on the articulations-第4章

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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；　as　formerly　described；　for　they　do
not　admit　of　being　restored　to　their　place；　and　the　prominence　of
the　bone　is　very　sharp。　For　the　most　part；　then；　it　should　be　known；
no　harm　results　to　the　shoulder　or　to　the　rest　of　the　body　from
fracture　of　the　clavicle；　unless　it　sphacelate；　and　this　rarely
happens。　A　deformity；　however；　may　arise　from　fracture　of　the
clavicle；　and　in　these　cases　it　is　very　great　at　first；　but　by　and
by　it　becomes　less。　A　fractured　clavicle；　like　all　other　spongy　bones；
gets　speedily　united；　for　all　such　bones　form　callus　in　a　short
time。　When；　then；　a　fracture　has　recently　taken　place；　the　patients
attach　much　importance　to　it；　as　supposing　the　mischief　greater　than
it　really　is；　and　the　physicians　bestow　great　pains　in　order　that　it
may　be　properly　bandaged；　but　in　a　little　time　the　patients；　having　no
pain；　nor　finding　any　impediment　to　their　walking　or　eating；　become
negligent；　and　the　physicians　finding　they　cannot　make　the　parts
look　well；　take　themselves　off；　and　are　not　sorry　at　the　neglect　of
the　patients；　and　in　the　meantime　the　callus　is　quickly　formed。　The
method　of　dressing　which　is　most　appropriate；　is　similar　to　that
used　in　ordinary　cases；　consisting　of　cerate；　compresses；　and
bandages；　and　it　should　be　most　especially　known　in　this　operation；
that　most　compresses　should　be　placed　on　the　projecting　bone；　and　that
the　greatest　pressure　should　be　made　there。　There　are　certain
physicians　who　make　a　show　of　superior　skill　by　binding　a　heavy
piece　of　lead　on　the　part　in　order　to　depress　the　projecting　bone；　but
this　mode　of　treatment　does　not　apply　to　the　clavicle；　for　it　is
impossible　to　depress　the　projecting　part　to　any　extent　worth
mentioning。　There　are　others　who；　knowing　the　fact　that　the　bandages
are　apt　to　slip　off；　and　that　they　do　not　keep　the　projecting　parts　in
their　place；　apply　compresses　and　bandages　like　the　others；　and　then
having　girt　the　patient　with　a　girdle；　where　it　is　usually　applied
with　most　effect；　they　make　a　heap　of　the　compresses　upon　of　the
compresses　upon　the　projecting　bone　when　they　apply　them；　and　having
fastened　the　head　of　the　bandage　to　the　girdle　in　front；　they　apply　it
so　as　to　bring　the　turns　of　it　into　the　line　of　the　clavicle；　carrying
them　to　the　back；　and　then　bringing　them　around　the　girdle　they
carry　them　to　the　fore　part　and　again　backward。　There　are　others　who
do　not　apply　the　bandage　round　the　girdle；　but　carry　the　rounds　of
it　by　the　perineum　and　anus；　and　along　the　spine；　so　as　to　compress
the　fracture。　To　an　inexperienced　person　these　methods　will　appear　not
far　from　natural；　but　when　tied；　they　will　be　found　of　no　service；　for
they　do　not　remain　firm　any　length　of　time；　even　if　the　patient　keep
his　bed；　although　in　this　position　they　answer　best；　and　yet　even　when
lying　in　bed；　should　he　bend　his　leg；　or　should　his　trunk　be　bent；　all
the　will　be　displaced；　and；　moreover；　the　bandaging　is　inconvenient；
in　as　much　as　the　anus　is　comprehended　by　it；　and　many　turns　of　the
bandage　are　crowded　there　in　a　narrow　space。　And　in　the　method　with
the　girdle；　the　girdle　cannot　be　so　firmly　girt　around；　but　that　the
turns　of　the　bandage　force　the　girdle　to　ascend；　and　hence　of
necessity　all　the　other　bandages　must　be　slackened。　He　would　seem　to
me　to　come　nearest　his　purpose；　although　after　all　he　effects　but
little；　who　would　take　a　few　turns　round　the　girdle；　few　turns　round
the　girdle；　but　would　use　the　bandage　principally　to　secure　the　former
bandaging；　for　in　this　manner　the　bandages　would　be　most　secure；　and
would　mutually　assist　one　another。　Every　thing　now　almost　has　been
said　which　applies　to　fracture　of　the　clavicle。　But　this　also　should
be　known；　that　in　fractures　of　the　clavicle；　it　is　the　part　attached
to　the　breast　which　is　uppermost；　and　that　the　piece　attached　to　the
acromion　is　the　lowermost。　The　cause　of　this　is；　that　for　the　most
part　the　breast　can　neither　be　depressed　nor　raised；　there　being　but　a
slight　movement　of　the　joint　at　the　breast；　for　the　sternum　is
connected　together　on　both　sides　with　the　spine。　The　clavicle　admits
of　most　motion　at　the　joint　of　the　shoulder；　and　this　arises　from
its　connection　with　the　acromion。　And；　moreover；　when　broken；　the　part
which　is　connected　with　the　sternum　flies　upward；　and　is　not　easily
forced　downward；　for　it　is　naturally　light；　and　there　is　more　room　for
it　above　than　below。　But　the　shoulder；　the　arm；　and　the　parts
connected　with　them；　are　easily　moved　from　the　sides　and　breast；
and；　on　that　account；　they　admit　of　being　considerably　elevated　and
depressed。　When；　therefore；　the　clavicle　is　broken；　the　fragment
attached　to　the　shoulder　inclines　downward；　for　it　inclines　much
more　readily　with　the　shoulder　and　arm　downward　than　upward。　Matters
being　as　I　have　stated；　they　act　imprudently　who　think　to　depress
the　projecting　end　of　the　bone。　But　it　is　clear　that　the　under　part
ought　to　be　brought　to　the　upper；　for　the　former　is　the　movable
part；　and　that　which　has　been　displaced　from　its　natural　position。
I