Book 15: Fractures

1. Understanding Fractures: Definitions and Variations

In Galen’s view, a fracture constitutes a discontinuity in a bone, a condition referred to by the Greeks as “Catagma.” There are various ways in which bones can be harmed or injured, including separation, dislocation, unnatural fusion, cutting or division, contusion, abscess, putrefaction, and rotting. Additionally, the exposure or loss of the periosteum can occur. Among these injuries, we will focus on fractures.

The types of fractures are nearly limitless. Some fractures are complete and perfect, while others are imperfect. They can present in different orientations: some are longitudinal, others transverse, and still others oblique. A fracture may result in large fragments, or it may break into small scales, which can have either blunt or sharp edges that may irritate or damage nearby muscles, nerves, veins, or arteries.

In some cases, a bone may not break into splinters along its length but instead fracture simultaneously into two pieces across its width. This specific type of fracture is known as “Raphanedon,” named for its resemblance to a radish.
A fracture known as Caryedon, or resembling a nut, occurs when a bone shatters into numerous small pieces, each separated from the others, similar to how a nut breaks apart when struck with a hammer or mallet on an anvil. This type of fracture is also called Alphitidon due to its resemblance to meal or flour, and is commonly seen in injuries caused by bullets fired from guns or other explosive devices.

In contrast, some fractures are referred to as Schidacidon, where the bone splinters or splits in a manner akin to a board or piece of timber, splitting vertically along the bone. These fractures can be visibly apparent or may be so fine as to be invisible to the naked eye, hence termed Capillary. These minute fractures are only detectable when ink is applied and then scraped away.

At times, a bone may be merely compressed by an impact, or conversely, it may be displaced upwards, creating a vaulted effect. When a bone is shattered into many small fragments and chips, the condition is termed attrition. The resulting fragments from such fractures can vary in texture; some are smooth and polished, while others are uneven, sharp, and rough, with tiny projections.

Some fractures only affect the surface of the bone, removing just a sliver, while others do not displace the bone but merely split it longitudinally without detaching any pieces. There are also fractures that penetrate deep into the bone, reaching the marrow.
Furthermore, some fractures are simple and isolated, while others are accompanied by a variety of additional effects and symptoms, such as wounds, hemorrhage, inflammation, gangrene, and similar conditions. Additionally, fractures can be classified based on the specific body parts involved, including the head, ribs, limbs, joints, and other regions of the body. One should also consider the differences arising from the physical condition of individuals—whether they are young or old, and whether they have a tendency toward ill humors or are well-balanced—as each of these factors has its own unique implications for treatment.

The causes of fractures primarily stem from excessive force or impacts from external sources that can cut, bruise, break, or jolt the bones. This category of causes also includes falls from great heights and numerous other potential incidents, which would be too extensive to list in detail.

2. Signs of a fracture.

We can identify a broken bone through several clear signs. The most definitive indication occurs when, upon examining the suspected area, we can feel the separated fragments of the bone and hear a distinct crackling sound caused by the friction of the shattered pieces beneath our fingers.

Another sign is the loss of function in the affected area, which is particularly evident when the bones of the leg, collarbone, elbow, or forearm are fractured. If only the collarbone or forearm is broken, the patient may still be able to walk and move their arm, as the collarbone primarily supports the muscles rather than the body itself, unlike the leg bone.

The third sign is a visible deformity in the affected area. It may appear hollow where the bone has been displaced and bulging where it has shifted. Additionally, the patient experiences significant pain due to the damaged periosteum and the membrane surrounding the bone marrow, as well as the compression or irritation of nearby tissues.

3. Prognostic Assessments in Fracture Cases

When assessing fractures, we must predict whether they will lead to the patient’s deterioration or recovery, whether the healing process will be prolonged or brief, straightforward or fraught with difficulties and dangers, and what potential complications and symptoms may arise. A thorough understanding of these factors can be achieved by someone well-versed not only in the anatomical structure of bones but also in the overall temperament, composition, and condition of the body.

First and foremost, it is important to remind surgeons that during the winter months, when everything is stiff from the cold, even a minor fall or seemingly trivial incident can easily result in broken bones. In these conditions, the bones become brittle due to the surrounding dry air, losing moisture—an effect that is commonly observed with wax and tallow candles. Conversely, during moist weather, the bones retain more moisture, making them more flexible and better able to withstand external forces.

This understanding should inform your prognostics: bones, due to their inherent dryness, do not heal and bond as easily as flesh does. However, in children, as noted by Galen, the abundance of moisture allows for more effective healing, often referred to as healing by “first intention,” where the lost tissue is restored with similar substance. In adults, however, when fractures occur, a hard substance typically forms around the injury, derived from the abundant nourishment available to the broken bone, which helps to bond the fragments together when they are properly aligned.
This substance is known as callus, and over time, it hardens to the point where the bone at the fracture site becomes firmer and more resilient than in any other area. Thus, the common medical adage that rest is essential for the healing of broken bones holds true. The callus can easily break down if movement occurs before it has fully and solidly formed.

The composition of a callus should be appropriate in both quantity and quality, much like the blood that flows to regenerate lost tissue in wounds. It is crucial that there is sufficient material for the formation of a callus, which requires the affected area to possess a healthy disposition; otherwise, there may be little to no callus formation, or it may develop at a significantly slower rate.

Fractures tend to heal more readily in younger individuals than in older ones. This is because younger bodies contain a rich supply of primordial and vital moisture, which is conducive to cohesion and healing, whereas older bodies often have an abundance of watery and wasteful substances.

From this, it is clear that one cannot definitively determine the time required for callus formation, as it varies from person to person. This variability can be attributed to factors such as the season and region, the patient’s constitution, and their diet, as well as the method of immobilization used. Patients with weakened vitality and thinner, more watery blood typically experience slower callus formation. Conversely, those with stronger constitutions tend to heal more rapidly, particularly if there is an abundance of dense and viscous material available. Therefore, it is advisable to consume richer, more nourishing foods and to apply medicinal treatments that support the natural healing process, as will be discussed further.
When bones are fractured near the joints, movement becomes increasingly difficult, especially if the callus that forms is thick and protruding. If the fracture is accompanied by injury to the joints, the loss of motion may not only occur but could also endanger the patient’s life due to severe inflammation and intense pain, particularly in the tendinous areas.

Fractures involving both bones of the arm or leg are generally more challenging to treat than those affecting only one. This increased difficulty arises because the intact bone provides support for the fractured one, making it harder to keep both in their proper positions. Additionally, forming a callus around a larger bone takes more time than around a smaller one.

Furthermore, bones that are more porous and spongy tend to heal more quickly with the aid of a callus compared to denser, solid bones. A callus develops more rapidly in sanguine (blood-rich) individuals than in choleric (bile-rich) ones. However, it is important to note that regardless of the body type, broken bones rarely heal without leaving some irregularity or uneven protrusion at the site where the callus forms.
Therefore, the surgeon should perform artificial ligations to ensure that the callus does not protrude excessively or sink too low. Among fractures, those that are simple are the least troublesome. In contrast, fractures that result in splintering are more problematic, while those that break into small, sharp fragments are the most troublesome. This latter type poses a risk of nerve or periosteum damage, potentially leading to convulsions.

Sometimes, the fragments of a broken bone remain in their proper position; at other times, they may shift, causing one fragment to sit above another. This misalignment can lead to noticeable deformities, such as one area being depressed while another bulges, accompanied by pain from nerve irritation. Additionally, the affected limb may become shorter than its counterpart on the opposite side and more swollen due to muscle contraction toward their origins.

When a bone is fractured and you observe any depression, it is crucial to place your hands on both sides, above and below the injury, and to exert as much force as possible to realign the bone. If not addressed, the stretched and contracted muscles and nerves will prevent the bones from returning to their proper positions. This extension should be performed in the initial days following the injury; otherwise, inflammation may set in. Once inflammation occurs, attempting to manipulate the nerves and tendons too forcefully can lead to serious complications such as abscesses, convulsions, gangrene, and tissue necrosis. Consequently, Hippocrates advises against delaying such manipulations until the third or fourth day.

Fractures are particularly concerning when the fragments are large and displaced, especially in bones filled with marrow. When broken or dislocated bones cannot return to their natural positions, the affected area may suffer from a lack of nourishment. This is due to the disruption of the natural pathways of veins, arteries, and nerves, as well as the immobility of the fractured part. As a result, vital spirits and nutritive fluids do not flow adequately to the area.

If the dislocated or fractured limb is accompanied by significant inflammation, it becomes uncertain whether attempting to restore it will provoke convulsions. Therefore, it is often advisable to postpone the reduction until the underlying inflammation has subsided, the swelling has decreased, and the pain has been alleviated.

4. General Treatment Approaches for Broken and Dislocated Bones

To treat a broken or dislocated bone, the goal is to restore it to its original shape and position. To achieve this, the surgeon should focus on three key objectives: First, to reposition the bone; second, to stabilize it once it has been restored; and third, to prevent the onset of complications or, if they do occur, to manage their severity. Such complications may include pain, inflammation, fever, abscess, gangrene, and necrosis.

For the first objective, it is essential to attempt to realign the broken or dislocated bone as soon as possible—ideally, immediately after the injury or within the same day. At this early stage, the intensity of pain and inflammation is typically manageable, and the muscle contraction is not yet significant or resistant.

To begin the procedure, both the patient and the surgeon should be in a well-lit environment. It is important to have reliable and skilled assistants present, along with appropriate ligatures and, if necessary, suitable instruments. Friends and bystanders should remain quiet and refrain from actions or words that could interfere with the surgeon’s work.
Next, the surgeon should position one hand above the affected area—closer to the center of the body—and the other hand below, as close as possible to the injury site. The surgeon must then gently stretch the limb. If the hands are placed too far from the injured area, excessive pressure may be applied to the healthy part of the limb, rendering the stretching effort ineffective. Conversely, focusing solely on pulling from below without adequate support above can be dangerous, as it risks inadvertently drawing the entire body toward the surgeon.

Once this positioning is established, it is crucial for the surgeon to apply a straight and even extension to the affected area. When a bone is fractured or dislocated, the muscles contract toward their origin, pulling the bones closer together, as noted by Galen. Therefore, restoring the bones to their original position is impossible without first extending the muscles. By extending the affected area, the broken bones can be repositioned more easily and effectively. After realigning the bones, gentle pressure should be applied with your hand to any areas that are raised or protruding. Finally, secure the area by applying appropriate bolsters and splints.
In cases of dislocation, after extending the limb, it may be necessary to slightly bend the joint to facilitate proper alignment. Surgeons may sometimes need to use mechanical aids for this process, especially if the dislocation is chronic or if the broken or dislocated bones are large, particularly in robust individuals with substantial joints. In such instances, greater strength is required than what the surgeon can provide with their hands alone. The stronger the patient’s muscles, the more powerfully they will contract toward their origins.

However, it is essential to avoid excessive force during extension, as this can tear the muscles and nerves, leading to pain, convulsions, paralysis, and gangrene. These complications are more likely to occur in strong, older individuals than in children, women, or generally softer bodies, which are less susceptible to injury from violent pulling due to their inherent moisture and flexibility. Just as leather can be easily stretched when moistened, dry and hard materials are more likely to tear than stretch.

Therefore, the surgeon should exercise moderation in extending and manipulating the affected limb, tailoring their approach to the patient’s body type. You can determine that the bone is properly aligned when the pain subsides, indicating that the muscle fibers and surrounding tissues have returned to their original positions, and any compression caused by the displaced bones has been relieved. You should feel for any protruding or uneven areas, ensuring that the surface of the limb is smooth and even. Additionally, the injured limb should closely resemble its opposite counterpart in terms of joint composition, length, and thickness.

To ensure optimal results, the surgeon must examine the area frequently during treatment. It is possible for a well-set bone to become misaligned again due to the patient inadvertently moving while in bed or experiencing involuntary muscle contractions during sleep. This can cause the muscles to contract towards their origins, leading to renewed pain and discomfort, which will only resolve once the bone is repositioned. The surgeon must remain vigilant in monitoring for such occurrences.

If, during the healing process, one bone overlaps another, it could result in the affected bone being shorter than it should be, leading to a permanent limp if the leg is involved. Therefore, the patient should take care not to move the broken limb until the callus has fully hardened. In contrast, dislocations generally require less concern, as once they are properly set and secured, they do not easily dislocate again like fractured bones.
The second objective is to ensure that the bones being restored are securely maintained in their proper position. This can be achieved using bandages, ligatures, bolsters, and other materials, which will be discussed in detail later. Appropriate medicinal applications are also important, such as using rose oil mixed with egg whites and other similar substances that help repel inflammation. Additionally, resolving medicines should be applied as needed based on the situation.

For this purpose, it is advisable to moisten your rollers and bolsters in oxycrate or, if the fracture is simple, in rose vinegar. If the fracture is accompanied by a wound, warm red wine or a similar liquid is recommended, according to Galen. It is especially beneficial to moisten the affected area more frequently during the summer months, as this strengthens the tissue and helps repel excess fluid, thus alleviating inflammation and pain.

Once the acute symptoms have subsided, you should refrain from further moistening the area to avoid delaying the formation of a callus. This can be accomplished through the methods we will outline later. Additionally, allowing the affected part to rest in its natural position is crucial for maintaining stability and preventing movement.

Dressing the injury should only occur when necessary and with appropriate materials, while minimizing the risk of inflammation and pain. The ideal position is one that maintains the muscles in their natural alignment without causing discomfort, allowing the patient to endure it comfortably over time.

After these steps are taken, it is important to ask the patient if the bandaging feels too tight. If the response is negative—barring a slight tightness around the fracture or dislocation, which is acceptable—you can conclude that the binding is adequate. The initial bandaging for fractures should remain intact for three to four days unless pain necessitates adjustments. In cases of dislocation, the same binding can be maintained for seven to eight days, unless symptoms arise that require earlier intervention. The surgeon must vigilantly prevent any adverse events or complications, which will be addressed in the following chapter.

5. Strategies for Achieving the Third Objective in the Treatment of Fractures and Dislocations: Prevention and Management of Complications

To achieve this third objective, it is essential to handle the fractured or dislocated limb as gently and painlessly as possible. We must employ medications to dispel any impending fluid accumulation in the affected area, while also strengthening the region. By recommending a proper diet, we can prevent the formation of waste in the body and facilitate its elimination through purging and bloodletting.

However, if complications have already arisen, we must address each one according to its specific nature, as they can vary widely. One common issue is itching, which initially torments the patient. This sensation stems from a buildup of irritating vapors released from the blood and other humors beneath the skin. This can lead to a mild itch or a more intense, painful itching, as noted by Galen. To alleviate this, it is crucial to evacuate the underlying material causing the itch; however, this is challenging due to the closure of the pores, which are obstructed by dressings, cushions, and bandages.

Additionally, the affected area may not be functioning optimally, resulting in diminished heat necessary to disperse the accumulated impurities. Therefore, it is advisable to loosen the bandages every third day, allowing the stagnant and noxious waste trapped beneath the skin to escape. If not addressed, these substances can lead to irritation and ulceration, as often seen in those who neglect this practice.

Furthermore, the area should be treated with prolonged applications of hot water or a decoction of sage, chamomile, roses, and melilotus mixed with wine and water. Extended fomentation helps to thin and expel excess fluid, while shorter applications provide soothing relief, as described by Hippocrates. Gentle friction using the hands or a warm cloth should be applied in upward, lateral, and circular motions.

If blisters form on the skin, they must be carefully punctured to prevent the underlying fluid from causing further skin damage. Following this, the area should be treated with cooling and drying ointments, such as Camphorated ointment, Red Desiccative ointment, or Rose ointment without vinegar, possibly enhanced with powdered rotten wood or prepared tutia.

Other more serious complications may occur, which we will address later. If the scales of the bone are completely detached, they must be removed immediately, especially if they are pressing against the muscles. In cases where the bone is splintered and protruding from the flesh, it should be excised with appropriate surgical tools as needed.

In the meantime, it is crucial to ensure that the affected area remains ventilated and is not overly constricted, as excessive pressure can lead to inflammation. This concludes our discussion on fractures and dislocations in general; we will now turn our attention to specific cases, beginning with a fracture of the nose.

6. Nasal Fractures

The nose consists of a cartilaginous lower section and a bony upper section. Consequently, fractures do not occur in the cartilaginous part (unless perhaps due to a significant impact), but rather result in depression, distortion, or contusion. In contrast, fractures are common in the bony part, which may sustain such severe depression on the inner side that, if not diligently addressed, the nose can become flattened or displaced, leading to breathing difficulties.

To restore this type of fracture, any bone that is protruding must be gently pressed down, while any depressed bone should be lifted using a spatula or a small stick, carefully fashioned and wrapped in cotton or linen to minimize discomfort. Hold the spatula in one hand while using the other to guide and reposition the bone. Once the bone is realigned, appropriate-sized dressings or tents should be placed inside the nose. These can be made from sponge, flax, or pieces of animal lungs, as they are soft and serve to prevent the nasal bones from shifting again while also helping to elevate them.

Additionally, the nose should be supported with bolsters on either side until the bones heal completely, ensuring that its shape and alignment are preserved. I have often inserted gold, silver, or lead pipes into fractured noses, securing them with thread to the patient’s nightcap. This method not only prevents the bones from becoming misaligned but also allows for the free passage of fluids without obstructing breathing.

At the same time, care must be taken not to bind the nose too tightly, unless absolutely necessary, to avoid causing it to become too wide, flat, or crooked. If a wound accompanies the fracture, it should be treated in the same manner as wounds of the head. Once the fracture has been addressed, a medicinal application that can repel and suppress fluid accumulation, strengthen the area, and dry up any existing matter should be applied to the nose and other affected dry areas.
Prescription:
Combine one and a half ounces each of frankincense, mastic, Armenian bole, and dragon’s blood. Additionally, include two drachms of rock alum and pine resin. Grind all ingredients together until they reach a very fine consistency.

Alternatively:
Mix one and a half ounces of volatile flour with sufficient egg white to achieve a cohesive mixture, allowing it to form a medicinal preparation.
You should not employ any other method to treat a fracture of the cartilaginous part of the nose. Hippocrates refers to this condition as a “solution of continuity,” similar to a fracture in bone, because he could find no more suitable term to describe it. Cartilage, being the hardest tissue next to bone, warrants this terminology. A callus typically forms in fractured noses unless obstructed within twelve to fifteen days.

7. Fractures of the Mandible

The lower jaw extends into two projections: one ends sharply and receives a tendon from the temporal muscle, while the other ends bluntly and rounded beneath the mammillary process, where it is situated in a small cavity. The two halves are joined at the midline of the chin by the symphysis and are narrow within.

When a fracture occurs in this area, treatment involves inserting your fingers into the patient’s mouth and applying pressure both inside and outside to align and smooth the fractured bones. If the fracture is complete and the bones overlap, extension must be applied to both sides, moving in opposite directions—upward and downward—to facilitate the proper alignment and joining of the bones.

Meanwhile, if the teeth are loosened or dislodged, they must be repositioned in their sockets and secured to the adjacent stable teeth using gold or silver wire, or ordinary thread, until they are firmly anchored and the bones have healed with a callus. To stabilize the fractured bone fragments, a splint made of shoe leather should be applied externally, ensuring it is split at the chin and is of adequate length and width to support the jaw.

A ligature, two fingers wide and sufficiently long, should be fashioned with both ends cut lengthwise to encircle the chin on either side. This will create four ends of the ligature, with the two lower ends secured at the crown of the head, sewn to the patient’s nightcap. The two upper ends should also be sewn securely to the cap at the nape of the neck.

A clear indication that the jaw is properly aligned and set is when the teeth are positioned correctly. The patient should avoid lying on the injured jaw to prevent the bone fragments from displacing, which could exacerbate the injury.

Unless complications such as inflammation arise, the fracture typically strengthens with a callus within twenty days, given that the jawbone is spongy, hollow, and rich in marrow, particularly in its center. However, healing may occur more slowly depending on the patient’s overall health, a phenomenon that applies to other fractures as well.

The adhesive and repellent treatments discussed in the previous chapter should be administered, along with any other remedies as needed. The patient should consume liquid foods that do not require chewing until the callus has sufficiently hardened, to avoid displacing the fragile or poorly aligned fragments during the act of chewing. Suitable nourishment includes water gruel, pounded foods, broths, soft custards, jellies, rare eggs, restorative liquids, and similar items.

8. Fractures of the Clavicle

The nature and type of a fractured clavicle dictate the appropriate method of treatment and restoration. Regardless of how this bone is broken, the end connected to the shoulder and shoulder blade will always be lower than the end attached to the chest, as the arm pulls it downward. A fracture that occurs across the clavicle is generally easier to heal than one that splits lengthwise. This is because a bone broken across can more readily return to its original position when lifted on either side with your fingers. In contrast, a fracture that occurs in a longitudinal or splintered manner is more challenging to align and unite, as the fragments may easily separate with even slight arm movements, causing the portion attached to the shoulder to sag toward the lower part of the breast. This difficulty arises because the clavicle does not move independently; it moves in conjunction with the arm.

In addressing this or any other fracture, it is crucial to ensure that the bone fragments do not overlap or become excessively separated. To facilitate this, one assistant should pull the arm backward while another pulls the shoulder in the opposite direction, creating a counter-extension. During this process, the surgeon should use their fingers to realign the fracture, pressing down any part that is elevated and lifting any part that is depressed.

Some practitioners, to simplify the reduction of such fractures, place a ball of yarn under the patient’s armpit to fill the cavity. They then forcefully press the elbow against the ribs, guiding the bone back into its proper position. If the ends of the broken bones are so depressed that they cannot be elevated by these means, the patient should lie on their back, positioned between the shoulders on a firm pillow or an inverted tray covered with a rug. The assistant should then press down on the patient’s shoulders until the hidden and depressed ends of the bones emerge. Once this is accomplished, the surgeon can more easily realign the fractured bone.

If the bone is shattered into splinters that cannot be restored, and if any splinters penetrate the flesh and cause breathing difficulties, the skin must be incised over the affected area. Using appropriate instruments, the surgeon should lift the depressed splinters and trim their sharp points to prevent life-threatening complications.

For multiple fragments, once they are aligned, they should be covered with a binding agent made of wheat flour, frankincense, bole armenick, sanguis draconis, and pine resin, all ground into powder and mixed with egg whites. Splints, covered with soft, worn linen rags and the same binding agent, should be applied, with three bolsters soaked in the mixture. Two bolsters are placed on the sides, and the thickest one is positioned over the prominent fracture to stabilize it and prevent further movement of the fragments. These bolsters should be of adequate thickness and breadth to fill the spaces above and below the bone.

A suitable bandage, approximately a hand’s breadth wide and two and a half ells long (more or less, depending on the patient’s body), should be used for ligation. The patient should be wrapped in such a way that their arm is gently drawn backward, with bolsters placed in the armpits, particularly near the fractured bone, to enhance comfort during binding. The patient should also be encouraged to bend their arm backward and rest their hand on their hip, similar to the position adopted by country folk when playing leapfrog.

Despite the utmost care taken in treating this type of fracture, it is often inevitable that some degree of deformity will remain, as it is not possible to secure a ligature around the clavicle in the same manner as one would around a leg or arm. A callus typically forms on this bone within twenty days due to its rare and spongy nature.

9. Fractures of the Scapula

The Greeks refer to it as “Omoplata,” while the Latins call it “Scapula” or “Scapulae patella,” meaning the shoulder blade. It is attached to the back through the ribs, specifically the vertebrae of the chest and neck, not by a joint, but rather through the interposition of muscles, as discussed in our anatomy. At the front, it articulates with the collarbone and the humerus, or arm bone. The projection known as the acromion—shaped like a thorn and longer and more prominent in some individuals—serves as the point of connection for the collarbone. Consequently, some anatomists, following the interpretation of Hippocrates, refer to this articulation between the collarbone and the hollowed process of the shoulder blade as the acromion.

Additionally, there is another projection on the shoulder blade called the “cervix omoplatae,” or the neck of the shoulder blade. This structure is relatively short but ends in a broad, curved head designed to accommodate the shoulder or arm bone. Close to this process is another projection known as the “coracoid,” named for its resemblance to a crow’s beak. This feature helps stabilize the shoulder bone and contributes to the strength of the area.

Fractures of the shoulder blade can occur in various locations, including along the ridge that runs like a hill through its center, which provides structural safety, similar to the vertebrae of the back. The broader area of the blade can also be compressed or depressed, as can the articulation where the top of the shoulder connects. Depending on the specific location of the fracture, the resulting injuries can range from mild to severe.
We can recognize a fracture or irregularity in the spine or ridge of the shoulder blade when a painful inequality is detected by touch. You may notice that the broader or thinner part is depressed if you feel a cavity accompanied by a sharp pain and if numbness affects the outstretched arm. If the fragments remain attached to the bone and do not penetrate the flesh, they should be repositioned and stabilized using adhesive medicines that promote the formation of callus, along with appropriate bolsters and rollers.

However, if the fragments do not adhere to the bone or press against the underlying flesh, an incision must be made over them to extract them using a crow’s beak instrument. Even if the fragments are mobile, if they still adhere to the periosteum and ligaments without irritating the muscles, they should not be removed. I have often observed that such fragments can integrate with the adjacent bones over time. If the fragments are completely detached and do not even adhere to the periosteum, they must be removed; otherwise, they will eventually be expelled by the body’s natural processes, as the living tissue tends to reject the dead. As Hippocrates stated, the living expels the dead.

This principle was illustrated in the case of the Marquis of Villars, who was wounded in the shoulder by a pistol bullet during the Battle of Dreux. Some splinters of his broken bone were extracted along with pieces of his armor and the lead bullet. Shortly thereafter, the wound healed completely. However, more than seven years later, due to the strain of his military duties and the weight of his armor at the Battle of Montcontour, the wound reopened, causing several bone fragments along with remnants of the lead bullet to emerge on their own.

If a fracture occurs in the neck of the shoulder blade or at the shoulder joint, the prognosis for recovery is grim. I have witnessed this in the cases of Anthony of Bourbon, King of Navarre; Francis of Lorraine, Duke of Guise; Count Rhingrave Philibert; and many others during the recent civil wars. The area surrounding the shoulder joint contains several large blood vessels, including the axillary vein and artery, as well as nerves originating from the cervical vertebrae that extend into the arm’s muscles. Additionally, inflammation and infection can easily spread from this region due to its proximity to vital organs, leading to severe complications and often resulting in death.

10. Fractures and Depressions of the Sternum (Breastbone)

The sternum can sometimes be fractured, or it may simply be displaced without breaking. An irregularity felt upon examination indicates a fracture, as does the sensation of depression when pressing with a finger and the sound of bones cracking beneath your touch. A visible cavity in the area, accompanied by coughing, spitting blood, and difficulty breathing due to compression of the membranes surrounding the ribs and lungs, suggests that the sternum has been depressed.

To restore this bone, whether fractured or depressed, the patient should be positioned on their back with a cushion filled with tow or hay placed under the vertebrae, similar to the method used for setting the collarbone. A helper should apply firm pressure on the patient’s shoulders as if to push them down, while the surgeon presses on the ribs on each side to reposition the bone with their hand. Following this, the previously mentioned treatments should be applied to prevent inflammation and alleviate pain. Bolsters should be positioned accordingly, and a ligature should be tied across the shoulders, ensuring it is not too tight to avoid hindering the patient’s breathing.

By employing these techniques, I successfully treated Anthony Benand, a Knight of the Order, at the request of Anthony of Bourbon, King of Navarre. He had sustained a concave chest from an iron bullet fired from a field piece, causing his sternum to be driven inward. He collapsed as if dead from the impact and experienced blood spitting for three months after I realigned the bone. Remarkably, he is now in perfect health.

11. Fractures of the ribs

The true ribs, being bony structures, can sustain fractures at any point. In contrast, the false ribs can only be fractured at the back, as they are bony only in that region and cartilaginous toward the breastbone. Consequently, these ribs can only be bent or distorted rather than truly broken. Those ribs prone to fractures may break inwards or outwards. However, it often occurs that they are not completely fractured but rather splintered, sometimes inwardly but not outwardly. The fissure typically does not extend beyond the middle substance of the rib, but in some cases, it can break through entirely, causing fragments and splinters to puncture the membrane lining the ribs, which poses significant risk.

When a fracture is simple—without accompanying wounds, compression, or punctures to the membrane, and without other symptoms—the danger is less pronounced. Hippocrates advises that individuals suffering from such injuries should eat more freely, as a moderate fullness of the stomach acts as a support for the ribs, helping to keep them properly aligned. This principle is particularly relevant for fractures of the false ribs, as patients often report feeling better after eating. An empty stomach can lead to a suspension of the ribs, lacking the necessary support from food.

Fractures that occur outwardly tend to heal more easily than those that are inward, as inward fractures can irritate the pleura and lead to inflammation, which may result in empyema. Additionally, inward fractures are more challenging to manage, making restoration more difficult because the necessary techniques to reposition the bone—such as traction and stabilization—are not as easily performed.

Typically, fractures heal within twenty days if no complications arise. The signs of fractured ribs are quite evident; by palpating the affected area, one can easily detect the fracture through irregularities in the bone and the characteristic crackling sound, especially when the rib is completely separated. If a rib is broken on the inside, the patient experiences a sharp, piercing pain, often more severe than that of pleurisy, due to the sharp splinters irritating the costal membrane. This can lead to significant breathing difficulties, coughing, and spitting blood, as blood from the damaged vessels may be drawn into the lungs and subsequently expelled through a dry cough.

Some practitioners attempt to elevate a severely broken and depressed rib using a cupping glass, which is ill-advised. This method can exacerbate pain and attract excess fluids due to the pressure and contraction of surrounding tissues, a practice Hippocrates also discourages. Instead, it is preferable to follow a different approach. The patient should lie on their unaffected side, and an ointment composed of turpentine, rosin, black pitch, wheat flour, mastic, and aloes should be applied to the fractured side, spread on a strong cloth. After allowing it to adhere for some time, the cloth should be pulled off suddenly and forcefully from below upwards, which may help realign the rib. This process should be repeated until the patient experiences relief and improved breathing.

The chances of successful restoration increase if the patient avoids coughing and holds their breath while the surgeon performs this maneuver. However, if sharp splinters cause intense pain by irritating the costal membrane—richly supplied with nerves, veins, and arteries—resulting in breathing difficulties, coughing, spitting blood, and fever, the only viable solution may be to incise the area where the rib is broken. This allows for the removal of any sharp fragments with surgical instruments or the excision of the fragments themselves. If a significant wound is created during this procedure, it should be sutured and treated according to standard wound care protocols.

Regarding diet, phlebotomy, and purgation, as Hippocrates notes, these measures are generally unnecessary for a simple fracture without symptoms warranting such interventions. However, in cases with complicated symptoms such as convulsions, fever, or empyema, appropriate treatments must be prescribed by the overseeing physician. A cerate and other suitable remedies should be applied to the affected area, using only ligatures that effectively secure local treatments. Finally, the patient’s comfort and preferences should guide any recommendations for position and rest.

12. The Various Abnormal Effects Associated with Fractured Ribs

Numerous symptoms arise from fractured and contused ribs; however, among them, two uncommon effects warrant discussion here. The first is the swelling or inflation of the contused flesh, which can also occur due to minor bone injuries that have been neglected initially. This swelling is not merely a result of the flesh itself becoming puffy; it is also caused by the accumulation of a specific phlegmatic, glutinous, and viscous fluid in the area.

The underlying cause of this condition is the weakened digestive capacity of the affected region, resulting from the trauma and subsequent distress. This impairment prevents the area from assimilating nourishment as it normally would, whether due to pain drawing fluid to the site or nature’s instinctive response to protect itself. Consequently, this semi-digested fluid remains trapped, leading to significant flatulence or, when acted upon by diminished heat, transforming into cloudy vapors. This results in localized swelling, while the skin becomes soft, as if inflated by a quill.

When you place your hand on the swollen area, you may hear the sound of air escaping and observe a cavity forming, akin to what is seen in edematous tumors. If this inflation is not addressed, it can lead to inflammation, fever, abscess formation, difficulty breathing, and ultimately the second condition we intend to explore in this chapter: the putrefaction, corruption, or deterioration of the ribs.

An abscess and the separation of flesh from bone are the primary causes of this deterioration. The bone, stripped of its natural protective covering, becomes vulnerable to exposure to air, which it has not previously encountered, leading to its eventual decay. When this occurs, patients may cough up foul matter and, if left untreated, may succumb to consumption and death.

To prevent these complications, it is imperative to promptly restore the fractured bones using previously discussed methods. Additionally, the mucous swelling must be addressed with appropriate heating and dispersing treatments, and supported with bolsters and bandages to ensure the flesh re-establishes contact with the bone as it should. However, the binding should not be so tight as to restrict the natural movement of the ribs during inhalation and exhalation.

If the swelling develops into an abscess, it should be opened without delay to prevent the retained matter from corrupting the underlying bone due to the spread of putrefaction. Once the ulcer is opened, the pus can be drained using a tube inserted into the wound, the end of which should be secured with thread to prevent it from falling into the chest cavity and allowing for easy removal at your convenience.

13. On Vertebral Fractures and Their Processes

The vertebrae may occasionally be fractured, bruised, or internally strained, resulting in compression and distortion of the membranes surrounding the spinal cord, as well as the spinal cord itself. This can lead to various severe complications, the severity of which can often be predicted based on their extent. Among the symptoms are numbness, paralysis, or loss of sensation in the arms, legs, perineum, and bladder, which can diminish or eliminate the ability to feel and move. Consequently, bodily functions such as urination and defecation may occur involuntarily, or may be completely suppressed. When these symptoms arise, Hippocrates suggests that one can foresee that death may be imminent due to injury to the spinal cord.

In such cases, a surgical incision may be necessary to remove splinters from the fractured vertebrae that are pressing on the spinal cord and its nerves. If surgery is not feasible, at the very least, one should apply medications to alleviate pain and reduce inflammation. Over time, the fractured bones may realign, assisted by methods we will discuss later regarding spinal dislocation.

If only the processes of the vertebrae are fractured, the fragments can typically be repositioned unless they are completely detached from the periosteum. In cases of detachment, the skin should be incised to remove the fragments, followed by appropriate wound care. We can ascertain that only the processes of the vertebrae are affected if, in the absence of the previously mentioned symptoms of numbness and paralysis, palpation reveals a bone fragment moving beneath the surface, accompanied by a crackling sound and a sense of hollowness and depression. Additionally, if the patient experiences increased pain when bending forward or stooping, compared to standing upright, this further indicates the nature of the injury.

When stooping, the skin of the back is stretched and pressed against the sharp edges of the fragments, causing significant discomfort. Conversely, standing upright relaxes the skin, resulting in less irritation from the jagged fragments. Fractured processes of the vertebrae typically heal well unless complicated by more severe issues, such as a significant contusion. As previously noted from Hippocrates, all porous and spongy bones tend to knit together with a callus within a matter of days.

14. Fracture of the Sacred Bone (holy bone)

Additionally, the holy bone, located in a specific area, can be easily healed yet may be fractured by a forceful impact, such as a bullet fired from a musket, as I have observed in many cases. However, if the fracture also damages the vertebrae and the spinal cord contained within, the patient is unlikely to survive, for the reasons explained in the previous chapter.

15. Fracture of the Sacrum (Rump)

The rump consists of four bones: the first contains a cavity that accommodates the lowest vertebra of the holy bone, while the other three are joined together by symphysis or coalition. At the end of these bones hangs a small piece of cartilage. To treat a fracture of these bones, one must insert a finger into the patient’s rectum and gently push it toward the fractured area. This technique allows you to maneuver the fragment back into place while using your other hand to support the back. For optimal healing, it is essential for the patient to remain in bed throughout the recovery period. If it becomes necessary for the patient to rise, they should sit on a perforated seat to avoid putting pressure on the broken area. Appropriate remedies for healing fractures should be applied as needed.

16. Fracture of the Hip, or Os Ilium.

The hip is comprised of three bones: the first is called the os ilium, or haunch bone; the second is the os ischium, known as the huckle bone; and the third is the os pubis, referred to as the share bone. In fully grown individuals, these three bones are so tightly fused together that they cannot be separated; however, in children, they may be separated with relative ease. A fracture can occur in any part of these bones, typically resulting from a blow or a fall onto a hard surface.

Signs of a fracture include pain, a prickling sensation, a depressed area, unevenness, and numbness in the leg on the affected side. If the bone fragments are completely detached, they must be removed through incision during the initial dressing. It is crucial to avoid injuring the muscle heads, major blood vessels, and the large nerve that serves the thigh and leg during this procedure. Conversely, fragments that remain attached to their periosteum should be gently realigned and smoothed with your fingers as appropriate. Additional measures should be taken as guided by medical principles and the specific circumstances at hand.

17. Fracture of the Shoulder (Humerus)

The arm bone is round, hollow, and filled with marrow, characterized by a slightly raised neck and a somewhat thick head at its upper end. At the lower end, it features two processes—one located at the front and the other at the back—between which lies a semi-circular cavity resembling a pulley. Each end of this cavity leads into a corresponding space, one interior and the other exterior. These hollow stops serve to limit the bending and extension of the arm, preventing the cubit bone from sliding back and forth in a circular manner, which could disrupt its motion, much like a rope moving in a pulley. If the circular cavity were perfect, the cubit could rotate completely, complicating its function.

It is essential for a surgeon to understand these anatomical details to effectively restore fractures and dislocations of the arm. If one fragment of a fractured bone is significantly displaced over the other, and the patient has a strong physique, the arm should be extended while the patient is seated on a low chair. This position prevents the patient from rising and interfering with the procedure, allowing the surgeon to perform the operation more easily. Hippocrates, however, recommended that the patient sit higher for a different reason.

The surgeon must ensure that the shoulder bone is drawn directly downward and that the cubit is bent as it would be when placed in a sling. If someone attempts to set the bone while lifting the arm upward or extending it, that position must be maintained. Otherwise, if the alignment is altered, the setting may be compromised when the arm is placed in a sling. Therefore, the surgeon should carefully position the arm so that it rests on the chest, pointing downward toward the waist.

When applying splints and securing ligatures, it is crucial to avoid excessive pressure on the joints. According to Hippocrates, applying pressure to sensitive, nerve-rich areas can lead to severe pain, inflammation, and exposure of both the bone and nerve, particularly if the compression affects the inner part of the bent arm. Consequently, the splints used for this area should be shorter.

Once the arm bone is properly set, the arm should be positioned at a right angle on the chest and secured in a sling. This keeps the arm stable and prevents the patient from unintentionally disrupting the setting when movement is necessary. The arm must remain immobile until the fragments unite with a callus, which typically takes around forty days, though this may vary based on individual body conditions.

18. Fracture of the Cubit (forearm), or the Ell-bone (ulna) and Wand (radius).

Both the ulna and radius can be fractured simultaneously, or only one may be broken. Fractures can occur in the middle or at the ends of the bones, either near the elbow or the wrist. The most severe fracture involves both bones, rendering the limb nonfunctional and complicating the healing process. In such cases, the intact bone stabilizes the arm and prevents muscle retraction, which typically occurs when both bones are fractured.

A fracture of the ulna, or “elbow bone,” is the most serious, while a fracture of the radius, or “wand,” is less problematic since the ulna supports the fractured portion. When both bones are broken, stronger support is needed due to increased muscle contraction.

Whenever either bone remains intact, it offers better support than ligatures or splints, keeping the muscles aligned. After setting the bones and securing them with ligatures and splints, the arm should be positioned in a scarf around the neck, ensuring the hand is not significantly elevated above the elbow to prevent fluid pooling. The hand should rest in a neutral position, between prone and supine, allowing the radius to lie directly beneath the ulna, as noted by Hippocrates.
In a supine position, both the bones and muscles are misaligned. The apophysis, styloid processes, and olecranon of the ulna should be in alignment, which does not happen in this position. The styloid process of the ulna aligns improperly against the inner process of the humerus.

For the muscles, their insertion points determine their positioning, and in a supine position, those muscles that flex the elbow have their tails positioned higher and more externally.

It’s important to occasionally bend and extend the patient’s arm gently to prevent stiffness and adhesion due to prolonged immobilization. This can lead to a condition called ankylosis, where the arm may become rigid and immovable.

If a fracture accompanies a wound, ensure to apply plates and secure the area with a proper ligature, keeping the bone fragments in their correct position. The arm should rest on a soft pillow or cushion as shown in the accompanying figure.

19. Fracture of a Hand

The bones of the wrist and after-wrist may sustain fractures, primarily due to a type of injury known as a Sedes, according to Hippocrates. If such a fracture occurs, the following method should be employed for their restoration.
The patient should extend their hand on a flat, smooth table. Next, your assistant should gently realign the broken bones, while the practitioner ensures they are properly positioned. Once restored, the bones must be stabilized using standard methods for other fractures, such as ointments, compresses, linen bandages, and splints. The fractured fingers should be bound together with their neighboring fingers to facilitate their healing, much like being secured to a stake. Given the unique, porous nature of these bones, they typically strengthen and unite quickly through the formation of a callus.

After these procedures, the palm of the hand should be filled with a tennis ball. This will not only help maintain the proper alignment of the broken bones but also keep the fingers in a neutral position—neither fully open nor completely closed. If the fingers are held in any other position, the resulting callus may distort or completely impair the hand’s ability to grasp objects.

In contrast, the management of fractured toes requires them to be kept straight and evenly aligned to avoid hindering walking or standing.

20. Fracture of a Thigh

Realigning the fragments of a fractured thigh is a challenging task due to the large and powerful muscles in that area. These muscles, when pulled back toward their origin—whether by natural movement or involuntary contraction—tend to draw the bone fragments along with them. Therefore, to properly restore a fracture of this bone, the patient should lie on their back with the leg fully extended. The surgeon must apply significant force to extend the thigh. If the surgeon alone cannot achieve adequate extension, they should enlist the help of two strong assistants to ensure that the bone fragments are aligned and set against one another.

To aid in this process, the ancients employed a device known as a Glossocomium, which was specifically designed for such situations. Here is an illustration of this instrument.

Instead of using the Glossocomium, you may opt for my pulley system. Hippocrates advocated for significant extension when dealing with fractures of this bone. He noted that even if the ends of the fragments are somewhat separated, leaving an empty space between them, a ligature should still be applied. This situation differs from the extensions of other bones, where the application of ligatures immobilizes the muscles.
In the case of the extended thigh, the ligature does not exert sufficient force to maintain the alignment of the bones and muscles as positioned by the surgeon. This is because the thigh muscles are large and powerful, easily overcoming the ligature’s hold. The surgeon must also take into account that the thigh bone is hollow on the inner side and rounded on the outer side; therefore, it should be restored to its natural shape. Failing to consider this may result in a straightened bone, causing the patient to limp for life. To preserve this inner hollowness, a compress or bolster should be placed within it, coated with an ointment such as unguentum rosatum to prevent it from slipping out. This will allow the ligature to more effectively keep the bone fragments in their proper positions. Additionally, compresses should be applied to the thinner and less prominent areas of the thigh, particularly near the ham and knee, ensuring that the entire ligation is uniform and, consequently, more secure.

As previously noted, ligatures serve three primary purposes. First, they keep the bones in place until they are strengthened by a callus. Second, they help prevent fluid accumulation in the damaged and dislocated areas, which can result from pain and weakness.
The third purpose is to secure and hold in place the splints and medications that are applied. Inflammation is mitigated by restricting the flow of blood and other bodily fluids into the affected area while also compressing any fluids that are abnormally present, directing them into the surrounding tissues above and below. Therefore, great care must be taken in preparing ligatures; they should be made from high-quality, finely woven cloth that is neither coarse nor rough. The ligatures should be of appropriate length and width, as determined by the surgeon’s informed judgment regarding the thickness and length of the limb, as well as the severity of the fracture. They must be broad enough to encompass and cover the entire fractured area, as well as a significant portion of the healthy tissue. While I have previously outlined and endorsed the binding techniques of Hippocrates in my book on bandages, I believe it is now important to describe the methods commonly employed by our contemporary surgeons.
Today, our surgeons require three ligatures for treating fractures. The first ligature is applied directly to the injured area—whether it is broken, dislocated, or merely strained—beginning with firm wrappings that bind the injury tightly, while allowing for a looser application on either side. These wrappings are drawn upward and finished at the top. They should be rolled thick but not wide; this way, if they are layered one on top of another, they will hold the bones more securely and effectively compress any excess blood from the healthy tissue surrounding the fracture.

The second ligature is then applied directly over the fracture itself, consisting of two wraps that move downward. However, these wraps should be looser and spaced further apart than those of the first ligature. This approach helps to minimize pressure on the fluids at the extremities of the injured area, preventing an overwhelming buildup of fluids that could lead to inflammation or the risk of gangrene. This is particularly important as the extremities are less capable of accommodating the excess fluids compared to the center of the injury, which retains greater natural heat. At the lower end of the injured area, the wrappings either conclude or are twisted back upward.

They then apply the third ligature at the lower end of the injured area, wrapping it smoothly and gently upward, with the windings made in the opposite direction of the first and second ligatures. This technique helps to draw the muscles back into their natural position, which may have been displaced by the tension of the earlier wrappings.

Once these ligatures are complete, they position three splints made of pasteboard or a similar material. The first splint is placed below the fracture and is significantly wider and long enough to provide adequate support. The other two splints are positioned on either side, spaced a finger’s breadth apart, to stabilize the bone and prevent any lateral movement. These splints are secured with tow or cotton.

Next, they contemplate the optimal positioning of the injured area, concentrating on three key objectives. First, the affected part should rest on a soft surface; second, it should be smooth and even; and third, it should be slightly elevated. It is crucial for the injured area to lie on a soft surface, as a hard foundation can apply pressure, resulting in pain and inflammation. Such discomfort may compel the patient to shift positions in search of relief, inadvertently moving the fractured area, which must remain still to facilitate healing.

The surface must also be smooth and even; an irregular or uneven base can distort the injured part, causing one section to be supported while another hangs unsupported. This can lead to further complications. Therefore, Hippocrates advises us to ensure that the heel does not hang down and that the foot is not left without adequate support, as this can lead to pain and an undesirable accumulation of fluids.

Moreover, the injured part should be positioned somewhat higher to prevent fluid accumulation, which is easily provoked by a downward angle. If the foot is placed lower than the leg, the blood flow from the leg can lead to inflammation. Conversely, if the foot is elevated, it prevents any fluid from pooling. Consequently, not only the foot but also the thigh and leg should be positioned higher than the rest of the body, while ensuring that the elevation does not cause excessive stretching, as Hippocrates cautions.
In the meantime, the injured leg or side should be aligned to match the length of the uninjured side. To accomplish this, it must be adequately supported on both sides with padding—a technique we will elaborate on later when discussing the treatment of a broken leg.

As the bandaging is applied, the following night and into the next day, the patient will notice that the affected limb feels more securely bound than it did initially. Indeed, the knee may appear elevated due to the buildup of fluid from the injured area. However, on the subsequent day, the bandaging may feel looser and more relaxed, as some of the accumulated fluid is absorbed. By the next day, the overall sensation will be even more relaxed, as there is a greater resolution of the fluid.

At this stage, it is essential to loosen the bandages—not only to prevent the fragments of bone from shifting out of alignment but also to provide the patient with relief from the constriction. Furthermore, this adjustment helps to mitigate itching, a common issue in areas that have been tightly bound for extended periods due to the accumulation of irritants and waste products. These substances can build up significantly in a resting and confined part of the body, arising from both excrementitious fluids that dampen the area and alimentary fluids that accumulate in a stationary limb. The lack of movement impedes normal diffusion and transpiration, while the tight bandaging clogs the skin’s pores. Consequently, the retention of these irritants can lead to discomfort, including itching, and in some cases, the skin may deteriorate due to the corrosive nature of the trapped vapors and fluids, resulting in ulceration.

To prevent such complications, the affected area should be fomented with warm water and oil for a duration deemed appropriate. This fomentation alleviates pain, relaxes any excessive tightness caused by the binding, and addresses the cooling of the area resulting from the stasis of blood and vital spirits, thereby reviving the natural internal heat. If swelling accompanies contusion and bruising, it should be fomented for a longer period to facilitate the digestion of the stagnant fluid. However, if this duration proves insufficient, stronger digestive agents may be employed, with caution taken not to use them for too long, as this could impede the formation of a callus.

It is important to remember Hippocrates’ observation that a weak fomentation employed for a short duration attracts but does not disperse, while a longer and stronger application may deplete tissue. Additionally, consideration must be given to the patient’s constitution; fomentations can draw excessive humors to the area in individuals with a plethoric condition. The ancients advised loosening the ligatures every third day until the seventh day, and then every seventh day thereafter. However, no rigid rule can be established, as the timing for dressing changes must be adjusted based on the patient’s condition, requiring flexibility in renewing the ligatures and other aspects of care.

Therefore, if no symptoms necessitate intervention, I recommend minimizing the frequency and urgency of any actions taken during the initial dressing. Even slight movement of the bone fragments can hinder the healing process, as the union of bones is akin to how wood is bonded with glue and pewter with solder; nature facilitates the joining of bone fragments through the formation of a callus. Consequently, broken bones require ample rest for callus formation; otherwise, the healing material may dissipate without effect.

To support the generation of a callus, which typically commences around the thirteenth to fifteenth day, an emplastrum made from egg whites, combined with powdered red rose leaves and wheat flour, may be applied, along with other catagmatic plasters that will be detailed later in the discussion on leg fractures.

21. Regarding fractures of the thigh near the joint, whether at the upper or lower end of the bone

A fracture can sometimes occur at the hip joint in the neck of the thigh bone, as I once witnessed in a respectable matron. When I was called to her, I observed that the injured thigh was shorter than the other, with noticeable prominence of the ischium. At first glance, I believed this prominence was due to the head of the thigh bone. Consequently, I convinced myself that it was a dislocation rather than a fracture. Therefore, I extended the bone and attempted to reposition the head into its socket. The subsequent equalization of both legs in size further reinforced my belief that it was a dislocation. However, when I visited her again the following day, I found her in significant pain, with the injured leg still shorter and her foot twisted inward.
I then loosened all her ligatures and noted a prominence reminiscent of what I had observed earlier. Consequently, I attempted once again to reposition the head of the bone as I had previously done. While I was focused on this task, I heard a faint crackling sound. Moreover, I observed that there was neither a cavity nor a depression in the joint. These indicators convinced me that the bone was fractured rather than dislocated. It is crucial to understand that not only can such fractures occur, but the separation of the head or appendix of the bone from its proper position can also lead to misconceptions of dislocation. This has, at times, misled some inattentive surgeons who, unaware of the potential for separation at the top of the thigh bone, have mistakenly diagnosed it as a mere dislocation.
Returning to my previous account, I proceeded to set the bone and align the fragments. I applied splints with compresses and secured them with a roller, wrapping two heads around the joint and crossing the bandage over the body. To shield her foot from any pressure caused by the bedding, I placed it in a protective case. I then fastened a rope to a post, allowing it to hang down into the center of the bed, and tied several knots along its length. This setup provided her with a means to grasp and lift herself, which is essential in cases of fractures and dislocations of the thigh and leg.

This arrangement enables patients to have something to hold onto, allowing them to assist themselves when they wish to rise, reposition in bed, or use the toilet. Additionally, it promotes perspiration and ventilation for the lower back, buttocks, and other areas that may become compressed and fatigued from prolonged lying down. Without these measures, patients can suffer from heat and pain, which can lead to the development of ulcers, resulting in torment through fever, sleeplessness, and discomfort.

The opportunity to raise the body from the bed is particularly crucial in this case, as the fracture is closer to the joint. Fractures in this area are more dangerous than those occurring in the mid-thigh, making them more challenging to treat and heal. This difficulty arises from the lack of blood flow and the abundance of nerves, tendons, and ligaments, which are susceptible to various complications. Therefore, the surgeon must exercise diligent care in managing this type of fracture, frequently checking to ensure that the set bone does not displace again. Such dislocation can easily occur with any slight movement of the body, as the thigh consists of only a single bone.
Consequently, each time the bandages are loosened and the fracture is dressed, the surgeon should carefully examine the alignment of the bone and the size of the affected area, comparing it to the healthy side. Once the fragments of the broken bone are properly aligned, they should remain in contact with one another. However, before the bone fully heals, the affected area must be extended and restored to its original state to prevent the patient from limping for the rest of their life.

I have read in Avicenna’s writings that very few recover from a fractured thigh without experiencing some degree of limp. Therefore, it is essential for the patient to minimize movement as much as possible. Many ancient texts suggest that the consolidation of this bone takes about fifty days; however, as I previously mentioned, there is no definitive timeline for this process. Regardless of the duration required for healing, the patient must avoid putting weight on the affected limb immediately after the bone has knitted, as weakness persists in the area for an extended period. During this time, patients often need to rely on crutches to assist their mobility while regaining strength.

22. Fracture of the Patella, or whirly-bone (kneecap) of the knee

The kneecap, or patella, is often bruised but less frequently fractured. However, when a fracture does occur, it typically results in two or three pieces, which may be oriented longitudinally or transversely. Occasionally, the bone may break in the middle or shatter into multiple splinters, with or without an accompanying wound.

Symptoms of a patellar fracture include difficulty in walking, a noticeable hollowness in the affected area, and a palpable separation of the bone fragments, often accompanied by a crackling sound when touched.

Treatment involves the following steps: the patient should extend their leg and maintain this position throughout the healing process. To prevent accidental bending of the knee, a bolster should be placed behind the knee to fill the hollowness. If the knee bends, the displaced fragments of the patella may separate again. Once positioned correctly, the surgeon will align the fragments as needed and secure them using appropriate remedies, including ligatures and padding, similar to the treatment for a femur fracture.

Finally, it is important to follow the same care protocols as for a leg fracture. In terms of prognosis, I must note that I have observed none of those who suffered a fracture of the patella who did not experience a permanent limp. This is due to the formation of a callus during the healing process, which restricts the knee’s ability to bend freely. Walking on level ground may be manageable for the patient, but ascending inclines is often significantly more challenging and painful. Consequently, the patient must remain in bed or at least rest for a minimum of forty days following this type of fracture.

23. Broken legs

This type of fracture is treated in much the same way as fractures of the arm or forearm. Hippocrates warns that a fracture of the tibia, or leg bone, is more perilous and more challenging to heal than a fracture of the fibula, or shin bone. This is due to the tibia being thicker and serving as the primary support for the body’s weight, while the fibula acts as an auxiliary structure, providing stability for the leg muscles and facilitating movement of the foot.

When only the tibia is fractured, the symptoms are typically observed on the inner side of the leg, as the intact fibula prevents the tibia from displacing outward. Conversely, if the fibula is fractured alone, the symptoms manifest on the outer side of the leg, since the intact tibia restrains the fibula from shifting inward. In cases where both bones are fractured, symptoms will be evident on both sides.

However, when only one of these bones is fractured, the injury is generally easier to treat and heal. The intact bone provides a more stable support for the damaged bone than any splints could offer. To better prepare the surgeon for managing this type of fracture, I will share a personal example to illustrate the process.
John Nestor, Doctor of Medicine, Richard Hubert, and I set out together to visit a patient at the Place of the Friar Minorites. As we approached the Seine, intending to cross within sight of the location, I attempted to guide my horse onto the boat by giving him a light switch on the rear. The stubborn creature, agitated by this, lashed out at me with his hind legs, fracturing both bones in my left leg about four fingerbreadths above the ankle.
In a moment of panic, fearing further injury and anticipating another strike from the horse, I instinctively withdrew. As I retreated, the broken bones splintered further, piercing through the flesh, stocking, and boot, becoming visible. The pain I experienced was beyond what one might believe a person could endure.

Consequently, I was quickly carried into the boat to be transported across the water for treatment. However, the movement of the boat as they rowed nearly overwhelmed me with the bitterness of pain, as the sharp fragments of bone scraped against the surrounding flesh. Once ferried across, my agony intensified as I was transferred into the nearby houses. The hands of several individuals lifted me, sometimes raising me high, at other times lowering me, and shifting my body from side to side, exacerbating my suffering at every turn.

At last, when I was laid upon a bed, I found some relief from the bitterness of my pain and had a chance to wipe the sweat that streamed down my body. I was treated with whatever remedies were available at the time and place; the mixture consisted of egg whites, wheat flour, soot from a chimney, and melted butter.

I then asked Richard Hubert to attend to my injury as if he were a stranger, ensuring that his care was not softened by any affection for me. I urged him to stretch my foot straight out and, if the wound was not sufficiently wide, to enlarge it with his incision knife, so he could more easily realign the broken bones. I requested that he use his fingers—whose judgment is far more reliable than any instrument—to determine whether the splinters in the wound were completely severed from the bone and needed to be removed. I asked him to press out the blood and clots that had accumulated at the mouth of the wound, and to bind and position my leg in the way he deemed best.

He should prepare three rollers: the first to be placed directly over the wound, beginning his ligation there. He should apply splints—three of them, or two fingerbreadths in width and about half a foot long, slightly depressed and hollowed to fit more easily around my leg. These splints should be aligned straight at their ends, spaced a finger’s breadth apart, and secured with strips of cloth similar to those women use to bind their hair, ensuring that the binding was taut over the wound. Additionally, he should fill the cavity of my ham and ankle with bolsters made of flax wrapped in linen, and reinforce the sides of my leg with supports made of small sticks, lined with linen cloth, extending from my heel to my groin and secured in four places. This would help maintain the proper alignment of my leg against any external forces.

He should gently and smoothly elevate my leg to an appropriate height, and finally protect it from further injury by placing it in a box or case. It is crucial to note that the proper positioning of the leg is of utmost importance; any error could result in permanent lameness. If the leg is lifted too high, the callus will form hollow on the front side; if too low, it will protrude unnaturally. Moreover, neglecting to fill the cavities around the ankles as described can lead to significant discomfort in the heel, which would be forced to endure prolonged and painful pressure, ultimately resulting in inflammation due to restricted blood flow.

I learned this through experience, often wishing for someone to elevate my heel occasionally, so it could benefit from perspiration and allow the spirits to flow freely, letting the trapped vapors escape. In conclusion, my injured leg was finally laid upon a cushion, following the method I have described below.

24. Factors to Consider for Ligation When a Fracture Is Accompanied by a Wound

This principle, derived from the teachings of ancient scholars, must be firmly upheld: ligation should be applied directly to the wound. Failing to do so can cause the injured area to swell into a significant tumor, as the humors are forced into the site by the pressure of ligation applied above and below. This can lead to a host of serious complications.

You can observe this phenomenon on healthy, fleshy tissue; if you bind it above and below without applying pressure to the center, the tissue will elevate into a considerable tumor, altering its vibrant color to a livid or blackish hue due to the accumulation of humors pushed from the surrounding areas. Such effects are even more pronounced in wounded or ulcerated regions. Consequently, the ulcer may remain unhealed and weeping, discharging a crude and liquid sanies reminiscent of what typically flows from inflamed eyes. If this sanies comes into contact with bone and lingers, it can burn and corrupt the bone, especially if it is fragile or soft.

Signs of bone corruption include an increased volume of foul sanies emanating from the ulcer beyond what is typical for a simple ulcer, inverted ulcer lips, surrounding flesh becoming soft and flaccid, and the patient experiencing severe, intermittent pain. If probing reveals the bone is stripped of its periosteum or if the probe encounters a rough or scaly texture, or penetrates the bone substance, these are further indicators of decay. We have discussed bone rot extensively in our dedicated treatise on the subject.

However, such decay will not occur if the injured area is properly bandaged according to medical standards. Thus, I believe it is prudent to remind the surgeon to apply compression to the wound whenever feasible, unless excessive pain and inflammation necessitate a deviation from this standard treatment approach. In such cases, if no other options are available, the surgeon should compensate for the lack of ligation and rollers with a linen cloth—neither too weak nor overly worn—doubled two or three times, to encircle the wound and surrounding tissue. The edges of the cloth should be stitched to the sides of the wound to avoid disturbing the bone fragments, which must remain stable once set.

Broken bones do not require as frequent dressing as wounds or ulcers. This illustrates that both inadequate binding and excessive looseness in the absence of pain can lead to phlegmon and abscess formation, just as overly tight ligation in the presence of pain can produce similar complications. Therefore, all actions should be balanced according to the previously mentioned rules and circumstances.

I reiterate these points because many practitioners still adhere to the methods of Paulus, employing excessive circumvolutions above and below the wound. This cross or lattice-style ligation is to be avoided; we should instead follow the approach outlined by Hippocrates. Now, let us return to the account of my own misfortune and describe what transpired following that initial dressing I previously mentioned.

25. What was applied to the author's leg following the initial dressing

I was brought home to my house in Paris in the afternoon, where they drew approximately six ounces of blood from my left arm at the Basilica. During the second dressing, the edges of the wound and the surrounding areas were treated with unguentum rosatum, which, by the consensus of ancient physicians, is highly recommended in the early stages of fractures. This ointment alleviates pain and reduces inflammation by drawing harmful humors away from the injured area, as it possesses cold, astringent, and repelling properties, as indicated by its composition of oleo omphacino, aqua rosacea, a bit of vinegar, and white wax.

I applied this ointment for six days, occasionally soaking the compresses and rollers in oxycrate or thick, astringent red wine to strengthen the affected area and control the humors. According to Hippocrates, it is essential to be vigilant about these two factors, especially in fractures accompanied by a wound. If the compresses or rollers began to dry out, I would sometimes moisten them with oxycrate or rose vinegar. Excessive dryness can lead to pain and inflammation, and if they are too tightly bound, they can cause harm due to their rigidity.

You will find many surgeons who, throughout the entire treatment, rely solely on astringent and emplastic remedies, which is contrary to the methods advocated by Hippocrates and endorsed by Galen. The prolonged use of such treatments can close the pores and breathing passages of the skin, leading to the retention of dark excrement, increased external heat, itching, and ultimately, the formation of ulcers due to the irritation from long-held acrid and serous humors. This illustrates that astringent and emplastic medicines should not be used for more than six days. Instead, you should apply the plasters that I will describe shortly.

In the early days of my illness, I maintained a very restricted diet, consuming only twelve stewed prunes, six small pieces of bread, and a pint of sweetened water each day for nine days. This water was composed as follows.
Prescription:
– Combine:
– 12 ounces of white sugar
– 12 pounds of spring water
– 3 drams of cinnamon
– Allow the mixture to boil together using the appropriate technique.
At times, I utilized syrup of maidenhair mixed with boiled water. On other occasions, I crafted the beverage referred to as the divine drink, which consists of the following ingredients:

– Prescription:
– Use:
– 6 pounds of distilled water
– 4 ounces of white sugar
– 1 ounce of lemon juice
– Stir the mixture thoroughly.
– Transfer it frequently into glass containers.
I took a dose of Cassia cinnamon and rhubarb as a laxative and inserted Castle soap suppositories to facilitate bowel movements. Whenever the urge to evacuate struck, an intense, almost unnatural heat would grip my kidneys. Despite adhering to an exquisite diet, I could not prevent a fever from developing on the eleventh day, accompanied by a significant flow of pus that ultimately turned into an abscess. I believe this was due to overly loose binding (as I could not tolerate anything tighter) which led to humors being suppressed at the base of the wound. Furthermore, fragments of bone had broken off, and as they began to decay, they drew the surrounding tissue into a state of deterioration. The resulting putrid heat significantly contributed to the inflammation and discharge. I believed these were scales separated from the bone, suggested by the thin, foul fluid seeping from the wound, the swollen edges, and the loose, spongy flesh encircling it. One night while I slept, my muscles contracted violently, pulling my entire leg upward. This force displaced the bones, pressing against the sides of the wound. They could not be realigned without further painful manipulation. After enduring a fever for seven days, it finally reached a crisis, culminating in the eruption of matter and profuse sweating.

26. What could be the cause of the convulsive twitching in fractured limbs?

This contraction, resembling convulsive twitching, commonly occurs in fractured limbs during sleep. I believe this phenomenon arises because the body’s natural heat retreats to its core while we rest, causing the extremities to become cold. In response, nature, through its inherent wisdom, dispatches vital spirits to support the injured area. However, since these spirits cannot be accommodated by the affected region, they gather and, in their usual swift manner, return to their original position. The muscles follow suit, pulling the bones to which they are attached. As a result, the bones become displaced once again, leading to significant pain as they fall from their previous alignment. This contraction of the muscles moves toward their origin.

27. Certain documents regarding the areas where the patient must rest while lying in bed.

Those with a broken leg must remain confined to their beds for an extended period due to intense pain and the need for healing. This immobility affects areas such as the heel, back, sacrum, buttocks, and muscles of the injured leg, leading to diminished strength and function. Over time, the lack of movement results in the accumulation of waste, causing abnormal heat and increasing the risk of complications like discharge, abscesses, and ulcers, particularly in the sacrum, buttocks, and heel. The sacrum’s limited cushioning makes it vulnerable, while the heel suffers due to its sensitivity.

Healing these ulcers is difficult; they often lead to gangrene and decay in surrounding tissues and bones, resulting in persistent fever, delirium, and convulsions, along with hiccups due to sympathetic reactions. Both the heel and stomach are sensitive areas, with the stomach heavily innervated by the sixth cranial nerves. The heel connects to a major tendon formed by three calf muscles, making both regions susceptible to the loss of essential heat and potential infection from harmful vapors.

Recognizing these dangers, I sought ways to elevate my heel from the bed. Using a rope for support, I lifted myself to relieve pressure. To aid recovery, I rested my heel and buttocks on a round cushion filled with soft feathers, allowing for air circulation. I applied linen cloths with rose ointment to soothe pain and reduce heat.

Additionally, I designed a metal case to securely hold my broken leg, offering better stability than other supports. This case allows for movement and prevents my heel from resting heavily on the bed. A soft bolster is placed beneath the calf in the hollow section, and a small arch protects the heel from bedclothes. These innovations will be illustrated in the following figure.

A. The bottom or belly of the cast.
B. The wings or sides that can be opened and shut at will.
C. The end of the wings where the sole or arch is fitted.
D. The arch.
E. The sole.
F. An open space where the heel extends out of the cast.
I applied the following remedies to the abscess that formed on my wound. Upon noticing the abscess, I created a suppurative mixture of egg yolks, common oil, turpentine, and a bit of wheat flour, which I used until the abscess opened. To cleanse it afterward, I employed the remedy described below.
Ingredients:
– 2 ounces of rose syrup
– 2 ounces of Venetian turpentine
– 1.5 drams of powdered iris root
– 1.5 drams of aloes
– 1.5 drams of mastic
– 1.5 drams of barley flour

– Combine ingredients in a mixing container, stir the mixture well until all ingredients are fully incorporated

I ensured that the area where I suspected the bone splinters would emerge was lined with tents made of sponge or flax, allowing me to keep the ulcer open as needed. Additionally, I placed catagmatic and cephalic powders at the bottom of the ulcer, along with a bit of burnt alum to facilitate the release of the aforementioned scales.
Once the scales were expelled, I used burnt alum to cicatrize the ulcer. Its drying and astringent properties helped to firm up the loose, spongy flesh and control the flow of liquid sanies, thereby assisting nature’s process of healing.
The bone fragments, due to their inherent dryness and hardness, cannot rejoin on their own. They require a substance that will thicken and solidify at their ends, effectively gluing them together and securing them like solder.
This substance consists of the natural marrow of the bones, while its form is derived from native heat and moderate emplastic medicines. In contrast, medicines that apply excessive heat break down and thin the matter of the callus, preventing proper healing. Therefore, I recommend using the following emplasters, known for their effectiveness in promoting knitting or consolidation.
Prescription:

– Oil of blueberries and rose oil: 1.5 lbs each
– Root of marshmallow: 2 lbs
– Root of ash and its leaves: as needed
– Root of greater comfrey and its leaves: as needed
– Leaves of willow: 1 m.

Make a decoction with a sufficient quantity of red wine and water of beans for the intended use.

Add to the strained decoction:

– Powder of myrrh and frankincense: 1.5 oz each
– Goat fat: 1.5 lbs
– Purified turpentine: 4 oz
– Mastic: 3 drams
– Gold and silver litharge: 2 oz each
– Armenian bole: 1.5 oz
– Seal earth: 1.5 oz
– Red lead: 6 drams
– White wax: as needed

Mix to create a plaster according to the art.
In place of this, you may use the black plaster, of which this is the description:
Take 1 pound of gold litharge, 2 pounds of oil and vinegar; let them be cooked together over a slow fire until a black and shining plaster is obtained, and it does not stick to the fingers.

Or else,
Take 2 ounces each of rose oil and myrtle oil, 1.5 ounces of cypress nuts, 1.5 ounces of dragon’s blood powder, and 4 ounces of diachalcite plaster; let them melt together, and make a plaster according to the art.
In the absence of other options, you may use a cere-cloth or Gualter’s cloth, which is prepared as follows:

Take 2 ounces each of powdered frankincense, volatile flour, mastic, resin from pine, cypress nuts, and madder. Additionally, use 1.5 pounds each of sheep tallow and white wax. Prepare a plaster from these ingredients.

While the mixture is still warm, dip a linen cloth into it for the intended application. Emplastrum Diacalcithios is highly recommended for treating fractures, as endorsed by the ancients. However, its preparation should vary with the seasons. In summer, it should be dissolved in the juice of plantain and nightshade to avoid overheating.

It is crucial to consider the condition of the affected bodies during treatment. The bodies of children should not be dried out as much as those of older individuals. If drying agents intended for older patients are applied to younger ones, they could dissolve the callus rather than allowing it to form correctly. Therefore, the surgeon must exercise great care in selecting the appropriate remedies. Remedies that are beneficial on their own can become harmful if misapplied or used without proper judgment, leading to serious complications. This may result in the callus becoming too soft, hard, thin, or crooked, or it may take much longer to heal—all of which would reflect poorly on the surgeon.

28. How can we determine that the callus is forming?

I began to realize that my leg was healing when I noticed a decrease in the discharge from the ulcer, the pain subsided, and finally, the involuntary twitching ceased. This led me to conclude that it was appropriate to change the dressing less frequently than I had been doing. Constant cleaning and dressing of an ulcer while a callus is forming can remove essential materials needed for healing—known as Ros, Cambium, and Gluten—crucial nutrients for both bone and flesh.

I also inferred the formation of the callus from other signs, particularly the appearance of a certain moist blood seeping gently from the edges and pores of the wound. This blood, which lightly soaked the dressings and bandages, indicated the flow of finer, delicate substances necessary for the callus to develop. Additionally, I experienced a pleasant tickling sensation from a warm vapor that softly radiated from the upper areas down to the site of the wound.

From that moment on, I loosened the bandaging slightly to allow the blood, which is vital for the formation of the callus, to reach the bone fragments without obstruction. I believed it was crucial to provide nourishment that would promote the production of thicker, more robust blood suitable for creating a callus. To this end, I included tougher, gelatinous parts of animals, such as the heads, feet, legs, and ears of pigs, cattle, sheep, and kids. I boiled these with rice, French barley, and similar grains, alternating between them to keep my meals enjoyable. I sometimes prepared a dish of frumity, which consists of wheat boiled in capon broth with egg yolks. For drink, I opted for a rich, astringent red wine, moderately mixed with water.

For my second course, I enjoyed chestnuts and medlars, and I mention this deliberately. I am particular about my diet because certain heavy foods, especially brittle and fragile ones like beef, can be just as detrimental to the formation of a callus as lighter meats. Foods that are too dry can hinder the callus, while those that are overly tender can weaken it. Therefore, as Galen states, the best meats for generating a callus are those that are neither brittle nor fragile, nor too watery and thin, nor excessively dry; they should be moderately hearty, viscous, fatty, and tough.

These meats, once digested into a substance called chylus in the stomach, are then transported to the intestines. From there, they pass through the mesenteric veins into the portal vein and into the liver, subsequently entering the vena cava and spreading throughout the body via various veins. Some of these veins carry blood into the bones, where marrow resides in the larger cavities, while a more marrow-like substance nourishes the smaller cavities. The generation of marrow comes from the denser portions of the blood, which flows into the larger bone cavities through larger veins and arteries, and into the smaller cavities through narrower vessels that terminate in tiny pores and passages.

In larger bones, you can observe prominent passages through which veins and arteries enter for the purposes mentioned earlier. The nerves also travel through these channels, giving rise to a membrane that encases the marrow of the bones. This arrangement endows the marrow with remarkable sensitivity; as experience shows, this is why many believe that the marrow possesses a sense of feeling, as injury to these membranes can result in intense pain. Consequently, from the marrow and the bone’s own substance, a thick, earthy fluid is secreted. Through the action of the assimilating faculty, which acts in place of a formative one, a callus forms and binds together.

Simple fractures of the leg typically heal within a few weeks; however, due to the severity of my injury, with the wound and surrounding tissue completely damaged, it took a full three months for the fragments of my bones to knit together properly. It was another month before I could walk on my leg without the aid of a crutch. For several days, walking was quite painful because the callus had taken the place of the muscles. Before I could regain my previous freedom of movement in the healed area, it was necessary for the tendons and membranes to gradually separate from the scar tissue. Throughout this process, I received diligent and faithful assistance from the surgeons, particularly Anthony Portall, the King’s surgeon, among others.

29. Factors that may impede the formation of a callus, and how to rectify any issues that arise if it is improperly formed

Having previously discussed the signs of a callus beginning to form, as well as its generation and the process involved, it is now essential to address the factors that hinder its formation, as well as those that promote its proper development.

The elements that either completely obstruct or delay the generation of a callus possess strong properties that are either dissolving or attenuating, or they may be oily, unctuous, and moist. Such substances can either melt away the vital juices necessary for the callus or render them soft and relaxed.

Conversely, the substances that encourage the formation of a callus should be drying, thickening, hardening, and capable of promoting tissue formation. They should be moderately warm and astringent. Moist and relaxing agents should generally be avoided in this context, unless the callus is poorly formed—too thick, crooked, or otherwise misshapen—resulting in it being weakened or broken, thus allowing for a potential restoration to a better form. However, such measures should only be considered if the callus is still in its early stages and significantly deviates from the natural shape of the area, affecting its function.

In such cases, the affected area should be treated with a fomentation made from a decoction of sheep’s head and entrails, along with the roots of marshmallow, briony, flax seeds, fenugreek, pigeon droppings, bay berries, and similar ingredients. Additionally, you should apply the following ointment and plaster.
Prescription:
Take 4 ounces of marshmallow ointment, 1 ounce each of lily oil and goose fat, and a small amount of aqua vitae. Melt them together to create a liniment to be applied to the affected area.

Then apply the following poultice:

Prescription:
Take 3 ounces each of Vigo plaster with mercury and Philagrius’s ointment, and 1 ounce each of dill oil and lily oil. Melt all these ingredients together to create a poultice.
Apply it to leather for the intended purpose. Once the callus appears to be sufficiently softened through these methods, it can be broken, allowing the bones to return to their natural position, and then the healing process for the fracture can continue as initially planned. If the callus has hardened over time, it is better to leave it alone rather than attempt to break it, as this could lead to more serious complications for the patient. There is a risk that, in trying to break the callus, the bone might fracture in a different location before it gives way at the site of the callus. Thus, a wise patient would prefer to live with a limp than to risk their life by trying to avoid this issue.

If the callus is excessively thick and still fresh, it can be reduced using emollient, dissolving, and strong astringent treatments that can dissolve, dry, and diminish it. Additionally, it’s advisable to vigorously massage the callus with bay oil mixed with dissolved saltpeter or another type of salt. Afterward, wrap the area tightly with a bandage and place a lead plate on top to prevent the flow of nourishing fluids to the area, allowing the callus to gradually break down and lessen over time.
If, on the other hand, the callus is too thin or develops slowly—perhaps because it is bound too tightly, or because the affected area has remained immobile for too long without proper use—these factors can contribute significantly to its inadequacy. Lack of exercise is a major cause of this thinness, as movement stimulates the natural heat of the area, which is essential for digestion and nourishment. Additionally, poor nutrition—whether in quality, quantity, or both—can impede healing. Frequent loosening of the binding or premature stress on the area can also hinder recovery.

In response to these varying causes, appropriate treatments should be applied. If the binding is too tight, it should be loosened. In fact, the fractured area should be completely freed from any binding, and a new bandage should be applied. This new binding should start from the base of the blood vessels—meaning from the armpit for an arm or from the groin for a leg—down to the fracture site. This technique allows blood to be drawn from the source and directed towards the affected area, counteracting the previous method we advised to prevent inflammation.

Gentle massage and warm water compresses can also be beneficial, but should be stopped once the area starts to feel warm and swell. Prolonged use of these treatments can lead to the opposite effect, drawing fluids away from the area instead of promoting healing. We have often observed that the effectiveness of rubbing and compresses can vary greatly depending on how long they are applied. Additionally, certain forms of stimulation and other remedies typically used for areas suffering from atrophy or lack of nourishment can be helpful in this situation.

30. Fomentations used for broken bones

Various fomentations are used for broken bones for multiple reasons. Warm water for fomentation refers to a lukewarm temperature, comfortable for both the physician and the patient. This type of fomentation, applied briefly, moderately heats, thins, and prepares superficial humor for resolution. It draws blood and nutritional humor to atrophied areas, alleviates pain, relaxes tense muscles, and provides gentle warmth to chilled limbs. However, excessive heat from fomentation can cool the area by digesting and dispersing the hot humor within. Fomentation should be brief when the area reddens and swells, and moderate when it is clearly red and swollen. If the redness fades and swelling decreases, it signals that too much time has been spent on treatment. The body’s condition must also be considered; in a plethoric body, ordinary fomentation may cause excessive swelling from surplus humors, while in a lean body, it can enhance fleshiness and succulence in the area treated. Next, we will address fractures of the bones in the feet.

31. Fractures of the bones in the feet

The bones of the instep, back, and toes of the feet are susceptible to fractures, much like the bones of the hands. Therefore, these injuries should be treated in a similar manner. However, it is crucial that the bones of the toes are not allowed to remain in a crooked position, unlike the bones of the fingers, to prevent impairment or distortion of their function. Just as we rely on our legs for walking, we depend on our feet for standing. Additionally, the patient should remain in bed until the fractures have healed properly.