Book 16: Dislocations

1. Types of Dislocations

A dislocation refers to the displacement of the head of a bone from its proper cavity into an abnormal position, which obstructs voluntary movement. Another type of dislocation, known as luxation, occurs due to violent stretching, as well as the divergence and expansion of the ligaments and surrounding connective tissues that support and stabilize the joints.
Individuals who have endured the torture of being racked often experience severe stretching of the thick ligament located in the inner cavity of the hip bone. Similarly, those who have suffered the strappado—the torture technique involving suspension by the arms—face violent and forcible distension of the ligaments surrounding the joint where the arm bone connects to the shoulder blade.
Similarly, those who have strained their foot from slipping experience a comparable effect.
There exists a third type of luxation, characterized by the separation of adjacent bones that are closely joined, with one appearing to be bound to the side of the other. This can be observed in the arm when the elbow separates from the forearm, and in the leg when one bone moves apart from the other. However, this can also be classified under the second category of dislocations, as it typically occurs alongside the stretching or tearing of the ligaments.
There is also a fourth type, occurring when the epiphyses and heads of bones are detached from the bones to which they were originally attached. This improperly termed kind of luxation primarily affects the bones of young individuals and is recognized by the weakness of the affected area, as well as the noise and grinding of the cracking bones when manipulated. Additionally, the bones of young people are susceptible to another condition: while the bones of the elderly tend to break due to their dryness and rigidity, the bones of children may bend or become crooked because of their natural softness and moisture.

2. Differences of Dislocations.

Some dislocations are simple, while others are compound. We classify them as simple when no other preternatural effects are associated; compound dislocations are those complicated by one or more preternatural conditions, such as when a dislocation occurs alongside a wound, fracture, significant pain, inflammation, or an abscess. Due to these complications, we are often compelled to delay addressing the luxation until they resolve on their own or through our intervention. Some dislocations are complete and perfect, where the bone entirely falls out of its cavity; others are imperfect, where it is only slightly displaced and not fully out, which we refer to as subluxations or strains. Differences in luxations are also categorized by location: sometimes the bone is displaced forward, backward, upward, or downward; at other times, it may be displaced in various combinations of these directions. Additionally, differences can be noted based on the condition of the dislocated joint, such as its size and the depth of the cavity or sinus involved, as well as the duration since the injury occurred, whether recent or of long standing. I have deemed it necessary to outline all these variations, as they lead to different indications for treatment, which we will discuss further.

3. Causes of Dislocations

There are three general causes of luxations: internal, external, and hereditary. Internal causes include excrementitious humors and flatulencies that settle into the joints with great force and abundance, making the ligaments that bind the bones slippery, soft, and relaxed, allowing them to easily fall out of their cavities. Alternatively, these humors may fill and distend the ligaments, making them short and contracted, which then pulls the appendices of the bones from their origins, or draws the heads of the bones out of their cavities. This is particularly pronounced when the violence of a noxious humor is also present, as it can infiltrate and occupy the cavities of the joints, displacing them from their proper positions. This often occurs in the hip joint due to sciatica or in the vertebrae of the spine, resulting in deformities such as gibbosity or other forms of curvature.
External causes of dislocations include falls from heights, bruising and heavy blows, the rack, strappado, slipping while walking, and other similar actions that can force the heads of the bones out of their seats or cavities. This can also occur in infants during birth if they are carelessly and violently pulled out by the midwife, resulting in dislocated arms or legs.

Hereditary causes arise from traits that parents pass on to their offspring; thus, it is common for crooked individuals to be born of crooked parents and lame individuals from lame parents. This is evident in daily experience. Furthermore, Hippocrates asserts that infants in the womb can have their joints dislocated due to falls, blows, compression, or excessive humidity and looseness of the joints. As a result, many are born with crooked legs and feet, leaving no room for doubt or astonishment regarding this phenomenon.
Galen observes in his work on joints that children may develop abscesses in their mothers’ wombs, which can release pus when the ulcers open spontaneously, healing naturally. Additionally, some children are born with joint cavities that are not sufficiently depressed and with more dilated edges than normal, making it difficult for the heads of the bones to fit properly. Others may have ligaments that are inherently weak, either due to inadequate strength from the start or an excess of phlegm, which can lead to excessive slipperiness, hindering the stability of the joints. In such cases, bones can be easily dislocated but may also be readily restored without the need for a surgeon, as I have observed in some instances.

4. Signs of dislocations

Signs indicating a luxated bone include both common indicators for all dislocations and specific signs unique to particular luxations. A typical sign is the presence of a tumor at the site where the bone has moved and a hollowness on the opposite side. Specific signs will be discussed when addressing particular types of luxations. A complete dislocation is identified by the loss of motion in the affected part, and pain also suggests a dislocation, as the displaced bone head compresses surrounding flesh and distends nerves. Comparing the injured joint with a healthy one is essential; the healthy joint must show no signs of deformity, decay, or swelling, as any such issues may lead to misinterpretation. Difficulty in movement indicates an incomplete luxation or strain. Additionally, if the ligaments connecting the joint are stretched or relaxed, pressing the bone head with your fingers may allow it to move easily to the opposite side and then return. If inserting a finger into the joint meets no resistance, it suggests an empty space within, indicating either difficult motion or none at all.

5. Prognostic Considerations for Luxations

All joints can be dislocated or luxated, but not all can be restored in the same manner. Dislocation of the head can lead to immediate death due to compression of the spinal cord at its origin. Similarly, dislocation of a vertebra in the spine or the jawbone, when displaced on both sides, can cause inflammation and significant swelling before it can be properly set. The ease or difficulty of restoring dislocated bones varies depending on the joint and the extent of the dislocation.
The less a joint is moved out of its place, the more quickly it can be restored; conversely, the further it is displaced, the more slowly and difficultly it can be set. The shape of the luxated bone also indicates how easily or hard it can be restored. For instance, in the arm, the more easily the bones dislocate, the more easily they can be restored once luxated. Bones do not easily dislocate in fleshy bodies; however, when they do, they are not easily repositioned. In such cases, the articulation is tightly held in place by the thickness of the surrounding muscles and the abundance of fat. In contrast, lean individuals, particularly those who were previously more robust, have looser joints, making it easier for their bones to dislocate. Additionally, due to digestive issues, they may have joints filled with mucous humors, causing the heads of the bones to be less stable, as noted by Hippocrates.
Slender bodies, being naturally dry, compact, and dense, possess stronger and drier muscles and ligaments, making their bones more resistant to displacement; when displaced, they are also more difficult to set. Some bones may separate from one another, such as the shoulder blade from the collarbone at the acromion, the ulna from the radius in the arm, and the tarsal bones in the leg. Once separated, these bones typically cannot be rejoined, nor can they regain their original shape or strength. This often occurs because the ligaments are either torn apart or have become lax. Bones dislocated due to external forces may easily dislocate again after being set, as the ligaments, saturated with harmful humors, lack the firmness to hold them in place. Often, the ligaments are not completely torn, but only partially, leading to diminished function or strength in the affected area. Dislocation becomes incurable when the ligaments, swollen with excess moisture, shorten and thicken, pulling away the bone appendages from their origins. Since bones and their appendices connect through various cavities and prominences, they cannot be adequately repositioned, regardless of the skill of the practitioner.
Old and chronic dislocations, in which a tough humor has solidified in the cavity instead of the head of the bone, cannot be restored. Similarly, when the heads of the dislocated bones have worn away to create a new cavity in the adjacent bone, restoration is not feasible. Even if such bones are realigned, the correction is neither stable nor enduring, as the natural cavity is filled with foreign material, and the newly formed cavity cannot adequately and securely accommodate the repositioned head of the bone. Individuals with a dislocated shoulder can still utilize their hand for various tasks, much like they would with the unaffected hand, since the weight of the body is supported by the legs rather than the arms. The more the hand is exercised, the more robust the arm becomes.
Conversely, if the thigh bone is dislocated, particularly if it is twisted inwards, the entire leg quickly deteriorates due to atrophy, as the affected area loses all motion. According to Hippocrates, engaging in proper movement enhances strength and improves the condition of the part, while idleness leads to weakness and atrophy. If a significant wound and fracture accompany a dislocation, there is a risk that while attempting to restore the bone through extension, the nerves may be pulled too forcefully, potentially resulting in damage to the nerves, veins, and arteries, which could lead to inflammation, convulsions, and other serious complications. Therefore, Hippocrates advises against attempting to set the dislocated bone in such complex cases, as the attempt could result in death, whereas leaving it alone may only lead to lameness. Every dislocation must be addressed before inflammation sets in; if inflammation is already present, it is crucial to alleviate it immediately. The patient should rest to avoid aggravating the condition, as increased pain may lead to convulsions, gangrene, and ultimately death, as I have occasionally witnessed. Once inflammation and other severe symptoms are managed, one may proceed to restore the dislocation, especially if the body and affected limb are conducive to it. Restoration will be quicker and easier in slender, delicate individuals, while it will be more challenging in those who are robust and solid. This should suffice as a guide for prognostics in dislocations.

6. General Treatment of Dislocations

Although I have previously outlined the general method for treating fractures and dislocations, it is worthwhile to reiterate here the aspects relevant to the treatment of dislocations. To successfully address dislocations, one must focus on five key steps, which should be executed in the following order: the first is Holding; the second is Drawing or Extending; the third is Forcing in; the fourth is Placing in the appropriate position; and the fifth is Correcting the accompanying symptoms.
The first step, referred to as Holding, pertains to either the entire body or a specific part of it. When dealing with dislocations of the shoulder, vertebrae, or thigh bones, the whole body must be securely held by a strong embrace from an assistant. However, for dislocations of the collarbone, elbow, hand, knee, or foot and leg, it is sufficient to hold the affected part firmly in your hands. It is essential to hold either the body or a specific part to prevent the dislocated bone from being extended while the rest of the body moves, as any movement could render all efforts to restore the dislocation futile.
The second step, known as Drawing or Extending, aims to create a space between the luxated bones, allowing the dislocated bone to be more easily repositioned into its cavity. The method of drawing or extending varies in intensity and technique, depending on the strength of the muscles and ligaments as well as the specific dislocation. This process is typically performed by hand; if manual efforts are insufficient, instruments may be employed, which will be illustrated later. Extension should be applied until the bone’s head aligns with its cavity. Once this alignment is achieved, the surgeon must quickly proceed to the third step, which involves gently placing the head of the bone back into its cavity. Care must be taken to ensure that the bone is directed into its proper cavity, as forcing it incorrectly could lead to further dislocation, such as a thigh bone being displaced into the back instead of the front. To avoid this, the bone should be returned in the same direction it was dislocated, which is easier in recent injuries. The successful repositioning is often indicated by a popping sound, signifying that the bone has been properly thrust into its cavity, along with a reduction in pain.

The fourth step focuses on ensuring the bone remains in its proper position once set. For a dislocated arm, it should be secured in a scarf; for dislocated thigh, knee, leg, or foot, they should be appropriately supported in bed. Following the reduction, the surgeon should wrap the affected joint with cloths or compresses soaked in rose vinegar and apply suitable medications, securing them with a bandage that counteracts the direction of the dislocation. Additional padding should be placed where the bone was dislocated to prevent re-displacement. After these measures, the surgeon should refrain from further intervention for four to five days unless pain or other symptoms arise, at which point the fifth step involves addressing those symptoms, such as pain or inflammation, as discussed in detail in the treatise on fractures.

Before addressing long-standing dislocations, it is important to hydrate the ligaments, tendons, and muscles using fomentations, cataplasms, and liniments, allowing these parts to be more pliable for the surgeon. The dislocated bones should then be gently mobilized to warm and soften any stagnant fluids and relax the surrounding tissues, facilitating easier extension. However, if significant swelling, pain, or inflammation is present, these issues must be prioritized for treatment before attempting to restore the dislocation.

7. Description of Specific Devices for the Treatment of Dislocations

Before discussing the specific types of dislocations, it is important to describe three types of bandages that are most suitable for holding and extending dislocations. The first bandage, indicated by the letter A, is designed to secure the affected limb. The second bandage, marked with the letter B, is intended for drawing or extension and features a single knot. The third bandage, denoted by the letter C, consists of two knots and is used to provide a tighter hold or binding.

I have also deemed it necessary to illustrate the following device, designed for drawing and extending with greater power when manual effort is insufficient. This device resembles a pulley, indicated by the letters D D. Inside, it contains three wheels through which a rope, marked with the letter H, runs for drawing. At each end of the pulley, hooks are attached; one is used to secure the pulley to a post, while the other is for pulling the ligature attached to the affected area. The boxes or cases that house the pulley are marked with B B, and their covers are labeled A A. A screw pin, which can be twisted and secured to a post, allowing one end of the pulley to be hooked, is marked with C. A gimlet, indicated by F, is used to create a hole in the post for inserting the screw pin. All of these components are depicted in the accompanying figure.

Some practitioners, instead of using this pulley, utilize the instrument described hereafter, which they refer to as the Manubrium versatile or hand-vice. The end of this device is shaped like a gimlet and is designed to be twisted into a post. Inside the handle lies a screw with a hooked end to which the string or ligature must be attached. The screw rod, or male screw, is inserted into the female component by twisting the handle, thereby allowing the ligature to be drawn sufficiently to reposition the dislocated bone.

Having presented these general principles, I will now address the luxations of each specific part, from the jawbone to the toes of the feet.

8. Dislocation of the Jawbone

The jawbone can be dislocated for various reasons, often due to yawning or other significant movements of the mouth. It is more commonly luxated forward than backward, owing to the mammillary attachments that prevent it from falling back. Dislocation may occur on one side or, at times, on both sides. If the jaw is luxated on one side, it, along with the chin, is pulled toward the opposite side that remains intact. The area from which it has moved is hollow, while the area it has shifted to is swollen. The patient is unable to close their mouth, forced to keep it open, making eating impossible. The jaw and teeth protrude slightly forward, and the alignment of the teeth is disrupted, with the lower teeth positioned beneath the upper ones. If both sides are dislocated, the entire jaw and chin hang forward toward the chest. The temporal muscles appear distended, saliva dribbles uncontrollably from the patient’s mouth, and the lower teeth extend further than the upper, preventing the mouth from closing and hindering the tongue’s ability to move freely, resulting in stammering speech. Dislocation on both sides is more challenging to correct, and symptoms are more severe; thus, prompt intervention is crucial to avoid severe throat pain, inflammation, fever, and potentially death within ten days due to injury to the five branches of nerves from the second and fifth cranial nerves, which control the jaw muscles. Practitioners assert that after twelve days post-realignment, the jaw is less likely to relapse. If dislocated for a few days, softening and relaxing treatments should be applied before attempting to restore it. Once repositioned, a remedy made from egg whites and rose oil should be used to alleviate pain, along with cloths soaked in oxycrate. For the second treatment, apply substances that can reinforce and strengthen the ligaments and other relaxed tissues, ensuring the jaw remains in place. This outlines the form of the required remedy.

Prescription:

Take the following ingredients: powdered Armenian bole, dragon’s blood, powdered mastic, pitch, and resin, each in the quantity of one and a half ounces (℥. ss.). Combine these with a sufficient quantity of egg albumen to form a cohesive medication.

Subsequently, you may utilize Diacalcitheos plaster, dissolved in a mixture of rose oil and vinegar, along with any additional substances as the situation requires.

9. Procedure for Repositioning a Bilaterally Dislocated Jaw

First, the patient should be positioned on the ground or a low seat, facing upwards, while an assistant securely holds their head to ensure stability. The surgeon should then wrap their thumbs in cloth to prevent injury from the patient’s teeth and to ensure a firm grip. The thumbs should be carefully inserted into the patient’s mouth to apply pressure against the larger teeth of the dislocated jaw, while the surgeon’s other fingers should support the chin to lift the entire jaw.

If this approach proves ineffective due to the mouth being tightly closed, wooden wedges made from softwood, such as hazel or fir, should be placed on either side of the molars. A ligature should then be positioned under the chin, with the ends held by the assistant, who will apply upward pressure by kneeling on the patient’s shoulders. Simultaneously, the surgeon will exert downward pressure on the wooden wedges.

Once the jawbones are successfully realigned, they should be secured with appropriate ligation, and the patient should receive suitable medication for pain management. It is crucial to instruct the patient to refrain from speaking or opening their mouth unnecessarily and to avoid hard foods or anything requiring extensive chewing until the pain has completely subsided. Instead, the patient should focus on consuming soft foods such as barley creams, ponadoes, jellies, cullasses, broths, and similar items.

Prescription:

Subsequently, you may utilize Diacalcitheos plaster, dissolved in a mixture of rose oil and vinegar, along with any additional substances as the situation requires.

10. Correcting a Jaw Dislocated Forwards on One Side

To address a jaw dislocated forwards but on one side, position the patient in a low seat so that they are situated below the surgeon. An assistant should stand behind the patient to hold their head securely, preventing any movement during the procedure. The surgeon will then place their thumb between the molars to apply downward pressure on the jaw, gently drawing it aside to reposition it into the socket. The patient should help by keeping their mouth as closed as possible, opening only enough to allow the surgeon’s thumb, which aids in repositioning the temporal muscles.

If the patient opens their mouth excessively, the muscles may become overly stretched; conversely, if the patient clenches their teeth too tightly, there will be insufficient space for the surgeon’s thumb. Some believe that the jaw can dislocate backwards, resulting in the mouth being tightly shut and the lower teeth positioned further back than the upper ones. To address such a dislocation, the patient’s head should be held firmly while the surgeon inserts both thumbs into the mouth, supporting the chin with their other fingers. By gently shaking the jaw and applying forward traction, the surgeon can guide it back into alignment.

However, the author acknowledges having never encountered this specific backward dislocation and suggests its rarity, conjecturing that if it does occur, it may be an incomplete dislocation with the jaw slightly displaced towards the throat. This condition can usually be resolved by lifting or pulling the jaw forward while applying upward pressure.

Prescription:

Subsequently, you may utilize Diacalcitheos plaster, dissolved in a mixture of rose oil and vinegar, along with any additional substances as the situation requires.

11. Luxation of the Collarbone

The collarbone can experience fractures, twisting, or dislocations, either at the sternum or the acromion of the shoulder blade. Such dislocations are relatively rare due to the robust connections that the collarbone has with these structures, particularly at its joint with the sternum, which is reinforced by the first rib. Dislocations may occur in several directions—inwardly, outwardly, or sideways—each requiring specific correction techniques. In most cases, the collarbone can be realigned by manipulating or extending the arm. If necessary, the patient should be positioned lying on their back, with a tray or firm cushion placed beneath their shoulders. This position allows the shoulder and chest to protrude, enabling the surgeon to lift, press down, or draw the arm forward or backward to guide the bone back into its proper cavity. After realignment, it is critical to secure and support the area, treating it as if it were fractured to ensure optimal healing. Galen recounts that at the age of thirty-five, he experienced a significant separation of his collarbone from the acromion, resulting in a gap equivalent to three fingers. This dislocation required a healing period of forty days, achieved through a tight and resilient binding that enabled him to feel the pulsation of the arteries beneath the bone. However, few patients can endure such an extended period of immobilization, which is often necessary for proper recovery. Recognizing this type of dislocation can be challenging, and many surgeons have erroneously diagnosed collarbone dislocations as shoulder joint issues. Symptoms typically include swelling at the top of the shoulder, a noticeable depression where the collarbone has shifted, severe pain, inflammation, and a marked inability to lift or move the arm effectively. If the dislocated collarbone is not properly repositioned, the patient risks long-term impairment, making it difficult or impossible to raise their hand to their head or mouth.

Prescription:

Subsequently, you may utilize Diacalcitheos plaster, dissolved in a mixture of rose oil and vinegar, along with any additional substances as the situation requires.

12. Luxation of the Spine (Backbone)

12. Luxation of the Spine (Backbone)
The backbone, composed of numerous bony vertebrae arranged in interconnected rows resembling wheels, allows for remarkable movement and flexibility. Were it a singular bone, the trunk of the body would remain rigid, immobilized as if impaled by a stake. Each vertebra contains a central canal through which the spinal cord traverses, extending from the brain like a conduit that generates and distributes sensory and motor nerves throughout the body below the head.

To support this intricate system, the vertebrae are perforated with multiple openings along their sides, facilitating the exit of certain nerve branches while enabling veins and arteries to ingress for nourishment and vitality. The exterior of the spine is characterized by a rough texture, adorned with four types of processes: some jutting upward, others downward, some oriented directly, and others transversely. This array of sharp, thorn-like projections lends the spine its distinctive name.

As one moves further down the spine from the neck, the vertebrae increase in size, with the largest found at the base. This architectural principle aligns with the understanding that structures bearing weight should be larger than those being supported. Thus, the sacrum is positioned beneath the other vertebrae as a foundational element. The lateral processes of the rib bones in the chest not only protect the spinal cord from external injuries but also firmly anchor the ribs through strong connections.

Between the vertebrae lies cartilage and a tough, albuminous fluid that permits smooth movement, contributing to the spine’s flexibility and agility when bending forward, though it constrains backward movement. This limitation serves to protect the hollow ascending vein and the large descending artery situated beneath. Consequently, the joints of the vertebrae are reinforced by robust ligaments that are oriented predominantly toward the back.

I find it essential to mention these characteristics of the spine before delving into the dislocations that may occur. While I will omit the extensive details thoroughly covered by Galen, it is worth noting that nothing within the entirety of human skeletal structure illustrates the craftsmanship of God’s design more vividly than the composition of the spine and its vertebrae.

Prescription:

Subsequently, you may utilize Diacalcitheos plaster, dissolved in a mixture of rose oil and vinegar, along with any additional substances as the situation requires.

13. Dislocation of the Head

The head is supported by the neck, which connects to the first vertebra via two processes extending from its base, adjacent to the foramen through which the spinal cord descends into the spinal column. These processes fit securely into cavities carved within the first vertebra. However, these connections can occasionally dislocate, leading to a posterior dislocation. This condition exerts excessive pressure on the spinal cord, resulting in bruising and stretching. In such instances, the chin is forced against the chest, severely restricting the patient’s ability to drink or speak. Tragically, this type of dislocation may result in death, not due to any shortcomings on the surgeon’s part, but rather because of the severity of the injury, which proves resistant to all forms of treatment.

14. Dislocation of the vertebrae, or Rack-bones of the neck.

Other cervical vertebrae are susceptible to both dislocation and strain. If dislocation is not swiftly addressed, it can lead to sudden death by compressing the spinal cord at its origin, adversely affecting the nerves that emerge from it, particularly those responsible for respiration. This compression prevents the proper distribution of the vital ‘animal spirit’ throughout the body, resulting in sudden inflammation, quinsy, and severe breathing difficulties. In contrast, a strain or incomplete dislocation does not carry such grave outcomes. In these cases, the vertebrae may be slightly misaligned, causing the neck to twist and the face to darken, accompanied by difficulties in speaking and breathing.

To treat either condition, the patient should be seated at a low level, and the practitioner must apply their full weight onto the shoulders. Meanwhile, the surgeon should grasp the patient’s head around the ears with both hands, gently shaking and maneuvering it until the vertebra returns to its proper position. Successful restoration is indicated by the immediate relief of pain that the patient previously experienced and their newfound ability to turn and move the head and neck freely in all directions. After realignment, the head should be tilted toward the side opposite the dislocation, and the neck should be secured around the shoulder joint. It is essential to ensure that the ligature is not overly tight to avoid compressing the trachea and esophagus, which could impede breathing and swallowing.

15. Dislocated Vertebrae of the back

The vertebrae of the back can become dislocated in various directions: inward, outward, to the right, or to the left. Inward dislocation is characterized by a depressed area in the spine, while outward dislocation manifests as a noticeable bulge on the back. When vertebrae luxate to the right or left, they create an oblique protrusion on the corresponding side. Dislocations can arise from both internal and external factors, similar to other types of luxations. Internal causes may include the flow of bodily humors to the ligaments, congestion due to inherent weakness, or a response to pain and heat. External factors might encompass falls from heights onto hard surfaces, heavy impacts, prolonged stooping—often experienced by vineyard workers and the elderly—or conditions that force individuals to hunch due to an irreparable dislocation of the thigh bone.

Inward dislocation requires considerable force, and if it does occur, it usually results in ligament tears, as ligaments are more likely to rupture than withstand such stress. This type of dislocation is particularly hazardous because it severely compresses the spinal cord, leading to numbness and loss of sensation in areas below the injury. Restoration of the dislocated vertebra is typically unfeasible, as it cannot be repositioned through the abdomen. Patients may experience difficulties with urine and bowel movements, including either retention or involuntary expulsion. Additionally, coldness in the knees and legs may set in, accompanied by a loss of sensation and mobility in these extremities. Inward luxation occurs more frequently than outward dislocation because the nerves emerging from the spine are more deeply embedded within the body. The consequent inflammation of the spinal cord exacerbates the condition, potentially leading to further inflammation in surrounding structures that can impair the bladder’s ability to expel urine. When nerves are compressed, they become incapable of transmitting the vital animal faculties, resulting in a loss of sensation and movement in the affected areas. Consequently, the inability to perceive bodily urges can lead to the retention and involuntary release of excretions. In contrast, outward dislocation seldom causes compression of the spinal cord or nerves.

16. Restoring an Outwardly Dislocated Spine

When the vertebrae are dislocated outwardly, causing a protrusion, the patient should be laid face down on a table and secured with towels under the armpits and around the flanks and thighs. Then, gentle upward and downward traction should be applied without force, as such extension is necessary for proper alignment, allowing the processes and cavities of the vertebrae to interlock for better healing. Place your hands on the protruding area and attempt to push the prominent vertebrae back in. If this method fails, it is advisable to wrap two wooden pieces, approximately four fingers in length and one finger in thickness, in linen cloth. These should be placed on either side of the dislocated vertebrae, and with your hands, press against the protrusion until the vertebrae are guided back into their proper position, following the outlined technique.

Take care not to touch the processes that protrude along the spine, as they are easily broken. The restoration of the vertebrae is indicated by the even smoothness of the entire spine. Once the vertebrae have been set back into place, it is important to secure the area using splints or plates of lead specifically designed for this purpose, ensuring they only contact the sides and do not press against the crests or middle processes of the vertebrae. The patient should then be positioned on their back in bed, and the splints should remain in place for an extended period to prevent the vertebrae from dislocating again.

17. A detailed investigation into the dislocation of the vertebrae caused by internal factors

The vertebrae can become luxated due to an inherent weakness in the structures, particularly the nervous ligament that connects them. This ligament does not connect to the spinal cord but binds the vertebrae externally. In addition to the two membranes covering the spinal cord, a robust, nervous coating derived from the pericranium protects the cord from injury during spinal flexion. The ligaments that hold the vertebrae together are surrounded by a viscous fluid to facilitate movement. However, a cold, thick humor can accumulate due to excessive bodily secretions, leading to swelling that compresses both the nerves and ligaments. This tension can misalign the vertebrae, causing dislocation in various forms: cyphosis (hunchback), lordosis (saddleback), or scoliosis (curvature resembling an ‘S’). Galen also identified a condition where the vertebrae remain in place but are loose, termed seisis. Another specific spinal condition occurs when the spinal cord is detached from the vertebrae due to trauma, which is often irreversible. Children, with their softer bodies, are particularly vulnerable to these internal causes of dislocation. External factors, such as overly tight binding by caregivers or improper handling, can exacerbate the risk of vertebral dislocation.

18. Prognostics of Dislocated Vertebrae in the Back

If vertebral dislocation occurs in infancy, the ribs will grow minimally or not at all in width, extending outward and causing the chest to lose its natural width, resulting in a pointed shape. This condition can lead to asthma, as the lungs and muscles responsible for breathing become compressed and elongated. To ease breathing, affected individuals often hold their heads up, creating the appearance of having large throats. The pressure on the windpipe causes wheezing, and they may snore during sleep due to smaller lungs, which impair air intake and expulsion. Furthermore, they are susceptible to significant lung distillations, leading to a shorter lifespan. Those with a hunched posture below the diaphragm are more prone to kidney and bladder diseases, exhibit thinner thighs and legs, and have slower and sparser hair growth, including beards. Ultimately, they experience reduced fertility and a higher likelihood of barrenness compared to those with curvature above the diaphragm. External bumps may often be treated, but those arising from internal causes are generally incurable unless addressed early with considerable care and effort.

Children born with spinal deformities cannot be helped, as their crooked and protruding spines do not grow properly. Instead, their arms and legs develop fully while their chest and back areas become thinner. This occurs because the misalignment of veins, arteries, and nerves restricts the flow of vital spirits and nourishing juices, resulting in leanness. The limbs remain unaffected, as only the nearby regions suffer from this condition.

When multiple vertebrae are dislocated simultaneously, the risk is less severe than when a single vertebra is luxated. A single dislocated vertebra can pull the spinal cord into a sharp angle, posing a risk of severe injury or death, as the spinal cord is a crucial extension of the brain. In contrast, dislocation of several vertebrae at once forces them into a more obtuse angle or semicircle, leading to compression without necessarily causing death. This observation aligns with Hippocrates’ assertion that circular dislocation of the vertebrae is less dangerous than angular dislocation.

19. Dislocation of the Rump

The rump is often dislocated inwards due to a violent fall onto the buttocks or a significant blow. In this condition, the patient cannot bring their heel to their buttocks, and bending the knee is possible only with great effort. Defecation is painful, and sitting is only comfortable in a hollow chair. To restore this dislocation, one must insert a finger into the rectum to reach the affected area, as done in a fracture. Then, the bone must be forcefully raised while simultaneously aligning it with the neighboring parts using the other hand. Finally, it should be reinforced with previously mentioned remedies and maintained in place. Recovery typically occurs around the twentieth day after the adjustment. During this period, the patient should avoid defecating unless seated on a hollow chair to prevent the bone from dislocating again before it is fully healed.

20. Luxation of the Ribs

Ribs may become dislocated due to a severe and bruising impact, causing them to separate from the vertebrae to which they are attached, potentially shifting inwards or sideways. Although the ancients did not specifically address this type of dislocation, they acknowledged that all bones can be displaced from their articulating positions. Signs of a dislocated rib include noticeable asymmetry, creating a hollow area on one side and a protrusion on the other; if the rib is driven inwards, there will be a depression where it connects to the vertebrae. Such dislocations can lead to various symptoms, including difficulty breathing, as the injured rib restricts chest movement; pain when bending or lifting the body, mimicking pleurisy; and swelling of the surrounding muscle tissue due to mucus and gas buildup, as discussed in our treatise on fractures. To address these issues, the dislocation must be promptly corrected, and any swelling must be treated. If the dislocated rib has moved upward relative to the vertebrae, the patient should be positioned upright, hanging by their arms from a high door or window, while pressure is applied to the protruding rib to guide it back into its cavity. Conversely, if the rib has fallen downward, the patient should bend forward and place their hands on their knees, allowing for the dislocation to be corrected by pressing the protruding section back in. However, if the rib has shifted inwards, it cannot be restored or repositioned by the surgeon’s hand, similar to an inwardly dislocated vertebra, for the reasons previously explained.

21. Dislocated shoulders

The shoulder is prone to dislocation due to the softness and looseness of its ligaments, coupled with the shallow cavity of the shoulder blade, which is smooth and polished like that of the shoulder bone. Additionally, there is no internal ligament connecting the bones to strengthen this articulation, as seen in the leg and knee. However, this should not be viewed as a flaw in nature but rather as a testament to divine providence, as this joint allows for not only extension and bending but also circular motion, enabling the arm to move in various directions.

The shoulder bone, referred to by Hippocrates as the arm bone, can be dislocated in four ways: upwards, downwards, into the armpit, and forwards or outwards, but never backwards. This is because the cavity of the shoulder blade, which receives the head of the arm bone, is positioned against it, making a backward dislocation improbable. It is also never dislocated inwardly due to the presence of strong muscles, specifically the deltoid, as well as the back and acromion of the blade and the beak-like process, all of which prevent inward slipping.

Hippocrates noted that he had only observed one type of dislocation for this bone, specifically downward or into the armpit, which is the most common. When the shoulder is dislocated downward, a depression can be felt in the upper part of the joint, and the acromion appears sharper and more prominent as the head of the shoulder bone slips down and hides under the armpit, resulting in swelling. The elbow also shifts outward, appearing further from the ribs, and despite efforts to force it, it cannot touch them. The patient is unable to lift their hand to their ear, mouth, or shoulder on that side. This sign is not exclusive to a luxated shoulder but can also occur with contusions, fractures, inflammation, wounds, abscesses, or any nerve issues stemming from the cervical vertebrae. Additionally, the affected arm appears longer than the other, and the patient experiences pain with any movement due to the stretched and compressed muscles, with some fibers possibly torn.

There are six methods to restore a shoulder dislocated downward into the armpit: the first involves using a fist or towel; the second uses a length of yarn placed under the armpit and pushed up with the heel; the third method involves placing one’s shoulder under the armhole; this method, along with the first, is most suitable for new and easily restored dislocations, particularly in individuals with loose flesh, such as children, eunuchs, and women. The fourth method uses a ball placed under the armpit with the arm draped over a piece of wood supported by two people or posts. The fifth method employs a ladder, and the sixth uses a device called an Ambi. We will detail these six methods for your consideration.

22. Of the first method for reducing a dislocated shoulder, which involves the use of one's fist

First, let a strong individual, positioned on the opposite side, firmly hold the patient at the shoulder joint to prevent movement during the necessary extension. Another person should grasp the arm above the elbow and draw it downwards, aligning the head of the bone against the cavity in the blade bone. Finally, the surgeon should lift and force the head of the bone into its cavity using their fist. It is important to note that in fresh dislocations, particularly in individuals who are soft, effeminate, moist, and not overly corpulent, the head of the bone may sometimes relocate itself into its proper cavity simply through extension. This occurs as the muscles restore themselves to their original position, drawing the bone with them. In many cases, extending the arm alone has sufficed for proper relocation. However, if the dislocation is chronic and manual methods fail, the patient’s shoulder must be secured to a post with a ligature or held firmly by someone standing behind them. The arm should then be tied just above the elbow with a band, to which a cord is attached. This cord, fastened to a pulley, should be drawn as needed. Finally, the surgeon, using a towel or ligature around their neck and positioned under the patient’s armpit near the dislocation, should raise themselves with all their strength, lifting the shoulder while simultaneously bringing the patient’s arm to their chest, forcing the head of the shoulder bone into its cavity with both hands, as illustrated in the accompanying figure.

Cover all adjacent areas with a medicine made from volatile flour, Armenian bole, myrtle, pitch, resin, and alum, ground into powder and mixed with egg white. Fill the hollowness under the arm with a ball of wool or cotton yarn, or a linen cloth lightly oiled with rose or myrtle oil, vinegar, and rose ointment or Galen’s cooling ointment, to prevent sticking to any hairs. Next, bind the area with a ligature about five fingerbreadths wide and two ells long, adjusted as necessary for the body. Place the center under the armpit, cross it over the injured shoulder, and wrap it under the opposite arm. Finally, lay the arm across the chest, securing it in a scarf at a right angle, allowing the hand to nearly touch the healthy shoulder to prevent the bone from dislocating again. Do not disturb the initial dressing for four to five days unless significant symptoms arise that require attention.

23. Regarding the second method of restoring a shoulder, which involves the heel, this approach is suitable when the patient is unable to sit or stand due to pain

The patient should be positioned on their back on a coverlet or mat. A ball made of yarn or leather, filled with tow or cotton and sized to fill the cavity, must be placed under the armpit to facilitate the alignment of the bone. The surgeon should sit opposite the dislocated shoulder; if the right shoulder is dislocated, the right heel should be placed against the ball, and if the left, the left heel. The surgeon should then pull the patient’s arm towards them with both hands while simultaneously pressing down on the armpit with their heel. During this process, an assistant should stand at the patient’s back, lifting the shoulder with a towel or similar item and pressing down on the top of the shoulder blade with their heel. Another assistant should sit on the opposite side of the patient to prevent movement during the necessary extension for repositioning the shoulder, as illustrated in the accompanying figure.

24. The Third manner of restoring a dislocated Shoulder.

A person of adequate height and strength should place the sharp edge of their shoulder beneath the patient’s armpit while forcefully drawing the patient’s arm toward their own chest, allowing the patient’s body to hang. Simultaneously, another individual should apply their weight to the dislocated shoulder, shaking it with their entire body. This combined action—one pulling downward and the other shaking—can help restore the shoulder to its proper position, assisted by the surgeon, who will guide these vigorous movements as illustrated in the accompanying figure.

25. The Fourth manner of restoring a dislocated Shoulder.

Take a piece of wood, approximately two inches wide and six feet long, resembling the yoke used by water-bearers in Paris. Secure a ball of yarn or a similar-sized object in the center to fill the cavity of the armpit. Insert two pins, one on each side of the ball, to keep the shoulder in place and prevent the ball from slipping. Have two strong men, either naturally or artificially taller than the patient, position the yoke on their shoulders. The patient should rest their armpit on the ball while the surgeon pulls down on the hanging arm. This allows the patient to hang from the yoke, effectively guiding the shoulder back into its socket, as illustrated in the accompanying figure, which shows the yoke with the two wooden pins and the central ball.

26. The fifth method of reducing the shoulder joint, which is executed using a ladder

A dislocated shoulder in the armpit can be restored using a ladder as follows: Secure a round object, such as a ball or ball of yarn, to one of the upper ladder steps. Place a low stool at the foot of the ladder for the patient to stand on. Bind the patient’s legs and sound arm behind their back to prevent interference during the procedure. Position the patient’s arm over the ladder step, resting the armpit on the secured ball, while encouraging them to bring their body close to the ladder steps to avoid the risk of breaking the shoulder bone. Ensure the patient’s head is not between the steps. Bind the arm above the elbow with a suitable ligature, and have an assistant pull down on the arm while removing the stool from under the patient’s feet, allowing them to hang from the ladder. This action will help the shoulder head to realign, assisted by the surgeon pressing down on the shoulder blade and moving it gently. Once the bone is set, replace the stool to allow the patient to ease their arm back from the ladder step. Caution them against lifting their arm too high to avoid re-dislocation. This description serves to instruct you in performing the operation as if witnessing it firsthand.

Nicholas Picart, the Duke of Guise’s surgeon, encountered a unique challenge when called to assist a countryman with a dislocated shoulder. With only the patient and his wife present, he devised a method using a ladder. He secured the patient, bound as previously described, to the ladder. Next, he tied a staff to the lower end of the ligature around the patient’s arm above the elbow and positioned it under one of the ladder’s steps. Straddling the ladder, he applied his full weight while instructing his wife to remove the stool from beneath him. As a result, the bone was successfully realigned, as illustrated in the accompanying figure.

In the absence of a ladder, a piece of wood can be placed across two posts as an alternative. Additionally, a door can be utilized, as illustrated in the accompanying figure. It is important to incorporate a flat piece of wood or spatula with attached strings, the purpose of which will be explained in the following chapter.

27. The sixth method for restoring a shoulder that has been dislocated into the armpit

Hippocrates states that this is the most effective method for restoring a dislocated shoulder. Use a wooden spatula that is approximately four to five fingers wide, two fingers thick or less, and about a yard long. One end should be narrow and thin, with a rounded head that is slightly hollowed. This end is placed under the armpit to accommodate part of the shoulder bone’s head, which should not bend towards the ribs but rather towards the top of the shoulder. The upper part of the spatula must be wrapped in a soft linen or wool rag to minimize discomfort. Insert it under the armpit so that it penetrates thoroughly between the ribs and the shoulder bone’s head.

The spatula should have two holes at three different points, evenly spaced, through which soft strings can be threaded to tie it to the arm. These strings should run along the length of the arm to the fingers, with one tied just below the shoulder bone’s head, another just above the elbow, and the third at the wrist, ensuring a firm hold. The upper part of the spatula should extend beyond the arm’s head to reach the innermost part of the armpit.

A cross pin or piece of wood should be secured between two posts or a frame, with the arm positioned over it so that the pin is under the armpit, creating opposing forces with the body and the arm. The pin should be set high enough for the patient to stand on tiptoes. This is the best method for restoring a shoulder. Instead of two posts or a frame, a ladder, door, bedposts, or any available structure can be used.

Henry Arvet, a skilled surgeon from Orleans, noted that he had success with this method unless the flesh had grown into the cavity or the shoulder bone had created a new cavity in its fallen position. In such cases, the bone may not be restored or may fall back into the new hollow. Young surgeons are advised not to lose hope if the bone does not return to its place on the first attempt; instead, they should gently manipulate the joint, as this may eventually facilitate its movement back into the natural cavity. Once restored, the shoulder should be secured with compresses and rollers as previously described.
To the previous illustrations, I have decided to add this, which demonstrates the method of restoring a shoulder dislocated into the armpit using a spatula, following Hippocrates’ technique. This spatula, secured with an iron pin to the standing frame, can be turned, lifted, and pressed down at your convenience. A indicates the wooden spatula, while B represents the frame or standing posts.

For the proper use of this instrument, the patient should sit on a seat that is somewhat lower than the standing frame, allowing the spatula inserted into the armpit to be pressed down more forcefully, thus facilitating the reintroduction of the shoulder bone head. The patient’s feet must also be tied to prevent him from lifting himself while the surgeon attempts the restoration. The surgeon should proceed to restore the shoulder after binding the extended arm of the dislocated shoulder to the spatula and inserting one end beneath the displaced head of the shoulder bone, as previously illustrated. By pressing down on the other end of the spatula, which extends to the hand, the bone can be pushed back into its socket. It is important to pay close attention to the wooden spatula, which I have depicted separately; Hippocrates refers to it as Ambi, with its head slightly hollowed, marked with the letter B. The entire spatula is labeled with the letter A, featuring three strings attached for securing the arm to maintain stability, as demonstrated in the following figure.

There are additional modifications to this Ambi, the design of which I now present, created by Nicholas Picart, the surgeon to the Duke of Lorraine. The knowledge and usage of this instrument, imparted to me by the inventor himself, I wish to share with the diligent reader.

AA. Demonstrate the two ear stops designed to secure the top of the shoulder, preventing it from slipping out when placed in the frame or supporter.
BB. The frame or supporter upon which the Ambi is positioned.
CC. The pin or axletree that attaches the Ambi to the supporter.
DD. Screw-pins used to secure the foot of the supporter, ensuring it remains stable during the operation.
EE. The holes in the foot of the supporter, allowing for the fastening of screw-pins to the floor.

28. How to restore a shoulder dislocated forwards

The shoulder is rarely dislocated forwards; however, even the most stable structures in our bodies can be compromised by a violent force, leading to dislocation. This is evident in a forward dislocated shoulder, which is reinforced by strong anatomical barriers such as the acromion and the end of the collarbone, as well as powerful muscles like the epomis and biceps, which seem to provide protection against such injuries.

Hippocrates, confined to the limited regions of lesser Asia, never witnessed this type of dislocation, which Galen noted five times. I, too, have encountered it only once, in the case of a nun who, weary of her life in the convent, jumped from a window and landed on her elbow, resulting in a forward dislocation of her shoulder. This dislocation is characterized by a distortion in the shape of the arm, with the head of the shoulder displaced towards the chest, and the patient unable to bend their elbow.

The dislocation is corrected using the same methods as for other luxations: by straight holding, extending, and forcing in. The patient should lie on the ground face up. To extend the shoulder, the approach differs from when it is luxated into the armpit. In that case, the arm is first drawn forward and then forced upward until it aligns with the cavity for re-entry. However, for this particular dislocation, since the top of the shoulder is positioned in front of the disarticulation, enclosed by muscles that open outward, the manipulation must be directed toward the back.

First, a servant should be positioned behind the patient to pull back a strong, broad bandage wrapped around the armpit (similar to the Carchesius, which consists of two opposing and continuous strings) to prevent the shoulder from following the arm during extension. A piece of yarn should be placed in the armpit to fill the space. Next, extend the arm while applying another ligature just above the elbow, ensuring the head does not slip into the armpit. This can be achieved by using the yarn to support the arm and directing the shoulder head away. Then, by relaxing the extension, allow the joint to be drawn and forced back into its cavity as the muscles naturally retract, thus facilitating an easy restoration. This method of extension alone is sufficient for the correction.

29. Outwardly luxated shoulder

Dislocation of the shoulder outwardly is rare; however, if it occurs, extending the arm will be very difficult, particularly towards the outward part rather than inward. A depressed cavity can be felt towards the chest, with a protrusion externally where the head of the shoulder bone has moved from. To restore it, the patient should lie flat on their belly, and the elbow must be forcibly drawn inward towards the breast. The protruding head of the arm bone should be pushed back into its cavity for easier restoration. Regardless of the direction of dislocation, the arm should be extended and drawn directly downward. After reduction, appropriate medicines should be applied around the joint. Something should be placed in the armpit to fill it, and compresses or bolsters should be applied to the area where the bone has dislocated. These should be secured with a strong, broad two-headed ligature placed under the armpit, crossing over the shoulder joint and extending to the opposite armpit with as many loops as necessary. The arm should then be secured in a scarf at right angles, a position that should be maintained not only for shoulder dislocations but also for arm fractures, as it minimizes pain and allows for longer immobilization.

30. Upwardly dislocated shoulder

The shoulder may sometimes luxate upwards, presenting with a noticeable bulge at the end of the collarbone, an enlarged hollowness in the armpit, and the elbow positioned further from the ribs compared to a downward dislocation. This results in the arm being unable to perform normal functions. To reduce this luxation, the surgeon should stoop down, place their shoulder under the patient’s arm, and then rise as high as possible while pressing down on the head of the shoulder bone to guide it back into the socket. Alternatively, the patient can be laid on their back, and while someone extends the affected arm downward, the surgeon can manually push the head of the bone into its cavity. After the operation, standard care for luxations should be followed, including applying compresses to the injured area and securing it with bandages. In these four types of dislocations, the restoration of the luxated bone is indicated by the audible sound of the bone returning to place, the recovery of normal arm movements such as bending and lifting, a reduction in pain, and by comparing the affected arm to the uninjured one for symmetry and equality.

31. Dislocation of the Elbow

The elbow can be dislocated in four ways: inwardly, outwardly, upwards, and downwards. The inward dislocation refers to the part that faces the center of the body when the arm is in a natural position, positioned between prone and supine. Conversely, the outward part faces away from the center. The upper dislocation points towards the sky, while the lower dislocation is directed towards the ground. The elbow joint, having more heads and cavities than the shoulder joint, is more challenging to reduce when luxated and is more prone to inflammation and stiffness, as noted by Hippocrates.

The elbow joint is more difficult to dislocate than the shoulder joint and is harder to set due to the way the bones of the forearm and arm articulate in a manner known as Ginglymus, as previously discussed in our anatomy and fracture treatises. The elbow dislocates because its processes do not rotate fully around the shoulder bone. Consequently, if the forearm is bent too sharply, the inner process cannot maintain its position in the bottom of its socket, causing the outer process to fall out and resulting in a backward dislocation.

When the fore process is violently extended and forced against the bottom of its cavity, it dislocates, moving out of place as if struck or forced away. This type of dislocation is much more challenging to restore than the previous one. Additionally, the outer extremity of the forearm, known as the Olecranum, is positioned higher than the inner part, resulting in a greater ease for bending the forearm compared to extending it. Therefore, this dislocation is caused by a more intense force than that applied to the inner side. The sign of this dislocation is that the arm remains extended and cannot be bent, as the inner process remains lodged in the external cavity of the shoulder bone, which was previously occupied by the inner part of the Olecranum. This situation complicates the restoration, as the process is effectively trapped there.

When dislocated to the front, the arm appears crooked, not extended, and is shorter than the other. If the elbow dislocates in another manner, either upwards or downwards, its natural shape is altered; the arm may be stretched out but is slightly bent towards the direction from which the bone has moved, creating a position that is intermediate between bending and extending. Regardless of the type of dislocation, the function of the elbow will be impaired or entirely lost until it is returned to its proper position. There is swelling in the area where the bone has shifted and a cavity where it has moved from, which is also seen in dislocations of other body parts. Furthermore, dislocations of the elbow can be classified as complete and perfect or imperfect. The latter occurs more easily and can be restored with minimal effort, while a complete dislocation is rare and typically results from significant force, making it more difficult to treat, especially if inflammation is not controlled, as this can complicate or even prevent proper restoration, particularly in cases of outward dislocation.

32. How to restore an outwardly dislocated elbow

You may recognize an outward dislocation of the elbow if you observe that the arm appears swollen and cannot bend. It is crucial to address this issue promptly to prevent complications such as swelling and inflammation, which can result from the intense pain associated with the dislocation.

To restore the elbow, one effective method involves having an assistant firmly and steadily hold the patient’s arm just below the shoulder joint. Meanwhile, the surgeon should grasp the arm and gently pull it outward, while also pushing the shoulder bone outward and the elbow inward. The surgeon should gradually extend and maneuver the arm, carefully adjusting it to guide the dislocated bone back into its proper position.

It is important for aspiring surgeons to understand that the arm should not be bent during the reduction process. Bending the arm will hinder the restoration, as the inner process of the ulna will occupy the space meant for the outer process within the shoulder joint. If the arm remains bent, the ulna will merely be raised rather than correctly repositioned.

If manual manipulation alone does not achieve the desired result, you may need to assist the dislocated arm in a slightly bent position against a post. In this case, the end of the ulna, known as the olecranon, should be secured with a strong ligature. Then, using a stick or staff inserted into the ligature, you can carefully leverage the arm back into its socket, as illustrated in the accompanying figure.

There is also a more refined method of restoration, illustrated in the latter figure. In this technique, a band of approximately one inch in width is wrapped around the olecranon of the arm, securing it to a post or pillar. The band is then tightened until the dislocated bone is repositioned. We can confirm that the bone has returned to its proper place and is restored when the pain subsides, the arm’s shape and natural alignment are regained, and bending and extending the arm become effortless and painless.

33. On the dislocation of the elbow inward, including both complete and incomplete luxations.

If the elbow is dislocated inward, the arm must be forcefully extended and then quickly bent with sudden violence, so that the hand strikes against the shoulder. Some practitioners place a round object in the bend of the elbow and apply sudden force to drive the elbow toward the shoulder, as previously described.

In cases where the ulna is only slightly displaced—either upward or downward—it can be easily repositioned by gently pulling and guiding it back into its socket. This can be done by having two individuals extend the arm, holding it at the shoulder and wrist, while each pulls toward themselves. Meanwhile, the surgeon present should apply counter-pressure to the dislocated bone, pushing it back into alignment. Once realigned, the arm should be secured in a straight position and properly bandaged, with suitable medications applied as mentioned earlier. The arm can then be supported in a sling around the neck, similar to the method used for shoulder dislocations.

Hippocrates advises that after the joint is set, the patient should frequently attempt to bend their hand up and down, as well as extend and flex the arm. Additionally, the patient should try lifting heavy objects with their hand. This practice helps to soften and loosen the ligaments around the joint, enabling them to regain their normal function. It also helps to prevent a condition known as ankylosis, where the bones of the ulna and shoulder become fused, limiting movement.

Ankylosis is characterized by an abnormal adhesion and fusion of bones within a joint, which can impede bending and extension. Notably, a callus forms in the elbow more quickly than in any other joint, whether the bone remains dislocated or is realigned. This occurs due to rest and inactivity, which cause a viscous fluid—naturally present in joints, along with another fluid drawn there by pain—to accumulate and harden, adhering the bones together. This has been observed frequently due to prolonged immobility.

To counteract this effect, it is essential to mobilize the joint regularly, ideally every third day, to prevent stiffness. Gentle movements should be performed in all directions during this time. Typically, within twenty to twenty-five days, the restored bones regain their strength, though this may vary depending on individual circumstances.

It is also crucial for the surgeon to be aware that the radius can sometimes dislocate when the ulna is completely displaced. Therefore, when realigning the ulna, the surgeon must also ensure that the radius is correctly positioned. The upper part of the radius features a slightly hollowed round process that accommodates the shoulder bone, as well as a prominence that allows for attachment of the biceps muscle.

34. On the Dislocation of the Styliform or Bodkin-like Process of the Ulna

The process of the ulna, known as the styloid process, is articulated to the wrist via a diarthrosis joint, allowing it to fit into a small cavity. This joint can become dislocated, shifting either inward or outward. Such dislocations typically occur when a person falls from a height and lands on their hands.

To restore the dislocated process, one must carefully reposition it into its proper place, secure it with binding, and apply potent astringent and drying medications. However, despite meticulous efforts in managing dislocations, it is often impossible to achieve a perfect restoration of the bone to its original position. This observation aligns with the findings of Hippocrates, who noted that when a larger bone, such as the ulna, is displaced from its counterpart (the radius), it is not easily returned to its original state.

Hippocrates pointed out that no other form of bone connection, known as symphysis or union, can be restored to its prior condition once it has been disrupted. This is due to the ligaments that previously held the bones in place becoming excessively stretched and relaxed. Consequently, I have frequently observed that the surgeon’s diligence and care are often insufficient in these cases.

35. Dislocation of the Wrist.

The wrist is understood as a complex bony structure comprising eight bones, which are connected to the forearm through a diarthrosis joint. When considered in its entirety, the wrist articulates with both the ulna and the radius; it connects to the little finger on one side and to the thumb on the other. This dual articulation enhances the stability of the joint.

However, the wrist can become dislocated in various directions: inward, outward, or sideways. It is classified as luxated inwardly when the palm faces upward, and outwardly when the hand is bent inward and cannot be straightened. If the dislocation occurs sideways, the wrist may tilt either toward the little finger or the thumb, depending on the direction of the luxation.

The underlying cause of these dislocations is often related to the differing articulations of the ulna and radius with the wrist. The radius, which articulates with the wrist at the thumb, allows for circular motions of the hand by accommodating the outward swelling or condyle of the ulna in its cavity. Conversely, the ulna, which connects at the little finger with the wrist, articulates at the shoulder bone, enabling bending and extension of the arm.

To restore the aforementioned dislocations, the arm on one side and the hand on the other must be extended flat on a firm, smooth surface. Care must be taken to position the part from which the dislocated bone has fallen lower than where it has moved. Finally, the prominences of the bones should be pressed down by the surgeon’s hand until the dislocated bones are successfully repositioned into their proper cavities through a combination of pressure and alignment.

36. Dislocated bones of the Wrist

The wrist is composed of eight bones that are generally held securely in place, only dislocating under extraordinary force. If dislocation occurs, it will be evident through swelling in the affected area and a noticeable depression in the region from which the bones have shifted.

To restore the dislocated bones, the injured hand should be placed flat on a table. If the bones are dislocated inward, the palm should face upward. The surgeon will then use the palm of their hand to apply pressure on the prominent areas of the bones, guiding each one back into its proper position. Conversely, if the dislocation is outward, the palm should be placed against the table, and the pressing technique will be applied similarly.

In cases of lateral dislocation, the displaced bones must be pushed back toward the opposite side. Once the bones have been successfully realigned, they should be secured in place using appropriate remedies, such as binding, rolling, and immobilizing the hand in a scarf.

37. Dislocated bones of the palm

The palm, or after-wrist, consists of four bones. The two central bones cannot be dislocated sideways, as their position is stabilized by the surrounding structures that resist lateral movement. Similarly, the bone corresponding to the little finger and the one beneath the forefinger cannot be dislocated toward the central bones; they can only dislocate outward, away from their neighboring bones. However, all four bones can be dislocated both inwardly and outwardly. Their restoration follows the same procedure as that of the wrist bones.

38. Dislocated fingers

The bones of the fingers can be dislocated in four different ways: inwardly, outwardly, and towards either side. To restore them, the fingers should be laid flat on a table and then carefully repositioned into their joints. This method allows for easier restoration, as their sockets are not deep, their joints are relatively short, and their ligaments are less robust. Within twelve days, the fingers will regain their strength, just as with dislocations affecting the wrist and after-wrist.

39. Dislocated Thigh or Hip

The thigh, or hip, can dislocate and shift in any of four directions. However, dislocations most commonly occur inward, followed by outward, while forward and backward dislocations are quite rare. Unlike the shoulder joint, a subluxation cannot occur in the hip joint due to external causes. In contrast, subluxations are more frequent in the elbow, hand, knee, and foot. This difference arises because the heads of the thigh and shoulder bones are perfectly round, and their corresponding sockets possess defined borders and edges. Additionally, strong muscles surround each joint, preventing any part of the bone’s head from being partially contained within the socket while other parts remain dislocated. Any displaced parts are typically restored to their proper positions through joint movement and the strength of the surrounding muscles.

However, a subluxation can appear to occur from an internal cause when the ligaments and tendons become softened and relaxed, failing to pull the bone head back into alignment with the socket’s edges. If the hip dislocates inward, the affected leg appears longer and larger than the other, while the knee may appear slightly lower and angled outward, preventing the patient from standing on that leg.

In summary, the head of the thigh bone can be palpably felt in the groin, accompanied by visible swelling. The leg on the affected side will be longer than the healthy leg because the head of the thigh bone has moved out of its socket and is positioned lower, in the groin. Consequently, the knee protrudes as the lower part of the thigh bone is misaligned with the socket. This pattern is consistent across all dislocated bones: when a dislocation occurs to one side, the opposite end of the bone tends to shift outward.
Consequently, if the upper head of the thigh bone dislocates inward, the corresponding head at the knee must necessarily point outward. This phenomenon is consistent across various types of dislocations. The leg cannot be bent toward the groin because the dislocated bone keeps the extensor muscles in that region tightly stretched, preventing them from relaxing or allowing the flexor muscles to engage. In normal movement, flexion must precede extension, and vice versa.

40. Prognostic Factors Associated with a Dislocated Hip

Dislocations of the hip present a significant challenge, as the bone may either be difficult to reposition or, once restored, may easily dislocate again. If the tendons, ligaments, and other supportive structures are rigid and strong, their stiffness can impede the bone’s return to its proper alignment. Conversely, if these structures are soft, loose, and weak, they may fail to hold the bone securely in place.

Additionally, if the short, strong ligament that secures the head of the thigh bone within the hip socket is either torn or relaxed, the situation worsens. Such damage can occur due to a violent impact or accident, while relaxation may result from the accumulation of thick, viscous fluid around the joint, which softens the supporting structures. If the ligament is torn, no matter how many times the bone is repositioned, it is likely to dislocate again. If it is simply relaxed, there remains a glimmer of hope for stabilization by reducing the excess fluid through medicinal treatments and cauterization. Treatments that involve burning are particularly effective, as they dry and strengthen the affected area more robustly.

Furthermore, factors such as body leanness and the absence of aponeuroses—broad tendons and external ligaments that encase the knee—complicate the challenge of maintaining proper alignment of the joint.
The surrounding tissues adjacent to a dislocated and unrepaired bone gradually weaken and atrophy due to a lack of nourishment. This deterioration occurs for two reasons: first, the affected area is forced to cease its normal functions and movements; second, the veins, arteries, and nerves become compressed and displaced, restricting the flow of vital fluids and nutrients to the region. As a result, the affected part becomes weaker, and its inherent heat diminishes due to inactivity, making it unable to attract the nourishing fluids it requires or to effectively digest and assimilate whatever small amount does reach it.

The thigh bone, once dislocated from its socket, ceases to grow in the same manner as the other bones in the body. Consequently, over time, it may become noticeably shorter than the healthy bone. However, the bones of the leg and foot continue to grow normally, as they remain properly aligned. The perceived slenderness of the entire leg is primarily due to the atrophy and loss of muscle mass in that area.

A similar phenomenon occurs in the hand when the shoulder is dislocated, although the impact is less severe. With a shoulder dislocation, some function remains in the hand, allowing for a certain degree of nourishment to still flow to the affected areas. In contrast, when the thigh bone is dislocated, particularly in an unborn child or infant, significantly less nourishment reaches the leg and foot due to their reduced mobility resulting from the hip dislocation.

It is important to interpret Hippocrates’ assertion that dislocated bones which remain unrepaired suffer from stunted growth as applicable primarily to individuals who have not yet reached their full physical development. In fully grown individuals, while unrepaired bones may become more slender, they do not shorten in length, as evidenced by Hippocrates’ observations regarding the shoulder.

41. Of the signs of the hip, dislocated outwardly or inwardly.

When the thigh bone or hip is dislocated outwardly and remains untreated, the initial pain eventually subsides, and flesh begins to develop around the area. Over time, the head of the dislocated bone carves out a new cavity in the adjacent hip, allowing the patient to walk without the aid of a cane, and preventing significant atrophy in the leg. However, if the dislocation occurs inwardly, the resulting atrophy is more pronounced. This is due to the natural inward orientation of the blood vessels, as noted by Galen in his observations on vertebral dislocations. Consequently, individuals with an inward dislocation experience greater distress, as the thigh bone is unable to move against the shin bone.

If the dislocated bone is not realigned, the patient must swing their leg outwards while walking, similar to the way oxen move. As a result, the sound leg occupies less space during movement compared to the affected leg, which must travel a wider arc. Furthermore, when patients stand on their injured leg to advance their healthy one, they are compelled to adopt a crooked posture, often relying on a cane for support to prevent falling.

Moreover, individuals with a dislocated thigh bone—whether backward or outward—who do not receive treatment, often find that the affected area becomes stiff and hardened. This stiffness allows them to bend their knee with minimal discomfort and enables them to stand or rise onto their toes. However, when they wish to move more quickly, they must stoop and support themselves by placing a hand on their affected thigh with each step. This is necessary because their injured leg is shorter, and they must avoid placing the full weight of their body directly on the joint or head of the thigh bone. Over time, they may learn to walk without the aid of a cane, but in the meantime, their sound leg becomes increasingly deformed. This occurs because it bears the entire weight of the body while providing stability for the injured leg, which causes the knee to bend occasionally.

Conversely, when the head of the thigh bone is dislocated inward and remains untreated, individuals who have reached full growth may eventually walk without a cane. This is because the dislocated leg cannot be easily bent toward the groin or knee, causing them to rest more on their heels than on their toes. If this inward dislocation becomes chronic, it cannot be restored. Such complications arise when the thigh bone is dislocated inward or when the internal ligament that holds the joint is torn or weakened.

In contrast, an outward dislocation results in a shorter lame leg, as the head of the thigh bone shifts to a position higher than its original cavity. The muscles in that area contract toward their origin, pulling the bone upward. As a result, the leg, along with the knee and foot, turns inward, making it impossible for the patient to walk on their heels; instead, they must walk on their toes. Unlike inward dislocation, the leg can bend in this case, as noted by Paulus.

It is crucial to understand the interpretation of Hippocrates’ statement regarding this condition. The phrase “Sed neque conflectere quemadmodum sanum crus possunt” should be read positively: “Sed conflectere.” In cases of outward dislocation, the lame leg is better able to bear the body’s weight than in inward dislocation, as the head of the thigh bone is more vertically aligned under the body’s weight. Over time, as the bone wears down and forms a cavity in the neighboring bone, the dislocation may become permanent, but the patient can still walk without a cane, as they will no longer experience pain. Consequently, the affected leg may become less atrophied, as movement becomes less painful and the blood vessels are less constrained than in cases of inward dislocation.

42. Forward dislocated Thigh-bone

It is rare for the thigh to dislocate forward; however, when it does occur, certain signs can indicate this condition. The head of the thigh bone shifts toward the groin, causing swelling in the groin area, while the opposite buttock becomes wrinkled and shrunken due to muscle contraction. The patient experiences significant pain when attempting to extend or even bend the leg toward the groin, as the muscle originating from the hip bone is compressed by the dislocated head of the thigh, preventing its proper extension. Additionally, bending the knee is accompanied by considerable pain.

Although the affected leg remains level with the heel of the other leg, the patient struggles to stand on their toes. Consequently, when forced to walk, they can only touch the ground with their heel, as the sole of their foot is less inclined forward. It is not uncommon for this injury to lead to urinary suppression, as the dislocated thigh head exerts pressure on the major nerves that innervate the bladder. This compression can cause pain and inflammation in the bladder, and if inflammation extends to the sphincter muscle, it can severely impede the flow of urine due to swelling.

43. Backwards dislocated thigh-bone

Dislocation of the thigh bone backward is also uncommon, as the posterior part of the hip joint is deeper and more recessed than the anterior. This anatomical structure makes dislocation of the thigh toward the inner side more frequent than other types. In this condition, the patient is unable to extend or bend the affected leg due to significant compression and tension in the muscles surrounding the head of the thigh. The pain intensifies when attempting to bend the knee, as this action further stretches the muscles involved.

The injured leg appears shorter than the unaffected one. When pressure is applied to the buttocks, the head of the thigh can be felt hidden among the surrounding muscles, while the opposite groin remains lax, soft, and noticeably depressed with a visible cavity. The heel does not touch the ground because the head of the thigh is pulled backward by the surrounding muscles of the buttocks, particularly the larger muscle that forms the cushion of the buttock. This pressure inhibits knee bending, as the tension on the large tendon that covers the knee is excessive.

If the patient attempts to stand on the foot of the dislocated leg without support, they will likely fall backward, as the body leans toward that side, and the head of the thigh is not positioned directly underneath to provide stability. Consequently, the patient must rely on a crutch on the same side for support.

Having outlined the differences, signs, symptoms, and prognostics of this condition, we will now briefly describe the various methods for restoring the thigh to its proper position, depending on the specific type of dislocation. First, the patient should be positioned on a bench or table, either lying face down, face up, or on their side, with a soft quilt or covering placed underneath for added comfort.
To begin the reduction of a dislocated thigh bone, you must position the patient so that the affected area is elevated, while the site from which the bone has dislocated remains lower. If the thigh bone is dislocated outward or backward, the patient should be laid face down; if inward, they should lie on their back; and if forward, they should be positioned on their side.

Next, you will need to apply both extension and pressure toward the hip joint to coax the bone back into place. For fresh dislocations, particularly in individuals with softer tissues—such as women or children—there is no need for excessive force or strong ligatures to restore the bone. The surgeon’s hand, or a strip of cloth or towel wrapped around the joint, should suffice. Meanwhile, the dislocated bone should be stabilized with compresses applied around the joint.

The surgeon should then grasp the thigh above the knee and extend it in a straight line toward the hip joint, aligning it directly with the cavity before applying pressure to push it back in. It is crucial to lift the head of the thigh slightly during this process to prevent the edges of the joint from pushing it back out and obstructing its re-entry.

Since proper extension is essential for a successful reduction, it is often better to extend the thigh a bit more than necessary, provided that no muscles, tendons, or nerves are at risk of being damaged. As Hippocrates noted, when the muscles are strong and large, they can withstand more extension without causing displacement.

If manual extension is insufficient, you may need to utilize a mechanical device such as a pulley system secured to two posts. The rope should be adjusted to provide the necessary force for the procedure. During this process, it is advisable for the patient’s friends to remain absent, allowing the surgeon to maintain focus and resolve without being swayed by the emotions of the patient or their family.

As this guide is primarily intended for the benefit of young practitioners, it seems appropriate to outline these general principles for restoring the thigh bone before delving into specific types of dislocations, starting with inward dislocations.

44. Restoring the thigh-bone dislocated inwards

The patient should be positioned as previously described, on a table or bench, with a sturdy wooden pin approximately one foot long and as thick as a spade handle securely fastened in the center. This pin must be wrapped in soft cloth to prevent injury to the buttocks, and it should be placed between them, as noted in Hippocrates’ methods for extending a broken leg.

The purpose of the wooden pin is to stabilize the body, preventing it from moving in response to the traction applied by the surgeon. Once sufficient extension is achieved, the pin should rest between the perineum and the head of the dislocated thigh. This setup reduces the need for significant counter-extension in the upper body and aids in pushing the bone back into its proper cavity. The surgeon will assist by applying pressure, occasionally twisting to one side and then the other, to effectively guide the entire process.
When extension requires counter-extension, it is essential to have the appropriate ligatures on hand, as previously discussed in the context of restoring a dislocated shoulder. One ligature should be securely fastened above the hip joint and pulled by a strong individual, while another should be placed above the knee and similarly extended by another strong person.

If a wooden pin is unavailable, a strong ligature can be applied directly to the hip joint and held firmly by the hands of a strong individual, ensuring it does not press against the head of the thigh, as that would impede the reduction process.
This method of extension is applicable to four types of hip dislocation. However, the technique for repositioning the bone into its socket must be adjusted for each case, based on the specific orientation of the femoral head. For instance, if the femoral head has shifted inward, it should be pushed outward to restore its proper alignment, and the opposite applies for other types of dislocation, depending on their specific characteristics.
Clownish and ignorant knot-knitters, lacking skill and understanding, mistakenly secure the lower ligature below the ankle, resulting in excessive extension of the foot and knee joints compared to the hip joint. This occurs because the foot and knee are closer to the ligature and, consequently, to the applied force. Instead, the ligatures for a dislocated shoulder should be fastened above the elbow, not at the hand or wrist. If manual force proves insufficient, mechanical assistance should be employed.

To proceed correctly, the patient should be positioned appropriately, with the affected area securely held. A round object should be placed in the groin, while the patient’s knee and entire leg are forcefully drawn inward toward the opposite leg. Simultaneously, the head of the femur must be firmly pushed toward the hip socket, ultimately restoring it to its proper position, as illustrated in the accompanying figure.

When the head of the thigh bone is released from the surrounding muscles through careful extension, and those muscles are also stretched to become more pliable, it is essential to slightly relax the tension on the rope and cease further extension. If this is not done, the stronger force from the apparatus may oppose the surgeon’s efforts to reposition the bone into the joint. This guideline must be adhered to when restoring this and other dislocations.

You can confirm that the thigh has been properly restored by observing the symmetry of the legs and the ability to extend and flex the injured leg without pain. Finally, the application of adhesive remedies, as previously discussed, will help stabilize the repositioned bone. To achieve this, a ligature should be applied, first positioned at the site where the head of the thigh bone was displaced and then brought over to the opposite, unaffected side, traversing the abdomen and lower back.

In the meantime, the groin cavity should be supported with a firm bolster to help maintain the head of the bone in its proper position. Additionally, it is important to include supportive padding extending down to the ankles, as noted in the treatment of thigh fractures. Both thighs should then be bound together to immobilize the dislocated limb, providing increasing stability. This binding should not be loosened for four to five days, unless a more serious symptom arises that necessitates a change.

In conclusion, the patient should remain in bed for a month to allow the relaxed muscles, nerves, and ligaments to regain their strength. If this rest period is not observed, there is a risk that the bone may dislocate again due to premature walking. The thigh should be positioned and maintained in a neutral alignment; however, this neutral position should emphasize extension rather than flexion, as demonstrated by Hippocrates, since such alignment is more natural and comfortable for the leg.

45. Restoring the thigh dislocated outwardly

The patient should be positioned face down on a table for this type of dislocation. As before, ligatures should be applied around the hip and lower thigh. Next, downward extension should be performed, accompanied by upward counter-extension. The surgeon must then manually guide the head of the bone back into its proper position. If manual pressure is insufficient, a pulley system should be utilized, as illustrated in the following figure.

This type of dislocation is the easiest to restore among those affecting the thigh or hip. I have observed on several occasions that the head of the thigh can be drawn back into its socket simply by the retraction of the extended muscles toward their original positions. This may sometimes occur with a noticeable noise or pop, while at other times it may happen silently. Once this is accomplished, apply a compress to the joint and proceed with the remaining steps as you would for an internal dislocation.

46. Restoring the Thigh dislocated forewards

When the thigh is dislocated forward, the patient should be positioned on their unaffected side and secured as previously described. The surgeon should then place a bolster on the prominent head of the bone, ensuring that an assistant holds it firmly in place. Next, while applying gentle traction, the surgeon should use their hand to push the bone back into the socket. If this proves insufficient, the surgeon may use their knee to assist in the process. Finally, the surgeon should implement the previously mentioned methods to stabilize the restored bone.

47. Restoring the thigh dislocated backwards

The patient should be positioned face down on a table or bench, with the affected limb extended as before. One ligature should be secured from the groin, and another from the knee. The surgeon will then attempt to push the protruding bone back into place with their hand while simultaneously pulling the knee away from the unaffected leg. Once the bone is properly aligned and restored, the treatment requires no further intervention other than to bind the area and keep the patient in bed for an extended period. This is essential to prevent the thigh from moving, which could cause the nerves to loosen further and result in dislocation. The thigh is particularly susceptible to re-injury because the cavity of the hip joint is only slightly depressed, and the weight of the hanging or adjacent thigh can be significant.

48. Dislocation of the whirle-bone of the knee (patella)

The patella of the knee can dislocate into the inner, outer, upper, or lower parts, but it will never shift to the rear, as the surrounding bones prevent this movement. To restore it, the patient must stand with their foot firmly on a level surface, while the surgeon applies manual force to reposition the bone back into its proper place. Once the bone is realigned, the cavity behind the knee should be filled with bolsters to prevent the leg from bending. Bending the leg poses a significant risk of the whirligig bone slipping out again.

Next, a protective case or box should be placed around the knee, particularly on the side where the dislocation occurred. This case should be somewhat flat and rounded, resembling the whirly-bone itself, and secured tightly with ligatures and medicinal applications to ensure it remains immobile. After a sufficient period of rest, the patient can gradually begin to bend their knee, allowing them to safely and comfortably regain movement in the joint over time.

49. Dislocated Knee

The knee can be dislocated in three primary ways: inward, outward, and backward, though dislocation toward the front is rare and typically requires significant force. The whirligig bone, resting upon the knee, prevents it from slipping out and helps keep it in place. The inward and outward dislocations are more common because the cavity of the leg bone is shallow and smooth, while the lower end of the thigh bone is shaped like a spout or gutter and features a smooth, slippery surface. Overall, the knee joint is considerably more lax than the elbow joint, making it easier to dislocate but also facilitating a more straightforward restoration. Additionally, inflammation is less of a concern in knee dislocations, as noted by Hippocrates.

Common causes of knee dislocation include falls from heights, jumping, and excessive running. A key sign of dislocation is the inability to bend or lift the leg toward the thigh, preventing the patient from touching their buttock with their heel. For inward and outward dislocations, gentle extension and manual manipulation of the bones back into their proper positions are generally effective.

To restore a backward dislocation, the patient should be positioned on a bench of suitable height, allowing the surgeon to stand behind and bend the patient’s leg, bringing it toward their buttocks. If this method fails, a loop of yarn can be secured to the middle of a staff. One person can insert this staff into the cavity behind the knee, applying pressure to push the bone forward. Meanwhile, another individual should place a ligature about three fingers’ breadth above the knee and pull it upward. All participants should then simultaneously bend the affected leg until the heel touches the buttocks.

50. Forwards dislocation of the knee

If the knee is dislocated forward—a rare occurrence—the patient should be positioned on a table, with a suitable ligature applied above the knee and another just below it. The surgeon will then apply steady pressure with both hands on the displaced bone until it returns to its proper position. If manual strength is insufficient to achieve the necessary extension in either direction, the use of a mechanical device, as illustrated in the following figure, may be employed to assist in the procedure.

You will know that the bone has been successfully restored when the leg can be extended freely and without pain. Only then should medications, supports, and strengthening ligatures be considered. In the meantime, the patient should refrain from walking for as long as the affected area appears to need it.

51. Regarding the separation of the greater and lesser focile

The fibula, or lesser focile, is attached to the tibia, the larger leg bone, without any intervening cavity. It connects above at the knee and below at the ankle. However, it can be displaced or drawn aside in three ways: forward and to either side. This typically occurs when we lose our footing, causing us to slip in a slippery area, which may twist the fibula inward or outward. When this happens, the weight of the body can pull the leg inward, resulting in dislocation or separation of the two bones. Such injuries can also occur from a fall from a height or a severe impact. Additionally, their appendices may sometimes become detached.

To restore these bones to their proper positions, it is essential for a surgeon to manually realign them. Once in place, they should be securely bound, with compresses applied to the area where the fibula has been displaced. The ligation should begin at the site of the dislocation for optimal support. The patient should rest for forty days to allow sufficient time for the ligaments to strengthen.

52. Of the dislocation and separation of the leg bone, or greater focile, from the pastern bone (talus)

The leg bone can sometimes become dislocated and separated from the pastern bone (talus), either inwardly or outwardly. This condition can be identified by the swelling of the bone in one direction or another. If the issue is merely a subluxation or strain, it can typically be corrected by gently realigning the bone. Once the bone has been restored, it should be secured using compresses and appropriate bandaging, applying cross and contrary bindings to the side opposite to the direction in which the bone was displaced. This method helps to further encourage the bone to remain in its proper position.

During this process, it is crucial to avoid applying excessive pressure to the large tendon located at the heel. Generally, this type of dislocation can be resolved within forty days, barring any unforeseen complications that may arise.

53. Dislocation of the heel

Those who leap from a great height and land heavily on their heel may experience a dislocation of the heel, resulting in its separation from the pasterne bone. This type of dislocation occurs more frequently inwardly than outwardly, as the prominence of the lesser focile tightly surrounds the pasterne bone, providing a more secure connection.

Restoration of the dislocation involves extension and gentle realignment, which is usually manageable unless a significant swelling or inflammation complicates the situation. When binding the affected area, it is essential to apply the bandage firmly to the injured site to encourage blood flow into the surrounding tissues. However, care must be taken to ensure that the binding is not overly tight, as this could cause pain or excessively compress the nerves and the large tendon leading to the heel.

Typically, this dislocation is not considered resolved until the fortieth day, provided no complications arise. However, it is common for various symptoms to develop due to the severity of the injury. Therefore, it would be prudent to address these symptoms in a separate chapter.

54. Of the symptoms which follow upon the contusion of the Heel.

As a result of the severity of the contusion, both veins and arteries may release blood through the delicate layers of their walls, as well as from their openings. This can lead to the development of ecchymosis, or bruising, across the heel, accompanied by pain, swelling, and other related symptoms that require medical attention.

To address these issues, appropriate remedies should be employed, including a suitable diet and the withdrawal of blood through venesection. Although Hippocrates does not specifically mention this practice, it is necessary here due to the presence of fever and inflammation. If required, purgation may also be beneficial, particularly methods that encourage vomiting to help expel the underlying matter.

Additionally, local treatments should be applied, especially those that soften and thin the skin beneath the heel, which tends to become hard and thick. Warm water and oil fomentations are effective in this regard. In some cases, it may be necessary to scarify the skin with a lancet, taking care to avoid the underlying flesh. This approach can facilitate the dispersal and eventual resolution of the accumulated blood in the affected area.
All these measures must be taken before inflammation sets in, as failure to do so may lead to the risk of convulsions. When blood escapes from the vessels, it tends to putrefy quickly due to the density of the affected area, which restricts ventilation and prevents the blood from dispersing to surrounding tissues.

It is also important to note that the large tendon covering the heel is highly sensitive, and the area itself is richly supplied with numerous nerves. Additionally, lying on the back and heel poses an increased risk of inflammation, as previously mentioned in relation to leg fractures.

Therefore, I urge the surgeon to be vigilant and diligent in implementing the necessary interventions we have discussed. If inflammation occurs, there is a grave risk of gangrene and tissue necrosis, as the decomposing tissue can rapidly affect the underlying bone. This may be accompanied by a persistent and severe fever, along with symptoms such as trembling, hiccupping, and delirium.

The corruption of this area can quickly spread to adjacent tissues, leading to a fever that can impact the heart through the constriction and heating of the arteries. The nerves and the prominent tendon formed by the convergence of the calf muscles may also become affected, resulting in a cascade of complications that can lead to convulsions, delirium, and life-threatening hiccups.

55. Of the dislocated pastern or ankle-bone.

The astragalus, or pastern bone, can become dislocated and shift out of its proper position in various directions. When it dislocates inward, the sole of the foot turns outward; conversely, if it dislocates outward, the opposite occurs. If the bone is displaced forward, the broad tendon beneath the heel becomes hardened and distended at the back. If it luxates backward, the entire heel becomes concealed within the foot. Such dislocations typically result from significant trauma.

To restore the bone, it must be gently extended with the hands and maneuvered back into its original position. Once properly aligned, it should be stabilized through the application of appropriate medications and secure binding. The patient must remain in bed for an extended period to prevent the bone, which supports the entire body, from becoming dislodged again under strain, particularly if the surrounding ligaments have not yet healed and strengthened adequately.

56. Of the dislocation of the Instep and back of the foot.

The bones of the instep and the back of the foot can also become luxated, either upward or downward, and occasionally to one side, although lateral dislocations are rare for the reasons previously discussed regarding similar bones in the hand.

When the bones are dislocated upward, the patient should step firmly on a flat, even surface. The surgeon can then apply pressure to guide the bones back into their proper positions. Conversely, if the bones have protruded from the sole of the foot, they should be pressed upward to restore each bone to its correct alignment. The same technique applies if the bones are displaced to either side.

It is important to note that while ligatures typically consist of a single loop for other dislocations, Hippocrates recommends using those with two loops in this case. This is due to the fact that dislocations in the foot more commonly occur from below to above or from above to below, rather than laterally.

57. Of the dislocation of the Toes.

The toes can be dislocated in four ways, much like the fingers of the hand, and they can be restored using a similar technique. First, extend the toes directly forward, then gently manipulate each joint back into place, and finally secure them as appropriate. The realignment of the toes is relatively straightforward, as they cannot stray far from their normal position.

In summary, the bones of the feet are dislocated and treated using methods akin to those employed for the hands. However, it is important to note that when a dislocation occurs in the foot, the patient must remain in bed, whereas a dislocation in the hand requires the patient to carry it in a scarf. The patient should rest for twenty days, or until they are able to stand firmly on their feet again.

58. Of the symptoms, and other accidents which may befall a broken or dislocated member.

A variety of complications can arise from broken or dislocated limbs, including bruising, severe pain, inflammation, fever, abscesses, gangrene, tissue necrosis, ulcers, fistulas, and atrophy—all of which necessitate the expertise and diligence of a skilled surgeon for proper treatment. These issues often occur due to the impact of a heavy object on the affected area or from a fall from a height, leading to the accumulation of blood beneath the skin. If this accumulation is significant, it must be promptly addressed through scarification to relieve the pressure and prevent the risk of gangrene. The deeper the blood appears to be and the more swollen the skin becomes, the more profound the scarification should be. Additionally, leeches may be applied for the same therapeutic purpose.

Regarding pain, we previously noted that it typically arises when bones are displaced from their proper positions. This misalignment can irritate the surrounding muscles and nerves, leading to discomfort from pressure and pinching. Consequently, this may result in inflammation, abscess formation, fever, and, at times, gangrene, ultimately causing necrosis that deteriorates the bones. In some cases, a sinus ulcer or fistula may develop. Additionally, atrophy and weakness can occur due to the inactivity and neglect of the affected limb, which diminishes its strength. Furthermore, excessive tightness from ligation can obstruct blood flow, further impeding recovery.

Leanness resulting from excessive tight ligation can be treated by loosening the bindings that constrain the limb. In contrast, weakness caused by inactivity can be remedied through moderate exercise, which includes extending, bending, lifting, and lowering the affected member, provided that the individual is able to tolerate such activity. If exercise is not feasible, gentle frictions and warm water fomentations should be employed.

The frictions should strike a balance between firmness and gentleness, and their duration should vary accordingly. Similarly, the temperature of the water and the length of the fomentation sessions must be carefully regulated; excessive duration can cause the blood to dissipate, while insufficient time may yield little to no benefit. Following the fomentation, hot, emollient preparations made from pitch, turpentine, euphorbium, pellitory of Spain, sulphur, and similar substances should be applied. These treatments should be renewed daily, adjusted in frequency as needed based on the condition’s requirements.

These remedies are referred to as Dropaces, and their composition is as follows:

℞ Black pitch, ammoniacum, bdellium, and gum elemi, each dissolved in an adequate amount of aqua vitae (two ounces each). Additionally, incorporate one ounce of lauric oil, along with two ounces of powdered pepper, ginger, paradise seeds, laurel berries, and juniper berries. Prepare an emplastrum according to established methods, and spread it evenly over leather.

It is also advisable to bind the corresponding healthy limb with a ligature, ensuring that it is done without causing pain. For instance, if the right arm begins to deteriorate due to a lack of nourishment, the left arm should be wrapped, starting from the hand and extending to the armpit. Similarly, if the right leg is affected, the left leg should be swathed from the sole of the foot to the groin. This technique helps redirect a significant portion of blood back into the vena cava, or hollow vein, which becomes distended and overfilled, while the affected area experiences diminished blood flow. Additionally, it is beneficial to keep the healthy limb at rest, reducing its demand for nourishment, which in turn allows more resources to be directed toward revitalizing the weakened part.

Some individuals also advocate for binding the affected limb with moderate ligation, arguing that this technique draws blood toward the area. Just as we bind the arm when we intend to draw blood by opening a vein with a lancet, this practice is thought to be beneficial. Additionally, it is advisable to immerse the limb in water that is slightly warmer than body temperature, holding it there until it becomes red and swollen. This process encourages blood to flow into the veins, as observed in those who practice venesection on the saphena and salvatella veins. If, after performing these methods, the affected area becomes warm, red, and swollen, it is a sign that recovery is possible. Conversely, if the opposite occurs, the situation is dire, and further attempts should be avoided.

Moreover, hardness may sometimes remain in the joints after fractures and dislocations have been treated. It is advisable to soften this hardness by resolving the retained fluid through the use of fomentations, liniments, cataplasms, and plasters made from the roots of marshmallows, briony, lilies, flaxseed, fenugreek seed, and similar ingredients. Additionally, one can utilize gums dissolved in strong vinegar, such as Ammoniacum, bdellium, opopanax, labdanum, sagapenum, styrax liquida, and various animal fats, including goose, chicken, and human fat, as well as lily oil.

Patients should also be encouraged to move the affected limb regularly, albeit gently and without causing pain, to promote warmth, thinning of the retained fluid, and ultimately its resolution. This practice aims to restore the limb as much as possible through therapeutic means, although sometimes complete recovery may not be achievable.

If the limb remains weak and painful due to the fracture occurring near a joint, the individual may experience ongoing difficulties with movement for the rest of their life. This is particularly true if the callus that forms is thick and substantial, or if the joint itself has been contused or fractured from a blow, as often occurs in gunshot wounds.