TREATISE ON FRACTURES BY HIPPOCRATES

FULL TEXT

Part I

Hippocrates

In treating fractures and dislocations, the physician must take the extension as straight as possible, for this is the most natural direction. But if it incline to either side, it should rather turn to that of pronation, for there is thus less harm than if it be toward supination. Those, then, who act in such cases without deliberation, for the most part do not fall into any great mistake, for the person who is to have his arm bound, presents it in the proper position from necessity, but physicians who fancy themselves learned in these matters, are they who commit blunders. There is no necessity of giving the longer directions on this subject, because I know physicians who have the reputation of being skilled in giving the proper position to the arm in binding it up, while in reality they are only showing their own ignorance. But many other things in our art are judged of in this manner, for people rather admire what is new, although they do not know whether it be proper or not, than what they are accustomed to, and know already to be proper; and what is strange, they prefer to what is obvious. I must now state what the mistakes of medical men are, which I wish to unteach, and what instructions I have to say regarding it, will apply to the other bones of the body.

Part 2

The arm, then, for that is the subject we were treating of, was presented in the prone position to be bound, but the physician forced his patient to hold it as the archers do when they project the shoulder, and in this position he bound it up, thinking within himself that he was acting according to Nature, and in proof of this he pointed out that all the bones in the fore-arm were thus in a straight line, and that the integuments both inside and outside, were also in a straight line, and that the flesh and nerves (tendons?) were thus put in their natural position, and he appealed to what happens in archery, as a proof of this. And so saying, and so doing, he is looked up to as a sage; and yet he forgets that in all the other arts and performances, whether executed whether executed by strength or dexterity, what is reckoned the natural position is not the same, and that in the same piece of work it may happen that the natural position of the right arm is not the same as that of the left. For there is one attitude in throwing the javelin, and another in slinging, another in casting stones, another in boxing, and another in a state of repose. And whatever arts one examines, it will be found that the natural position of the arms is not the same in each, but that in every case the arms are put into the attitude which suits best with the instrument that is used, and the work to be performed. In practicing archery, no doubt this is the best attitude of the left arm, for gingly-moid extremity of the humerus being fixed in the cavity of the ulna, in this position, throws the bones of the forearm and arm into a line, as if they constituted a single bone, and all flexion at the joint is revented in this position. It is no doubt certain that the member is thus put into the most unbending and extended position possible, so as not to be overcome or yield when the string is drawn by the right arm, and thus will the archer be enabled to draw the string farthest, and discharge his arrow with the greatest force and rapidity, for arrows thus discharged have the greatest swiftness and force, and are carried to the greatest distances. But there is nothing in common between the binding up of an arm and archery. Moreover, if having thus bound up the arm, the physician direct the patient to keep it thus, he will occasion him greater pain than he had from the wound itself; and thus also, if the physician order him to bend the arm, neither the bones, the nerves, nor the flesh will any longer be in the same condition, but will be arranged differently, having overcome the bandaging. What use, then, is there of the archer's attitude? And these mistakes, the physician, conceited in his knowledge, would probably not have committed if he had allowed the patient himself to present his arm.

Part 3

But another physician putting the arm into the state of supination, gives orders to extend the arm thus, and bandages it in this position, reckoning it the one according to nature, judging thus from the skin, and also fancying the bones to be thus in their natural position, because the bone which protrudes at the wrist, where the little finger is, appears to be in a line with the bone from which people measure the bone of the fore-arm. These things he brings forward as proofs that the parts are in their natural state, and he is supposed to speak correctly. But, indeed, if the arm be kept stretched in a supine position, it will become very painful, and this fact any one may ascertain by extending his own arm in this attitude. And also a weaker man grasping with his hands a stronger man whose arm is turned in a supine position, could lead him wherever he chose, and neither, if a man held a sword thus in his hand, could he make any proper use of it, so constrained is this position. And, moreover, if, when a physician has thus bound up the arm, he allow it to remain in the same position, the patient will endure greater pain if he walk about, but considerable, even if he remain at rest. And thus, too, if he shall bend the arm, the muscles and the bones must necessarily assume a different position. But, in addition to other mischief, he is ignorant of these facts regarding the position, that the bone which protrudes at the wrist, close to the little finger, belongs to the fore-arm, whereas the one at the joint, from which people measure the fore-arm, is the head of the humerus. He fancies that both these belong to the same bone, and many others are of this opinion. The latter, in fact, is the same part as that which is called the elbow, upon which we sometimes rest, and when he holds the arm thus in a supine position, in the first place the bone appears distorted, and in the next place the tendons which extend from the carpus along the inner side and from the fingers become distorted while the arm has a supine position; for these tendons proceed to the bone of the humerus, from which the fore-arm is measured. Such, and so many mistakes and marks of ignorance are committed, regarding the natural construction of the arm. But if one will extend a broken arm as I direct, he will turn the bone, situated at the extremity of the little finger, into the straight line, and also the one at the elbow, and the tendons which stretch from the carpus to the extremity of the humerus will be placed in the straight line; and when the arm is suspended in a sling, it will be in the same attitude as that in which it was bound up, and will give no pain to the patient when he walks about, nor when he lies reclined, and will not become fatigued. The man should be so seated that the prominent part of the bone may be turned to the brightest light which is at hand, so that the operator in making the extension, may be at no loss to discover if it be sufficiently straight. The prominence of a broken bone could not escape being detected by the hand of an experienced person, when applied for this purpose, and, moreover, the projecting part is particularly painful to the touch.

Part 4

In cases of fracture in either of the bones of the forearm, it is easier to effect a cure if the upper bone be broken, although it be the thicker one, both because the sound bone is situated below, and forms a support to it, and because the deformity is more easily concealed, there being a thick mass of flesh on the upper side, except near to the wrist. But the lower bone is without a covering of flesh, is not easily concealed, and requires stronger extension. If it is not this bone, but the other which is broken, a more feeble extension proves sufficient, but if both be broken, a more powerful extension is required. In the case of a young person I have known the extension made more strong than was necessary, but in general the extension made is less than what is required. And when they are extended, the physician should apply the palms of the hands, and adjust the fractured parts and then having rubbed the parts with cerate, but not in large quantity so that the bandages may not come off, it is to be bound up in this state, care being taken that the hand be not lower than the elbow, but a little higher, so that the blood do not flow toward the extremity, but may be determined to the upper part; and then it is to be secured with the bandage, the head of which is to be placed at the fracture, and the bandage should impart firmness to the parts without occasioning strong compression. When you have carried the bandage twice or thrice round at the seat of the fracture, it is to be carried upward, so that the afflux of blood into it may be stopped, and the bandage should terminate there, and the first bandages ought not to be long. The head of the second bandage is also to be placed upon the seat of the fracture, and a single round of it being made there, it is then to be carried downward, and is not to be applied so tight as the other, and there should be greater distances between the turns, so that the bandage may prove sufficient to revert to the spot where the other terminated. The bandages may be rolled to the left hand or to the right, or to whatever side suits best with the position of the fractured arm, or according to the inclination which it may have. Afterward we must place along the arm, compresses, smeared with a little cerate, for thus they occasion less uneasiness, and are more easily arranged. And then we must apply the bandages crossways, sometimes to the right hand, and sometimes to the left, for the most part beginning below and terminating above, but sometimes commencing above and ending below. The parts which are thinly covered with flesh should be wrapped round with compresses, and inequalities should be made up, not by a number of folds at once, but by degrees. Some slack turns are also to be made around the wrist, to this side and to that. These two bandages are sufficient at first.

Part 5

And these are the signs that the patient has been well treated and properly bandaged: if you ask him if the arm feels tight, and he says it does, but moderately so, and especially about the fracture; and this reply he should make all along, if the bandage be properly applied. And these are symptoms of the bandaging being moderately tight; if for the first day and night he fancies that the tightness does not diminish, but rather increases; and if on the next day there be a soft swelling in the hand, for this is a sign of moderate compression, but at the end of the second day the compression should feel less, and on the third day the bandaging should appear loose. And if any of these symptoms be wanting, you may conclude that the bandaging is slacker than it should be; or if any of these symptoms be in excess, you may infer that the compression is more than moderate; and judging from these, you will apply the next bandages either slacker or tighter. Having removed the bandages on the third day, you must make extension and adjust the fracture, and bind it up again; and if the first bandaging was moderately applied, the second bandaging should be made somewhat tighter. The heads the bandages should be placed on the fractures as in the former case; for, so doing, the humors will be driven to the extremities, whereas if you bandage any other part beforehand, the humors will he forced from it to the seat of the fracture: it is of much importance that this should be properly understood. Thus the bandaging and compression should always commence at the seat of the fracture, and everything else should be conducted on the same principle, so that the farther you proceed from the fracture, the compression should always be the less. The bandages should never be actually loose, but should be smoothly put on. At each dressing the number of bandages should be increased; and the patient, if asked, should answer, that he feels the bandages somewhat tighter than on the former occasion, especially about the fracture, and everything else in proportion; and with respect to the swelling, the pain, and recovery, everything should proceed as after the former dressing. But on the third day the outer bandaging should appear looser. Then having removed the bandages, you should bind it up again, somewhat tighter than before, and with all the bandages which will be required on the occasion, and afterwards one ought to experience the same train of symptoms as at the former periods of bandaging.

Part 6

When the third day arrives, that is to say, the seventh from the first dressing, if properly done, the swelling in the hand should be not very great; and the part which has been bandaged should be found more slender and less swelled at each time, and on the seventh day the swelling should be quite gone, and the broken bones should be more readily moved, and admit of being easily adjusted. And if these things be so, you should, after setting the fracture, apply the bandages so as to suit the splints, and a little more tight than formerly, unless there be more pain from the swelling in the hand. When you have applied the bandages, you must adjust the splints all around the limb, and secure them secure them with strings so loose as just to keep them in their place, without the application of the splints contributing at all to the compression of the arm. After this the pain and recovery should proceed as in the preceding periods of the bandaging. But if, on the third day, the patient say that the bandaging is loose, you must then fasten the splints, especially at the fracture, but also elsewhere, wherever the bandaging is rather loose than tight. The splint should be thickest where the fracture protrudes, but it should not be much more so than elsewhere. Particular attention should be paid to the line of the arm corresponding to the thumb, so that no splint be laid on it, but upon each side of it, nor in the line of the little finger where the bone is prominent at the wrist, but on each side of it. And if it be found necessary that splints should be applied in these directions at the seat of the fracture, they should be made shorter than the others, so as that they may not reach the bones which are prominent at the wrist, for otherwise there is danger of ulceration, and of the tendons being laid bare. The splints should be adjusted anew every third day, in a very gentle manner, always keeping in mind that the object of the splints is to maintain the lower bandages in their place, and that they are not needed in order to contribute to the compression.

Part 7

If, then, you see that the bones are properly adjusted by the first dressings, and that there is no troublesome pruritus in the part, nor any reason to suspect ulceration, you may allow the arm to remain bandaged in the splints until after the lapse of more than twenty days. The bones of the fore-arm generally get consolidated in thirty days altogether; but there is nothing precise in this matter, for one constitution differs from another, and one period of life from another. When you remove the bandages, you must pour hot water on the arm and bind it up again, but somewhat slacker, and with fewer bandages than formerly: and again on the third day you undo the bandages, and bind it still more loosely, and with still fewer bandages. And if, while the arm is bound up in the splints, you should at any time suspect that the bones do not lie properly, or if anything about the bandages annoys the patient, you should loose them at the middle of the time, or a little earlier, and apply them again. A diet slightly restricted will be sufficient in those cases in which there was no external wound at first, or when the bone does not protrude; but one should live rather sparingly until the tenth day, as being now deprived of exercise; and tender articles of food should be used, such as moderately loosen the bowels; but one should abstain altogether from flesh and wine, and then by degrees resume a more nourishing diet. This diet. may be laid down as a just rule in the treatment of fractures, both as to how they should be treated, and what will be the results of a proper plan of treatment; so that one may know, that if things do not turn out thus, there has been some defect or excess in the treatment. And in this simple plan of treatment it is necessary to attend also to the following directions, which some physicians pay little attention to, although, when improperly executed, they are capable of marring the whole process of bandaging: for if both the bones be broken, or the lower one only, and the patient who has got his arm bandaged keep it slung in a shawl, and that the shawl is particularly loose at the fracture, so that the arm is not properly suspended at this end or that, in this case the bone must necessarily be found distorted upwards; whereas, when both bones are thus broken, if the arm recline in the shawl at the wrist and elbow, but the rest of it be not kept up, the bone in this case will be distorted to the lower side. The greater part of the arm and the wrist of the hand should therefore be equally suspended in a broad soft shawl.

Part 8

When the arm is broken, if one stretch the fore-arm and adjust it while in this position, the muscle of the arm will be bound while extended; but when the dressing is over, and the patient bends his arm at the elbow, the muscle of the arm will assume a different shape. The following, then, is the most natural plan of setting the arm: having got a piece of wood a cubit or somewhat less in length, like the handles of spades, suspend it by means of a chain fastened to its extremities at both ends; and having seated the man on some high object, the arm is to be brought over, so that the armpit may rest on the piece of wood, and the man can scarcely touch the seat, being almost suspended; then having brought another seat, and placed one or more leather pillows under the arm, so as to keep it a moderate height while it is bent at a right angle, the best plan is to put round the arm a broad and soft skin, or broad shawl, and to hang some great weight to it, so as to produce moderate extension; or otherwise, while the arm is in the position I have described, a strong man is to take hold of it at the elbow and pull it downward. But the physician standing erect, must perform the proper manipulation, having the one foot on some pretty high object, and adjusting the bone with the palms of his hands; and it will readily be adjusted, for the extension is good if properly applied. Then let him bind the arm, commencing at the fracture, and do otherwise as directed above; let him put the same questions and avail himself of the same signs to ascertain whether the arm be moderately tight or not; and every third day let him bind it anew and make it tighter; and on the seventh or ninth day let him bind it up with splints, and leave it so until after the lapse of more than thirty days. And if he suspect that the bone is not lying properly, let him remove the bandages in the interval, and having adjusted the arm, let him bind it up again. The bone of the arm is generally consolidated in forty days. When these are past, the dressing is to be removed, and fewer and slacker bandages applied instead of it. The patient is to be kept on a stricter diet, and for a longer space of time than in the former case; and we must form our judgment of it from the swelling in the hand, looking also to the strength of the patient. This also should be known, that the arm is naturally inclined outward; to this side, therefore, the distortion usually takes place, if not properly treated; but indeed, all the other bones are usually distorted during treatment for fracture to that side to which they naturally incline. When, therefore, anything of this kind is suspected, the arm is to be encircled in a broad shawl, which is to be carried round the breast, and when the patient goes to rest, a compress of many folds, or some such thing, is to be folded and placed between the elbow and the side, for thus the bending of the bone will be rectified, but care must be taken lest it be inclined too much inwards.

Part 9

The human foot is composed of several small bones like the hand. These bones therefore are scarcely ever broken, unless the skin at the same time be wounded by some sharp and heavy body. The treatment of stich injuries, therefore, will be delivered under the head of wounds. But if any bone be moved from its place, or a joint of the toes be luxated, or any of the bones of the part called the tarsus be displaced, it must be forced back again to its place as described with regard to the hand; and is to be treated with cerate, compresses, and bandages, like the fractures, with the exception of the splints; and is to be secured tightly in the same way, and the bandages renewed on the third day; and the patient thus bandaged should return the same answers as in fractures, as to the bandages feeling tight or slack. All these bones recover perfectly in twenty days, except those that are connected with the bones of the leg, and are in a line with them. It is advantageous to lie in bed during the whole of this time; but the patients, thinking light of the complaint, have not perseverance to do this, and they walk about before they get well; wherefore many of these do not make a perfect recovery. And often the pain puts them in mind of the injury; and deservedly, for the feet sustain the weight of the whole body. When, therefore, they walk about before they are whole, the joints which have been luxated are cured incompletely; and, on that account, while walking about, they have pains in the leg from time to time.

Part 10

But those bones which are connected with the bones of the legare larger than the others, and the cure of them when luxuated is more protracted. The mode of treatment then is the same; but we must use more bandages and more splints, and the bandage is to be carried round to this side and to that, and pressure is to be made as in the other cases, particularly at the seat of the luxation, and the first circles of the bandages are to be made there. And at each time the bandages are taken off, much hot water is to be used, for in all injuries at joints the affusion of hot water in large quantity is to be had recourse to. And the same symptoms of compression and relaxation should manifest themselves in the same times, as in the cases formerly treated of, and the subsequent bandagings should be conducted in like manner. These cases get completely well for the most part in forty days, if the patients have resolution to keep their bed; but if not, they are subjected to the complaints formerly described, or still worse.

Part 11

In persons who jumping from any high object pitch upon their heel with great force, the bones are separated, and the veins pour forth their contents, owing to the contusion of the flesh surrounding the bone, and hence a swelling and much pain supervene. For this bone (os calcis) is not a small one, protrudes beyond the line of the leg, and is connected with important veins and tendons; for the back tendon of the leg is inserted into this bone. Such cases are to be treated with cerate, and with compresses and bandages; and hot water is to be used in large quantity; and they require many bandages, which ought to be particularly good and appropriate. And if the patient happen to have a tender skin about the heel, nothing is to be done to it; but if, as some have it, the skin be thick and hardened, it is to be pared down smoothly and thinned, but without wounding it. It is not everybody who can apply the bandage properly in such cases; for if one shall bind the parts, as in other accidents about the ankle, sometimes bringing a fold round the foot and sometimes round the tendon, these turns leave out the heel, which is the seat of the contusion, and thus there is danger that the os calcis may sphacelate; and if this should take place, the impediment may endure for life and also in all the other cases of sphacelus, not proceeding from such a cause as this; as when, from being carelessly allowed to lie in a certain position during confinement to bed, the heel becomes black, or when a serious wound has occurred in the leg and it is long of healing, and is connected with the heel, or when the same thing happens in the thigh, or when in any disease a protracted decubitus takes place on the back, in all such cases the sores are inveterate, troublesome, and frequently break out again, unless particular attention be paid to the cure, along with much rest, as in all the cases attended with sphacelus. And cases of sphacelus connected with this cause, in addition to other inconveniences, are attended with great danger to the whole body. For they are apt to be attended with very acute fevers, of the continual type, accompanied with tremblings, hiccup, aberration of intellect, and which prove fatal within a few days: and there may be lividities of bloody veins, with nausea, and gangrene from pressure; these diseases may occur, besides the sphacelus. Those which have been described are the most violent contusion; but in general the contusions are mild, and no great care is required with regard to the treatment, and yet it must be conducted properly. But when the contusion appears to be severe, we must do as described above, making many turns of the bandage around the heel, sometimes carrying it to the extremity of the foot, sometimes to the middle, and sometimes around the leg; and, in addition, all the surrounding parts are to be bandaged in this direction and that, as formerly described; and the compression should not be made strong, but we should make use of many bandages, and it is better also to administer hellebore the same day or on the morrow; and the bandages should be removed on the third day and reapplied. And these are the symptoms by which we discover whether the case will get worse or not: when the extravasated blood, the lividities, and the surrounding parts become red and hard, there is danger of an exacerbation. But if there be no fever, we must give emetics, as has been said, and administer the other remedies which are applicable when the fever is not of a continual type; but if continual fever be present, we must not give strong medicines, but enjoin abstinence from solid food and soups, and give water for drink, and not allow wine but oxyglyky (a composition from vinegar and honey?). But if the case be not going to get worse, the ecchymosed and livid parts, and those surrounding them become greenish and not hard; for this is a satisfactory proof in all cases of ecchymosis, that they are not to get worse; but when lividity is complicated with hardness, there is danger that the part may become blackened. And we must so manage the foot as that it may be generally raised a little higher than the rest of the body. Such a patient will get well in sixty days if he keep quiet.

Part 12

The leg consists of two bones, of which the one is much more slender than the other at one part, but not much more slender at another. These are connected together at the foot, and form a common epiphysis, but they are not united together along the line of the leg;and at the thigh they are united together and form an epiphysis, and this epiphysis has a diaphysis; but the other bone in a line with the little toe is a little longer. Such is the nature of the bones of the leg.

Part 13

Sometimes the bones connected with the foot are displaced, sometimes both bones with their epiphysis; sometimes the whole epiphysis is slightly moved, and sometimes the other bone. These cases are less troublesome than the same accidents at the wrist, if the patients will have resolution to give them rest. The mode of treatment is the same as that of the other, for the reduction is to be made, as of the other, by means of extension, but greater force is required, as the parts of the body concerned are stronger in this case. But, for the most part, two men will be sufficient, by making extension in opposite directions, but, not withstanding, if they are not sufficiently strong, it is easy to make more powerful extension in the following way: having fixed in the ground either the nave of a wheel, or any such object, something soft is to be bound round the foot, and then some broad thongs of ox-skin being brought round it, the heads of the thongs are to be fastened to a pestle or any other piece of wood, the end of which is to be inserted into the nave, and it, the pestle, is to be pulled away, while other persons make counter-extension by grasping the shoulders and the ham. It is also sometimes necessary to secure the upper extremity otherwise; this if you desire to effect, fasten deeply in the ground a round, smooth piece of wood, and place the upper extremity of the piece of wood at the perineum, so that it may prevent the body from yielding to the pulling at the foot, and, moreover, to prevent the leg while stretched, from inclining downward; some person seated at his side should push back the hip, so that the body may not turn round with the pulling, and for this purpose, if you think fit, pieces of wood may be fastened about the armpits on each side, and they are to be stretched by the hands, and thus secured, while another person takes hold of the limb at the knee, and aids in thus making counter-extension. Or thus, if you prefer it: having bound other thongs of leather about the limb, either at the knee, or around the thigh, and having fastened another nave of a wheel in the ground above the head, and adjusted the thongs piece of wood adapted to the nave, extension may thus be made in the opposite direction to the feet. Or if you choose, it may be done thus: instead of the naves, lay a moderate-sized beam under the couch, and then having fastened pieces of wood in this beam, both before and behind the head, make counter-extension by means of thongs, or place windlasses at this extremity and that, and make extension by means of them. There are many other methods of making extension. But the best thing is, for any physician who practices in a large city, to have prepared a proper wooden machine, with all the mechanical powers applicable in cases of fractures and dislocation, either for making extension, or acting as a lever. For this purpose it will be sufficient to possess a board in length, breadth, and thickness, resembling the quadrangular threshing-boards made of oak.

Part 14

When you have made proper extension, it is easy reduce the joint, for the displaced bone is thus raised into a line with the other. And the bones are to be adjusted with the palms of the hands, pressing upon the projecting bone with the one, and making counter-pressure below the ankle with the other. When you have replaced the bones, you must apply the bandages while the parts are upon the stretch, if you possibly can; but if prevented by the thongs, you must loose them, and make counter-extension until you get the bandages applied. The bandage is to be applied in the manner formerly described, the heads of the bandages being placed on the projecting part, and the first turns made in like manner, and so also with regard to the number of compresses and the compression; and turns of the bandages are to be brought frequently round on this and on that side of the ankle. But this joint must be bound more tight at the first dressing than in the case of the hand. But when you have applied the bandage, you must place the bandaged part somewhat higher than the rest of the body, and in such a position that the foot may hang as little as possible. The attenuation of the body is to be made proportionate to the magnitude of the luxation, for one luxation is to be a small, and another to a great extent. But in general we must reduce more, and for a longer time, in injuries about the legs, than in those about the hands; for the former parts are larger and thicker than the latter, and it is necessary that the body should be kept in a state of rest, and in a ecumbent position. There is nothing to prevent or require the limb to be bandaged anew on the third day. And all the treatment otherwise is to be conducted in like manner, as in the preceding cases. And if the patient have resolution to lie quiet, forty days will be sufficient for this purpose, if only the bones be properly reduced, but if he will not lie quiet, he will not be able to use the limb with ease, and he will find it necessary to wear a bandage for a long time. When the bones are not properly replaced, but there has been some defect in this respect, the hip, the thigh, and the leg become wasted, and if the dislocation be inward, the external part of the thigh is wasted, and vice versa. But for the most part the dislocation is inward.

By Hippocrates (ca. 400 B.C.E.) Translated by Francis Adams  in http://www.indiana.edu/ adapted and illustrated to be posted by Leopoldo Costa.