on the articulations-第3部分

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　　11。　It　deserves　to　be　known　how　a　shoulder　which　is　subject　to
frequent　dislocations　should　be　treated。　For　many　persons　owing　to
this　accident　have　been　obliged　to　abandon　gymnastic　exercises；　though
otherwise　well　qualified　for　them；　and　from　the　same　misfortune　have
become　inept　in　warlike　practices；　and　have　thus　perished。　And　this
subject　deserves　to　be　noticed；　because　I　have　never　known　any
physician　treat　the　case　properly；　some　abandon　the　attempt
altogether；　and　others　hold　opinions　and　practice　the　very　what　is
proper。　For　physicians　have　burned　the　shoulders　subject　to
dislocation；　at　the　top　of　the　shoulder；　at　the　anterior　part　where
the　head　of　the　humerus　protrudes；　and　a　little　behind　the　top　of
the　shoulder；　these　burnings；　if　the　dislocation　of　the　arm　were
upward；　or　forward；　or　backward；　would　have　been　properly　performed；
but　now；　when　the　dislocation　is　downward；　they　rather　promote　than
prevent　dislocations；　for　they　shut　out　the　head　of　the　humerus　from
the　free　space　above。　The　cautery　should　be　applied　thus：　taking
hold　with　the　hands　of　the　skin　at　the　armpit；　it　is　to　be　drawn
into　the　line；　in　which　the　head　of　the　humerus　is　dislocated；　and
then　the　skin　thus　drawn　aside　is　to　be　burnt　to　the　opposite　side。
The　burnings　should　be　performed　with　irons；　which　are　not　thick　nor
much　rounded；　but　of　an　oblong　form　（for　thus　they　pass　the　more
readily　through）；　and　they　are　to　be　pushed　forward　with　the　hand；　the
cauteries　should　be　red…hot；　that　they　may　pass　through　as　quickly
as　possible；　for　such　as　are　thick　pass　through　slowly；　and　occasion
eschars　of　a　greater　breadth　than　convenient；　and　there　is　danger　that
the　cicatrices　may　break　into　one　another；　which；　although　nothing
very　bad；　is　most　unseemly；　or　awkward。　When　you　have　burnt　through；
it　will　be　sufficient；　in　most　cases；　to　make　eschars　only　in　the
lower　part；　but　if　there　is　no　danger　of　the　ulcers　passing　into　one
another；　and　there　is　a　considerable　piece　of　skin　between　them；　a
thin　spatula　is　to　be　pushed　through　these　holes　which　have　been
burned；　while；　at　the　same　time；　the　skin　is　stretched；　for
otherwise　the　instrument　could　not　pass　through；　but　when　you　have
passed　it　through　you　must　let　go　the　skin；　and　then　between　the　two
eschars　you　should　form　another　eschar　with　a　slender　iron；　and　burn
through　until　you　come　in　contact　with　the　spatula。　The　following
directions　enable　you　to　determine　how　much　of　the　skin　of　the
armpit　should　be　grasped；　all　men　have　glands　in　the　armpit　greater　or
smaller；　and　also　in　many　other　parts　of　the　body。　But　I　will　treat　in
another　work　of　the　whole　constitution　of　the　glands；　and　explain　what
they　are；　what　they　signify；　and　what　are　their　offices。　The　glands；
then；　are　not　to　be　taken　hold　of；　nor　the　parts　internal　to　the
glands；　for　this　would　be　attended　with　great　danger；　as　they　are
adjacent　to　the　most　important　nerves。　But　the　greater　part　of　the
substances　external　to　the　glands　are　to　be　grasped；　for　there　is　no
danger　from　them。　And　this；　also；　it　is　proper　to　know；　that　if　you
raise　the　arm　much；　you　will　not　be　able　to　grasp　any　quantity　of　skin
worth　mentioning；　for　it　is　all　taken　up　with　the　stretching；　and　also
the　nerves。　which　by　all　means　you　must　avoid　wounding；　become　exposed
and　stretched　in　this　position；　but　if　you　only　raise　the　arm　a
little；　you　can　grasp　a　large　quantity　of　skin；　and　the　nerves　which
you　ought　to　guard　against　are　left　within；　and　at　a　distance　from　the
operation。　Should　not；　then；　the　utmost　pains　be　taken　in　the　whole
practice　of　the　art　to　find　out　the　proper　attitude　in　every　case？
So　much　regarding　the　armpit；　and　these　contractions　will　be
sufficient；　provided　the　eschars　be　properly　placed。　Without　the
armpit　there　are　only　two　places　where　one　might　place　the　eschars
to　obviate　this　affection；　the　one　before　and　between　the　head　of
the　humerus　and　the　tendon　at　the　armpit；　and　then　the　skin　may　be
fairly　burned　through；　but　not　to　any　great　depth；　for　there　is　a
large　vein　adjacent；　and　also　nerves；　neither　of　which　must　be　touched
with　the　heat。　But　externally；　one　may　form　another　eschar
considerably　above　the　tendon　at　the　armpit；　but　a　little　below　the
head　of　the　humerus；　and　the　skin　must　be　burned　fairly　through；　but
it　must　not　be　made　very　deep；　for　fire　is　inimical　to　the　nerves。
Through　the　whole　treatment　the　sores　are　to　be　so　treated；　as　to
avoid　all　strong　extension　of　the　arm；　and　this　is　to　be　done
moderately；　and　only　as　far　as　the　dressing　requires；　for　thus　they
will　be　less　cooled　（for　it　is　of　importance　to　cover　up　all　sorts
of　burns　if　one　would　treat　them　mildly）；　and　then　the　lips　of　them
will　be　less　turned　aside；　there　will　be　less　hemorrhage　and　fear　of
convulsions。　But　when　the　sores　have　become　clean；　and　are　going　on　to
cicatrization；　then　by　all　means　the　arm　is　to　be　bound　to　the　side
night　and　day；　and　even　when　the　ulcers　are　completely　healed；　the　arm
must　still　be　bound　to　the　side　for　a　long　time；　for　thus　more
especially　will　cicatrization　take　place；　and　the　wide　space　into
which　the　humerus　used　to　escape　will　become　contracted。

　　12。　When　attempts　to　reduce　a　dislocated　shoulder　have　failed；　if
the　patient　be　still　growing；　the　bone　of　the　affected　arm　will　not
increase　like　the　sound　one；　for　although　it　does　increase　in　so　far
it　becomes　shorter　than　the　other；　and　those　persons　called
weasel…armed；　become　so　from　two　accidents；　either　from　having　met
with　this　dislocation　in　utero；　or　from　another　accident；　which　will
be　described　afterward。　But　those　who　while　they　were　children　have
had　deep…seated　suppurations　about　the　head　of　the　bone；　all　become
weasel…armed；　and　this；　it　should　be　well　known；　will　be　the　issue；
whether　the　abscess　be　opened　by　an　incision　or　cautery；　or　whether　it
break　spontaneously。　Those　who　are　thus　affected　from　birth　are
quite　able　to　use　the　arm　yet　neither　can　they　raise　the　arm　to　the
ear；　by　extending　the　elbow；　but　they　do　this　much　less　efficiently
than　with　the　sound　arm。　But　in　those　who　have　had　the　shoulder
dislocated　after　they　were　grown　up；　and　when　it　has　not　been　reduced；
the　top　of　the　shoulder　becomes　much　less　fleshy；　and　the　habit　of
body　at　that　part　is　attenuated；　but　when　they　cease　to　have　pain；
whatever　they　attempt　to　perform　by　raising　the　elbow　from　the　sides
obliquely；　they　can　no　longer　accomplish　as　formerly；　but　whatever
acts　are　performed　by　carrying　the　arm　around　by　the　sides；　either
backward　or　forward；　all　those　they　can　perform；　for　they　can　work
with　an　auger　or　a　saw；　or　with　a　hatchet；　and　can　dig；　by　not　raising
the　elbow　too　much；　and　do　all　other　kinds　of　work　which　are　done　in
similar　attitudes。

　　13。　In　those　cases　where　the　acromion　has　been　torn　off；　the　bone
which　is　thus　separated　appears　prominent。　The　bone　is　the　bond　of
connection　between　the　clavicle　and　scapula；　for　in　this　respect　the
constitution　of　man　is　different　from　that　of　other　animals；
physicians　are　particularly　liable　to　be　deceived　in　this　accident
（for　as　the　separated　bone　protrudes；　the　top　of　the　shoulder
appears　low　and　hollow）；　so　that　they　make　preparations　as　if　for
dislocation　of　the　shoulder；　for　I　have　known　many　physicians；
otherwise　not　inexpert　at　the　art；　who　have　done　much　mischief　by
attempting　to　reduce　such　shoulders；　thus　supposing　it　a　case　of
dislocation；　and　they　did　not　desist　until　they　gave　over　mistake　of
supposing　that　they　had　reduced　the　shoulder。　The　treatment；　in
these　cases；　is　similar　to　that　which　is　applicable　in　others　of　a
like　kind；　namely；　cerate；　compresses；　and　suitable　bandaging　with
linen　cloths。　The　projecting　part　must　be　pushed　down；　and　the　greater
number　of　compresses　are　to　be　placed　on　it；　and　most　compression　is
to　be　applied　at　that　part；　and　the　arm　being　fastened　to　the　side
is　to　be　kept　elevated；　for　thus　the　parts　which　had　been　torn　asunder
are　brought　into　closest　proximity　with　one　another。　All　this　should
be　well　known；　and　if　you　choose　you　may　prognosticate　safely　that
no　impediment；　small　or　great；　will　result　from　such　an　injury　at
the　shoulder；　only　there　will　be　a　deformity　in　the　place；　for　the
bone　cannot　be　properly　restored　to　its　natural　situation；　but　there
must　necessarily　be　more　or　less　tumefaction　in　the　upper　part。　For
neither　can　any　other　bone　be　made　exactly　as　it　was；　which　having
become　incorporated　with　another　bone；　and　having　grown　to　it　as　an
apophysis；　has　been　torn　from　its　natural　situation。　If　properly
bandaged；　the　acromion　becomes　free　of　pain　in　a　few　days。

　　14。　When　a　fractured　clavicle　is　fairly　broken　across　it　is　more
easily　treated；　but　when　broken　obliquely　it　is　more　difficult　to
manage。　Matters　are　different　in　these　cases　from　what　one　would
have　supposed；　for　a　bone　fairly　broken　across　can　be　more　easily
restored　to　its　natural　state；　and　with　proper　care　the　upper　part　may
be　brought　down　by　means　of　suitable　position　and　proper　bandaging；
and　even　if　not　properly　set；　the　projecting　part　of　the　bone　is　not
very　sharp。　But　in　oblique　fractures　the　case　is　similar　to　that　of
bones　which　have　been　torn　away；