes　up　above　the　joint；
and　to　it　（the　olecranon？）　are　attached　the　nerves　（ligaments？）
which　go　downward　to　the　junction　of　the　bones；　and　the　slender　bone
（ulna？）　has　more　to　do　with　the　insertion　of　the　ligaments　in　the
arm　than　the　thick　bone　（radius？）。　The　configuration　then　of　the
articulations；　and　of　the　bones　of　the　elbow；　is　such　as　I　have
described。　Owing　to　their　configuration；　the　bones　at　the　knee　are
indeed　frequently　dislocated；　but　they　are　easily　reduced；　for　no
great　inflammation　follows；　nor　any　constriction　of　the　joint。　They
are　displaced　for　the　most　part　to　the　inside；　sometimes　to　the
outside；　and　occasionally　into　the　ham。　The　reduction　in　all　these
cases　is　not　difficult；　but　in　the　dislocations　inward　and　outward；
the　patient　should　be　placed　on　a　low　seat；　and　the　thigh　should　be
elevated；　but　not　much。　Moderate　extension　for　the　most　part
sufficeth；　extension　being　made　at　the　leg；　and　counter…extension　at
the　thigh。
　　38。　Dislocations　at　the　elbow　are　more　troublesome　than　those　at　the
knee；　and；　owing　to　the　inflammation　which　comes　on；　and　the
configuration　of　the　joint；　are　more　difficult　to　reduce　if　the
bones　are　not　immediately　replaced。　For　the　bones　at　the　elbow　are
less　subject　to　dislocation　than　those　of　the　knee；　but　are　more
difficult　to　reduce　and　keep　in　their　position；　and　are　more　apt　to
become　inflamed　and　ankylosed。
　　39。　For　the　most　part　the　displacements　of　these　bones　are　small；
sometimes　toward　the　ribs；　and　sometimes　to　the　outside；　and　the　whole
articulation　is　not　displaced；　but　that　part　of　the　humerus　remains　in
place　which　is　articulated　with　the　cavity　of　the　bone　of　the
forearm　that　has　a　protuberance　（ulna？）。　Such　dislocations；　to
whatever　side；　are　easily　reduced；　and　the　extension　is　to　be　made
in　the　line　of　the　arm；　one　person　making　extension　at　the　wrist；
and　another　grasping　the　armpit；　while　a　third；　applying　the　palm　of
his　hand　to　the　part　of　the　joint　which　is　displaced；　pushes　it　inward
ward；　and　at　the　same　time　makes　counterpressure　on　the　opposite
side　near　the　joint　with　the　other　hand。
　　40。　The　end　of　the　humerus　at　the　；elbow　gets　displaced
（subluxated？）　by　leaving　the　cavity　of　the　ulna。　Such　luxations
readily　yield　to　reduction；　if　applied　before　the　parts　get
inflamed。　The　displacement　for　the　most　part　is　to　the　inside；　but
sometimes　to　the　out