ON THE INSTRUMENTS OF REDUCTION

OR, MOCHLICON

Translated by Charles Darwin Adams

1. With regard to the construction of bones, the bones and joints of the fingers are simple, the bones of the hand and foot are numerous, and articulated in various ways; the uppermost are the largest; the heel consists of one bone which is seen to project outward, and the back tendons are attached to it. The leg consists of two bones, united together above and below, but slightly separated in the middle; the external bone ( fibula ), where it comes into proximity with the little toe, is but slightly smaller than the other, more so where they are separated, and at the knee, the outer hamstring arises from it; these bones have a common epiphysis below, with which the foot is moved, and another epiphys is above in which is moved the articular extremity of the femur, which is simple and light in proportion to its length, in the form of a condyle, and having the patella (connected with it?), the femur itself bends outward and forward; its head is a round epiphysis which gives origin to ligament inserted in the acetabulum of the hip-joint. This bone is articulated somewhat obliquely, but less so than the humerus. The ischium is united to the great vertebra contiguous to the os sacrum by a cartilaginous ligament. The spine, from the os sacrum to the great vertebra, is curved backward; in this quarter are situated the bladder, the organs of generation, and the inclined portion of the rectum; from this to the diaphragm it proceeds in a straight line inclining forward, and the psoae are situated there; from this point, to the great vertebra above the tops of the shoulders, it rises in a line that is curved backward, and the curvature appears greater than it is in reality, for the posterior processes of the spine are there highest; the articulation of the neck inclines forward. The vertebrae on the inside are regularly placed upon one another, but behind they are connected by a cartilaginous ligament; they are articulated in the form of synarthrosis at the back part of the spinal marrow; behind they have a sharp process having a cartilaginous epiphysis, whence proceeds the roots of nerves running downward, as also muscles extending from the neck to the loins, and filling the space between the ribs and the spine. The ribs are connected to all the intervertebral spaces on the inside, from the neck to the lumbar region, by a small ligament, and before to the sternum, their extremities being spongy and soft; their form is the most arched in man of all animals; for in this part, man is, of all animals, the narrowest in proportion to his bulk. The ribs are united to each vertebra by a small ligament at the place from which the short and broad lateral processes ( transverse processes? ) arise. The sternum is one continuous bone, having lateral pits for the insertion of the ribs; it is of a spongy and cartilaginous structure. The clavicles are rounded in front, having some slight movements at the sternum, but more free at the acromion. The acromion, in man, arises from the scapula differently from most other animals. The scapula is cartilaginous toward the spine, and spongy elsewhere, having an irregular figure externally; its neck and articular cavity cartilaginous; it does not interfere with the movements of the ribs, and is free of all connection with the other bones, except the humerus. The head of the humerus is articulated with its ( glenoid? ) cavity, by means of a small ligament, and it consists of a rounded epiphysis composed of spongy cartilage, the humerus itself is bent outward and forward, and it is articulated with its ( glenoid? ) cavity by its side, and not in a straight line. At the elbow it is broad, and has condyles and cavities, and is of a solid consistence; behind it is a cavity in which the coronoid process ( olecranon? ) of the ulna is lodged, when the arm is extended; here, too, is inserted the benumbling nerve, which arises from between the two bones of the forearm at their junction, and terminates there.

2. When the nose is fractured, the parts should be modeled instantly, if possible. If the fracture be in its cartilaginous part, introduce into the nostrils a tent formed of caddis, inclosed in the outer skin of a Carthaginian hide, or anything else which does not irritate; the skin is to be glued to the parts displaced, which are to be thus rectified. Bandaging in this case does mischief. The treatment is to consist of flour with manna, or of sulphur with cerate. You will immediately adjust the fragments, and afterward retain them in place with your fingers introduced into the nostrils, and turning the parts into place; then the Carthaginian skin is to be used. Callius forms even when there is a wound; and the same things are to be done, even when there is to be exfoliation of the bones, for this is not of a serious nature.

3. In fractures of the ears, neither bandages nor cataplasms should be used; or, if any bandage be used, it should be put on very tight; the cerate and sulphur should be applied to agglutinate the bandages. When matter forms in the ears, it is found to be more deeply seated than might be supposed, for all parts that are pulpy, and consist of juicy flesh, prove deceptious in such a case. But no harm will result from making an opening, for the parts are lean, watery, and full of mucus. No mention is here made of the places and circumstances which render it fatal to make an opening. The cure is soonest effected by transfixing the ear with a cautery; but the ear is maimed and diminished in size, if burned across. If opened, one of the gentle medicines for flesh wounds should be used as a dressing.

4. The jaw-bone is often slightly displaced ( subluxated? ), and is restored again; it is dislocated but rarely, especially in gaping; in fact, the bone is never dislocated unless it slips while the mouth is opened wide. It slips, however, the more readily from its ligaments being oblique, supple, and of a yielding nature. The symptoms are: the lower jaw protrudes, it is distorted to the side opposite the dislocation, and the patient cannot shut his mouth; when both sides are dislocated, the jaw projects more, the mouth can be less shut, but there is no distortion; this is shown by the rows of the teeth in the upper and lower jaw corresponding with one another. If, then, both sides be dislocated, and not immediately reduced, the patient for the most part dies on the tenth day, with symptoms of continued fever, stupor, and coma, for the muscles there induce such effects; there is disorder of the bowels attended with scanty and unmixed dejection; and the vomitings, if any, are of the same character. The other variety is less troublesome. The method of reduction is the same in both:-The patient being laid down or seated, the physician is to take hold of his head, and grasping both sides of the jaw-bone with both hands, within and without, he must perform three manoeuvres at once,-rectify the position of the jaw, push it backward, and shut the mouth. The treatment should consist of soothing applications, position, and applying a suitable bandage to support the jaw-bone, so as to cooperate with the reduction.

5. The bone of the shoulder is dislocated downward. I have never heard of any other mode. The parts put on the appearance of dislocation forward, when the flesh about the joint is wasted during consumption, as also seems to be the case with cattle when in a state of leanness after winter. Those persons are most liable to dislocations who are thin, slender, and have humidities about their joints without inflammation, for it knits the joints. Those who attempt to reduce and rectify dislocations in oxen, commit a blunder, as forgetting that the symptoms arise from the manner in which the ox uses the limb, and that the appearance is the same in a man who is in a similar condition, and forgetting also that Homer has said, that oxen are most lean at that season. In this dislocation, then, when not reduced, the patient cannot perform any of those acts which others do, by raising the arm from the side. I have thus stated who are the persons most subject to this dislocation, and how they are affected. In congenital dislocations the nearest bones are most shortened, as is the case with persons who are weasel-armed ; the fore-arm less so, and the hand still less; the bones above are not affected. And the parts (near the seat of the injury) are most wasted in flesh; and this happens more especially on the side of the arm opposite the dislocation, and that during adolescence, yet in a somewhat less degree than in congenital cases. The deep-seated suppurations occur most frequently to new-born infants about the joint of the shoulder, and these produce the same consequences as dislocations. In adults, the bones are not so diminished in size, and justly, seeing that the others will not increase as in the former case; but wasting of the flesh takes place, for it is increased, and is diminished every day, and at all ages. And attention should be paid to the force of habit, and to the symptom produced by the tearing away of the acromion, whereby a void is left, which makes people suppose that the humerus is dislocated. The head of the humerus is felt in the armpit, and the patient cannot raise his arm, nor swing it to this side and that, as formerly. The other shoulder shows the difference. Modes of reduction:-The patient himself having placed his fist in the arm pit, pushes up the head of the humerus with it, and brings the hand forward to the breast. Another:-Force it backward, so that you may turn it round. Another:-Apply your head to the acromion, and your hands to the armpit, separate the head of the humerus ( from the side? ), and push the elbow in the opposite direction; or, instead of your knees, another person may turn aside the elbow, as formerly directed. Or, place the patient on your shoulder, with the shoulder in his armpit. Or, with the heel, something being introduced to fill up the hollow of the armpit, and using the right foot to the right shoulder. Or, with a pestle. Or, with the step of a ladder. Or, by rotation made with piece of wood stretched below the arm. Treatment:-As to attitude, the arm placed by the side, the hand and shoulder raised; the bandaging and adjustment of the parts while in this attitude. If not reduced, the top of the shoulder becomes attenuated.

6. When the acromion is torn away, the appearance is the same as in dislocation of the shoulder; but there is no impediment, except that the bone does not return to its position. The figure should be the same as in dislocation, both as regards bandaging and suspending the limb. The bandaging according to rule.

7. When partial displacement ( sub-luxation? ) takes place at the elbow, either inside or outside, but the sharp point ( olecranon? ) remains in the cavity of the humerus, make extension in a straight line, and push the projecting parts backward and to the sides.

8. In complete dislocations to either side, make extension while the arm is in the position it is put in to be bandaged for a fracture, for thus the rounded part of the elbow will not form an obstacle to it. Dislocation most commonly takes place inward. The parts are to be adjusted by separating the bones as much as possible, so that the end of the humerus may not come in contact with the olecranon, but it is to be carried up and turned round, and not forced in a straight line; at the same time the opposite sides are to be pushed together, and the bones reduced to their place. In these cases rotation of the elbow cooperates; that is to say, turning the arm into a state of supination and pronation; so much for the reduction. With regard to the attitude in which it is to be put,-the hand is to be placed somewhat higher than the elbow, and the arm by the side; this position suits with it when slung from the neck, is easily borne, is its natural position, and one adapted for ordinary purposes, unless callus form improperly: the callus soon forms. Treatment:-By bandages according to the common rule for articulations, and the point of the elbow is to be included in the bandage.

9. The elbow, when luxated, induces the most serious consequences, fevers, pain, nausea, vomiting of pure bile; and this especially in dislocations backward, from pressure on the nerve which occasions numbness; next to it is dislocation forward. The treatment is the same. The reduction of dislocation backward is by extension and adaptation: the symptom of this variety, loss of the power of extension; of dislocation forward, loss of the power of flexion. In it a hard ball is to be placed in the bend of the elbow, and the fore-arm is to be bent over this while sudden extension is made.

10. Diastasis of the bones may be recognized by examining the part where the vein which runs along the arm divides.

11. In these cases callus is speedily formed. In congenital dislocations, the bones below the seat of the injury are shorter than natural; in this case, the greatest shortening is in the nearest, namely, those of the fore-arm; second, those of the hand; third, those of the fingers. The arm and shoulders are stronger, owing to the nourishment which they receive, and the other arm, from the additional work it has to perform, is still more strong. The wasting of the flesh, if the dislocation was outward, is on the inside; or if otherwise, on the side opposite the dislocation.

12. In dislocation at the elbow, whether outward or inward, extension is to be made with the fore-arm at right angles to the arm; the arm is to be suspended by a shawl passed through the armpit, and a weight is to be attached to the extremity of the elbow; or force is to be applied with the hands. The articular extremity being properly raised, the parts are to be adjusted with the palms of the hands, as in dislocations of the hands. It is to be bandaged, suspended in a sling, and placed, while in this attitude.

13. Dislocations backward are to be rectified with the palms of the hands along with sudden extension. These two acts are to be performed together, as in other cases of the kind. In dislocation forward, the arm is to bend around a ball of cloth, of proper size, and at the same time replaced.

14. If the displacement be on the other side both these operations are to be performed in effecting the adjustment of the arm. With regard to the treatment,-the position and the bandaging are the same as in the other cases. For all these cases may be reduced by ordinary distention.

15. With regard to the modes of reduction, some act upon the principle of carrying the one piece of bone over the other, some by extension, and some by rotation: these last consist in rapidly turning the arm to this side and that.

16. The joint of the hand is dislocated inward or outward, but most frequently inward. The symptoms are easily recognized; if inward, the patient cannot at all bend his fingers, but if outward, he cannot extend them. Reduction:-By placing the fingers above a table, extension and counter-extension are to be made by assistance, while, with the palm of the hand or the heel on the projecting bone, one presses forward, and from behind, upon the other bone, and lays some soft substance on it; and, if the dislocation be above, the hand is to be turned into a state of pronation; or, if backward, into a state of supination. The treatment is to be conducted with bandages.

17. The whole hand is dislocated either inward, or outward, but especially inward, or to this side or that. Sometimes the epiphysis is displaced, and sometimes there is displacement ( diastasis ) of the one bone from the other. Powerful extension is to be made in this case; and the projecting part is to be pressed upon, and counter-pressure made on the opposite side: both modes being performed at the same time, both backward and laterally, either with the hands on a table, or with the heel. These accidents give rise to serious consequences and deformities; but in time the parts get so strong as to admit of being used. The treatment consists of bandages comprehending the hand and forearm, and splints are to be applied as far as the fingers; when put in splints, they are to be more frequently loosed than in fractures, and more copious allusions of water are to be used.

18. In congenital dislocations the hand becomes shortened, and the atrophy of the flesh is generally on the side opposite the dislocation. In the adult the bones remain of their proper size.

19. The symptoms of dislocation of the finger are obvious, and need not be described. This is the mode of reduction:-By stretching in a straight line, and making pressure on the projecting part, and counter-pressure, at the opposite side, on the other. The proper treatment consists in the application of bandages. When not reduced, the parts unite by callus outside of the joints. In congenital dislocations, and in those which occur during bones below the dislocation are shortened, and the flesh is wasted principally on the side opposite to the dislocation; in the adult the bones remain of their proper size.

20. Dislocation at the hip-joint occurs in four modes, inward most frequently, outward next, the others of equal frequency. The symptoms:-The common, a comparison with the sound leg. The peculiar symptoms of dislocations inward; the head of the bone is felt at the perineum; the patient cannot bend his leg as formerly; the limb appears elongated, and to a great extent, unless you bring both limbs into the middle space between them in making a comparison of them; and the foot and the knee are inclined outward. If the dislocation has taken place from birth, or during one’s growth, the thigh is shortened, the leg less so, and the others according to the same rule; the fleshy parts are atrophied, especially on the outside. Such persons are afraid to stand erect, and crawl along on the sound limb; or, if compelled, they walk with one or two staves, and bear up the affected limb; and the smaller the limb so much the more do they walk. If the accident happens to adults the bones remain of their proper size, but the flesh is wasted, as formerly described; the patients walk in a wriggling manner, like oxen; they are bent toward the flank, and the buttock on the uninjured side is prominent; for the uninjured limb must necessarily come below that it may support the body, whilst the other must be carried out of the way, as it cannot support the body, like those who have an ulcer in the foot. They poise the body by means of a staff on the sound side, and grasp the affected limb with the hand above the knee so as to carry the body in shifting from one place to another. If the parts below the hip-joint be used, the bones below are less atrophied, but the flesh more.

21. The symptoms and attitudes in dislocation outward are the opposite, and the knee and foot incline a little inward. When it is congenital, or occurs during adolescence, the bones do not grow properly; according to the same rule, the bone of the hip-joint is somewhat higher than natural, and does not grow proportionally. In those who have frequent dislocations outward, without inflammation, the limb is of a more humid (flabby?) temperament than natural, like the thumb, for it is the part most frequently dislocated, owing to its configuration; in what persons the dislocation is to a greater or less extent; and in what persons it is more difficultly or easily produced; in what there is reason to hope that it can be speedily reduced, and in what not; and the remedy for this; and in what cases the dislocation frequently happens, and treatment of this. In dislocation outward from birth, or during adolescence, or from disease, (and it happens most frequently from disease, in which case there is sometimes exfoliation of the bone, but even where there is no exfoliation), the patients experience the same symptoms, but to an inferior degree to those in dislocations inward, if properly managed so that in walking they can put the whole foot to the ground and lean to either side. The younger the patient is, the greater care should be bestowed on him; when neglected, the case gets worse; when attended to, it improves; and, although there be atrophy in all parts of the limb, it is to a less extent.

22. When there is a dislocation on both sides, the affections of the bones are the same; the flesh is well developed, except within, the nates protrude, the thighs are arched, unless there be sphacelus. If there be curvature of the spine above the hip-joint, the patients enjoy good health, but the body does not grow, with the exception of the head.

23. The symptoms of dislocation backward are:-The parts before more empty, behind they protrude, the foot straight, flexion impossible, except with pain, extension least of all: in these the limb is shortened. They can neither extend the limb at the ham, nor at the groin, unless it be much raised, nor can they bend it. The uppermost joint, in most cases, takes the lead: this is common in joints, nerves, muscles, intestines, uteri, and other parts. There the bone of the hip-joint is carried backward to the nates, and on that account it is shortened, and because the patient cannot extend it. The flesh of the whole leg is wasted in all cases, in which most, and to what extent, has been already stated. Every part of the body which performs its functional work is strong, but, not withstanding, if inactive, it gets into a bad condition, unless its inactivity arise from fatigue, fever, or inflammation. And in dislocations outward, the limb is shortened, because the bone is lodged in flesh which yields; but, not withstanding, in dislocations inward, it is longer, because the bone is lodged on a projecting bone. Adults, then, who have this dislocation unreduced, are bent at the groins in walking, and the other ham is flexed; they scarcely reach the ground with the ball of the foot; they grasp the limb with the hand, and walk without a staff if they choose; if the staff be too long, their foot cannot reach the grounds-if they wish to reach the ground, they must use a short staff. There is wasting of the flesh in cases attended with pain; and the inclination of the leg is forward, and the sound leg in proportion. In congenital cases, or when in adolescence, or from disease, the bone is dislocated (under what circumstances will be explained afterward), the limb is particularly impaired, owing to the nerves and joints not being exercised, and the knee is impaired for the reasons stated. These persons, keeping the limb bent, walk with one staff or two. But the sound limb is in good flesh from usage.

24. In dislocations forward the symptoms are the opposite: a vacuity behind, a protuberance before; of all motions they can least perform flexion, and extension best; the foot is straight, the limb is of the proper length at the heel; at its extremity the foot a little turned up; they are especially pained at first: of all these dislocations retention of urine occurs most frequently in this variety, because the bone is lodged among important nerves. The fore parts are stretched, do not grow, are diseased, and are obnoxious to premature decay; the back parts are wrinkled. In the case of adults, they walk erect, resting merely on the heel, and this they do decidedly if they can take great steps; but they drag it along; the wasting is least of all in this variety of dislocation, owing to their being able to use the limb, but the wasting is most behind. The whole limb being straighter than natural they stand in need of a staff on the affected side. When the dislocation is congenital, or has occurred during adolescence, if properly managed, the patient has the use of the limb as well as adults (otherwise?) have of it. But, if neglected, it is shortened and extended, for in such cases the joint is generally in a straight position. The diminution of the bones, and wasting of the fleshy parts, are analogous.

25. In reduction-the extension of the thigh is to be powerful, and the adjustment what is common in all such cases, with the hands, or a board, or a lever, which, in dislocations inward, should be round, and in dislocations outward, flat; but it is mostly applicable in dislocations outward. Dislocations inward are to be remedied by means of bladders, extending to the bare part of the thigh, along with extension and binding together of the limbs. The patient may be suspended, with his feet a little separated from one another, and then a person inserting his arm within the affected limb, is to suspend himself from it, and perform extension and readjustment at the same time; and this method is sufficient in dislocations forward and the others, but least of all in dislocations backward. A board fastened under the limb, like the board fastened below the arm in dislocations at the shoulder, answers in dislocations inward, but less so in the other varieties. Along with extension you will use pressure either with the foot, the hand, or a board, especially in dislocations forward and backward.

26. Dislocations at the knee are of a milder character than those of the elbow, owing to the compactness and regularity of the joint; and hence it is more readily dislocated and reduced. Dislocation generally takes place inward, but also outward and backward. The methods of reduction are-by circumflexion, or by rapid excalcitration, or by rolling a fillet into a ball, placing it in the ham, and then letting the patient’s body suddenly drop down on his knees: this mode applies best in dislocations backward. Dislocations backward, like those of the elbows, may also be reduced by moderate extension. Lateral dislocations may be reduced by circumflexion or excalcitration, or by extension (but this is most applicable in dislocation backward), but also by moderate extension. The adjustment is what is common in all. If not reduced, in dislocations backward, they cannot bend the leg and thigh upon one another, but neither can they do this in the others except to a small extent; and the fore parts of the thigh and leg are wasted. In dislocations inward they are bandy-legged, and the external parts are atrophied. But, in dislocations outward, they incline more outward, but are less lame, for the body is supported on the thicker bone, and the inner parts are wasted. The consequences of a congenital dislocation, or one occurring during adolescence, are analogous to the rule formerly laid down.

27. Dislocations at the ankle-joint require strong extension, either with the hands or some such means, and adjustment, which at the same time effects both acts; this is common in all cases.

28. Dislocations of the bones of the foot are to be treated like those of the hand.

29. Dislocations of the bones connected with the leg, if not reduced, whether occurring at birth or during adolescence, are of the same character as those in the hand.

30. Persons who, in jumping from a height, have pitched on the heel, so as to occasion diastasis (separation) of the bones, ecchymosis of the veins, and contusion of the nerves,-when these symptoms are very violent, there is danger that the parts may sphacelate, and give trouble to the patient during the remainder of his life; for these bones are so constructed as to slip past one another, and the nerves communicate together. And, likewise in cases of fracture, either from an injury in the leg or thigh, or in paralysis of the nerves connected with these parts, or, when in any other case of confinement to bed the heel, from neglect, becomes blackened, in all these cases serious effects result therefrom. Sometimes, in addition to the sphacelus, very acute fevers supervene, attended with hiccup, tumors, aberration of intellect, and speedy death, along with lividity of the large bloodvessels, and gangrene. The symptoms of the exacerbations are these: if the ecchymosis, the blackened parts, and those around them, be somewhat hard and red, and if lividity be combined with the hardness, there is danger of mortification; but, not withstanding, if the parts are sublivid, or even very livid and diffused, or greenish and soft, these symptoms, in all such cases, are favorable. The treatment consists in the administration of hellebore, if they be free from fever, but otherwise, they are to have oxyglyky for drink, if re-quired. Bandaging,-agreeably to the rule in other joints; but this is to be attended to also,-the bandages should be numerous, and softer than usual; compression less; more water than usual to be used in the allusions; to be applied especially to the heel. The same object should be sought after in the position as in the bandaging, namely, that the humors may not be determined to the heel; the limb to be well laid should have the heel higher than the knee. Splints not to be used.

31. When the foot is dislocated, either alone, or with the epiphysis, the displacement is more apt to be inward. If not reduced, in the course of time the parts of the hips, thigh, and leg, opposite the dislocation, become attenuated. Reduction:-As in dislocation at the wrist; but the extension requires to be very powerful. Treatment:-Agreeably to the rule laid down for the other joints. Less apt to be followed by serious consequences than the wrist, if kept quiet. Diet restricted, as being in an inactive state. Those occurring at birth, or during adolescence, observe the rule formerly stated.

32. With regard to slight congenital dislocations, some of them can be rectified, especially club-foot. There is more than one variety of club-foot. The treatment consists in modeling the foot like a piece of wax; applying resinous cerate, and numerous bandages; or a sole, or a piece of lead is to be bound on, but not upon the bare skin; the adjustment and attitudes to correspond.

33. If the dislocated bones cause a wound in the skin, and protrude, it is better to let them alone, provided only they are not allowed to hang, nor are compressed. The treatment consists in applying pitched cerate, or compresses dipped in hot wine (for cold is bad in all such cases), and certain leaves; but in winter unwashed wool may be applied as a cover to the part; neither cataplasms nor bandaging; restricted diet. Cold, great weight, compression, violence, restricted position, all such are to be accounted as fatal measures. When treated moderately (they escape), maimed and deformed; for, if the dislocation be at the ankle, the foot is drawn upward, and, if elsewhere, according to the same rule. The bones do not readily exfoliate; for only small portions of them are denuded, and they heal by narrow cicatrices. The danger is greatest in the greatest joints, and those highest up. The only chance of recovery is, if they are not reduced, except at the fingers and hand, and in these cases the danger should be announced beforehand. Attempts at reduction to be made on the first or second day; or, if not accomplished then, on the tenth, by no means on the fourth. Reduction by levers. Treatment:-As in injuries of the bones of the head, and the part is to be kept hot; and it is better to give hellebore immediately after the parts have been reduced. With regard to the other bones, it should be well known, that, if replaced, death will be the consequence; the more surely and expeditiously, the greater the articulation, and the more high its situation. Dislocation of the foot is attended with spasm (tetanus) and gangrene; and if, upon its being replaced, any of these symptoms come on, the chance of recovery, if there be any chance, is in displacing it anew; for spasms do not arise from relaxation, but from tension of the parts.

34. Excision, either of articular bones or of pieces of bones, when not high up in the body, but about the foot or the hand, is generally followed by recovery, unless the patient die at once from deliquium animi. Treatment:-As in injuries of the head; warmth.

35. Sphacelus of the fleshy parts is produced by the tight compression of bleeding wounds, and by pressure in the fractures of bones, and by blackening, arising from bandages. And in those cases in which a portion of the thigh or arm, both the bones and the flesh drop off, many recover, the case being less dangerous than many others. In cases, then, connected with fracture of the bones, the separation of the flesh quickly takes place, but the separation of the bone, at the boundary of its denuded part, is slower in taking place. But the parts below the seat of the injury, and the sound portion of the body, are to be previously taken away (for they die previously), taking care to avoid producing pain, for deliquium animi may occasion death. The bone of the thigh in such a case came away on the eightieth day, but the leg was removed on the twentieth day. The bones of the leg, in a certain case, came away at the middle of the sixtieth day. In these cases the separation is quick or slow, according to the compression applied by the physician. When the compression is gently applied the bones do not drop off at all, neither are they denuded of flesh, but the gangrene is confined in the more superficial parts. The treatment of such cases must be undertaken; for most of them are more formidable in appearance than in reality. The treatment should be mild, but, not withstanding, with a restricted diet; hemorrhages and cold are to be dreaded; the position, so as that the limb may be inclined upward, and afterward, on account of the purulent abscess, horizontally, or such as may suit with it. In such cases, and in mortifications, there are usually, about the crisis, hemorrhages and crisis, hemorrhages and violent diarrhoeas, which, however, only last for a few days; the patients do not lose their appetite, neither are they feverish, nor should they be put upon a reduced diet.

36. Displacement of the spine, if inward, threatens immediate death, attended with retention of urine and loss of sensibility. Outward, the accident is free from most of these bad effects, much more so than where there is merely concussion without displacement; the effects in the former case being confined to the spot affected, whereas in the latter they are further communicated to the whole body, and are of a mortal character. In like manner, when the ribs are fractured, whether one or more, provided there be no splinters, there is rarely fever, spitting of blood, and sphacelus, and ordinary treatment without evacuation will suffice, provided there be no fever;-bandaging, according to rule; and the callus forms in twenty days, the bone being of a porous nature. But in cases of contusion, tubercles form, along with cough, suppurating sores, and sphacelus of the ribs, for nerves from all the parts run along each rib. In many of these cases haemoptysis and empyema also take place. The management of this case consists in careful treatment, bandaging according to rule, diet at first restricted, but afterward more liberal, quiet, silence, position, bowels, and venereal matters regulated. Even when there is no spitting of blood, these contusions are more painful than fractures, and are more subject in time to relapses; and when any mucous collection is left in the part, it makes itself be felt in disorders of the body. Treatment:-burning, when the bone is affected, down to the bone, but not touching the bone itself; if in the intercostal space, the burning must not extend through it, nor be too superficial. In sphacelus of the ribs, tents are to be tried, all other particulars will be stated afterward: but they should be learned by sight rather than by words, namely, food, drink, heat, cold, attitude; medicines, dry, liquid, red, dark, white, sour, for the ulcers, and so with regard to the diet.

37. Displacements ( of the vertebrae ) from a fall rarely admit of being rectified, and those above the diaphragm are most difficult to rectify. When the accident happens to children, the body does not grow, with the exception of the legs, the arms, and head. Excurvation, in adults, speedily relieves the individual from the disease he is laboring under, but in time it renews its attack, with the same symptoms as in children, but of a less serious nature. Some individuals have borne this affection well, and have turned out to be brawny and fat. But few of them have lived to the age of sixty. Lateral curvatures also occur, the proximate cause of which is the attitudes in which these persons lie. These cases have their prognostics accordingly.

38. The rule for the reduction and adjustment:-The axle, the lever, the wedge, pressure above; the axle to separate, the lever to push aside. Reduction and adjustment are to be accomplished by forcible extension, the parts being placed in such a position as will facilitate the conveying of the displaced bone over the extremity of the bone from which it was displaced: this is to be accomplished either with the hands, or by suspension, or axles, or turned round something. With the hands this is to be effected properly, according to the structure of the parts. In the case of the wrist and elbow, the parts are to be forced asunder, at the wrist in the line of the elbow, and the elbow with the fore-arm at a right angle with the arm, as when it is suspended in a sling. When we want to separate the protruding bones, and force them into place, in the case of the fingers, the toes, or the wrist, the proper separation may be made by hands, while the projecting part is forced into its place by pressing down with the heel or the palm of the hand upon some resisting object, while something moderately soft is laid under the projecting part, but nothing such under the other, and then pressure is to be made backward and downward, whether the dislocation be inward or outward. In lateral displacement, pressure and counter-pressure must be made on the opposite sides. Displacements forward can be reduced neither by sneezing, nor coughing, nor by the injection of air, nor by the cupping-instrument; and if anything can do good in such a case, it is extension. People are deceived in fractures of the spinal processes, the pain of which causing the patient to stoop forward, the case is taken for dislocation inward; these fractures heal speedily and easily. Dislocation outward is to be remedied by succussion, when high up, toward the feet; and when situated low down, in the contrary direction; the part is to be pressed back into its place, either with the foot or a board. Dislocations to either side, if they admit of any remedy, are to be treated by extension, and suitable attitudes, with regimen. The whole apparatus should be broad, soft, and strong; or otherwise, they should be wrapped in rags; before being used, they should all be prepared proportionately to the length, height, and breadth. In applying extension to the thigh, for example, the bands should be fastened at the ankle and above the knee, these stretching in the same direction, another band to be passed by the loins, and around the armpits, and by the perineum and thigh, one end passing up the breast and the other along the back, these all stretching in the same direction and being fastened either to a piece of wood resembling a pestle or to an axle. When this is done on a couch, either of its feet is to be fastened to the threshold, and a strong block of wood is to be laid across the other, and the pieces of wood resembling a pestle are to be raised on these, to make extension and counter-extension; the naves of a wheel are to be fastened in the floor, or a ladder is to be adjusted, so that extension may be made in both directions. The thing commonly used is a bench six cubits long, two cubits broad, one fathom in thickness, having two low axles at this end and that, and having at its middle two moderate sized pillars, to which is to be adjusted a transverse piece of wood like the step of a ladder, which is to receive the piece of wood tied below the limb, as is done in dislocation at the shoulder; and the bench is to have excavations like trays, smooth, four inches in breadth and depth, and at such an interval as to leave room for the lever used to reduce the limb. In the middle of the bench a square hole is to be scooped out to receive a small pillar, which, being adjusted to the perineum, will obviate the tendency of the body to slip downward, and being rather loose may act somewhat as a lever. In certain occasions a piece of wood is required, which is inserted into a hole scooped out of the wall; the other end of it is then to be pressed down, something moderately soft being placed under it.

39. In those cases where the bone of the palate has exfoliated, the nose sinks in its middle. In contusions of the head without a wound, either from a fall, a fracture, or pressure, in certain of these cases acrid humors descend from the head to the throat, and from the wound in the head to the liver and thigh.

40. The symptoms of subluxations and luxations, and where, and how, and how much these differ from one another. And the cases in which the articular cavity has been broke off, and in which the ligament has been torn, and in which the epiphysis has broken in which, and how, when the limb consists of two bones, one or both are broken: in consequence of these the dangers, chances in which bad, and when the injuries will result in death, and when in recovery. What cases are to be reduced or attempted, and when, and which, and when not; the hopes and dangers in these cases. Which and when congenital dislocations are to be undertaken: the parts in a state of growth, the parts fully grown, and why sooner, or slower: and why a part becomes maimed, and how, and how not: and why a certain part is atrophied, and where, and how, and in what cases to a less extent. And why fractured parts unite sooner or slower, how distortions and callosities form, and the remedy for them. In what cases there are external wounds, either at first or afterwards: in what fractures the bones are shortened, and in what not: in what cases the fractured bones protrude, and when they protrude most: in what cases dislocated bones protrude. That physicians are deceived, and by what means, in what they see, and in what they devise, regarding affections, and regarding cures. Established rules with regard to bandaging: preparation, presentation of the part, extension, adjustment, friction, bandaging, suspension and placing of the limb, attitude, seasons, diet. The more porous parts heal fastest, and vice versa. Distortions, where the bones are crooked. Flesh and tendons wasted on the side of the dislocation. The force used in reduction to be applied at as great a distance as possible from the seat of the displacement. Of nerves ( ligaments? ), those which are in motion and in humidity ( flabby? ) are of a yielding nature; those that are not, less so. In every dislocation the most speedy reduction is best. Reduction not to be made while the patient is in a febrile state, nor on the fourth or fifth day; and least of all, in those of the elbow, and all cases which induce torpor; the soonest the best, provided the inflammatory stage be avoided. Parts torn asunder, whether nerves, or cartilages, or epiphyses, or parts separated at symphyses, cannot possibly be restored to their former state; but callus is quickly formed in most cases, yet the use of the limb is preserved. Of luxations, those nearest the extremities are least dangerous. Those joints which are most easily dislocated are the least subject to inflammation. Those which have been least inflamed, and have not been subjected to after-treatment, are most liable to be dislocated anew. Extension should be made in the position most calculated to enable the one bone to clear the extremity of the other, attention being paid to configuration and place. Adjustment to be made in the direction of the displacement; to push the displaced limb straight backward and sideways. Parts suddenly drawn aside are to be suddenly drawn back by a rotatory motion. Articulations which have been oftenest dislocated are the most easily reduced; the cause is the conformation of the nerves ( ligaments? ) or of the bones; of the ligaments that they are long and yielding; and of the bones, the shallowness of the articular cavity, and roundness of the head [of the bone that enters it]. Usage, by its friction, forms a new socket. The cause-the disposition, and habit, and age. A part somewhat mucous is not subject to inflammation.

41. In those cases where there are wounds, either at first, or from protrusion of the bones; or afterwards, from pruritus, or irritation; in the latter case you are immediately to unloose the bandages, and having applied pitched cerate to the wound, bandage the limb, placing the head of the roller upon the wound, and proceeding otherwise as if there were no wound in the case; for thus will the swelling be reduced as much as possible, and the wound will suppurate most quickly, and the diseased parts will separate, and when it becomes clean the wound will most quickly heal. Splints are not to be applied to the place, nor is it to be bound tight. Proceed thus when no large bones exfoliate, but not in the latter case, for then there is great suppuration, and the same treatment is not applicable, but the parts require to be exposed to the air on account of the abscesses. In such cases where the bones protrude, and whether reduced or not, bandaging is not befitting, but distention is to be practiced by means of rolls of cloth, made like those used upon shackles; one of these is to be placed at the ankle, and the other at the knee; they are to be flattened toward the leg, soft, strong, and having rings; and rods made of cornel, and of a proper length and thickness are to be adjusted to them, so as to keep the parts distended; and straps, attached to both extremities, are to be inserted into the rings, so that the extremities being fixed into the rolls, may effect distention. Treatment:-Pitched cerate, in a hot state; the attitudes, position of the foot and hip; regulated diet. The bones which have protruded through the skin are to be replaced the same day, or next; not on the fourth or fifth, but when the swelling has subsided. Reduction is to be performed with levers; when the bone does not present any place upon which the lever can rest, a portion of the part which prevents this is to be sawed off. But the denuded parts will drop off, and the limb become shortened.

42. Dislocations at the joints are to a greater and less extent. Those that are to a less extent are the most easily reduced; those that are to a greater extent occasion lesions of the bones, of the ligaments, of the joints, of the fleshy parts, and of the attitudes. The thigh and arm resemble one another very much in their dislocations.

ON INJURIES OF THE HEAD

Translated by Charles Darwin Adams

1. MEN’S heads are by no means all like to one another, nor are the sutures of the head of all men constructed in the same form. Thus, whoever has a prominence in the anterior part of the head (by prominence is meant the round protuberant part of the bone which projects beyond the rest of it), in him the sutures of the head take the form of the Greek letter tau , T; for the head has the shorter line running transverse before the prominence, while the other line runs through the middle of the head, all the way to the neck. But whoever has the prominence in the back part of the head, in him the sutures are constructed in quite the opposite form to the former; for in this case the shorter line runs in front of the prominence, while the longer runs through the middle all along to the forehead. But whoever has a prominence of the head both before and behind, in him the sutures resemble the Greek letter eta E; for the long lines of the letter run transverse before each prominence while the short one runs through the middle and terminates in the long lines. But whoever has no prominence on either part he has the sutures of the head resembling the Greek letter chi; for the one line comes transverse to the temple while the other passes along the middle of the head. The bone at the middle of the head is double, the hardest and most compact part being the upper portion, where it is connected with the skin, and the lowest, where it is connected with the meninx (dura mater); and from the uppermost and lowermost parts the bone gradually becomes softer and less compact, till you come to the diploe . The diploe is the most porous, the softest, and most cavernous part. But the whole bone of the head, with the, exception of a small portion of the uppermost and lowermost portions of it, is like a sponge; and the bone has in it many juicy substances, like caruncles; and if one will rub them with the fingers, some blood will issue from them. There are also in the bone certain very slender and hollow vessels full of blood. So it is with regard to hardness, softness, and porosity.

2. In respect to thickness and thinness; the thinnest and weakest part of the whole head is the part about the bregma; and the bone there has the smallest and thinnest covering of flesh upon it, and the largest proportion of brain is situated in that region of the head. And hence it happens that from similar or even smaller wounds and instruments, when a person is wounded to the same or a less degree, the bone of the head there is more contused, fractured, and depressed; and that injuries there are more deadly and more difficult to cure; and it is more difficult to save one’s life in injuries there than in any other part of the head; that from having sustained a similar or even a less wound a man will die, and that, too, in a shorter space of time than from a wound in any other part of the head. For the brain about the bregma feels more quickly and strongly any mischief that may occur to the flesh or the bone; for the brain about the bregma is in largest quantity, and is covered by the thinnest bone and the least flesh. Of the other portions, the weakest is that about the temples; for it is the conjunction of the lower jaw with the cranium, and there is motion there up and down as at a joint; and the organ of hearing is near it; and further, a hollow and important vein runs along the temple. But the whole bone of the head behind the vertex and the ear is stronger than the whole anterior part, and the bone itself has a larger and deeper covering of flesh upon it. And hence it follows, that when exposed to the same or even greater injuries from instruments of the same or greater size, the bone is less liable to be fractured and depressed than elsewhere; and that in a fatal accident the patient will live longer when the wound is in the posterior part of the head than when elsewhere; and that pus takes longer time to form and penetrate through the bone to the brain, owing to the thickness of the bone; and moreover, as there is less brain in that part of the head, more persons who are wounded in the back part of the head escape than of those who wounded in the anterior part. And in fatal cases, a man will survive longer in winter than in summer, whatever be the part of the head in which the wound is situated.

3. As to the haedrae (dints or marks?) of sharp and light weapons, when they take place in the bone without fissure, contusion, or depression inwards (and these take place equally in the anterior and posterior part of the head), death, when it does occur, does not properly result from them. A suture appearing in a wound, when the bone is laid bare, on whatever part of the head the wound may have been inflicted, is the weakest point of the head to resist a blow or a weapon, when the weapon happens to be impinged into the suture itself; but more especially when this occurs in the bregma at the weakest part of the head, and the sutures happen to be situated near the wound, and the weapon has hit the sutures themselves.

4. The bone in the head is liable to be wounded in the following modes, and there are many varieties in each of these modes of fracture: When a wounded bone breaks, in the bone comprehending the fissure, contusion necessarily takes place where the bone is broken; for an instrument that breaks the bone occasions a contusion thereof more or less, both at the fracture and in the parts of the bone surrounding the fracture. This is the first mode. But there are all possible varieties of fissures; for some of them are fine, and so very fine that they cannot be discovered, either immediately after the injury, or during the period in which it would be of use to the patient if this could be ascertained. And some of these fissures are thicker and wider, certain of them being very wide. And some of them extend to a greater, and some to a smaller, distance. And some are more straight, nay, completely straight; and some are more curved, and that in a remarkable degree. And some are deep, so as to extend downwards and through the whole bone; and some are less so, and do not penetrate through the whole bone.

5. But a bone may be contused, and yet remain in its natural condition without any fracture in it; this is the second mode. And there are many varieties of contusion; for they occur to a greater or less degree, and to a greater depth, so as sometimes to extend through the whole bone; or to a less depth, so as not to extend through the whole bone; and to a greater and smaller length and breadth. But it is not possible to recognize any of these varieties by the sight, so as to determine their form and extent; neither, indeed, is it visible to the eyes when any mischief of this kind takes place, and immediately after the injury, whether or not the bone has been actually bruised, as is likewise the case with certain fractures at a distance from the seat of injury.

6. And the bone being fractured, is sometimes depressed inwards from its natural level along with the fractures, otherwise there would be no depression; for the depressed portion being fractured and broken off, is pushed inwards, while the rest of the bone remains in its natural position; and in this manner a fracture is combined with the depression. This is the third mode. There are many varieties of depression, for it may comprehend a greater and a small extent of bone, and may either be to a greater depth, or less so, and more superficial.

7. When a hedra , or dint of a weapon, takes place in a bone, there may be a fracture combined with it; and provided there be a fracture, contusion must necessarily be joined, to a greater or less extent, in the seat of the dint and fracture, and in the bone which comprehends them. This is the fourth mode. And there may be a hedra , or indentation of the bone, along with contusion of the surrounding bone, but without any fracture either in the hedra or in the contusion inflicted by the weapon. But the indentation of a weapon takes place in a bone, and is called hedra , when the bone remaining in its natural state, the weapon which struck against the bone leaves its impression on the part which it struck. In each of these modes there are many varieties, with regard to the contusion and fracture, if both these be combined with the hedra , or if contusion alone, as it has been already stated that there are many varieties of contusion and fracture. And the hedra , or dint, of itself may be longer and shorter, crooked, straight, and circular; and there are many varieties of this mode, according to the shape of the weapon; and they may be more or less deep, and narrower or broader, and extremely broad. When a part is cleft, the cleft or notch which occurs in the bone, to whatever length or breadth, is a hedra , if the other bones comprehending the cleft remain in their natural position, and be not driven inwards; for in this case it would be a depression, and no longer a hedra .

8. A bone may be injured in a different part of the head from that on which the person has received the wound, and the bone has been laid bare. This is the fifth mode. And for this misfortune, when it occurs, there is no remedy; for when this mischief takes place, there is no means of ascertaining by any examination whether or not it has occurred, or on what part of the head.

9. Of these modes of fracture, the following require trepanning: the contusion, whether the bone be laid bare or not; and the fissure, whether apparent or not. And if, when an indentation ( hedra ) by a weapon takes place in a bone it be attended with fracture and contusion, and even if contusion alone, without fracture, be combined with the indentation, it requires trepanning. A bone depressed from position rarely requires trepanning; and those which are most pressed and broken require trepanning the least; neither does an indentation ( hedra ） without fracture and contusion require trepanning; nor does a notch, provided it is large and wide; for a notch and a hedra are the same.

10. In the first place, one must examine the wounded person, in what part of the head the wound is situated, whether in the stronger or weaker parts; and ascertain respecting the hairs about the wound, whether they have been cut off by the instrument, and have gone into the wound; and if so, one should declare that the bone runs the risk of being denuded of flesh, and of having sustained some injury from the weapon. These things one should say from a distant inspection, and before laying a hand on the man; but on a close examination one should endeavor to ascertain clearly whether the bone be denuded of flesh or not; and if the denuded bone be visible to the eyes, this will be enough; but otherwise an examination must be made with the sound. And if you find the bone denuded of the flesh, and not safe from the wound, you must first ascertain the state of the bone, and the extent of the mischief, and of what assistance it stands in need. One should also inquire of the wounded person how and in what way he sustained the injury; and if it be not apparent whether the bone has sustained an injury or not, it will be still more necessary, provided the bone be denuded, to make inquiry how the wound occurred, and in what manner; for when contusions and fractures existin the bone, but are not apparent, we must ascertain, in the first place from the patient’s answers, whether or not the bone has sustained any such injuries, and then find out the nature of the case by word and deed, with the exception of sounding. For sounding does not discover to us whether the bone has sustained any of these injuries or not; but sounding discovers to us an indentation inflicted by a weapon, and whether a bone be depressed from its natural position, and whether the bone be strongly fractured; all which may also be ascertained visibly with the eyes.

11. And a bone sustains fractures, either so fine as to escape the sight, or such as are apparent, and contusions which are not apparent, and depression from its natural position, especially when one person is intentionally wounded by another, or when, whether intentionally or not, a blow or stroke is received from an elevated place, and if the instrument in the hand, whether used in throwing or striking, be of a powerful nature, and if a stronger person wound a weaker. Of those who are wounded in the parts about the bone, or in the bone itself, by a fall, he who falls from a very high place upon a very hard and blunt object is in most danger of sustaining a fracture and contusion of the bone, and of having it depressed from its natural position; whereas he that falls upon more level ground, and upon a softer object, is likely to suffer less injury in the bone, or it may not be injured at all. Of those instruments which, falling upon the head, wound the parts about the bone, or the bone itself, that which falls from a very high place, and the least on a level with the person struck, and which is at the same time very hard, very blunt, and very heavy, and which is the least light, sharp, and soft, such an instrument would occasion a fracture and contusion of the bone. And there is most danger that the bone may sustain these injuries, under such circumstances, when the wound is direct and perpendicular to the bone, whether struck from the hand or from a throw, or when any object falls upon the person, or when he is wounded by falling, or in whatever way the bone sustains a direct wound from this instrument. Those weapons which graze the bone obliquely are less apt to fracture, contuse, or depress the bone, even when the bone is denuded of flesh; for in some of those wounds thus inflicted the bone is not laid bare of the flesh. Those instruments more especially produce fractures in the bone, whether apparent or not, and contusions, and inward depression of the bone, which are rounded, globular, smooth on all sides, blunt, heavy, and hard; and such weapons bruise, compress, and pound the flesh; and the wounds inflicted by such instruments, whether obliquely or circularly, are round, and are more disposed to suppurate, and to have a discharge, and take longer time to become clean; for the flesh which has been bruised and pounded must necessarily suppurate and slough away. But weapons of an oblong form, being, for the most part, slender, sharp, and light, penetrate the flesh rather than bruise it, and the bone in like manner; and such an instrument may occasion a hedra and a cut (for a hedra and a cut are same thing); but weapons of this description do not produce contusions, nor fractures, nor depressions inwardly. And in addition the appearances in the bone, which you call detect by the sight, you should make inquiry as to all these particulars (for they are symptoms of a greater or less injury), whether the wounded person was stunned, and whether darkness was diffused over his eyes, and whether he had vertigo, and fell to the ground.

12. When the bone happens to be denuded of flesh by the weapon, and when the wound occurs upon the sutures, it is difficult to distinguish the indentation ( hedra ) of a weapon which is clearly recognized in other parts of the bone, whether it exist or not, and especially if the hedra be seated in the sutures themselves. For the suture being rougher than the rest of the bone occasions confusion, and it is not clear which is the suture, and which the mark inflicted by the instrument, unless the latter ( hedra ) be large. Fracture also for the most part is combined with the indentation when it occurs in the sutures; and this fracture is more difficult to discern when the bone is broken, on this account, that if there be a fracture, it is situated for the most part in the suture. For the bone is liable to be broken and slackened there, owing to the natural weakness of the bone there, and to its porosity, and from the suture being readily ruptured and slackened: but the other bones which surround the suture remain unbroken, because they are stronger than the suture. For the fracture which occurs at the suture is also a slackening of the suture, and it is not easy to detect whether the bone be broken and slackened by the indentation of a weapon occurring in the suture, or from a contusion of the bone at the sutures; but it is still more difficult to detect a fracture connected with contusion. For the sutures, having the appearance of fissures, elude the discernment and sight of the physician, as being rougher than the rest of the bone, unless the bone be strongly cut and slackened (for a cut and a hedra are the same thing). But it is necessary, if the wound has occurred at the sutures, and the weapon has impinged on the bone or the parts about it, to pay attention and find out what injury the bone has sustained. For a person wounded to the same, or a much smaller, extent, and by weapons of the same size and quality, and even much less, will sustain a much greater injury, provided he has received the blow at the sutures, than if it was elsewhere. And many of these require trepanning, but you must not apply the trepan to the sutures themselves, but on the adjoining bone.

13. And with regard to the cure of wounds in the head, and the mode of detecting injuries in the bone which are not apparent, the following is my opinion:- In a wound of the head, you must not apply anything liquid, not even wine, but as little as possible, nor a cataplasm, nor conduct the treatment with tents, nor apply a bandage to an ulcer on the head, unless it be situated on the forehead, in the part which is bare of hairs, or about the eyebrow and eye, for wounds occurring there require cataplasms and bandages more than upon any other part of the head. For the rest of the head surrounds the whole forehead, and the wounds wherever situated become inflamed and swelled, owing to an influx of blood from surrounding parts. And neither must you apply cataplasms and bandages to the forehead at all times; but when the inflammation is stopped and the swelling has subsided, you must give up the cataplasms and bandages. A wound in any other part of the head must not be treated with tents, bandages, or cataplasms, unless it also requires incision. You must perform incision on wounds situated on the head and forehead, whenever the bone is denuded of flesh, and appears to have sustained some injury from the blow, but the wound has not sufficient length and breadth for the inspection of the bone, so that it may be seen whether it has received any mischief from the blow, and of what nature the injury is, and to what extent the flesh has been contused, and whether the bone has sustained any injury, or whether it be uninjured by the blow, and has suffered no mischief; and with regard to the treatment, what the wound, and the flesh, and the injury of the bone stand in need of. Ulcers of this description stand in need of incision; and, if the bone be denuded of the flesh, and if it be hollow, and extend far obliquely, we cut up the cavity wherever the medicine cannot penetrate readily, whatever medicine it may be; and wounds which are more inclined to be circular and hollow, and for the most part others of the like shape, are cut up by making double incision in the circle lengthways, according to the figure of the man, so as to make the wound of a long form. Incisions may be practiced with impunity on other parts of the head, with the exception of the temple and the parts above it, where there is a vein that runs across the temple, in which region an incision is not to be made. For convulsions seize on a person who has been thus treated; and if the incision be on the left temple, the convulsions seize on the right side; and if the incision be on the right side, the convulsions take place on the left side.

14. When, then, you lay open a wound in the head on account of the bones having been denuded of the flesh, as wishing to ascertain whether or not the bone has received an injury from the blow, you must make an incision proportionate to the size of the wound, and as much as shall be judged necessary. And in making the incision you must separate the flesh from the bone where it is united to the membrane ( pericranium? ） and to the bone, and then fill the whole wound with a tent, which will expand the wound very wide next day with as little pain as possible; and along with the tents apply a cataplasm, consisting of a mass ( maza ） of fine flour pounded in vinegar, or boiled so as to render it as glutinous as possible. On the next day, when you remove the tent, having examined the bone to see what injury it has sustained, if the wound in the bone be not right seen by you, nor can you discover what mischief the bone itself has sustained, but the instrument seems to have penetrated to the bone so as to have injured it, you must scrape the bone with a raspatory to a depth and length proportionate to the suture of the patient, and again in a transverse direction, for the sake of the fractures which are not seen, and of the contusions which are not discovered, as not being accompanied with depression of the bone from its natural position. For the scraping discovers the mischief, if the injuries in the bone be not otherwise manifest. And if you perceive an indentation ( hedra ) left in the bone by the blow, you must scrape the dint itself and the surrounding bones, lest, as often happens, there should be a fracture and contusion, or a contusion alone, combined with the dint, and escape observation. And when you scrape the bone with the raspatory, and it appears that the wound in the bone requires the operation, you must not postpone it for three days, but do it during this period, more especially if the weather be hot, and you have had the management of the treatment from commencement. If you suspect that the bone is broken or contused, or has sustained both these injuries, having formed your judgement from the severity of the wound, and from the information of the patient, as that the person who inflicted the wound, provided it was done by another person, was remarkably strong, and that the weapon by which he was wounded was of a dangerous description, and then that the man had been seized with vertigo, dimness of vision, and stupor, and fell to the ground,- under these circumstances, if you cannot discover whether the bone be broken, contused, or both the one and the other, nor can see the truth of the matter, you must dissolve the jet-black ointment, and fill the wound with it when this dissolved, and apply a linen rag smeared with oil, and then a cataplasm of the maza with a bandage; and on the next day, having cleaned out the wound, scrape the bone with the raspatory. And if the bone is not sound, but fractured and contused, the rest of it which is scraped will be white; but the fracture and contusion, having imbibed the preparation, will appear black, while the rest of the bone is white. And you must again scrape more deeply the fracture where it appears black; and, if you thus remove the fissure, and cause it to disappear, you may conclude that there has been a contusion of the bone to a greater or less extent, which has occasioned the fracture that has disappeared under the raspatory; but it is less dangerous, and a matter of less consequence, when the fissure has been effaced. But if the fracture extend deep, and do not seem likely to disappear when scraped, such an accident requires trepanning. But having performed this operation, you must apply the other treatment to the wound.

15. You must be upon your guard lest the bone sustain any injury from the fleshy parts if not properly treated. When the bone has been sawed and otherwise denuded, whether it be actually sound, or only appears to be so, but has sustained some injury from the blow, there may be danger of its suppurating (although it would not otherwise have done so), if the flesh which surrounds the bone be ill cured, and become inflamed and strangled; for it gets into a febrile state, and becomes much inflamed. For the bone acquires heat and inflammation from the surrounding flesh, along with irritation and throbbing, and the other mischiefs which are in the flesh itself, and from these it gets into a state of suppuration. It is a bad thing for the flesh ( granulations? ） in an ulcer to be moist and mouldy, and to require a long time to become clean. But the wound should be made to suppurate as quickly as possible; for, thus the parts surrounding the wound would be the least disposed to inflammation, and would become the soonest clean; for the flesh which has been chopped and bruised by the blow, must necessarily suppurate and slough away. But when cleaned the wound must be dried, for thus the wound will most speedily become whole, when flesh devoid of humors grows up, and thus there will be no fungous flesh in the sore. The same thing applies to the membrane which surrounds the brain: for when, by sawing the bone, and removing it from the meninx, you lay the latter bare, you must make it clean and dry as quickly as possible, lest being in a moist state for a considerable time, it become soaked therewith and swelled; for when these things occur, there is danger of its mortifying.

16. A piece of bone that must separate from the rest of the bone, in consequence of a wound in the head, either from the indentation ( hedra ) of a blow in the bone, or from the bone being otherwise denuded for a long time, separates mostly by becoming exsanguous. For the bone becomes dried up and loses its blood by time and a multiplicity of medicines which are used; and the separation will take place most quickly, if one having cleaned the wound as quickly as possible will next dry it, and the piece of bone, whether larger or smaller. For a piece of bone which is quickly dried and converted, as it were, into a shell, is most readily separated from the rest of the bone which retains its blood and vitality; for, the part having become exsanguous and dry, more readily drops off from that which retains its blood and is alive.

17. Such pieces of bone as are depressed from their natural position, either being broken off or chopped off to a considerable extent, are attended with less danger, provided the membrane be safe; and bones which are broken by numerous and broader fractures are still less dangerous and more easily extracted. And you must not trepan any of them, nor run any risks in attempting to extract the pieces of bone, until they rise up of their own accord, upon the subsidence of the swelling. They rise up when the flesh ( granulations ) grows below, and it grows from the diploe of the bone, and from the sound portion, provided the upper table alone be in a state of necrosis. And the flesh will shoot up and grow below the more quickly, and the pieces of bone ascend, if one will get the wound to suppurate and make it clean as quickly as possible. And when both the tables of the bone are driven in upon the membrane, I mean the upper and lower, the wound, if treated in the same way, will very soon get well, and the depressed bones will quickly rise up.

18. The bones of children are thinner and softer, for this reason, that they contain more blood [than those of adults]; and they are porous and spongy, and neither dense nor hard. And when wounded to a similar or inferior degree by weapons of the same or even of an inferior power, the bone of a young person more readily and quickly suppurates, and that in less time than the bone of an older person; and in accidents, which are to prove fatal, the younger person will die sooner than the elder. But if the bone is laid bare of flesh, one must attend and try to find out, what even is not obvious to the sight, and discover whether the bone be broken and contused, or only contused; and if, when there is an indentation in the bone, whether contusion, or fracture, or both be joined to it; and if the bone has sustained any of these injuries, we must give issue to the blood by perforating the bone with a small trepan, observing the greatest precautions, for the bone of young persons is thinner and more superficial than that of elder persons.

19. When a person has sustained a mortal wound on the head, which cannot be cured, nor his life preserved, you may form an opinion of his approaching dissolution, and foretell what is to happen from the following symptoms which such a person experiences. When a bone is broken, or cleft, or contused, or otherwise injured, and when by mistake it has not been discovered, and neither the raspatory nor trepan has been applied as required, but the case has been neglected as if the bone were sound, fever will generally come on if in winter, and in summer the fever usually seizes after seven days. And when this happens, the wound loses its color, and the inflammation dies in it; and it becomes glutinous, and appears like a pickle, being of a tawny and somewhat livid color; and the bone then begins to sphacelate, and turns black where it was white before, and at last becomes pale and blanched. But when suppuration is fairly established in it, small blisters form on the tongue and he dies delirious. And, for the most part, convulsions seize the other side of the body; for, if the wound be situated on the left side, the convulsions will seize the right side of the body; or if the wound be on the right side of the head, the convulsion attacks the left side of the body. And some become apoplectic. And thus they die before the end of seven days, if in summer; and before fourteen, if in winter. And these symptoms indicate, in the same manner, whether the wound be older or more recent. But if you perceive that fever is coming on, and that any of these symptoms accompany it, you must not put off, but having sawed the bone to the membrane ( meninx ), or scraped it with a raspatory (and it is then easily sawed or scraped), you must apply the other treatment as may seem proper, attention being paid to circumstances.

20. When in any wound of the head, whether the man has been trepanned or not, but the bone has been laid bare, a red and erysipelatous swelling supervenes in the face, and in both eyes, or in either of them, and if the swelling be painful to the touch, and if fever and rigor come on, and if the wound look well, whether as regards the flesh or the bone, and if the parts surrounding the wound be well, except the swelling in the face, and if the swelling be not connected with any error in the regimen, you must purge the bowels in such a case with a medicine which will evacuate bile; and when thus purged the fever goes off, the swelling subsides, and the patient gets well. In giving the medicine you must pay attention to the strength of the patient.

21. With regard to trepanning, when there is a necessity for it, the following particulars should be known. If you have had the management of the case from the first, you must not at once saw the bone down to the meninx; for it is not proper that the membrane should be laid bare and exposed to injuries for a length of time, as in the end it may become fungous. And there is another danger if you saw the bone down to the meninx and remove it at once, lest in the act of sawing you should wound the meninx. But in trepanning, when only a very little of the bone remains to be sawed through, and the bone can be moved, you must desist from sawing, and leave the bone to fall out of itself. For to a bone not sawed through, and where a portion is left of the sawing, no mischief can happen; for the portion now left is sufficiently thin. In other respects you must conduct the treatment as may appear suitable to the wound. And in trepanning you must frequently remove the trepan, on account of the heat in the bone, and plunge it in cold water. For the trepan being heated by running round, and heating and drying the bone, burns it and makes a larger piece of bone around the sawing to drop off, than would otherwise do. And if you wish to saw at once down to the membrane, and then remove the bone, you must also, in like manner, frequently take out the trepan and dip it in cold water. But if you have not charge of the treatment from the first, but undertake it from another after a time, you must saw the bone at once down to the meninx with a serrated trepan, and in doing so must frequently take out the trepan and examine with a sound (specillum), and otherwise along the tract of the instrument. For the bone is much sooner sawn through, provided there be matter below it and in it, and it often happens that the bone is more superficial, especially if the wound is situated in that part of the head where the bone is rather thinner than in other parts. But you must take care where you apply the trepan, and see that you do so only where it appears to be particularly thick, and having fixed the instrument there, that you frequently make examinations and endeavor by moving the bone to bring it up. Having removed it, you must apply the other suitable remedies to the wound. And if, when you have the management of the treatment from the first, you wish to saw through the bone at once, and remove it from the membrane, you must, in like manner, examine the tract of the instrument frequently with the sound, and see that it is fixed on the thickest part of the bone, and endeavor to remove the bone by moving it about. But if you use a perforator ( trepan? ), you must not penetrate to the membrane, if you operate on a case which you have had the charge of from the first, but must leave a thin scale of bone, as described in the process of sawing.

THE HIPPOCRATIC OATH

Translated by Charles Darwin Adams

Scholars widely believe that Hippocrates, or one of his students wrote the ὅρκος, the traditional oath, taken by new physicians, swearing to a number of healing gods to uphold specific ethical standards. Of historic and traditional value, the oath is considered a rite of passage for practitioners of medicine in many countries, although nowadays the modernised version of the text varies. The oath was originally written in Ionic Greek from the late 5th century BC and remains a key text of the Hippocratic Corpus.

A twelfth century Byzantine manuscript of the Hippocratic Oath

THE HIPPOCRATIC OATH

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

THE LAW

OR, THE CANON

Translated by Charles Darwin Adams

1. Medicine is of all the Arts the most noble; but, not withstanding, owing to the ignorance of those who practice it, and of those who, inconsiderately, form a judgment of them, it is at present far behind all the other arts. Their mistake appears to me to arise principally from this, that in the cities there is no punishment connected with the practice of medicine (and with it alone) except disgrace, and that does not hurt those who are familiar with it. Such persons are like the figures which are introduced in tragedies, for as they have the shape, and dress, and personal appearance of an actor, but are not actors, so also physicians are many in title but very few in reality.

2. Whoever is to acquire a competent knowledge of medicine, ought to be possessed of the following advantages: a natural disposition; instruction; a favorable position for the study; early tuition; love of labor; leisure. First of all, a natural talent is required; for, when Nature opposes, everything else is in vain; but when Nature leads the way to what is most excellent, instruction in the art takes place, which the student must try to appropriate to himself by reflection, becoming an early pupil in a place well adapted for instruction. He must also bring to the task a love of labor and perseverance, so that the instruction taking root may bring forth proper and abundant fruits.

3. Instruction in medicine is like the culture of the productions of the earth. For our natural disposition is, as it were, the soil; the tenets of our teacher are, as it were, the seed; instruction in youth is like the planting of the seed in the ground at the proper season; the place where the instruction is communicated is like the food imparted to vegetables by the atmosphere; diligent study is like the cultivation of the fields; and it is time which imparts strength to all things and brings them to maturity.

4. Having brought all these requisites to the study of medicine, and having acquired a true knowledge of it, we shall thus, in traveling through the cities, be esteemed physicians not only in name but in reality. But inexperience is a bad treasure, and a bad fund to those who possess it, whether in opinion or reality, being devoid of self-reliance and contentedness, and the nurse both of timidity and audacity. For timidity betrays a want of powers, and audacity a want of skill. There are, indeed, two things, knowledge and opinion, of which the one makes its possessor really to know, the other to be ignorant.

5. Those things which are sacred, are to be imparted only to sacred persons; and it is not lawful to import them to the profane until they have been initiated in the mysteries of the science.

THE PHYSICIAN’S ESTABLISHMENT

OR, ON THE SURGERY

Translated by Charles Darwin Adams

1. It’s the business of the physician to know, in the first place, things similar and things dissimilar; those connected with things most important, most easily known, and in anywise known; which are to be seen, touched, and heard; which are to be perceived in the sight, and the touch, and the hearing, and the nose, and the tongue, and the understanding; which are to be known by all the means we know other things.

2. The things relating to surgery, are- the patient; the operator; the assistants; the instruments; the light, where and how; how many things, and how; where the body, and the instruments; the time; the manner; the place.

3. The operator is either sitting or standing, conveniently for himself, for the person operated upon, for the light. There are two kinds of light, the common and the artificial; the common is not at our disposal, the artificial is at our disposal. There are two modes of using each, either to the light, or from the light (to the side?). There is little use of that which is from ( or oblique to the light), and the degree of it is obvious. As to opposite the light, we must turn the part to be operated upon to that which is most brilliant of present and convenient lights, unless those parts which should be concealed, and which it is a shame to look upon; thus the part that is operated upon should be opposite the light, and the operator opposite the part operated upon, except in so far as he does not stand in his own light; for in this case the operator will indeed see, but the thing operated upon will not be seen. With regard to himself when sitting, his feet should be raised to a direct line with his knees, and nearly in contact with one another; the knees a little higher than the groins, and at some distance from one another, for the elbows to rest upon them. The robe, in a neat and orderly manner, is to be thrown over the elbows and shoulders equally and proportionally. With regard to the part operated upon; we have to consider how far distant, and how near, above, below, on this side on that side, or in the middle. The measure as to distance and proximity is, that the elbows do not press the knees before, nor the sides behind; that the hands be not raised higher than the breasts, nor lower than so as that when the breast reposes on the knees he may have the hands at right angles with the arm: thus it is as regards the medium; but as concerns this side or that, the operator must not be beyond his seat, but in proportion as he may require turning he must shift the body, or part of the body, that is operated upon. When standing, he must make his inspection, resting firmly and equally on both feet; but he must operate while supporting himself upon either leg, and not the one on the same side with the hand which he makes use of; the knee being raised to the height of the groins as while sitting; and the other measures in like manner. The person operated upon should accommodate the operator with regard to the other parts of his body, either standing, sitting, or lying; so as that he may continue to preserve his figure, avoid sinking down, shrinking from, turning away; and may maintain the figure and position of the part operated upon, during the act of presentation, during the operation, and in the subsequent position.

4. The nails should be neither longer nor shorter than the points of the fingers; and the surgeon should practice with the extremities of the fingers, the index-finger being usually turned to the thumb; when using the entire hand, it should be prone; when both hands, they should be opposed to one another. It greatly promotes a dexterous use of the fingers when the space between them is large, and when the thumb is opposed to the index. But it is clearly a disease when the thumb is impaired from birth, or when, from a habit contracted during the time of nursing, it is impeded in its motions by the fingers. One should practice all sorts of work with either of them, and with both together (for they are both alike), endeavouring to do them well, elegantly, quickly, without trouble, neatly, and promptly.

5. The instruments, and when and how they should be prepared, will be treated of afterwards; so that they may not impede the work, and that there may be no difficulty in taking hold of them, with the part of the body which operates. But if another gives them, he must be ready a little beforehand, and do as you direct.

6. Those about the patient must present the part to be operated upon as may seem proper, and they must hold the rest of the body steady, in silence, and listening to the commands of the operator.

7. There are two views of bandaging: that which regards it while doing, and that which regards it when done. It should be done quickly, without pain, with ease, and with elegance; quickly, by despatching the work; without pain, by being readily done; with ease, by being prepared for everything; and with elegance, so that it may be agreeable to the sight. By what mode of training these accomplishments are to be acquired has been stated. When done, it should fit well and neatly; it is neatly done when with judgment, and when it is equal and unequal, according as the parts are equal or unequal. The forms of it (the bandage?) are the simple, the slightly winding (called ascia), the sloping (sima), the monoculus, the rhombus, and the semi-rhombus. The form of bandage should be suitable to the form and the affection of the part to which it is applied.

8. There are two useful purposes to be fulfilled by bandaging: ( first ,) strength, which is imparted by the compression and the number of folds. In one case the bandage effects the cure, and in another it contributes to the cure. For these purposes this is the rule- that the force of the constriction be such as to prevent the adjoining parts from separating, without compressing them much, and so that the parts may be adjusted but not forced together; and that the constriction be small at the extremities, and least of all in the middle. The knot and the thread that is passed through should not be in a downward but in an upward direction, regard being had to the circumstances under which the case is presented; to position, to the bandaging, and to the compression. The commencement of the ligatures is not to be placed at the wound, but where the knot is situated. The knot should not be placed where it will be exposed to friction, nor where it will be in the way, nor where it will be useless. The knot and the thread should be soft, and not large.

9. ( Second. ) One ought to be well aware that every bandage has a tendency to fall off towards the part that declines or becomes smaller; as, for example, upwards, in the case of the head, and downwards, in the case of the leg. The turns of the bandage should be made from right to left, and from left to right, except on the head, where it should be in a straight direction. When opposite parts are to be bandaged together, we must use a bandage with two heads; or if we make use of a bandage with one head, we must attach it in like manner at some fixed point: such, for example, as the middle of the head; and so in other cases. Those parts which are much exposed to motion, such as the joints, where there is a flexion, should have few and slight bandages applied to them, as at the ham; but where there is much extension, the bandage should be single and broad, as at the kneepan; and for the maintenance of the bandage in its proper place, some turns should be carried to those parts which are not much moved, and are lank, such as the parts above and below the knee. In the case of the shoulder; a fold should be carried round by the other armpit; in that of the groin, by the flanks of the opposite side; and of the leg, to above the calf of the leg. When the bandage has a tendency to escape above, it should be secured below, and vice versa ; and where there is no means of doing this, as in the case of the head, the turns are to be made mostly on the most level part of the head, and the folds are to be done with as little obliquity as possible, so that the firmest part being last applied may secure the portions which are more movable. When we cannot secure the bandaging by means of folds of the cloth, nor by suspending them from the opposite side, we must have recourse to stitching it with ligatures, either passed circularly or in the form of a seam.

10. The bandages should be clean, light, soft, and thin. One should practice rolling with both hands together, and with either separately. One should also choose a suitable one, according to the breadth and thickness of the parts. The heads of the bandages should be hard, smooth, and neatly put on. That sort of bandaging is the worst which quickly falls off; but those are bad bandages which neither compress nor yet come off.

11. The following are the object which the upper bandage, the under bandage, or both aim at: The object of the under bandage is either to bring together parts that are separated, or to compress such as are expanded, or to separate what are contracted, or to restore to shape what are distorted, or the contrary. It is necessary to prepare pieces of linen cloth, which are light, thin, soft, clean, having no seams nor protuberances on them, but sound, and able to bear some stretching, or even a little more than required; not dry, but wetted with a juice suitable to the purpose required. We must deal with parts separated ( in a sinus? ) in such wise, that the parts which are raised may touch the bottom without producing pressure; we must begin on the sound part, and terminate at the wound; so that whatever humor is in it may be expelled, and that it may be prevented from collecting more. And straight parts are to be bandaged in a straight direction, and oblique obliquely, in such a position as to create no pain; and so that there may be no constriction nor falling off on a change of position, either for the purpose of taking hold of anything, or laying the limb; and that muscles, veins, nerves, and bones may be properly placed and adjusted to one another. It should be raised or laid in a natural position, so as not to occasion pain. In those cases in which an abscess is formed, we must act in a contrary way. When our object is to bring together parts which have become expanded, in other respects we must proceed on the same plain; and we must commence the bringing together from some considerable distance; and after their approach, we must apply compression, at first slight, and afterwards stronger, the limit of it being the actual contact of the parts. In order to separate parts which are drawn together, when attended with inflammation, we must proceed on the opposite plan; but when without inflammation, we must use the same preparations, but bandage in the opposite direction. In order to rectify distorted parts, we must proceed otherwise on the same principles; but the parts which are separated must be brought together by an underbandage, by agglutinants, and by suspending it ( the limb? ) in its natural position. And when the deformities are the contrary, this is to be done on the contrary plan.

12. In fractures we must attend to the length, breadth, thickness, and number of the compresses. The length should be that of the bandaging; the breadth, three or four fingers; thickness, three or fourfold; number so as to encircle the limb, neither more nor less; those applied for the purpose of rectifying a deformity, should be of such a length as to encircle it; the breadth and thickness being determined by the vacuity, which is not to be filled up at once. The upper bandages are two, the first of which is to be carried from the seat of the injury upwards, and the second from the seat of the injury downwards, and from below upwards; the parts about the seat of the injury being most compressed, the extremities least, and the rest in proportion. The upper bandages should take in a considerable portion of the sound parts. We must attend to the number, length, and breadth of the bandages; the number must be such as not to be inferior to what the injury requires, nor occasion compression with the splints, nor prove cumbersome, nor occasion any slipping of them, nor render them inefficient. As to length and breadth, they should be three, four, five, or six cubits in length, and as many fingers broad. The folds of the strings ( selvages? ) should be such as not to occasion pressure; they are to be soft and not thick; and all these things are to be proportionate to the length, breadth, and thickness of the part affected. The splints are to be smooth, even, and rounded at the extremities; somewhat less all along than the upper bandaging, and thickest at the part to which fracture inclines. Those parts where there are tuber-osities, and which are devoid of flesh, such as the ankles or fingers, we must guard from the splints which are placed over them, either by position, or by their shortness. They are to be secured by the strings in such a manner as not to occasion pressure at first. A soft, consistent, and clean cerate should be rubbed into the folds of the bandage.

13. As to the temperature and quantity of the water used, its heat should be just such as the hand can bear, and it ought to be known that a large quantity is best for producing relaxation and attenuation, whereas a moderate quantity is best for incarnating and softening. The limit to the affusion is, to stop when the parts become swelled up, and before the swelling subsides; for the parts swell up at first, and fall afterward.

14. The object on which to ( the limb? ) is laid should be soft, smooth, and sloping upwards toward the protuberant parts of the body, such as the heel or hips, so that there may be no projection, nor bending inwards, nor turning aside. The canal ( spout or gutter? ) should rather comprehend the whole limb than the half of it, attention being paid to the injury and to whatever else appears to create inconvenience.

15. The presentation of the injured part to the physician, the extension, the arrangement, and so forth, are to be regulated according to nature. What is nature in these operations is to be determined by the accomplishment of the object which we have in view, and for this purpose we must look to the part in the state of rest, in its middle state, and to habit; in regard to the state of rest and relaxation, as in the arm, that it be in a line with the hand; and with regard to the medium between flexion and extension, that the forearm be at right angles to the arm; and with regard to habit, it should be considered that some limbs bear certain positions preferably, as, for example, the thighs extension; for in such attitudes the parts can best bear to be placed for a considerable time without a change of posture. And in the change from the state of distention, the muscles, veins, nerves, and bones, when properly arranged and secured, will preserve their relations to one another while the limb is raised or placed.

16. The extension should be most powerful when the largest and thickest bones, or when both are broken; next when the under-bone, and least of all, when the upper. When immoderate, it is injurious, except in the case of children. The limb should be a little elevated. The model by which we judge if the part be properly set is the sound part of the same name, or the part which is its pair.

17. Friction can relax, brace, incarnate, attenuate: hard braces, soft relaxes, much attenuates, and moderate thickens.

18. The following should be the state of matters on the first application of the bandage. The person to whom it has been applied should say that he feels the compression particularly at the seat of the injury, but very little at the extremities; the parts should be adjusted but not pressed together, and that rather by the number of the bandages than by the force of the constriction; and the tightness should rather be on the increase during the first day and night; but on the next it should be less, and on the third the bandages should be loose. On the next day a soft swelling should be observed in the extremities; and on the third day, when the bandaging is loosed, the swelling should be found diminished in size, and this should be the case every time the bandages are removed. At the second application of the bandage, it should be ascertained whether the dressing has been properly done, and then greater compression should be made, and with more bandages; and on the third, still greater, and still more. On the seventh day from the first dressing, when the bandages are loosed, the limb should be found slender and the bones mobile. We must then have recourse to the splints, provided the limb be free of swelling, pruritus, and ulceration, and allow them to remain until twenty days after the accident; but if any suspicions arise, the bandages must be loosed in the interval. The splints should be tightened every third day.

19. The suspending of a fractured limb in a sling, the disposition of it, and the bandaging, all have for their object to preserve it in position. The principal considerations with regard to the position are the habits and the peculiar nature of each of the limbs: the varieties are shown in running, walking, standing, lying, action, repose.

20. It should be kept in mind that exercise strengthens, and inactivity wastes.

21. Compression should be produced by the number of bandages, rather than by the force of the constriction.

22. In cases of ecchymosis, contusions, sprains, or swellings not attended with inflammations, blood is to be expelled from the wound, in greatest quantity to the upper part, and in smallest to the inferior; neither the arm nor the leg should be placed in a declining position: the head of the bandage should be placed on the wound, and there the greatest pressure should be made; the least at the extremities, and intermediately in the middle; the last fold of the bandage should be at the upper part of the body. As to binding and compression, these objects are to be attained rather by the number of the bandages than the force of the constriction; and moreover, in these cases the bandages should be thin, light, soft, clean, broad, sound, so that they may effect their purpose, even without splints. And we must use affusions.

23. Dislocations, sprains, diastases of bones, violent separation, abruption of the extremities of bones, and distrainings, so as to induce varus or valgus , in these cases we must apply the bandages so as not to compress the part whence the displacement took place, and that we may render them tight at the side to which the displacement was, and give the limb an inclination in the opposite direction, and that in an excessive degree. We employ bandages, compresses, suspension of the limb in a sling, attitude, extension, friction, rectification; and along with these the affusion of much water.

24. In treating parts which are atrophied, we must comprehend a considerable part of the sound limb with the bandage, so that by the influx thereby produced, the wasted part may acquire a supply greater than its loss, and may be thus disposed to growth and restoration of its fleshy parts. It is better also to bandage the parts above, as the thigh in the case of the leg, and also the thigh and leg of the opposite side, so that they may be placed in similar circumstances, and may both equally be deprived of motion; and that the supply of nourishment may be alike curtailed and open to both. The compression should be the effect rather of the number of the bandages than of their tightness. We relax first the part most requiring it, and have recourse to that kind of friction which will promote the growth of flesh, and to affusion. No splints.

25. Those things which are for the purpose of giving support and strength to the part, as to the breast, side, head, and so forth, are used in such cases as the following: for pulsations, that there may be no motion in the part; and in separation at the sutures of the skull, in order to give support; and in order to strengthen the chest and head, in coughs, sneezings, and other movements. In all these cases the same measure of bandaging is to be observed, for where the injury is, there the bandage should compress most, and something soft is to be placed below that suits with the complaint; and we must not apply the bandages tighter than just to stop the pulsations from creating disturbance, and that the separated parts at the sutures may be brought into contact, they must not be such as absolutely to stop the coughs and sneezings, but so as to give support, and, without occasioning uneasiness, prevent the parts from being shaken.

Works of the Hippocratic Corpus

Ruins of an Asklepieion (a healing temple) on Kos. Hippocrates was probably trained at the asklepieion, taking lessons from the Thracian physician Herodicus of Selymbria.

Another view of the Asklepieion

ON THE NATURE OF MAN

Translated by W. H. S. Jones

It is now generally believed that On the Nature of Man and the following treatise, Regimen in Health, are both by the hand of Polybus, the son in law and disciple of Hippocrates, as shown by a testimony from Aristotle’s History of Animals . On the Nature of Man attempts to explain the human body in its anatomy and composition. The content is based on detailed observation and defended by logical explanations of the causes of each disease in order to readily meet outside criticism. The treatise places emphasis on disease not being of divine origin, but rather an imbalance of the four humours (collection of blood, phlegm, black bile, and yellow bile) in the body.

The work demonstrates the common Hippocratic interest in humourism and in such treatments as bloodletting — a procedure performed in order to regulate the patient’s four humours. Polybus gives first hand accounts and explanations of individual medical cases. For example, dysentery and nosebleeds occur in the spring and summer, as this is when the blood is at its hottest. The author concludes that the degree of damage a given disease can do to a person depends on its nature. The most serious of illnesses are those that affect the strongest part of the body. If the strongest part of the body is affected, then the weak parts are easily affected and may cause death. However, if a disease starts in a weak area of the body, often it is curable.

NATURE OF MAN

I. He who is accustomed to hear speakers discuss the nature of man beyond its relations to medicine will not find the present account of any interest. For I do not say at all that a man is air, or fire, or water, or earth, or anything else that is not an obvious constituent of a man; such accounts I leave to those that care to give them. Those, however, who give them have not in my opinion correct knowledge. For while adopting the same idea they do not give the same account. Though they add the same appendix to their idea — saying that “what is” is a unity, and that this is both unity and the all — yet they are not agreed as to its name. One of them asserts that this one and the all is air, another calls it fire, another, water, and another, earth; while each appends to his own account evidence and proofs that amount to nothing. The fact that, while adopting the same idea, they do not give the same account, shows that their knowledge too is at fault. The best way to realise this is to be present at their debates. Given the same debaters and the same audience, the same man never wins in the discussion three times in succession, but now one is victor, now another, now he who happens to have the most glib tongue in the face of the crowd. Yet it is right that a man who claims correct knowledge about the facts should maintain his own argument victorious always, if his knowledge be knowledge of reality and if he set it forth correctly. But in my opinion such men by their lack of understanding overthrow themselves in the words of their very discussions, and establish the theory of Melissus.

II. Now about these men I have said enough, and I will turn to physicians. Some of them say that a man is blood, others that he is bile, a few that he is phlegm. Physicians, like the metaphysicians, all add the same appendix. For they say that a man is a unity, giving it the name that severally they

wish to give it; this changes its form and its power, being constrained by the hot and the cold, and becomes sweet, bitter, white, black and so on. But in my opinion these views also are incorrect. Most physicians then maintain views like these, if not identical with them; but I hold that if man were a unity he would never feel pain, as there would be nothing from which a unity could suffer pain. And even if he were to suffer, the cure too would have to be one. But as a matter of fact cures are many. For in the body are many constituents, which, by heating, by cooling, by drying or by wetting one another contrary to nature, engender diseases; so that both the forms of diseases are many and the healing of them is manifold. But I require of him who asserts that man is blood and nothing else, to point out a man when he does not change his form or assume every quality, and to point out a time, a season of the year or a season of human life, in which obviously blood is the only constituent of man. For it is only natural that there should be

one season in which blood-in-itself appears as the sole constituent. My remarks apply also to him who says that man is only phlegm, and to him who says that man is bile. I for my part will prove that what I declare to be the constituents of a man are, according to both convention and nature, always alike the same; it makes no difference whether the man be young or old, or whether the season be cold or hot. I will also bring evidence, and set forth the necessary causes why each constituent grows or decreases in the body.

III. Now in the first place generation cannot take place from a unity. How could a unity generate, without copulating? Again, there is no generation unless the copulating partners be of the same kind, and possess the same qualities; nor would there be any offspring. Moreover, generation will not take place if the combination of hot with cold and of dry

with moist be not tempered and equal — should the one constituent be much in excess of the other, and the stronger be much stronger than the weaker. Wherefore how is it likely for a thing to be generated from one, when generation does not take place from more than one unless they chance to be mutually well-tempered? Therefore, since such is the nature both of all other things and of man, man of necessity is not one, but each of the components contributing to generation has in the body the power it contributed. Again, each component must return to its own nature when the body of a man dies, moist to moist, dry to dry, hot to hot and cold to cold. Such too is the nature of animals, and of all other things. All things are born in a like way, and all things die in a like way. For the nature of them is composed of all those things I have mentioned above, and each thing, according to what has been said, ends in that from which it was composed. So that too is whither it departs.

IV. The body of man has in itself blood, phlegm, yellow bile and black bile; these make up the nature of his body, and through these he feels pain or enjoys health. Now he enjoys the most perfect health when these elements are duly proportioned to one another in respect of compounding, power and bulk, and when they are perfectly mingled. Pain is

felt when one of these elements is in defect or excess, or is isolated in the body without being compounded with all the others. For when an element is isolated and stands by itself, not only must the place which it left become diseased, but the place where it stands in a flood must, because of the excess, cause pain and distress. In fact when more of an element flows out of the body than is necessary to get rid of superfluity, the emptying causes pain. If, on the other hand, it be to an inward part that there takes place the emptying, the shifting and the separation from other elements, the man certainly must, according to what has been said, suffer from a double pain, one in the place left, and another in the place flooded.

V. Now I promised to show that what are according to me the constituents of man remain always the same, according to both convention and nature. These constituents are, I hold, blood, phlegm, yellow bile and black bile. First I assert that the names of these according to convention are separated, and that none of them has the same name as the others; furthermore, that according to nature their essential forms are separated, phlegm being quite unlike blood, blood being quite unlike bile, bile being quite unlike phlegm. How could they be like one another, when their colours appear not alike to the sight nor does their touch seem alike to the hand? For they are not equally warm, nor cold, nor dry, nor moist. Since then they are so different from one another in essential form and in power, they cannot be one, if fire and water are not one. From the following evidence you may know that these elements are not all one, but that each of them has its own power and its own nature. If you were to give a man a medicine which withdraws phlegm, he will vomit you phlegm; if you give him one which withdraws bile, he will vomit you bile. Similarly too black bile is purged away if you give a medicine which withdraws black bile. And if you wound a man’s body so as to cause a wound, blood will flow from him. And you will find all these things happen on any day and on any night, both in winter and in summer, so long as the man can draw breath in and then breathe it out again, or until he is deprived of one of the elements congenital with him. Congenital with him (how should they not be so?) are the elements already mentioned. First, so long as a man lives he manifestly has all these elements always in him; then he is born out of a human being having all these elements, and is nursed in a human being having them all, I mean those elements I have mentioned with proofs.

VI. Those who assert that man is composed of one element seem to me to have been influenced by the following line of thought. They see those who drink drugs and die through excessive purgings vomiting, in some cases bile, in others phlegm; then they think that the man is composed of that one thing from the purging of which they saw him die. Those too who say that man is composed of blood use the same line of thought. They see men who are cut bleeding from the body, and so they think that blood composes the soul of a man. Such is the evidence they all use in their discussions. Yet first, nobody yet in excessive purgings has vomited bile alone when he died. But when a man has drunk a drug which withdraws bile, he first vomits bile, then phlegm also. Afterwards under stress men vomit after these black bile, and finally they vomit also pure blood. The same experiences happen to those who drink drugs which withdraw phlegm. First they vomit phlegm, then yellow bile, then black, and finally pure blood, whereon they die. For when the drug enters the body, it first withdraws that constituent of the body which is most akin to itself, and then it draws and purges the other constituents. For just as things that are sown and grow in the earth, when they enter it, draw each that constituent of the earth which is nearest akin to it — these are the acid, the bitter, the sweet, the salt and so on — first the plant draws to itself mostly that element which is most akin to it, and then it draws the other constituents also. Such too is the action of drugs in the body. Those that withdraw bile first evacuate absolutely pure bile, then bile that is mixed.

Those that withdraw phlegm first withdraw absolutely pure phlegm, and then phlegm that is mixed. And when men are cut, the blood that flows is at first very hot and very red, and then it flows with more phlegm and bile mixed with it.

VII. Phlegm increases in a man in winter; for phlegm, being the coldest constituent of the body, is closest akin to winter. A proof that phlegm is very cold is that if you touch phlegm, bile and bloody you will find phlegm the coldest. And yet it is the most viscid, and after black bile requires most force for its evacuation. But things that are moved by force become hotter under the stress of the force. Yet in spite of all this, phlegm shows itself the coldest element by reason of its own nature. That winter fills the body with phlegm you can learn from the following evidence. It is in winter that the sputum and nasal discharge of men is fullest of phlegm; at this season mostly swellings become white, and diseases generally phlegmatic. And in spring too phlegm still remains strong in the body, while the blood increases. For the cold relaxes, and the rains come on, while the blood accordingly increases through the, showers and the hot days. For these conditions of the year are most akin to the nature of blood, spring being moist and warm. You can learn the truth from the following facts. It is chiefly in spring and summer that men are attacked by dysenteries, and by hemorrhage from the nose, and they are then hottest and red. And in summer blood is still strong, and bile rises in the body and extends until autumn. In autumn blood becomes small in quantity, as autumn is opposed to its nature, while bile prevails in the body during the summer season and during autumn. You may learn this truth from the following facts. During this season men vomit bile without an emetic, and when they take purges the discharges are most bilious. It is plain too from fevers and from the complexions of men. But in summer phlegm is at its weakest. For the season is opposed to its nature, being dry and warm. But in autumn blood becomes least in man, for autumn is dry and begins from this point to chill him. It is black bile which in autumn is greatest and strongest. When winter comes on, bile being chilled becomes small in quantity, and phlegm increases again because of the abundance of rain and the length of the nights. All these elements then are always comprised in the body of a man, but as the year goes round they become now greater and now less, each in turn and according to its nature. For just as every year participates in every element, the hot, the cold, the dry and the moist — none in fact of these elements would last for a moment without all the things that exist in this universe, but if one were to fail all would disappear, for by reason of the same necessity all things are constructed and nourished by one another — even so, if any of these congenital elements were to fail, the man could not live. In the year sometimes the winter is most powerful, sometimes the spring, sometimes the summer and sometimes the autumn. So too in man sometimes phlegm is powerful, sometimes blood, sometimes bile, first yellow, and then what is called black bile. The clearest proof is that if you will give the same man to drink the same drug four times in the year, he will vomit, you will find, the most phlegmatic matter in the winter, the moistest in the spring, the most bilious in the summer, and the blackest in the autumn.

VIII. Now, as these things are so, such diseases as increase in the winter ought to cease in the summer, and such as increase in the summer ought to cease in the winter, with the exception of those which do not change in a period of days — the period of days I shall speak of afterwards. When diseases arise in spring, expect their departure in autumn. Such diseases as arise in autumn must have their departure in spring. Whenever a disease passes these limits, you may know that it will last a year. The physician too must treat diseases with the conviction that each of them is powerful in the body according to the season which is most conformable to it.

VI. Furthermore, one must know that diseases due to repletion are cured by evacuation, and those due to evacuation are cured by repletion; those due to exercise are cured by rest, and those due to idleness are cured by exercise. To know the whole matter, the physician must set himself against the established character of diseases, of constitutions, of seasons and of ages; he must relax what is tense and make tense what is relaxed. For in this way the diseased part would rest most, and this, in my opinion, constitutes treatment. Diseases arise, in some cases from regimen, in other cases from the air by the inspiration of which we live. The distinction between the two should be made in the following way. Whenever many men are attacked by one disease at the same time, the cause should be assigned to that which is most common, and which we all use most. This it is which we breathe in. For it is clear that the regimen of each of us is not the cause, since the disease attacks all in turn, both younger and older, men as much as women, those who drink wine as much as teetotallers, those who eat barley cake as much as those who live on bread, those who take much exercise as well as those who take little. For regimen could not be the cause, when no matter what regimen they have followed all men are attacked by the same disease. But when diseases of all sorts occur at one and the same time, it is clear that in each case the particular regimen is the cause, and that the treatment carried out should be that opposed to the cause of the disease, as has been set forth by me elsewhere also, and should be by change of regimen. For it is clear that, of the regimen the patient is wont to use, either all, or the greater part, or some one part, is not suited to him. This one should learn and change, and carry out treatment only after examination of the patient’s constitution, age, physique, the season of the year and the fashion of the disease, sometimes taking away and sometimes adding, as I have already said, and so making changes in drugging or in regimen to suit the several conditions of age, season, physique and disease. But when an epidemic of one disease is prevalent, it is plain that the cause is not regimen but what we breathe, and that this is charged with some unhealthy exhalation. During this period these are the recommendations that should be made to patients. They should not change their regimen, as it is not the cause of their disease, but rather take care that, their body be as thin and as weak as possible, by diminishing their usual food and drink gradually. For if the change of regimen be sudden, there is a risk that from the change too some disturbance will take place in the body, but regimen should be used in this way when it manifestly does no harm to a patient. Then care should be taken that inspiration be of the lightest, and also from a source as far removed as possible; the place should be moved as far as possible from that in which the disease is epidemic, and the body should be reduced, for such reduction will minimise the need of deep and frequent breathing.

VII. Those diseases are most dangerous which arise in the strongest part of the body. For should the disease remain where it began, the whole body, as the strongest limb in it feels pain, must be in pain; while should the disease move from a stronger part to one of the weaker parts, the riddance of it proves difficult. But when diseases move from weaker parts to stronger parts, it is easier to get rid of them, as the strength of the stronger part will easily consume the humours that flow into them.

XI. The thickest of the veins have the following nature. There are four pairs in the body. One pair extends from behind the head through the neck, and on either side of the spine externally reaches to the loins and legs, and then stretches through the shanks to the outside of the ankles and to the feet. So bleeding for pains in the back and loins should be made on the outside, behind the knee or at the ankle. The other pair of veins extend from the head by the ears through the neck, and are called jugular veins. They stretch right and left by the side of the spine internally along the loins to the testicles and thighs, then on the inside through the hollow of the knee, and finally through the shanks to the ankles on the inside and to the feet. Accordingly, to counteract pains in the loins and testicles, bleeding should be performed in the hollow of the knee and in the ankles on the inner side. The third pair of veins passes from the temples through the neck under the shoulder-blades, then they meet in the lungs and reach, the one on the right the left side, and the one on the left the right. The right one reaches from the lungs under the breast both to the spleen and to the kidneys, and the left one to the right from the lungs under the breast both to the liver and to the kidneys, both of them ending at the anus. The fourth pair begin at the front of the head and eyes, under the neck and collar-bones, passing on the upper part of the arms to the elbows, then through the forearms to the wrists and fingers, then back from the fingers they go through the ball of the hand and the forearm upwards to the elbow, and through the upper arm on the under side to the armpit, and from the ribs above one reaches to the spleen and the other to the liver, and finally both pass over the belly to the privy parts. Such is the arrangement of the thick veins. From the belly too extend over the body very many veins of all sorts, by which nourishment comes to the body. Veins too lead from the thick veins to the belly and to the rest of the body both from the outside and from the inside; they communicate with one another, the inside ones outside and the outside ones inside. Bleeding then should be practised according to these principles. The habit should be cultivated of cutting as far as possible from the places where the pains are wont to occur and the blood to collect. In this way the change will be least sudden and violent, and you will change the habit so that the blood no longer collects in the same place.

XII. Such as expectorate much pus without fever, or have a thick sediment of pus in the urine without pain, or whose stools remain stained with blood, as in dysentery, during a long period, being thirty-five years or older, all these are ill from the same cause. For these patients must have been in their youth hardworking, diligent and industrious; afterwards when delivered from their labours they must have put on soft flesh very different from their former flesh, and there must be a wide difference between the previous condition and the hypertrophied condition of their body, so that there is no longer harmony. Accordingly when a disease seizes men in such a condition, at first they escape, but after the disease the body in time wastes and serous matter flows through the veins wherever it finds the broadest passage. Now if the flux be to the lower bowel, the stools become very like the matter shut up in the body, because as the passage slopes downwards the matter cannot remain long in the intestine. When the flux is to the chest the patients suffer suppuration, because since the purging is along an upward passage and abides a long time in the chest it rots and turns to pus. When the matter empties itself into the bladder, owing to the warmth of the place the matter becomes hot and white, and separates itself out. The finest part becomes scum on the top, while the thickest sinks to the bottom and is called pus. Stones too form in children because of the heat of this place and of the whole body, but in men stones do not form because of the coldness of the body. For you must know that a man is warmest on the first day of his existence and coldest on the last. For it must be that the body is hot which grows and progresses with force; but when the body begins to decay with an easy decline it grows cooler. It is on account of this that a man, growing most on his first day, is proportionally hotter then; on his last day, decaying most, he is proportionally cooler. Most patients in the condition described above recover their health spontaneously forty-five days from the day on which they began to waste. Such of them as exceed this period, should no other illness occur, recover spontaneously in a year.

XIII. Diseases which arise soon after their origin, and whose cause is clearly known, are those the history of which can be foretold with the greatest certainty. The patient himself must bring about a cure by combating the cause of the disease, for in this way will be removed that which caused the disease in the body.

VIII. Patients whose urine contains a deposit of sand or chalk suffer at first from tumours near the thick vein, with suppuration; then, since the tumours do not break quickly, from the pus there grow out pieces of chalk, which are pressed outside through the vein into the bladder with the urine. Those whose urine is merely blood-stained have suffered in the veins. When the urine is thick, and there are passed with it small pieces of flesh like hair, you must know that these symptoms result from the kidneys and arthritic complaints. When the urine is clear, but from time to time as it were bran appears in it, the patients suffer from psoriasis of the bladder.

IX. Most fevers come from bile. There are four sorts of them, apart from those that arise in distinctly separate pains. Their names are the continued, the quotidian, the tertian and the quartan. Now what is called the continued fever comes from the most abundant and the purest bile, and its crises occur after the shortest interval. For since the body has no time to cool it wastes away rapidly, being warmed by the great heat. The quotidian next to the continued comes from the most abundant bile, and ceases quicker than any other, though it is longer than the continued, proportionately to the lesser quantity of bile from which it comes; moreover the body has a breathing space, whereas in the continued there is no breathing space at all. The tertian is longer than the quotidian and is the result of less bile. The longer the breathing space enjoyed by the body in the case of the tertian than in the case of the quotidian, the longer this fever is than the quotidian. The quartans are in general similar, but they are more protracted than the tertians in so far as their portion is less of the bile that causes heat, while the intervals are greater in which the body cools. It is from black bile that this excessive obstinacy arises. For black bile is the most viscous of the humours in the body, and that which sticks fast the longest. Hereby you will know that quartan fevers participate in the atrabilious element, because it is mostly in autumn that men are attacked by quartans, and between the ages of twenty-five and forty-five.  This age is that which of all ages is most under the mastery of black bile, just as autumn is the season of all seasons which is most under its mastery. Such as are attacked by a quartan fever outside this period and this age you may be sure will not suffer from a long fever, unless the patient be the victim of another malady as well.

REGIMEN IN HEALTH

Translated by W. H. S. Jones

I. THE layman ought to order his regimen in the following way. In winter eat as much as possible and drink as little as possible; drink should be wine as undiluted as possible, and food should be bread, with all meats roasted; during this season take as few vegetables as possible, for so will the body be most dry and hot. When spring comes, increase drink and make it very diluted, taking a little at a time; use softer foods and less in quantity; substitute for bread barley-cake; on the same principle diminish meats, taking them all boiled instead of roasted, and eating when spring comes a few vegetables, in order that a man may be prepared for summer by taking all foods soft, meats boiled, and vegetables raw or boiled. Drinks should be as diluted and as copious as possible, the change to be slight, gradual and not sudden. In summer the barley-cake to be soft, the drink diluted and copious, and the meats in all cases boiled. For one must use these, when it is summer, that the body may become cold and soft. For the season is hot and dry, and makes bodies burning and parched. Accordingly these conditions must be counteracted by way of living. On the same principle the change from spring to summer will be prepared for in like manner to that from winter to spring, by lessening food and increasing drink. Similarly, by opposing opposites prepare for the change from summer to winter. In autumn make food more abundant and drier, and meats too similar, while drinks should be smaller and less diluted, so that the winter may be healthy and a man may take his drink neat and scanty and his food as abundant and as dry as possible. For in this way he will be most healthy and least chilly, as the season is cold and wet.

II. Those with physiques that are fleshy, soft and red, find it beneficial to adopt a rather dry regimen for the greater part of the year. Fur the nature of these physiques is moist. Those that are lean and sinewy, whether ruddy or dark, should adopt a moister regimen for the greater part of the time, for the bodies of such are constitutionally dry. Young people also do well to adopt a softer and moister regimen, for this age is dry, and young bodies are firm. Older people should have a drier kind of diet for the greater part of the time, for bodies at this age are moist and soft and cold.

So — in fixing regimen pay attention to age, season, habit, land, and physique, and counteract the prevailing heat or cold. For in this way will the best health be enjoyed.

III. Walking should be rapid in winter and slow in summer, unless it be under a burning heat. Fleshy people should work faster, thin people slower. Bathe frequently in summer, less in winter, and the lean should bathe more than the fleshy. In winter wear unoiled cloaks, but soak them in oil in summer.

IV. Fat people who wish to become thin should always fast when they undertake exertion, and take their food while they are panting and before they have cooled, drinking beforehand diluted wine that is not very cold. Their meats should be seasoned with sesame, sweet spices, and things of that sort. Let them also be rich. For so the appetite will be satisfied with a minimum. They should take only one full meal a day, refrain from bathing, lie on a hard bed, and walk lightly clad as much as is possible. Thin people who wish to become fat should do the opposite of these things, and in particular they should never undertake exertion when fasting.

V. Emetics and clysters for the bowels should be used thus. Use emetics during the six winter months, for this period engenders more phlegm than does the summer, and in it occur the diseases that attack the head and the region above the diaphragm. But when the weather is hot use clysters, for the season is burning, the body bilious, heaviness is felt in the loins and knees, feverishness comes on and colic in the belly. So the body must be cooled, and the humours that rise must be drawn downwards from these regions. For people inclined to fatness and moistness let the clysters be rather salt and thin; for those inclined to dryness, leanness and weakness let them be rather greasy and thick. Greasy, thick clysters are prepared from milk, or water boiled with chick-peas or similar things. Thin, salt clysters are made of things like brine and sea-water. Emetics should be employed thus. Men who are fat and not thin should take an emetic fasting after running or walking quickly in the middle of the day. Let the emetic consist of half a cotyle of hyssop compounded with a chous of water, and let the patient drink this, pouring in vinegar and adding salt, in such a way as to make the mixture as agreeable as possible. Let him drink it quietly at first, and then more quickly. Thinner and weaker people should partake of food before the emetic in the following way. After bathing in hot water let the patient first drink a cotyle of neat wine; then let him take food of all sorts without drinking either during or after the meal, but after waiting time enough to walk ten stades, give him to drink a mixture of three wines, dry, sweet and acid, first rather neat, and taken in small sips at long intervals, then more diluted, more quickly and in larger quantities.

He who is in the habit of taking an emetic twice a month will find it better to do so on two successive days than once every fortnight, though the usual custom is just the contrary. Those who benefit from vomiting up their food, or whose bowels do not easily excrete, all these profit by eating several times a day, partaking of all sorts of food and of meats prepared in every way, and by drinking two or three sorts of wine. Those who do not vomit up their food, or have loose bowels, all these profit by acting in exactly the opposite way to this.

I. Infants should be washed in warm water for a long time, and be given to drink their wine well diluted and not altogether cold, and such that will least swell the belly and cause flatulence. This must be done that they may be less subject to convulsions, and that they may become bigger and of a better colour. Women should use a regimen of a rather dry character, for food that is dry is more adapted to the softness of their flesh, and less diluted drinks are better for the womb and for pregnancy.

VII. Athletes in training should in winter both run and wrestle; in summer they should wrestle but little and not run at all, walking instead a good deal in the cool. Such as are fatigued after their running ought to wrestle; such as are fatigued by wrestling ought to run. For by taking exercise in this way they will warm, brace and refresh best the part of the body suffering from fatigue. Such as are attacked by diarrhoea when training, whose stools consist of undigested food, should reduce their training by at least one-third and their food by one-half. For it is plain that their bowels cannot generate the heat necessary to digest the quantity of their food. The food of such should be well-baked bread crumbled into wine, and their drink should be as undiluted and as little as possible, and they ought not to walk after food. At this time they should take only one meal each day, a practice which will give the bowels the greatest heat, and enable them to deal with whatever enters them. This kind of diarrhoea attacks mostly persons of close flesh, when a man of such a constitution is compelled to eat meat, for the veins when closely contracted cannot take in the food that enters. This kind of constitution is apt sharply to turn in either direction, to the good or to the bad, and in bodies of such a sort a good condition is at its best only for a while. Physiques of a less firm flesh and inclined to be hairy are more capable of forcible feeding and of fatigue, and their good condition is of longer duration. Such as throw up their food the day after, whose hypochondria are swollen because of the undigested food, are benefited by prolonging their sleep, but apart from this their bodies should be subjected to fatigue, and they should drink more wine and less diluted, and at such times partake of less food. For it is plain that their bellies are too weak and cold to digest the quantity of food. When people are attacked by thirst, diminish food and fatigue, and let them drink their wine well diluted and as cold as possible. Those who feel pains in the abdomen after exercise or after other fatigue are benefited by resting without food; they ought also to drink that of which the smallest quantity will cause the maximum of urine to be passed, in order that the veins across the abdomen may not be strained by repletion. For it is in this way that tumours and fevers arise.

VIII.  When a disease arises from the brain, at first a numbness seizes the head and there is frequent passing of urine with the other symptoms of strangury; this lasts nine days. Then, if water or mucus break out at the nostrils or ears, the illness ceases and there is no more strangury. The patient passes without pain copious white urine for the next twenty days. His headache disappears, but his vision is impaired.

VIII.  A wise man should consider that health is the greatest of human blessings, and learn how by his own thought to derive benefit in his illnesses.

ON ULCERS

Translated by Charles Darwin Adams

1. We must avoid wetting all sorts of ulcers except with wine, unless the ulcer be situated in a joint. For, the dry is nearer to the sound, and the wet to the unsound, since an ulcer is wet, but a sound part is dry. And it is better to leave the part without a bandage unless a unless a cataplasm be applied. Neither do certain ulcers admit of cataplasms, and this is the case with the recent rather than the old, and with those situated in joints. A spare diet and water agree with all ulcers, and with the more recent rather than the older; and with an ulcer which either is inflamed or is about to be so; and where there is danger of gangrene; and with the ulcers an inflammation in joints; and where there is danger of convulsion; and in wounds of the belly; but most especially in fractures of the head and thigh, or any other member in which a fracture may have occurred. In the case of an ulcer, it is not expedient to stand; more especially if the ulcer be situated in the leg; but neither, also, is it proper to sit or walk. But quiet and rest are particularly expedient. Recent ulcers, both the ulcers themselves and the surrounding parts, will be least exposed to inflammation, if one shall bring them to a suppuration as expeditiously as possible, and if the matter is not prevented from escaping by the mouth of the sore; or, if one should restrain the suppuration, so that only a small and necessary quantity of pus may be formed, and the sore may be kept dry by a medicine which does not create irritation. For the part becomes inflamed when rigor and throbbing supervene; for ulcers then get inflamed when suppuration is about to form. A sore suppurates when the blood is changed and be-comes heated; so that becoming putrid, it constitutes the pus of such ulcers. When you seem to require a cataplasm, it is not the ulcer itself to which you must apply the cataplasm, but to the surrounding parts, so that the pus may escape and the hardened parts may become soft. Ulcers formed either from the parts having been cut through by a sharp instrument, or excised, admit of medicaments for bloody wounds ( ‘enaima ), and which will prevent suppuration by being desiccant to a certain degree. But, when the flesh has been contused and roughly cut by the weapon, it is to be so treated that it may suppurate as quickly as possible; for thus the inflammation is less, and it is necessary that the pieces of flesh which are bruised and cut should melt away by becoming putrid, being converted into pus, and that new flesh should then grow up. In every recent ulcer, except in the belly, it is expedient to cause blood to flow from it abundantly, and as may seem seasonable; for thus will the wound and the adjacent parts be less attacked with inflammation. And, in like manner, from old ulcers, especially if situated in the leg, in a toe or finger, more than in any other part of the body. For when the blood flows they become drier and less in size, as being thus dried up. It is this ( blood? ) especially which prevents such ulcers from healing, by getting into a state of putrefaction and corruption. But, it is expedient, after the flow of the blood, to bind over the ulcer a thick and soft piece of sponge, rather dry than wet, and to place above the sponge some slender leaves. Oil, and all things of an emollient and oily nature, disagree with such ulcers, unless they are getting nearly well. Neither does oil agree with wounds which have been recently inflicted, nor yet do medicines formed with oil or suet, more especially if the ulcer stands in need of more cleansing. And, in a word, it is in summer and in winter that we are to smear with oil these sores that require such medicines.

2. Gentle purging of the bowels agrees with most ulcers, and in wounds of the head, belly, or joints, where there is danger of gangrene, in such as require sutures, in phagedaenic, spreading and in otherwise inveterate ulcers. And when you want to apply a bandage, no plasters are to be used until you have rendered the sore dry, and then indeed you may apply them. The ulcer is to be frequently cleaned with a sponge, and then a dry and clean piece of cloth is to be frequently applied to it, and in this way the medicine which it is supposed will agree with it is to be applied, either with or without a bandage. The hot season agrees better than winter with most ulcers, except those situated in the head and belly; but the equinoctial season agrees still better with them. Ulcers which have been properly cleansed and dried as they should be, do not usually get into a the state. When a bone has exfoliated, or has been burned, or sawed, or removed in any other way, the cicatrices of such ulcers become deeper than usual. Ulcers which are not cleansed, are not disposed to unite if brought together, nor do the lips thereof approximate of their own accord. When the points adjoining to an ulcer are inflamed, the ulcer is not disposed to heal until the inflammation subside, nor when the surrounding parts are blackened by mortification, nor when a varix occasions an overflow of blood in the part, is the ulcer disposed to heal, unless you bring the surrounding parts into a healthy condition.

3. Circular ulcers, if somewhat hollow, you must scarify all along their edges, or to the extent of half the circle, according to the natural stature of the man. When erysipelas supervenes upon any sore, you must purge the body, in the way most suitable to the ulcer, either upward or downward. When swelling arises around an. ulcer, and if the ulcer remain free from inflammation, there will be a deposit of matter in process of time. And whatever ulcer gets swelled along with inflammation and does not subside as the other parts subside which became inflamed and swelled at the same time, there is a danger that such an ulcer may not unite. When from a fall, or in any other way, a part has been torn or bruised, and the parts surrounding the ulcer have become swelled, and, having suppurated, matter flows from the swelling by the ulcer, if in such cases a cataplasm be required, it should not be applied to the sore itself, but to the surrounding parts, so that the pus may have free exit, and the indurated parts may be softened. But when the parts are softened as the inflammation ceases, then the parts which are separated are to be brought toward one another, binding on sponges and applying them, beginning from the sound parts and advancing to the ulcer by degrees. But plenty of leaves are to be bound above the sponge. When the parts are prevented from coming together by a piece of flesh full of humors, it is to be removed. When the ulcer is deep seated in the flesh, it is swelled up, both from the bandaging and the compression. Such an ulcer should be cut up upon a director (specillum) if possible, at the proper time, so as to admit a free discharge of the matter, and then the proper treatment is to be applied as may be needed. For the most part, in every hollow ulcer which can be seen into which can be seen into direct without being any swelling present, if there be putrefaction in it, or if the flesh be flabby and putrid, such an ulcer, and the parts which surround it, will be seen to be black and somewhat livid. And of corroding ulcers, those which are phagedaenic, spread and corrode most powerfully, and, in this case, the parts surrounding the sore will have a black and sub-livid appearance.

4. Cataplasms for swellings and inflammation in the surrounding parts. Boiled mullein, the raw leaves of the trefoil, and the boiled leaves of the epipetrum, and the poley, and if the ulcer stand in need of cleansing, all these things also cleanse; and likewise the leaves of the fig-tree, and of the olive, and the horehound, all these are to be boiled; and more especially the chaste-tree, and the fig, and the olive, and the leaves of the pomegranate are to be boiled in like manner. These are to be used raw: and the leaves of the mallow pounded with wine, and the leaves of rue, and those of the green origany. With all these, linseed is to be boiled up and mixed by pounding it as a very fine powder. When there is danger of erysipelas seizing the ulcers, the leaves of woad are to be pounded and applied raw in a cataplasm along with linseed, or the linseed is to be moistened with the juice of strychnos or of woad, and applied as a cataplasm. When the ulcer is clean, but both it and the surrounding parts are inflamed, lentil is to be boiled in wine and finely triturated, and, being mixed with a little oil, it is to be applied as a cataplasm; and the leaves of the hip-tree are to be boiled in water and pounded in a fine powder and made into a cataplasm; and apply below a thin, clean piece of cloth wetted in wine and oil; and when you wish to produce contraction, prepare the leaves of the hip-tree like the lentil, and the cress; wine and finely-powdered linseed are to be mixed together. And this is proper: linseed, and raw chaste-tree, and Melian alum, all these things being macerated in vinegar.

5. Having pounded the white unripe grape in a mortar of red bronze, and passed it through the strainer, expose it to the sun during the day, but remove it during the night, that it may not suffer from the dew; rub it constantly during the day, so that it may dry equally, and may contract as much virtue as possible from the bronze: let it be exposed to the sun for as great a length of time as till it acquire the thickness of honey; then put it into a bronze pot with the fresh honey and sweet wine, in which turpentine resin has been previously boiled, boil the resin in the wine until it become hard like boiled honey; then take out the resin and pour off the wine: there should be the greatest proportion of the juice of unripe grape, next of the wine, and third of the honey and myrrh, either the liquid ( stacte ） or otherwise. The finest kind is to be levigated and moistened by having a small quantity of the same wine poured on it; and then the myrrh is to be boiled by itself, stirring it in the wine; and when it appears to have attained the proper degree of thickness, it is to be poured into the juice of the unripe grape; and the finest natron is to be toasted, and gently added to the medicine, along with a smaller quantity of the flowers of copper ( flos aeris ) than of the natron. When you have mixed these things, boil for not less than three days, on a gentle fire made with fuel of the fig-tree or with coals, lest it catch fire. The applications should all be free from moisture, and the sores should not be wetted when this medicine is applied in the form of liniment. This medicine is to be used for old ulcers, and also for recent wounds of the glans penis, and ulcers on the head and ears. Another medicine for the same ulcers:-The dried gall of an ox, the finest honey, white wine, in which the shavings of the lotus have been boiled, frankincense, of myrrh an equal part, of saffron an equal part, the flowers of copper, in like manner of liquids, the greatest proportion of wine, next of honey, and least of the gall. Another:-Wine, a little cedar honey, of dried things, the flowers of copper, myrrh, dried pomegranate rind. Another:-Of the roasted flower of copper half a drachm, of myrrh two half-drachms, of saffron three drachms, of honey a small quantity, to be boiled with wine. Another:-Of frankincense a drachm, of gall a drachm, of saffron three drachms; let each of these be dried and finely levigated, then, having mixed, triturate in a very strong sun, pouring in the juice of an unripe grape, until it become of a gelatinous consistence, for three days; then let them be allowed to macerate in an austere, dark-colored, fragrant wine, which is gradually poured upon them. Another:-Boil the roots of the holmoak in sweet white wine; and when it appears to be properly done, having poured off two parts of the wine, and of the lees of wine as free of water as possible one part; then boil, stirring it, so that it may not be burnt, at a gentle fire, until it appear to have attained the proper consistence. Another:-The other things are to be the same; but, not withstanding, instead of the wine, use the strongest white vinegar, and dip into it wool as greasy as can be procured, and then, moistening it with the lees of oil, boil, and pour in the juice of the wild fig-tree, and add Melian alum, and natron, and the flowers of copper, both toasted. This cleanses the ulcers better than the former, but the other is no less desiccant. Another:-Dip the wool in a very little water; and then, having added a third part of wine, boil until it attain the proper consistence. By these, recent ulcers are most speedily prevented from getting into a state of suppuration.

6. Another:-Sprinkle on it dried wakerobin, and add the green bark of the fig-tree, pounding it in the juice: do this with or without wine, and along with honey. Another:-Boiling the shavings of lotus with vinegar (the vinegar should be white); then mix the lees of oil and raw tar-water, and use it as a liniment or wash, and bandage above. These things in powder prevent recent wounds from suppurating, or they may be used for cleansing the sore along with vinegar, or for sponging with wine.

7. Another:-Sprinkle ( on the sore? ) lead finely triturated with the recrement of copper; and sprinkle on it, also, the shavings of lotus, and the scales of copper, and alum, and chalcitis, with copper, both alone, and with the shavings of lotus. And other-wise, when it is wanted to use these in a dry state, do it with the Illyrian spodos triturated with the shavings, and with the shavings alone. And the flowers of silver alone, in the finest powder; and birthwort, when scraped and finely pounded, may be sprinkled on the part. Another, for bloody sores myrrh, frankincense, galls, verdigris the roasted flower of copper, Egyptian alum roasted, vine flowers, grease of wool, plumbago, each of these things is to be diluted, in equal proportions, with wine like the former. And there is another preparation of the same:-The strongest vinegar of a white color, honey, Egyptian alum, the finest natron; having toasted these things gently, pour in a little gall; this cleanses fungous ulcers, renders them hollow, and is not pungent. Another:-The herb with the small leaves, which gets the name of Parthenium parviflorum, and is used for removing thymia ( warts? ) from the glans penis, alum, chalcitis, a little crude Melian alum (?); sprinkle a little dried elaterium, and a little dried pomegranate rind in like manner.

8. The herb which has got the name of lagopyrus, fills up hollow and clean ulcers; (when dried it resembles wheat; it has a small leaf like that of the olive, and more long;) and the leaf of horehound, with oil. Another:-The internal fatty part, resembling honey, of a fig much dried, of water two parts, of linseed not much toasted and finely levigated, one part. Another:-Of the dried fig, of the flower of copper levigated a little, and the juice of the fig. The preparation from dried fig:-The black chamaeleon, the dried gall of an ox, the other things the same. Of the powders:-Of the slender cress in a raw state, of horehound, of each equal parts; of the dried fig, two parts; of linseed, two parts; the juice of the fig. When you use any of these medicines, apply above it compresses wetted in vinegar, apply a sponge about the compresses and make a If the surrounding parts be in an inflamed state, apply to them any medicine which may appear suitable.

9. If you wish to use a liquid application, the medicine called caricum may be rubbed in, and the bandages may be applied as formerly described upon the same principle. The medicine is prepared of the following ingredients:-Of black hellebore, of sandarach, of the flakes of copper, of lead washed, with much sulphur, arsenic, and cantharides. This may be compounded so as may be judged most proper, and it is to be diluted with oil of juniper. When enough has been rubbed in, lay aside the medicine, and apply boiled wakerobin in a soft state, either rubbing it in dry, or moistening it with honey. But if you use the caricum in a dry state, you must abstain from these things, and sprinkle the medicine on the sore. The powder from hellebore and sandarach alone answers. Another liquid medicine:-The herb, the leaf of which resembles the arum (wakerobin) in nature, but is white, downy, of the size of the ivy-leaf: this herb is applied with wine, or the substance which forms upon the branches of the ilex, when pounded with wine, is to be applied. Another:-The juice of the grape, the strongest vinegar, the flower of copper, natron, the juice of the wild fig-tree. Alum, the most finely levigated, is to be put into the juice of the wild grape, and it is to be put into a red bronze mortar and stirred in the sun, and removed when it appears to have attained proper consistence.

10. These are other powders:-Black hellebore, as finely levigated as possible, is to be sprinkled on the sore while any humidity remains about it, and while it continues to spread. The bandaging is the same as when plasters are used. Another, in like manner:-The driest lumps of salt are to be put into a copper, or earthen pot, of equal size, as much as possible, and not large, and the finest honey, of double the size of the salt, as far as can be guessed, is to be poured upon the lumps of salt, then the vessel is to be put upon coals and allowed to sit there until the whole is consumed. Then, having sponged the ulcer and cleansed it, bandage it as before, and compress it a little more. Next day, wherever the medicine has not been taken in, sprinkle it on, press it down, and bandage. But when you wish to remove the medicine, pour in hot vinegar until it separate, and again do the same things, sponging it away, if necessary. Another corrosive powder:-Of the most finely-levigated misy, sprinkle upon the moist and gangrenous parts, and a little of the flower of copper, not altogether levigated. Another powder equally corrosive:-Having sponged the ulcer, burn the most greasy wool upon a shell placed on the fire until the whole be consumed; having reduced this to a fine powder, and sprinkled it on the sore, apply the bandage in the same manner. Another powder for the same ulcers:-The black chamaeleon, when prepared with the juice of the fig. It is to be prepared roasted, and alkanet mixed with it. Or, pimpernel, and Egyptian alum roasted, and sprinkle on them the Orchomenian powder. For spreading ulcers:-Alum, both the Egyptian roasted, and the Melian; but the part is to be first cleansed with roasted natron and sponged; and the species of alum called chalcitis roasted. It is to be roasted until it catch fire.

11. For old ulcers which occur on the fore part of the legs; they become bloody and black:-Having pounded the flower of the melilot and mixed it with honey, use as a plaster. For nerves ( tendons? ) which have been cut asunder:-Having pounded, sifted, and mixed with oil the roots of the wild myrtle, bind on the part; and the herb cinquefoil (it is white and downy, and more raised above the ground than the black cinquefoil), having pounded this herb in oil bind it on the part, and then remove it on the third day.

12. Emollients (?):-These medicines are to be used in winter rather than in summer. Emollient medicines which make the cicatrices fair:-Pound the inner mucous part of the squill and pitch, with fresh swine’s seam, and a little oil, and a little resin, and ceruse. And the grease of a goose, fresh swine’s seam, and squill, and a little oil. The whitest wax, fresh clean grease, or squill and white oil, and a little resin. Wax, swine’s seam (old and fresh), and oil, and verdigris, and squill and resin. Let there be two parts of the old grease to the fresh, and of the other things, q. s. Having melted the grease that is fresh, pour it into another pot; having levigated plumbago finely and sifted it, and mixed them together, boil and stir at first; boil until when poured upon the ground it concretes; then taking it off the fire, pour it all into another vessel, with the exception of the stony sediment, and add resin and stir, and mix a little oil of juniper, and what has been taken off. In all the emollient medicines to which you add the resin, when you remove the medicine from the fire, pour in and mix the resin while it is still warm. Another:-Old swine’s seam, wax, and oil, the dried shavings of the lotus, frankincense, plumbago,-namely, of the frankincense one part, and of the other one part, and of the shavings of the lotus one part; but let there be two parts of the old grease, one of wax, and of fresh swine’s seam one part. Another:-Or old swine’s seam along with the fresh grease of a goat; when cleaned, let it retain as little as possible of its membrane: having triturated or pounded it smooth, pour in oil, and sprinkle the lead with the spodium and half the shavings of the lotus. Another:-Swine’s seam, spodium, blue chalcitis, oil.

13. For Burns: -You must boil the tender roots of the ilex, and if their bark be very thick and green, it must be cut into small parts, and having poured in white wine, boil upon a gentle fire, until it appear to you to be of the proper consistence, so as to be used for a liniment. And it may be prepared in water after the same manner. Another, not corrosive:-Old swine’s seam is to be rubbed in by itself, and it is to be melted along with squill, the root of which is to be divided and applied with a bandage. Next day it is to be fomented; and having melted old swine’s seam and wax, and mixed with them oil, frankincense, and the shavings of lotus and vermilion, this is to be used as a liniment. Having boiled the leaves of the wakerobin in wine and oil, apply a bandage. Another:-When you have smeared the parts with old swine’s seam let the roots of asphodel be pounded in wine and triturated, and rubbed in. Another:-Having melted old swine’s seam, and mixed with resin and bitumen, and having spread it on a piece of cloth and warmed it at the fire, apply a bandage. When an ulcer has formed on the back from stripes or otherwise, let squill, twice boiled, be pounded and spread upon a linen cloth and bound on the place. Afterward the grease of a goat, and fresh swine’s seam, spodium, oil, and frankincense are to be rubbed in.

14. Swellings which arise on the feet, either spontaneously or otherwise, when neither the swellings nor the inflammation subside under the use of cataplasms, and although sponges or wool, or anything else be bound upon the sound part; but the swelling and inflammation return of themselves again, an influx of blood into the veins is the cause, when not occasioned by a bruise. And the same story applies if this happen in any other part of the body. But blood is to be abstracted, especially the from the veins, which are the seat of the influx, if they be conspicuous; but if not, deeper and more numerous scarifications are to be made in the swellings; and whatever part you scarify, this is to be done with the sharpest and most slender instruments of iron. When you have removed the blood, you must not press hard upon the part with the specillum, lest you produce contusion. Bathe with vinegar, and do not allow a clot of blood to remain between the lips of the wounds, and having spread greasy wool with a medicine for bloody wounds, and having carded the woof and made it soft, bind it on, having wetted it with wine and oil. And let the scarified part be so placed that the determination of the blood may be upward and not downward; and do not wet the part at all, and let the patient be put upon a restricted diet and drink water. If upon loosing the bandages you find the scarifications inflamed, apply a cataplasm of the fruit of the chaste-tree and linseed. But if the scarifications become ulcerated and break into one another, we must be regulated by circumstances, and otherwise apply whatever else appears to be proper.

15. When a varix is on the fore part of the leg, and is very superficial, or below the flesh, and the leg is black, and seems to stand in need of having the blood evacuated from it, such swellings are not, by any means, to be cut open; for, generally, large ulcers are the consequence of the incisions, owing to the influx from the varix. But the varix itself is to be punctured in many places, as circumstances may indicate.

16. When you have opened a vein and abstracted blood, and although the fillet be loosed the bleeding does not stop, the member, whether the arm or leg, is to be put into the reverse position to that from which the blood flows; so that the blood may flow backward, and it is to be allowed to remain in this position for a greater or less space of time. Then bind up the part while matters are so, no clots of blood being allowed to remain in the opening. Then having applied a double compress, and wetted it with wine, apply above it clean wool which has been smeared with oil. For, although the flow of blood be violent, it will be stopped in this way. If a thrombus be formed in the opening, it will inflame and suppurate. Venesection is to be practiced when the person has dined more or less freely and drunk, and when somewhat heated, and rather in hot weather than in cold.

17. When in cupping, the blood continues to flow after the cupping-instrument has been removed, and if the flow of blood, or serum be copious, the instrument is to be applied again before the part is healed up, so as to abstract what is left behind. Otherwise coagula of blood will be retained in the incisions and inflammatory ulcers will arise from them. In all such cases the parts are to be bathed with vinegar, after which they are not to be wetted; neither must the person lie upon the scarifications, but they are to be anointed with some of the medicines for bloody wounds. When the cupping instrument is to be applied below the knee, or at the knee, it should be done, if possible, while the man stands erect.

ON FISTULAE

Translated by Charles Darwin Adams

1. Fistulae are produced by contusions and tubercles, and they are also occasioned by rowing, on horseback, when blood accumulates in the nates near the anus. For, having become putrid, it spreads to the soft parts (the breech being of a humid nature, and the flesh in which it spreads being soft), until the tubercle break and corrupt below at the anus. When this happens, a fistula is formed, having an ichorous discharge, and faeces pass by it, with flatus and much and abomination. It is produced, then, by contusions when any of the parts about the anus are bruised by a blow, or a fall, or a wound, or by riding, or rowing, or any such cause. For blood is collected, and it, becoming corrupted, suppurates; and the from the the same accidents happen, as have been described in the case of tubercles.

2. In the first place, then, when you see any such tubercle formed, you must cut it open while still unripe, before it suppurate and burst into the rectum. But if a fistula be already formed when you undertake the case, take a stalk of fresh garlic, and having laid the man on his back, and separated his thighs on both sides, push down the stalk as far as it will go, and thereby measure the depth of the fistula. Then, having bruised the root of seseli to a very fine powder, and poured in some water, let it macerate for four days, and, mixing the water with honey, let the patient drink it, fasting, to the amount of three cyathi, and at the same time purge away the ascarides. Those who are left without treatment die.

3. In the next place, having moistened the strip of cotton cloth, with the juice of the great tithymallus, and sprinkling on it the flos aeris, roasted and triturated, and having made it into a tent equal in length to the fistula, and having passed a thread through the ends of the tent again through the stalk, and having placed the patient in a reclining position, and having examined the ulcerated parts of the rectum with a speculum, pass the stalk by it, and when it reaches the rectum, take hold of it and draw it out until the tent be pushed through, and be brought on a level above and below. When it ( the tent? ） has been pushed inward, introduce a ball of horn into the rectum (the rectum having been previously smeared with Cimolian chalk), and leave it there, and when the patient wants to go to stool, let it be taken out and again replaced, and let this practice be continued for five days. On the sixth day let it be removed, and drawing the tent out of the flesh, and afterwards pounding alum and filling the ball ( pessary ） and introducing it into the rectum, leave it until the alum melts. Anoint the rectum with myrrh until the parts appear to be united.

4. Another method of cure:-Taking a very slender thread of raw lint, and uniting it into five folds of the length of a span, and wrapping them round with a horse hair; then having made a director (specillum) of tin, with an eye at its extremity, and having passed through it the end of raw lint wrapped round as above described, introduce the director into the fistula, and, at the same time, introduce the index finger of the left hand per anum; and when the director touches the finger, bring it out with the finger, bending the extremity of the director and the end of the threads in it, and the director is to be withdrawn, but the ends of the threads are to be knotted twice or thrice, and the rest of the raw threads is to be twisted around and fastened into a knot. Then the patient is to be told that he may go and attend to his matters. The rest of the treatment:-Whenever any part of the thread gets loose owing to the fistula becoming putrid, it is to be tightened and twisted every day; and should the raw thread rot before the fistula is eaten through, you must attach another piece of raw thread to the hair, pass it through, and tie it, for it was for this purpose that the hair was rolled round the raw lint, as it is not liable to rot. When the fistula has sloughed through, a soft sponge is to be cut into very slender pieces and applied, and then the flowers of copper, roasted, are to be frequently applied with a director; and the sponge smeared with honey is to be introduced with the index finger of the left hand, and pushed forward; and another bit of added, it is to be bound on in the same manner as in the operation for hemorrhoids. Next day, having loosed the bandages, the fistula is to be washed with hot water, and cleansed, as far as possible, with the finger of the left hand by means of the sponge, and again the flos aeris is to be applied. This is to be done for seven days, for generally the coat of the fistula takes that time to fistula takes that time to slouch through. The same mode of bandaging is to be persevered in afterwards, until the cure be completed. For in this way, the fistula being forcibly expanded by the sponge will not fill up and heal unequally, but it will all become whole together. During the treatment, the part should be bathed with plenty of warm water, and the patient kept on a spare diet.

5. When the fistula does not get eaten through, having first examined it with a sound, cut down as far as it passes, and sprinkle with the flos aeris, and let it remain for five days. Then pour warm water upon it, and above lay flour mixed with water, and bind on it the leaves of beet. When the flos aeris comes away, and the fistulous sore becomes clean, cure it as before described. But if the fistula be in a part which does not admit of this treatment, and if it be deep, syringe it with the flowers of copper, and myrrh, and natron, diluted with urine, and introduce a piece of lead into the orifice of the fistula so that it may not close. Syringe the fistula by means of a quill attached to a bladder, so that the injection may distend the fistula. But it does not heal unless it be cut open.

6. If the anus gets inflamed, and there is pain, fever, a frequent desire of going to stool without passing anything, and the anus appears to protrude, owing to the inflammation, and if at times strangury come on, this disease is formed, when phlegm, collected from the whole body, is determined to the rectum. Warm things are beneficial in this case; for these, when applied, can attenuate and dissolve the phlegm, and dilute the acrid and salt particles, so that the heat subsides, and the irritation in the rectum is removed. Wherefore it is to be treated thus: The patient is to be put into a hip-bath of hot water, and sixty grains of the grana gnidia are to be pounded and infused in a hemina of wine, with half a hemina of oil, and injected. This brings away phlegm and faeces. When the patient does not take the hip-bath, boil eggs in dark-colored fragrant wine, and apply to the anus, and spread to the anus, and spread something warm below, either a bladder filled with warm water, or linseed toasted and ground, and its meal stirred up and mixed equally with dark, fragrant wine, and oil, and this applied very warm as a cataplasm; or, having mixed barley and Egyptian alum pulverized, form into an oblong ball ( suppository? ） and warming it gently at the fire, make it into a cataplasm, foment, form it into shape with the fingers, and then making it quite tepid, introduce it into the anus. The external parts are to be anointed with cerate, and a cataplasm of boiled garlic, with dark wine diluted, is to be applied. But if you remove these things, let him take the hip-bath of hot water, and having mixed together the juice of srychnos, the grease of a goose, swine’s seam, chrysocolla, resin, and white wax, and then having melted in the same and mixed together, anoint with these things, and while the inflammation lasts, use the cataplasm of boiled garlic. And if by these means he be freed from the pain, it is enough; but if not, give him the white meconium ( Euphorbia peplus? ), or, if not it, any other phlegmagogue medicine. While the inflammation lasts, the diet should be light.

7. The strangury comes on in this way:-The bladder being heated from the rectum, phlegm is attracted by the heat, and by the phlegm ( inflammation? ） the strangury is occasioned. If, then, as is frequently the case, it cease with the disease, well; but, not withstanding, if not, give any of the medicines for strangury.

8. If procidentia ani take place, having fomented the part with a soft sponge, and anointed it with a snail, bind the man’s hands together, and suspend him for a short time, and the gut will return. But if it still prolapse, and will not remain up, fasten a girdle round his loins and attach a shawl behind, and having pushed up the anus, apply to it a soft sponge, moistened with hot water in which the shavings of lotus have been boiled; pour of this decoction upon the anus by squeezing the sponge, then, bringing the shawl below between the legs, fasten it at the navel. But if he wish to evacuate the bowels, let him do so upon a very narrow night-stool. Or, if the patient be a child, let him be placed on the feet of a woman, with his back reclined to her knees, and when the bowels are evacuated, let the legs be extended. In this way the anus will be the least disposed to fall out. When a watery and ichorous discharge flows from the rectum, wash it out with burnt lees of wine, and water from myrtle, and having dried maiden-hair, pound and sift it, and apply as a cataplasm. But if there be a discharge of blood, having washed with the same, and pounded chalcitis, and the shavings of cypress, or of juniper, or of stone-pine, or of turpentine, the in equal proportions the apply as a cataplasm. Anoint the external parts with thick cerate.

9. When the gut protrudes and will not remain in its place, scrape the finest and most compact silphium ( assafoetida? ) into small pieces and apply as a cataplasm, and apply a sternutatory medicine to the nose and provoke sneezing, and having moistened pomegranate rind with hot water, and having powdered alum in white wine, pour it on the gut, then apply rags, bind the thighs together for three days, and let the patient fast, only he may drink sweet wine. If even thus matters do not proceed properly, having mixed vermillion with honey, anoint.

10. If procidentia ani be attended with a discharge of blood, pare off the rind of the root of wakerobin, then pound and mix flour with it, and apply it warm as a cataplasm. Another: Having scraped off the rind of the most tender roots of the wild vine, which some call psilothrion , boil in a dark austere wine undiluted; then having pounded, apply as a tepid cataplasm; but mix also flour and stir it up with white wine and oil in a tepid state. Another:-Having pounded the seed of hemlock, pour on it a fragrant white wine, and then apply in a tepid state as a cataplasm.

11. But if it be inflamed, having boiled in water the root of the ivy, finely powdered, and mixing the finest flour, and stirring it up with white wine, apply as a cataplasm, and mix up some fat with these things. Another:-Take the root of the mandrake, especially the green (fresh) root, but otherwise the dried, and having cleaned the green root and cut it down, boil in diluted wine, and apply as a cataplasm; but the dry may be pounded and applied as a cataplasm in the manner. Another:-Having bruised the inner part of a ripe cucumber to a soft state, apply as a cataplasm.

12. If there be pain without inflammation, having roasted red natron, and pounded it to a fine powder, and added alum and roasted salts, finely triturated, mix together in equal proportions; then having mixed it up with the best pitch and spread upon a rag, apply, and bind. Another:-Having pounded the green leaves of capers, put into a bag and bind on the part; and when it appears to burn, take it away and apply it afterward; or, if you have not the leaves of capers, pound the rind of its roots, and having mixed it up with dark-colored wine, bind on the part in the same manner. This is a good application also for pains of the spleen. Of these poultices, those which are cooling, stop the discharge; those which are emollient and heating, discuss; and those which are attractive, dry up and attenuate. This disease is formed when bile and phlegm become seated in the parts. When the anus is inflamed, it should be anointed with the ointment, the ingredients of which are resin, oil, wax, plumbago, and suet, these being all melted and applied quite hot as a cataplasm.

ON HEMORRHOIDS

Translated by Charles Darwin Adams

1. The disease of the hemorrhoids is formed in this way: if bile or phlegm be determined to the veins in the rectum, it heats the blood in the veins; and these veins becoming heated attract blood from the nearest veins, and being gorged the inside of the gut swells outwardly, and the heads of the veins are raised up, and being at the same time bruised by the faeces passing out, and injured by the blood collected in them, they squirt out blood, most frequently along with the faeces, but sometimes without faeces. It is to be cured thus:

2. In the first place it should be known in what sort of a place they are formed. For cutting, excising, sewing, binding, applying putrefacient means to the anus,-all these appear to be very formidable things, and yet, after all, they are not attended with mischief. I recommend seven or eight small pieces of iron to be prepared, a fathom in size, in thickness like a thick specillum, and bent at the extremity, and a broad piece should be on the extremity, like a small obolus. Having on the preceding day first purged the man with medicine, on the day of the operation apply the cautery. Having laid him on his back, and placed a pillow below the breech, force out the anus as much as possible with the fingers, and make the irons red-hot, and burn the pile until it be dried up, and so as that no part may be left behind. And burn so as to leave none of the hemorrhoids unburnt, for you should burn them all up. You will recognize the hemorrhoids without difficulty, for they project on the inside of the gut like dark-colored grapes, and when the anus is forced out they spurt blood. When the cautery is applied the patient’s head and hands should be held so that he may not stir, but he himself should cry out, for this will make the rectum project the more. When you have performed the burning, boil lentils and tares, finely triturated in water, and apply as a cataplasm for five or six days. But on the seventh, cut a soft sponge into a very slender slice, its width should be about six inches square. Then a thin smooth piece of cloth, of the same size as the sponge, is to be smeared with honey and applied; and with the index finger of the left hand the middle of the sponge is to be pushed as far up as possible; and afterward wool is to be placed upon the sponge so that it may remain in the anus. And having girded the patient about the loins and fastened a shawl to the girdle, bring up this band from behind between the legs and attach it to the girdle at the navel. Then let the medicine which I formerly said is calculated to render the skin thick and strong, be bound on. These things should be kept on for not less than twenty days. The patient should once a day take a draught from flour or millet, or bran, and drink water. When the patient goes to stool the part should be washed with hot water. Every third day he should take the bath.

3. Another method of cure:-Having got the anus to protrude as much as possible, foment with hot water, and then cut off the extremities of the hemorrhoids. But this medicine should be prepared beforehand, as an application to the wound:-Having put urine into a bronze vessel, sprinkle upon the urine the flower of bronze calcined and finely triturated; then, when it is moistened, shake the vessel and dry in the sun. When it becomes dry, let it be scraped down and levigated, and apply with the finger to the part, and having oiled compresses, apply them, and bind a sponge above.

4. Another method:-There grows upon the bleeding condyloma, a protuberance like the fruit of the mulberry, and if the condyloma be far without, an envelope of flesh is adherent to it. Having placed the man over two round stones upon his knees, examine, for you will find the parts near the anus between the buttocks inflated, and blood proceeding from within. If, then, the condyloma below the cover be of a soft nature, bring it away with the finger, for there is no more difficulty in this than in skinning a sheep, to pass the finger between the hide and the flesh. And this should be accomplished without the patient’s knowledge, while he is kept in conversation. When the condyloma is taken off, streaks of blood necessarily flow from the whole of the torn part. It must be speedily washed with a decoction of galls, in a dry wine, and the bleeding vein will disappear along with the condyloma, and its cover will be replaced. The older it is, the more easy the cure.

5. But if the condyloma be higher up, you must examine it with the speculum, and you should take care not to be deceived by the speculum; for when expanded, it renders the condyloma level with the surrounding parts, but when contracted, it shows the tumor right again. It is to be removed by smearing it with black hellebore on the finger. Then, on the third day, wash it out with a dry wine. You need not be surprised that there is no discharge of blood when you remove the condyloma, for neither, if you cut off the hands or legs at the articulations will there be any flow of blood; but if you cut them off above or below the joints, you will find there hollow veins which pour out blood, and you will have difficulty in stopping the bleeding. In the same manner, the bleeding vein in the anus, if you cut it above or below the point of separation of the condyloma, will pour forth blood; but if you take away the condyloma at its junction ( with the natural parts? ） there will be no flow of blood. If matters then be thus put to rights, it will be well; but otherwise burn it, taking care not to touch the place with the iron, but bringing it close so as to dry it up, and apply the flos aeris in the urine.

6. Another method of curing hemorrhoids:-You must prepare a cautery like the arundo phragmites , and an iron that exactly fits is to be adapted to it; then the tube being introduced into the anus, the iron, red hot, is to be passed down it, and frequently drawn out, so that the part may bear the more heat, and no sore may result from the heating, and the dried veins may heal up. But if you are neither disposed to burn nor excise, having first fomented with plenty hot water and turned out the anus, levigate myrrh, and having burnt galls and Egyptian alum, in the proportion of one and a half to the other things, and as much of melanteria; these things are all to be used in a dry state. The hemorrhoid will separate under the use of these medicines, like a piece of burnt hide. You are to proceed thus until the whole are removed, and a half part of burnt chalcitis does the same thing. But if you wish to effect the cure by suppositories, take the shell of the part fish a third part of plumbago, bitumen, alum, a little of the flos aeris, galls, a little verdigris; having poured a small quantity of boiled honey on these, and formed an oblong suppository, apply until you remove them.

7. An hemorrhoid in a woman may be thus cured. Having fomented with plenty of hot water, boil in the water certain of the fragrant medicines, add pounded tamarisk, roasted litharge and galls, and pour on them white wine, and oil, and the grease of a goose, pounding all together. Give to use after fomenting. In fomenting the anus is to be made to protrude as much as possible.