As a general rule it may be said, that in those cases in which a separation of bone is not expected, the same treatment should be applied as when the fractures are not complicated with an external wound; for the extension, adjustment of the bones, and the bandaging, are to be conducted in the same manner. To the wound itself a cerate mixed with pitch is to be applied, a thin folded compress is to be bound upon it, and the parts around are to be anointed with white cerate. The cloths for bandages and the other things should be torn broader than in cases in which there is no wound, and the first turn of the bandage should be a good deal broader than the wound. For a narrower bandage than the wound binds the wound like a girdle, which is not proper, or the first turn should comprehend the whole wound, and the bandaging should extend beyond it on both sides. The bandage then should be put on in the direction of the wound, and should be not quite so tight as when there is no wound, but the bandage should be otherwise applied in the manner described above. The bandages should be of a soft consistence, and more especially so in such cases than in those not complicated with a wound. The number of bandages should not be smaller, but rather greater than those formerly described. When applied, the patient should have the feeling of the parts being properly secured, but not too tight, and in particular he should be able to say that they are firm about the wound. And the intervals of time during which the parts seem to be properly adjusted, and those in which they get loose, should be the same as those formerly described. The bandages should be renewed on the third day, and the after treatment conducted in the same manner as formerly described, except that in the latter case the compression should be somewhat less than in the former. And if matters go on properly, the parts about the wound should be found at every dressing always more and more free of swelling, and the swelling should have subsided on the whole part comprehended by the bandages. And the suppurations will take place more speedily than in the case of wounds treated otherwise; and the pieces of flesh in the wound which have become black and dead, will sooner separate and fall off under this plan of treatment than any other, and the sore will come more quickly to cicatrization when thus treated than otherwise. The reason of all this is, that the parts in which the wound is situated, and the surrounding parts, are kept free of swelling. In all other respects the treatment is to be conducted as in cases of fracture without a wound of the integuments. Splints should not be applied. On this account the bandages should be more numerous than in the former case, both because they must be put on less tight, and because the splints are later of being applied. But if you do apply the splints, they should not be applied along the wound, and they are to be put on in a loose manner, especial care being taken that there may be no great compression from the splints. This direction has been formerly given. And the diet should be more restricted, and for a longer period, in those cases in which there is a wound at the commencement, and when the bones protrude through the skin; and, in a word, the greater the wound, the more severe and protracted should the regimen be. The treatment of the sores is the same in those cases of fracture in which there was no wound of the skin at first, but one has formed in the course of treatment, owing to the pressure of the splints occasioned by the bandages, or from any other cause. In such cases it is ascertained that there is an ulcer, by the pain and the throbbing; and the swelling in the extremities becomes harder than usual, and if you apply your finger the redness disappears, but speedily returns. If you suspect anything of the kind you must loose the dressing, if there be any itching below the under-bandages, or in any other part that is bandaged, and used a pitched cerate instead of the other. If there be nothing of that, but if the ulcer be found in an irritable state, being very black and foul, and the fleshy parts about to suppurate, and the tendons to slough away, in these cases no part is to be exposed to the air, nor is anything to be apprehended from these suppurations, but the treatment is to be conducted in the same manner as in those cases in which there was an external wound at first. You must begin to apply the bandages loosely at the swelling in the extremities, and then gradually proceed upward with the bandaging, so that it may be tight at no place, but particularly firm at the sore, and less so elsewhere. The first bandages should be clean and not narrow, and the number of bandages should be as great as in those cases in which the splints were used, or somewhat fewer. To the sore itself a compress, anointed with white cerate, will be sufficient, for if a piece of flesh or nerve ( tendon? ) become black, it will fall off; for such sores are not to be treated with acrid, but with emollient applications, like burns. The bandages are to be renewed every third day, and no splints are to be applied, but rest is to be more rigidly maintained than in the former cases, along with a restricted diet. It should be known, that if any piece of flesh or tendon be to come away, the mischief will spread much less, and the parts will much more speedily drop off, and the swelling in the surrounding parts will much more completely subside, under this treatment, than if any of the cleansing applications be put upon the sore. And if any part that is to come away shall fall off, the part will incarnate sooner when thus treated than otherwise, and will more speedily cicatrize. Such are the good effects of knowing how a bandage can be well and moderately applied. But a proper position, the other parts of the regimen, and suitable bandages cooperate. If you are deceived with regard to a recent wound, supposing there will be no exfoliation of the bones, while they are on the eve of coming out of the sore, you must not hesitate to adopt this mode of treatment; for no great mischief will result, provided you have the necessary dexterity to apply the bandages well and without doing any harm. And this is a symptom of an exfoliation of bone being about to take place under this mode of treatment; pus runs copiously from the sore, and appears striving to make its escape. The bandage must be renewed more frequently on account of the discharge, since otherwise fevers come on; if the sore and surrounding parts be compressed by the bandages they become wasted. Cases complicated with the exfoliation of very small bones, do not require any change of treatment, only the bandages should be put on more loosely, so that the discharge of pus may not be intercepted, but left free, and the dressings are to be frequently renewed until the bone exfoliate, and the splints should not be applied until then. Those cases in which the exfoliation of a larger piece of bone is expected, whether you discover this at the commencement, or perceive subsequently that it is to happen, no longer require the same mode of treatment, only that the extension and arrangement of the parts are to be performed in a manner that has been described; but having formed double compresses, not less than half a fathom in breadth (being guided in this by the nature of the wound), and considerably shorter than what would be required to go twice round the part that is wounded, but considerably longer than to go once round, and in number what will be sufficient, these are to be dipped in a black austere wine; and beginning at the middle, as is done in applying the double-headed bandage, you are to wrap the part around and proceed crossing the heads in the form of the bandage called ascia. These things are to be done at the wound, and on both sides of it; and there must be no compression, but they are to be laid on so as to give support to the wound. And on the wound itself is to be applied the pitched cerate, or one of the applications to recent wounds, or any other medicine which will suit with the embrocation. And if it be the summer season, the compresses are to be frequently damped with wine; but if the winter season, plenty of greasy wool, moistened with wine and oil, should be applied. And a goat’s skin should be spread below, so as to carry off the fluids which run from the wound; these must be guarded against, and it should be kept in mind, that parts which remain long in the same position are subject to excoriations which are difficult to cure. In such cases as do not admit of bandaging according to any of the methods which have been described, or which will be described, great pains should be taken that the fractured part of the body be laid in a right position, and attention should be paid that it may incline upward rather than downward. But if one would wish to do the thing well and dexterously, it is proper to have recourse to some mechanical contrivance, in order that the fractured part of the body may undergo proper and not violent extension; and this means is particularly applicable in fractures of the leg. There are certain physicians who, in all fractures of the leg, whether bandages be applied or not, fasten the sole of the foot to the couch, or to some other piece of wood which they have fixed in the ground near the couch. These persons thus do all sorts of mischief but no good; for it contributes nothing to the extension that the foot is thus bound, as the rest of the body will no less sink down to the foot, and thus the limb will no longer be stretched, neither will it do any good toward keeping the limb in a proper position, but will do harm, for when the rest of the body is turned to this side or that, the bandaging will not prevent the foot and the bones belonging to it from following the rest of the body. For if it had not been bound it would have been less distorted, as it would have been the less prevented from following the motion of the rest of the body. But one should sew two balls of Egyptian leather, such as are worn by persons confined for a length of time in large shackles, and the balls should have coats on each side, deeper toward the wound, but shorter toward the joints; and the balls should be well stuffed and soft, and fit well, the one above the ankles, and the other below the knee. Sideways it should have below two appendages, either of a single or double thong, and short, like loops, the one set being placed on either side of the ankle, and the other on the knee. And the other upper ball should have others of the same kind in the same line. Then taking four rods, made of the cornel tree, of equal length, and of the thickness of a finger, and of such length that when bent they will admit of being adjusted to the appendages, care should be taken that the extremities of the rods bear not upon the skin, but on the extremities of the balls. There should be three sets of rods, or more, one set a little longer than another, and another a little shorter and smaller, so that they may produce greater or less distention, if required. Either of these sets of rods should be placed on this side and that of the ankles. If these things be properly contrived, they should occasion a proper and equable extension in a straight line, without giving any pain to the wound; for the pressure, if there is any, should be thrown at the foot and the thigh. And the rods are commodiously arranged on either side of the ankles, so as not to interfere with the position of the limb; and the wound is easily examined and easily arranged. And, if thought proper, there is nothing to prevent the two upper rods from being fastened to one another; and if any light covering be thrown over the limb, it will thus be kept off from the wound. If, then, the balls be well made, handsome, soft, and newly stitched, and if the extension by the rods be properly managed, as has been already described, this is an excellent contrivance; but if any of them do not fit properly, it does more harm than good. And all other mechanical contrivances should either be properly done, or not be had recourse to at all, for it is a disgraceful and awkward thing to use mechanical means in an unmechanical way.