1. I am acquainted with one form in which the shoulder-joint is dislocated, namely, that into the armpit; I have never seen it take place upward nor outward; and yet I do not positively affirm whether it might be dislocated in these directions or not, although I have something which I might say on this subject. But neither have I ever seen what I considered to be a dislocation forward. Physicians, indeed, fancy that dislocation is very apt to occur forward, and they are more particularly deceived in those persons who have the fleshy parts about the joint and arm much emaciated; for, in all such cases, the head of the arm appears to protrude forward. And I in one case of this kind having said that there was no dislocation, exposed myself to censure from certain physicians and common people on that account, for they fancied that I alone was ignorant of what everybody else was acquainted with, and I could not convince them but with difficulty, that the matter was so. But if one will strip the point of the shoulder of the fleshy parts, and where the muscle (deltoid?) extends, and also lay bare the tendon that goes from the armpit and clavicle to the breast (pectoral muscle?), the head of the humerus will appear to protrude strongly forward, although not dislocated, for the head of the humerus naturally inclines forward, but the rest of the bone is turned outward. The humerus is connected obliquely with the cavity of the scapula, when the arm is stretched along the sides; but when the whole arm is stretched forward, then the head of the humerus is in a line with the cavity of the humerus, and no longer appears to protrude forward. And with regard to the variety we are now treating of, I have never seen a case of dislocation forward; and yet I do not speak decidedly respecting it, whether such a dislocation may take place or not. When, then, a dislocation into the armpit takes place, seeing it is of frequent occurrence, many persons know how to reduce it, for it is an easy thing to teach all the methods by which physicians effect the reductions, and the best manner of applying them. The strongest of those methods should be used when the difficulty of reduction is particularly great. The strongest is the method to be last described.
1. 1. ὤμου δὲ ἄρθρον ἕνα τρόπον οἶδα ὀλισθάνον, τὸν ἐς τὴν μασχάλην· ἄνω δὲ οὐδέποτε εἶδον, οὐδὲ ἐς τὸ ἔξω· οὐ μέντοι διισχυριείω ἔγωγε, εἰ ὀλισθάνοι ἂν, ἢ οὒ, καίπερ ἔχων περὶ αὐτοῦ ὅ τι λέγω. ἀτὰρ οὐδὲ ἐς τὸ ἔμπροσθεν οὐδέπω ὄπωπα, ὅ τι ἔδοξέ μοι ὠλισθηκέναι. τοῖσι μέντοι ἰητροῖσι δοκέει κάρτα ἐς τοὔμπροσθεν ὀλισθάνειν, καὶ μάλιστα ἐξαπατέονται ἐν τουτέοισιν, ὧν ἂν φθίσις καταλάβῃ τὰς σάρκας τὰς περὶ τὸ ἄρθρον τε καὶ τὸν βραχίονα· φαίνεται γὰρ ἐν τοῖσι τοιουτέοισι παντάπασιν ἡ κεφαλὴ τοῦ βραχίονος ἐξέχουσα ἐς τοὔμπροσθεν. καὶ ἔγωγέ ποτε τὸ τοιοῦτον οὐ φὰς ἐκπεπτωκέναι, ἤκουσα φλαύρως ὑπό τε τῶν ἰητρῶν, ὑπό τε τῶν δημοτέων, διὰ τοῦτο τὸ πρῆγμα· ἐδόκεον γὰρ αὐτοῖσιν ἠγνοηκέναι μοῦνος, οἱ δὲ ἄλλοι ἐγνωκέναι, καὶ οὐκ ἠδυνάμην αὐτοὺς ἀναγνῶσαι, εἰ μὴ μόλις, ὅτι τόδʼ ἐστὶ τοιόνδε· εἴ τις τοῦ βραχίονος ψιλώσειε μὲν τῶν σαρκέων τὴν ἐπωμίδα, ψιλώσειε δὲ ᾗ ὁ μῦς ἀνατείνει, ψιλώσειε δὲ τὸν τένοντα τὸν κατὰ τὴν μασχάλην καὶ τὴν κληῗδα πρὸς τὸ στῆθος ἔχοντα, φαίνοιτο ἂν ἡ κεφαλὴ τοῦ βραχίονος ἐς τοὔμπροσθεν ἐξέχουσα ἰσχυρῶς, καίπερ οὐκ ἐκπεπτωκυῖα· πέφυκε γὰρ ἐς τοὔμπροσθεν προπετὴς ἡ κεφαλὴ τοῦ βραχίονος· τὸ δʼ ἄλλο ὀστέον τοῦ βραχίονος ἐς τὸ ἔξω καμπύλον. Ὁμιλέει δὲ ὁ βραχίων τῷ κοίλῳ τῆς ὠμοπλάτης πλάγιος, ὅταν παρὰ τὰς πλευρὰς παρατεταμένος ἔῃ· ὅταν μέντοι ἐς τοὔμπροσθεν ἐκτανυσθῇ ἡ ξύμπασα χεὶρ, τότε ἡ κεφαλὴ τοῦ βραχίονος κατʼ ἴξιν τῆς ὠμοπλάτης τῷ κοίλῳ γίνεται, καὶ οὐκ ἔτι ἐξέχειν ἐς τοὔμπροσθεν φαίνεται. περὶ οὗ οὖν ὁ λόγος, οὐδέποτε εἶδον οὐδὲ ἐς τοὔμπροσθεν ἐκπεσόν· οὐ μὴν ἰσχυριείω γε οὐδὲ περὶ τούτου, εἰ μὴ ἐκπέσοι ἂν οὕτως, ἢ οὔ. ὅταν οὖν ἐκπέσῃ ὁ βραχίων ἐς τὴν μασχάλην, ἅτε πολλοῖσιν ἐκπίπτοντος, πολλοὶ ἐπίστανται ἐμβάλλειν· εὐπαίδευτον δέ ἐστι τὸ εἰδέναι πάντας τοὺς τρόπους, οἷσιν οἱ ἰητροὶ ἐμβάλλουσι, καὶ ὡς ἄν τις αὐτοῖσι τοῖσι τρόποισι τούτοισι κάλλιστα χρῷτο. χρέεσθαι δὲ χρὴ τῷ κρατίστῳ τῶν τρόπων, ἢν τὴν ἰσχυρονάτην ἀνάγκην ὁρᾷς· κράτιστος δὲ ὁ ὕστατος γεγραψόμενος.
2. Those who are subject to frequent dislocations at the shoulder-joint, are for the most part competent to effect the reduction themselves; for, having introduced the knuckles of the other hand into the armpit, they force the joint upward, and bring the elbow toward the breast. The physician might reduce it in the same manner, if having introduced his fingers into the armpit on the inside of the dislocated joint, he would force it from the ribs, pushing his own head against the acromion, in order to make counter-pressure, and with his knees applied to the patient’s elbow pushing the arm to the sides. It will be of advantage if the operator has strong hands, or the physician may do as directed with his head and hands, while another person brings the elbow toward the breast. Reduction of the shoulder may also be effected by carrying the fore-arm backward to the spine, and then with the one hand grasping it at the elbow, to bend the arm upward, and with the other to support it behind at the articulation. This mode of reduction, and the one formerly described, are not natural, and yet by rotating the bone of the joint, they force it to return.
2. 2. Ὅσοισι μὲν οὖν πυκινὰ ἐκπίπτει ὁ ὦμος, ἱκανοὶ ὡς ἐπὶ τὸ πλεῖστον αὐτοὶ σφίσιν αὐτοῖσιν ἐμβάλλειν εἰσίν· ἐνθέντες γὰρ τῆς ἑτέρης χειρὸς τοὺς κονδύλους ἐς τὴν μασχάλην, ἀναγκάζουσιν ἄνω τὸ ἄρθρον, τὸν δὲ ἀγκῶνα παράγουσιν ἐπὶ τὸ στῆθος. τὸν αὐτὸν δὲ τρόπον τοῦτον καὶ ὁ ἰητρὸς ἂν ἐμβάλλοι, εἰ αὐτὸς μὲν ὑπὸ τὴν μασχάλην ἐσωτέρω τοῦ ἄρθρου τοῦ ἐκπεπτωκότος ὑποτείνας τοὺς δακτύλους, ἀπαναγκάζοι ἀπὸ τῶν πλευρέων, ἐμβάλλων τὴν ἑωυτοῦ κεφαλὴν ἐς τὸ ἀκρώμιον, ἀντερείσιος ἕνεκα, τοῖσι δὲ γούνασι παρὰ τὸν ἀγκῶνα ἐς τὸν βραχίονα ἐμβάλλων, ἀντωθέοι πρὸς τὰς πλευράς· ξυμφέρει δὲ κρατερὰς τὰς χεῖρας ἔχειν τὸν ἐμβάλλοντα. ἢ αὐτὸς μὲν τῇσι χερσὶ καὶ τῇ κεφαλῇ οὕτω ποιοίη, ἄλλος δέ τις τὸν ἀγκῶνα παράγοι παρὰ τὸ στῆθος. ἐστὶ δὲ ἐμβολὴ ὤμου, καὶ ἐς τοὐπίσω ὑπερβάλλοντα τὸν πῆχυν ἐπὶ τὴν ῤάχιν, ἔπειτα τῇ μὲν ἑτέρῃ χειρὶ ἀνακλᾷν ἐς τὸ ἄνω τοῦ ἀγκῶνος ἐχόμενον, τῇ δὲ ἑτέρῃ παρὰ τὸ ἄρθρον ὄπισθεν ἐρείδειν. αὕτη ἡ ἐμβολὴ, καὶ ἡ πρόσθεν εἰρημένη, οὐ κατὰ φύσιν ἐοῦσαι, ὅμως ἀμφισφάλλουσαι τὸ ἄρθρον, ἀναγκάζουσιν ἐμπίπτειν.
3. Those who attempt to perform reduction with the heel, operate in a manner which is an approach to the natural. The patient must lie on the ground upon his back, while the person who is to effect the reduction is seated on the ground upon the side of the dislocation; then the operator, seizing with his hand the affected arm, is to pull it, while with his heel in the armpit he pushes in the contrary direction, the right heel being placed in the right armpit, and the left heel in the left armpit. But a round ball of a suitable size must be placed in the hollow of the armpit; the most convenient are very small and hard balls, formed from several pieces of leather sewed together. For without something of the kind the heel cannot reach to the head of the humerus, since, when the arm is stretched, the armpit becomes hollow, the tendons on both sides of the armpit making counter-contraction so as to oppose the reduction. But another person should be seated on the other side of the patient to hold the sound shoulder, so that the body may not be dragged along when the arm of the affected side is pulled; and then, when the ball is placed in the armpit, a supple piece of thong sufficiently broad is to be placed round it, and some person taking hold of its two ends is to seat himself above the patient’s head to made counter-extension, while at the same time he pushes with his foot against the bone at the top of the shoulder. The ball should be placed as much on the inside as possible, upon the ribs, and not upon the head of the humerus.
3. 3. οἱ δὲ τῇ πτέρνῃ πειρώμενοι ἐμβάλλειν, ἐγγύς τι τοῦ κατὰ φύσιν ἀναγκάζουσιν· χρὴ δὲ τὸν μὲν ἄνθρωπον χαμαὶ κατακλῖναι ὕπτιον, τὸν δὲ ἐμβάλλοντα χαμαὶ ἵζεσθαι ἐφʼ ὁκότερα ἂν τὸ ἄρθρον ἐκπεπτώκῃ· ἔπειτα λαβόμενον τῇσι χερσὶ τῇσιν ἑωυτέου τῆς χειρὸς τῆς σιναρῆς, κατατείνειν αὐτὴν, τὴν δὲ πτέρνην ἐς τὴν μασχάλην ἐμβάλλοντα ἀντωθέειν, τῇ μὲν δεξιῇ ἐς τὴν δεξιὴν, τῇ δὲ ἀριστερῇ ἐς τὴν ἀριστερήν. δεῖ δὲ ἐς τὸ κοῖλον τῆς μασχάλης ἐνθεῖναι στρογγύλον τι ἐναρμόσσον· ἐπιτηδειόταται δὲ αἱ πάνυ σμικραὶ σφαῖραι καὶ σκληραὶ, οἷαι ἐκ τῶν πολλῶν σκυτέων ῤάπτονται· ἢν γὰρ μή τι τοιοῦτον ἐγκέηται, οὐ δύναται ἡ πτέρνη ἐξικνέεσθαι πρὸς τὴν κεφαλὴν τοῦ βραχίονος· κατατεινομένης γὰρ τῆς χειρὸς, κοιλαίνεται ἡ μασχάλη· οἱ γὰρ τένοντες οἱ ἔνθεν καὶ ἔνθεν τῆς μασχάλης, ἀντισφίγγοντες, ἐναντίοι εἰσίν. χρὴ δέ τινα ἐπὶ θάτερα τοῦ κατατεινομένου καθήμενον κατέχειν κατὰ τὸν ὑγιέα ὦμον, ὡς μὴ περιέλκηται τὸ σῶμα, τῆς χειρὸς τῆς σιναρῆς ἐπὶ θάτερα τεινομένης· ἔπειτα ἱμάντος μαλθακοῦ πλάτος ἔχοντος ἱκανὸν, ὅταν ἡ σφαίρη ἐντεθῇ ἐς τὴν μασχάλην, περὶ τὴν σφαίρην περιβεβλημένου τοῦ ἱμάντος, καὶ κατέχοντος, λαβόμενον ἀμφοτερέων τῶν ἀρχέων τοῦ ἱμάντος, ἀντικατατείνειν τινὰ, ὑπὲρ κεφαλῆς τοῦ κατατεινομένου καθήμενον, τῷ ποδὶ προσβάντα πρὸς τοῦ ἀκρωμίου τὸ ὀστέον. ἡ δὲ σφαίρη ὡς ἐσωτάτω καὶ ὡς μάλιστα πρὸς τῶν πλευρέων κείσθω, καὶ μὴ ἐπὶ τῇ κεφαλῇ τοῦ βραχίονος.
4. There is another method of reduction performed by the shoulder of a person standing. The person operating in this way, who should be taller than the patient, is to take hold of his arm and place the sharp point of his own shoulder in the patient’s armpit, and push it in so that it may lodge there, and having for his object that the patient may be suspended at his back by the armpit, he must raise himself higher on this shoulder than the other; and he must bring the arm of the suspended patient as quickly as possible to his own breast. In this position he should shake the patient when he raises him up, in order that the rest of the body may be a counterpoise to the arm which is thus held. But if the patient be very light, a light child should be suspended behind along with him. These methods of reduction are all of easy application in the palestra, as they can all be performed without instruments, but they may also be used elsewhere.
4. 4. ἔστι δὲ καὶ ἄλλη ἐμβολὴ, ᾗ κατωμίζουσιν ἐς ὀρθόν· μείζω μέντοι εἶναι χρὴ τὸν κατωμίζοντα, διαλαβόντα δὲ τὴν χεῖρα, ὑποθεῖναι τὸν ὦμον τὸν ἑωυτοῦ ὑπὸ τὴν μασχάλην ὀξύν· κἄπειτα ὑποστρέψαι, ὡς ἂν ἐνίζηται ἕδρῃ, οὕτω στοχασάμενον ὅκως ἀμφὶ τὸν ὦμον τὸν ἑωυτοῦ κρεμάσαι τὸν ἄνθρωπον κατὰ τὴν μασχάλην· αὐτὸς δὲ ἑωυτὸν ὑψηλότερον ἐπὶ τοῦτον τὸν ὦμον ποιεέτω, ἢ ἐπὶ τὸν ἕτερον· τοῦ δὲ κρεμαμένου τὸν βραχίονα πρὸς τὸ ἑωυτοῦ στῆθος προσαναγκαζέτω ὡς τάχιστα· ἐν τούτῳ δὲ τῷ σχήματι προσανασειέτω, ὁκόταν μετεωρίσῃ τὸν ἄνθρωπον, ὡς ἀντιῤῥέποι τὸ ἄλλο σῶμα αὐτῷ, ἀντίον τοῦ βραχίονος τοῦ κατεχομένου· ἢν δὲ ἄγαν κοῦφος ἔῃ ὁ ἄνθρωπος, προσεπικρεμασθήτω τούτου ὄπισθέν τις κοῦφος παῖς. αὗται δὲ αἱ ἐμβολαὶ πᾶσαι κατὰ παλαίστρην εὔχρηστοί εἰσιν, ὅτι οὐδὲν ἀλλοίων ἀρμένων δέονται ἐπεισενεχθῆναι· χρήσαιτο δʼ ἄν τις καὶ ἄλλοθι.
5. Those who accomplish the reduction by forcibly bending it round a pestle, operate in a manner which is nearly natural. But the pestle should be wrapped in a soft shawl (for thus it will be less slippery), and it should be forced between the ribs and the head of the humerus. And if the pestle be short, the patient should be seated upon something, that his arm can with difficulty pass above the pestle. But for the most part the pestle should be longer, so that the patient when standing may be almost suspended upon the piece of wood. And then the arm and forearm should be stretched along the pestle, whilst some person secures the opposite side of the body by throwing his arms round the neck, near the clavicle.
5. 5. ἀτὰρ καὶ οἱ περὶ τὸ ὕπερον ἀναγκάζοντες, ἐγγύς τι τοῦ κατὰ φύσιν ἐμβάλλουσιν· χρὴ δὲ τὸ μὲν ὕπερον κατειλίχθαι ταινίῃ τινὶ μαλθακῇ (ἧσσον γὰρ ἂν ὑπολισθάνοι), ὑπηναγκάσθαι δὲ μεσηγὺ τῶν πλευρέων καὶ τῆς κεφαλῆς τοῦ βραχίονος· καὶ ἢν μὲν βραχὺ ἔῃ τὸ ὕπερον, καθῆσθαι χρὴ τὸν ἄνθρωπον ἐπί τινος, ὡς μόλις τὸν βραχίονα περιβάλλειν δύνηται περὶ τὸ ὕπερον· μάλιστα δὲ ἔστω μακρότερον τὸ ὕπερον, ὡς ἂν ἑστεὼς ὁ ἄνθρωπος κρέμασθαι μικροῦ δέῃ ἀμφὶ τῷ ξύλῳ. κἄπειτα ὁ μὲν βραχίων καὶ ὁ πῆχυς παρατεταμένος παρὰ τὸ ὕπερον ἔστω, τὸ δὲ ἐπὶ θάτερα τοῦ σώματος καταταγκαζέτω τις, περιβάλλων κατὰ τὸν αὐχένα παρὰ τὴν κληῗδα τὰς χεῖρας. αὕτη ἡ ἐμβολὴ κατὰ φύσιν ἐπιεικέως ἐστὶ, καὶ ἐμβάλλειν δύναται, ἢν χρηστῶς σκευάσωνται αὐτήν.
6. But the method with a ladder is another of the same kind, and still better, since by it the body can be more safely counterpoised on this side; and that, while in the method which the piece of wood resembling a pestle, there is danger of the body tumbling to either side. But some round thing should be tied upon the step of the ladder which may be fitted to the armpit, whereby the head of the bone may be forced into its natural place.
6. 6. ἀτὰρ καὶ ἡ διὰ τοῦ κλιμακίου ἑτέρη τις τοιαύτη, καὶ ἔτι βελτίων, ὅτι ἀσφαλεστέρως ἂν τὸ σῶμα, τὸ μὲν τῇ, τὸ δὲ τῇ, ἀντισηκωθείη μετεωρισθέν· περὶ γὰρ τὸ ὑπεροειδὲς ὁ ὦμος ἢν καὶ καταπεπήγῃ, περισφάλλεσθαι τὸ σῶμα κίνδυνος ἢ τῇ, ἢ τῇ· χρὴ μέντοι, καὶ ἐπὶ τῷ κλιμακτῆρι ἐπιδεδέσθαι τι ἄνωθεν στρογγύλον ἐναρμόσσον ἐς τὸ κοῖλον τῆς μασχάλης, ὃ προσδιαναγκάσει τὴν κεφαλὴν τοῦ βραχίονος ἐς τὴν φύσιν ἀπιέναι.
7. The following, however, is the strongest of all the methods of reduction. We must get a piece of wood, five, or at least four inches broad, two inches in thickness, or still thinner, and two cubits in length, or a little less; and its extremity at one end should be rounded, and made very narrow and very slender there, and it should have a slightly projecting edge (ambe) on its round extremity, not on the part that is to be applied to the side, but to the head of the humerus, so that it may be adjusted in the armpit at the sides under the head of the humerus; and a piece of soft shawl or cloth should be glued to the end of the piece of wood, so as to give the less pain upon pressure. Then having pushed the head of this piece of wood as far inward as possible between the ribs and the head of the humerus, the whole arm is to be stretched along this piece of wood, and is to be bound round at the arm, the fore-arm, and the wrist, so that it may be particularly well secured; but great pains should be taken that the extremity of this piece of wood should be introduced as far as possible into the armpit, and that it is carried past the head of the humerus. Then a cross-beam is to be securely fastened between two pillars, and afterward the arm with the piece of wood attached to it is to be brought over this cross-beam, so that the arm may be on the one side of it and the body on the other, and the cross-beam in the armpit; and then the arm with the piece of wood is to be forced down on the one side of the cross-beam, and the rest of the body on the other. The cross-beam is to be bound so high that the rest of the body may be raised upon tip-toes. This is by far the most powerful method of effecting reduction of the shoulder; for one thus operates with the lever upon the most correct principles, provided only the piece of wood be placed as much as possible within the head of the humerus, and thus also the counter-balancing weights will be most properly adjusted, and safely applied to the bone of the arm. Wherefore recent cases in this way may be reduced more quickly than could be believed, before even extension would appear to be applied; and this is the only mode of reduction capable of replacing old dislocations, and this it will effect, unless flesh has already filled up the (glenoid) cavity, and the head of the humerus has formed a socket for itself in the place to which it has been displaced; and even in such an old case of dislocation, it appears to me that we could effect reduction (for what object would a lever power properly applied not it move?), but it would not remain in its place, but would be again displaced as formerly. The same thing may be effected by means of the ladder, by preparing it in the same manner. If the dislocation be recent, a large Thessalian chair may be sufficient to accomplish this purpose; the wood, however, should be dressed up as described before; but the patient should be seated sideways on the chair, and then the arm, with the piece of wood attached to it, is to be brought over the back of the chair, and force is to be applied to the arm, with the wood on the one side, and the body on the other side. The same means may be applied with a double door. One should always use what happens to be at hand.
7. 7. κρατίστη μέντοι πασέων τῶν ἐμβολέων ἡ τοιήδε· ξύλον χρὴ εἶναι, πλάτος μὲν ὡς πενταδάκτυλον, ἢ τετραδάκτυλον τὸ ἐπίπαν, πάχος δὲ ὡς διδάκτυλον, ἢ καὶ λεπτότερον, μῆκος δὲ δίπηχυ, ἢ ὀλίγῳ ἔλασσον· ἔστω δὲ ἐπὶ θάτερα τὸ ἄκρον περιφερὲς καὶ στενότατον ταύτῃ καὶ λεπτότατον· ἄμβην δὲ ἐχέτω, σμικρὸν ὑπερέχουσαν, ἐπὶ τῷ ὑστάτῳ τοῦ περιφερέος, ἐν τῷ μέρεϊ, μὴ τῷ πρὸς τὰς πλευρὰς, ἀλλὰ τῷ πρὸς τὴν κεφαλὴν τοῦ βραχίονος ἔχοντι, ὡς ὑφαρμόσειε τῇ μασχάλῃ παρὰ τὰς πλευρὰς ὑπὸ τὴν κεφαλὴν τοῦ βραχίονος ὑποτιθέμενον· ὀθονίῳ δὲ ἢ ταινίῃ μαλθακῇ κατακεκολλήσθω ἄκρον τὸ ξύλον, ὅκως προσηνέστερον ἔῃ. ἔπειτα χρὴ ὑπώσαντα τὴν κεφαλὴν τοῦ ξύλου ὑπὸ τὴν μασχάλην ὡς ἐσωτάτω μεσηγὺ τῶν πλευρέων καὶ τῆς κεφαλῆς τοῦ βραχίονος, τὴν δὲ ὅλην χεῖρα πρὸς τὸ ξύλον κατατείναντα, προσκαταδῆσαι κατά τε τὸν βραχίονα, κατά τε τὸν πῆχυν, κατά τε τὸν καρπὸν τῆς χειρὸς, ὡς ἂν ἀτρεμέῃ ὅτι μάλιστα· περὶ παντὸς δὲ χρὴ ποιέεσθαι, ὅκως τὸ ἄκρον τοῦ ξύλου ὡς ἐσωτάτω τῆς μασχάλης ἔσται, ὑπερβεβηκὸς τὴν κεφαλὴν τοῦ βραχίονος. ἔπειτα χρὴ μεσηγὺ δύο στύλων στρωτῆρα πλάγιον εὖ προσδῆσαι, ἔπειτα ὑπερενεγκεῖν τὴν χεῖρα ξὺν τῷ ξύλῳ ὑπὲρ τοῦ στρωτῆρος, ὅκως ἡ μὲν χεὶρ ἐπὶ θάτερα ἔῃ, ἐπὶ θάτερα δὲ τὸ σῶμα, κατὰ δὲ τὴν μασχάλην ὁ στρωτήρ· κἄπειτα ἐπὶ μὲν θάτερα τὴν χεῖρα καταναγκάζειν ξὺν τῷ ξύλῳ περὶ τὸν στρωτῆρα, ἐπὶ θάτερα δὲ τὸ ἄλλο σῶμα. ὕψος δὲ ἔχων ὁ στρωτὴρ προσδεδέσθω, ὥστε μετέωρον τὸ ἄλλο σῶμα εἶναι ἐπʼ ἄκρων τῶν ποδῶν. οὗτος ὁ τρόπος παραπολὺ κράτιστος ἐμβολῆς ὤμου· δικαιότατα μὲν γὰρ μοχλεύει, ἢν μοῦνον ἐσωτέρω ἔῃ τὸ ξύλον τῆς κεφαλῆς τοῦ βραχίονος· δικαιόταται δὲ αἱ ἀντιῤῥοπαὶ, ἀσφαλέες δὲ τῷ ὀστέῳ τοῦ βραχίονος. τὰ μὲν οὖν νεαρὰ ἐμπίπτει θᾶσσον, ἢ ὡς ἄν τις οἴοιτο, πρὶν ἢ καὶ κατατετάσθαι δοκέειν· ἀτὰρ καὶ τὰ παλαιὰ μούνη αὕτη τῶν ἐμβολέων οἵη τε ἐμβιβάσαι, ἢν μὴ ἤδη ὑπὸ χρόνου σὰρξ μὲν ἐπεληλύθῃ ἐπὶ τὴν κοτύλην, ἡ δὲ κεφαλὴ τοῦ βραχίονος ἤδη τρίβον ἑωυτῇ πεποιημένη ἔῃ ἐν τῷ χωρίῳ, ἵνα ἐξεκλίθη· οὐ μὴν ἀλλʼ ἐμβάλλειν γάρ μοι δοκέει καὶ οὕτω πεπαλαιωμένον ἔκπτωμα τοῦ βραχίονος (τί γὰρ ἂν δικαίη μόχλευσις οὐχὶ κινήσειε);, μένειν μέντοι οὐκ ἄν μοι δοκέοι κατὰ χώρην, ἀλλʼ ὀλισθάνοι ἂν ὡς τὸ ἔθος. τὸ αὐτὸ δὲ ποιέει καὶ περὶ κλιμακτῆρα καταναγκάζειν, τοῦτον τὸν τρόπον σκευάσαντα. πάνυ μὴν ἱκανῶς ἔχει, καὶ περὶ μέγα ἕδος θεσσαλικὸν ἀναγκάζειν, ἢν νεαρὸν ἔῃ τὸ ὀλίσθημα· ἐσκευάσθαι μέντοι χρὴ τὸ ξύλον οὕτως, ὥσπερ εἴρηται· ἀτὰρ τὸν ἄνθρωπον καθίσαι πλάγιον ἐπὶ τῷ δίφρῳ· κἄπειτα τὸν βραχίονα ξὺν τῷ ξύλῳ ὑπερβάλλειν ὑπὲρ τοῦ ἀνακλισμοῦ, καὶ ἐπὶ μὲν θάτερα τὸ σῶμα καταναγκάζειν, ἐπὶ δὲ θάτερα τὸν βραχίονα σὺν τῷ ξύλῳ. τὸ αὐτὸ δὲ ποιέει καὶ ὑπὲρ δίκλειδος θύρης ἀναγκάζειν. χρέεσθαι δὲ χρὴ αἰεὶ τούτοισιν, ἃ ἂν τύχῃ παρεόντα.
8. Wherefore it should be known that one constitution differs much from another as to the facility with which dislocations in them may be reduced, and one articular cavity differs much from another, the one being so constructed that the bone readily leaps out and another less so; but the greatest difference regards the binding together of the parts by the nerves (ligaments?) which are slack in some and tight in others. For the humidity in the joints of men is connected with the state of the ligaments, when they are slack and yielding; for you may see many people who are so humid (flabby?) that when they choose they can disarticulate their joints without pain, and reduce them in like manner. The habit of the body also occasions a certain difference, for in those who are in a state of embonpoint and fleshy the joint is rarely dislocated, but is more difficult to reduce; but when they are more attenuated and leaner than usual, then they are subject to dislocations which are more easily reduced. And the following observation is a proof that matters are so; for in cattle the thighs are most apt to be dislocated at the hip-joint, when they are most particularly lean, which they are at the end of winter, at which time then they are particularly subject to dislocations (if I may be allowed to make such an observation while treating of a medical subject); and therefore Homer has well remarked, that of all beasts oxen suffer the most at that season, and especially those employed at the plow as being worked in the winter season. In them, therefore, dislocations happen most frequently, as being at that time most particularly reduced in flesh. And other cattle can crop the grass when it is short, but the ox cannot do so until it becomes long; for, in the others, the projection of the lip is slender, and so is the upper lip, but in the ox the projection of the lip is thick, and the upper jaw is thick and obtuse, and therefore they are incapable of seizing short herbs. But the solidungula as having prominent teeth in both their front jaws, can crop the grass and grasp it with their teeth while short, and delight more in short grass than in rank; for, in general, short grass is better and more substantial than rank, as having not yet given out its fructification. Wherefore the poet has the following line: “As when to horned cattle dear the vernal season comes,” because rank grass appears to be most sought after by them. But otherwise in the ox, this joint is slacker than in other animals, and, therefore, this animal drags his foot in walking more than any other, and especially when lank and old. For all these reasons the ox is most particularly subject to dislocations; and I have made the more observations respecting him, as they confirm all that was said before on this subject. With regard, then, to the matter on hand, I say that dislocations occur more readily, and are more speedily reduced in those who are lean than in those who are fleshy; and in those who are humid and lank there is less inflammation than in such as are dry and fleshy, and they are less compactly knit hereafter, and there is more mucosity than usual in cases not attended with inflammation, and hence the joints are more liable to luxations; for, in the main, the articulations are more subject to mucosities in those who are lean than in those who are fleshy; and the flesh of lean persons who have not been reduced by a proper course of discipline abounds more with mucosity than that of fat persons. But in those cases in which the mucosity is accompanied with inflammation, the inflammation binds (braces?) the joint, and hence those who have small collections of mucosities are not very subject to dislocations, which they would be if the mucosity had not been accompanied with more or less inflammation.
8. 8. εἰδέναι μὲν οὖν χρὴ, ὅτι φύσιες φυσίων μέγα διαφέρουσιν ἐς τὸ ῤηϊδίως ἐμπίπτειν τὰ ἐκπίπτοντα· διενέγκοι μὲν γὰρ ἄν τι κα κοτύλη κοτύλης, ἡ μὲν εὐυπέρβατος ἐοῦσα, ἡ δὲ ἧσσον· πλεῖστον δὲ διαφέρει καὶ τῶν νεύρων ὁ σύνδεσμος, τοῖσι μὲν ἐπιδόσιας ἔχων, τοῖσι δὲ ξυντεταμένος ἐών. καὶ γὰρ ἡ ὑγρότης τοῖσιν ἀνθρώποισι γίνεται ἡ ἐκ τῶν ἄρθρων, διὰ τῶν νεύρων τὴν ἀπάρτισιν, ἢν χαλαρά τε ἔῃ φύσει, καὶ τὰς ἐπιτάσιας εὐφόρως φέρῃ· συχνοὺς γὰρ ἄν τις ἴδοι, οἳ οὕτως ὑγροί εἰσιν, ὥστε, ὁπόταν ἐθέλωσι, τότε αὐτοῖσι τὰ ἄρθρα ἐξίσταται ἀνωδύνως, καὶ καθίσταται ἀνωδύνως. διαφέρει μέντοι τι καὶ σχέσις τοῦ σώματος· τοῖσι μὲν γὰρ εὖ ἔχουσι τὸ γυῖον καὶ σεσαρκωμένοισιν ἐκπίπτει τε ἧσσον, ἐμπίπτει τε χαλεπώτερον· ὅταν δὲ αὐτοὶ σφέων αὐτῶν λεπτότεροι καὶ ἀσαρκότεροι ἔωσι, τότε ἐκπίπτει τε μᾶλλον, ἐμπίπτει τε ῤᾷον. σημήϊον δὲ, ὅτι ταῦτα οὕτως ἔχει, καὶ τόδε· τοῖσι γὰρ βουσὶ τότε ἐκπίπτουσι μᾶλλον οἱ μηροὶ ἐκ τῆς κοτύλης, ἡνίκα ἂν αὐτοὶ σφέων αὐτῶν λεπτότατοι ἔωσιν· γίνονται δὲ βόες λεπτότατοι, τοῦ χειμῶνος τελευτῶντος· τότε οὖν καὶ ἐξαρθρέουσι μάλιστα, εἰ δή τι καὶ τοιοῦτο δεῖ ἐν ἰητρικῇ γράψαι· δεῖ δέ· καλῶς γὰρ Ὅμηρος καταμεμαθήκει, ὅτι πάντων τῶν προβάτων βόες μάλιστα πονέουσι ταύτην τὴν ὥρην, καὶ βοῶν οἱ ἀρόται, ὅτι κατὰ τὸν χειμῶνα ἐργάζονται. τούτοισι τοίνυν ἐκπίπτει μάλιστα· οὗτοι γὰρ μάλιστα λεπτύνονται. τὰ μὲν γὰρ ἄλλα βοσκήματα δύναται βραχείην τὴν ποίην βόσκεσθαι· βοῦς δὲ οὐ μάλα, πρὶν βαθεῖα γένηται· τοῖσι μὲν γὰρ ἄλλοισίν ἐστι λεπτὴ ἡ προβολὴ τοῦ χείλεος, λεπτὴ δὲ ἡ ἄνω γνάθος· βοϊ δὲ παχείη μὲν ἡ προβολὴ τοῦ χείλεος, παχείη δὲ καὶ ἀμβλεῖα ἡ ἄνω γνάθος· διὰ ταῦτα ὑποβάλλειν ὑπὸ τὰς βραχείας ποίας οὐ δύναται. τά τε αὖ μώνυχα τῶν ζώων, ἅτε ἀμφόδοντα ἐόντα, δύναται μὲν σαρκάζειν, δύναται δὲ ὑπὸ τὴν βραχείην ποίην ὑποβάλλειν τοὺς ὀδόντας, καὶ ἥδεται τῇ οὕτως ἐχούσῃ ποίῃ μᾶλλον, ἢ τῇ βαθείῃ· καὶ γὰρ τὸ ἐπίπαν ἀμείνων καὶ στερεωτέρη ἡ βραχείη ποίη τῆς βαθείης, ποτὶ καὶ πρὶν ἐκκαρπεῖν τὴν βαθείην. διὰ τοῦτο οὖν ἐποίησεν ὧδε τάδε τὰ ἔπη· [Ὡς δʼ ὁπότʼ ἀσπάσιον ἔαρ ἤλυθε βουσὶν ἕλιξιν], ὅτι ἀσμενωτάτη αὐτοῖσιν ἡ βαθείη ποίη φαίνεται. ἀτὰρ καὶ ἄλλως ὁ βοὺς χαλαρὸν φύσει τὸ ἄρθρον τοῦτο ἔχει μᾶλλον τῶν ἄλλων ζώων· διὰ τοῦτο καὶ εἰλίπουν ἐστὶ μᾶλλον τῶν ἄλλων ζώων, καὶ μάλιστα ὅταν λεπτὸν καὶ γηραλέον ἔῃ. διὰ ταῦτα πάντα καὶ ἐκπίπτει βοϊ μάλιστα· πλείω δὲ γέγραπται περὶ αὐτέου, ὅτι πάντων τῶν προειρημένων ταῦτα μαρτύριά ἐστιν. περὶ οὗ οὖν ὁ λόγος, τοῖσιν ἀσάρκοισι μᾶλλον ἐκπίπτει, καὶ θᾶσσον ἐμπίπτει, ἢ τοῖσι σεσαρκωμένοισιν· καὶ ἧσσον ἐπιφλεγμαίνει τοῖσιν ὑγροῖσιν καὶ τοῖσιν ἀσάρκοισιν, ἢ τοῖσι σκελιφροῖσι καὶ σεσαρκωμένοισιν, καὶ ἧσσόν γε δέδεται ἐς τὸν ἔπειτα χρόνον· ἀτὰρ καὶ ἡ μύξα πλείων ὑπείη τοῦ μετρίου μὴ ξὺν φλεγμονῇ, καὶ οὕτως ἂν ὀλισθηρὸν εἴη· μυξωδέστερα γὰρ τοὐπίπαν τὰ ἄρθρα τοῖσιν ἀσάρκοισιν, ἢ τοῖσι σεσαρκωμένοισίν ἐστιν· καὶ γὰρ αὗται αἱ σάρκες τῶν μὴ ἀπὸ τέχνης ὀρθῶς λελιμαγχημένων, αἱ τῶν λεπτῶν, μυξωδέστεραί εἰσιν, ἢ αἱ τῶν παχέων. Ὅσοισι μέντοι ξὺν φλεγμονῇ μύξα ὑπογίνεται, ἡ φλεγμονὴ δήσασα ἔχει τὸ ἄρθρον· διὰ τοῦτο οὐ μάλα ἐκπίπτει τὰ ὑπόμυξα, ἐκπίπτοντα ἂν, εἰ μή τι ἢ πλέον, ἢ ἔλασσον φλεγμονῆς ὑπεγένετο.
9. In cases of dislocation those persons who are not attacked with inflammation of the surrounding parts, can use the shoulder immediately without pain, and do not think it necessary to take any precautions with themselves; it is therefore the business of the physician to warn them beforehand that dislocation is more likely to return in such cases than when the tendons have been inflamed. This remark applies to all the articulations, but particularly to those of the shoulder and knee, for these are the joints most subject to luxations. But those who have inflammation of the ligaments cannot use the shoulder, for the pain and the tension induced by the inflammation prevent them. Such cases are to be treated with cerate, compresses, and plenty of bandages; but a ball of soft clean wool is to be introduced into the armpit, to fill up the hollow of it, that it may be a support to the bandaging, and maintain the joint in situ. The arm, in general, should be inclined upward as much as possible, for thus it will be kept at the greatest possible distance from the place at which the head of the humerus escaped. And when you bandage the shoulder you must fasten the arms to the sides with a band, which is to be carried round the body. The shoulder should be rubbed gently and softly. The physician ought to be acquainted with many things, and among others with friction; for from the same name the same results are not always obtained; for friction could brace a joint when unseasonably relaxed, and relax it when unseasonably hard; but we will define what we know respecting friction in another place. The shoulder, then, in such a state, should be rubbed with soft hands; and, moreover, in a gentle manner, and the joint should be moved about, but not roughly, so as to excite pain. Things get restored sometimes in a greater space of time, and sometimes in a smaller.
9. 9. οἷσι μὲν οὖν, ὅταν ἐμπέσῃ τὸ ἄρθρον, μὴ ἐπιφλεγμαίνει τὰ περιέχοντα, χρῆσθαί τε ἀνωδύνως αὐτίκα τῷ ὤμῳ δύνανται, οὗτοι μὲν οὐδὲν νομίζουσι δεῖν ἑωυτῶν ἐπιμελέεσθαι· ἰητροῦ μήν ἐστι καταμαντεύσασθαι τῶν τοιούτων· τοῖσι τοιούτοισι γὰρ ἐκπίπτει καὶ αὖθις μᾶλλον, ἢ οἷσιν ἂν ἐπιφλεγμήνῃ τὰ νεῦρα. τοῦτο κατὰ πάντα τὰ ἄρθρα οὕτως ἔχει, καὶ μάλιστα κατʼ ὦμον καὶ κατὰ γόνυ· μάλιστα γὰρ οὖν ὀλισθάνει ταῦτα. οἷσι δʼ ἂν ἐπιφλεγμήνῃ τὰ νεῦρα, οὐ δύνανται χρέεσθαι τῷ ὤμῳ· κωλύει γὰρ ἡ ὀδύνη καὶ ἡ ξύντασις τῆς φλεγμονῆς. τοὺς οὖν τοιούτους ἰῆσθαι χρὴ κηρωτῇ καὶ σπλήνεσι καὶ ὀθονίοισι πολλοῖσιν ἐπιδέοντα· ὑποτιθέναι δὲ ἐς τὴν μασχάλην εἴριον μαλθακὸν, καθαρὸν ξυνειλίσσοντα, ἐκπλήρωμα τοῦ κοίλου ποιέοντα, ἵνα ἀντιστήριγμα μὲν τῇ ἐπιδέσει ἔῃ, ἀνακωχέῃ δὲ τὸ ἄρθρον· τὸν δὲ βραχίονα ἐς τὸ ἄνω ῤέποντα ἴσχειν χρὴ τὰ πλεῖστα· οὕτω γὰρ ἂν ἑκαστάτω εἴη τοῦ χωρίου, ἐς ὃ ὤλισθεν ἡ κεφαλὴ τοῦ ὤμου. χρὴ δὲ, ὅταν ἐπιδησῃς τὸν ὦμον, ἔπειτα προσκαταδεῖν τὸν βραχίονα πρὸς τὰς πλευρὰς ταινίῃ τινὶ, κύκλῳ περὶ τὸ σῶμα περιβάλλοντα. χρὴ δὲ καὶ ἀνατρίβειν τὸν ὦμον ἡσυχαίως καὶ λιπαρῶς. πολλῶν δὲ ἔμπειρον δεῖ εἶναι τὸν ἰητρὸν, ἀτὰρ δὴ καὶ ἀνατρίψιος· ἀπὸ γὰρ τοῦ αὐτέου ὀνόματος οὐ τωὐτὸ ἀποβαίνει· καὶ γὰρ ἂν δήσειεν ἄρθρον ἀνάτριψις, χαλαρώτερον τοῦ καιροῦ ἐὸν, καὶ λύσειεν ἄρθρον, σκληρότερον τοῦ καιροῦ ἐόν· ἀλλὰ διοριεῖται ἡμῖν περὶ ἀνατρίψιος ἐν ἄλλῳ λόγῳ. τὸν γοῦν τοιοῦτον ὦμον μαλθακῇσι ξυμφέρει τῇσι χερσὶν ἀνατρίβειν, καὶ ἄλλως πρηέως· τὸ δὲ ἄρθρον διακινέειν μὴ βίῃ, ἀλλὰ τοσοῦτον, ὅσον ἀνωδύνως κινῆσαι. καθίσταται δὲ πάντα, τὰ μὲν ἐν πλείονι χρόνῳ, τὰ δʼ ἐν ἐλάσσονι.
10. A dislocation may be recognized by the following symptoms:—Since the parts of a man’s body are proportionate to one another, as the arms and the legs, the sound should always be compared with the unsound, and the unsound with the sound, not paying regard to the joints of other individuals (for one person’s joints are more prominent than another’s), but looking to those of the patient, to ascertain whether the sound joint be unlike the unsound. This is a proper rule, and yet it may lead to much error; and on this account it is not sufficient to know this art in theory, but also by actual practice; for many persons from pain, or from any other cause, when their joints are not dislocated, cannot put the parts into the same positions as the sound body can be put into; one ought therefore to know and be acquainted beforehand with such an attitude. But in a dislocated joint the head of the humerus appears lying much more in the armpit than it is in the sound joint; and also, above, at the top of the shoulder, the part appears hollow, and the acromion is prominent, owing to the bone of the joint having sunk into the part below; there is a source of error in this case also, as will be described afterward, for it deserves to be described; and also, the elbow of the dislocated arm is farther removed from the ribs than that of the other; but by using force it may be approximated, though with considerable pain; and also they cannot, with the elbow extended, raise the arm to the ear, as they can the sound arm, nor move it about as formerly in this direction and that. These, then, are the symptoms of dislocation at the shoulder. The methods of reduction and the treatment are as described.
10. 10. γινώσκειν δὲ, εἰ ἐκπέπτωκεν ὁ βραχίων, τοισίδε χρὴ τοῖσι σημείοισιν· τοῦτο μὲν, ἐπειδὴ δίκαιον ἔχουσι τὸ σῶμα οἱ ἄνθρωποι, καὶ τὰς χεῖρας, καὶ τὰ σκέλεα, παραδείγματι χρέεσθαι δεῖ τῷ ὑγιέϊ πρὸς τὸ μὴ ὑγιὲς, καὶ τῷ μὴ ὑγιεῖ πρὸς τὸ ὑγιὲς, μὴ τὰ ἀλλότρια ἄρθρα καθορῶντα (ἄλλοι γὰρ ἄλλων μᾶλλον ἔξαρθροι πεφύκασιν), ἀλλὰ τὰ αὐτοῦ τοῦ κάμνοντος, ἢν ἀνόμοιον ἔῃ τὸ ὑγιὲς τῷ κάμνοντι. καὶ τοῦτο εἴρηται μὲν ὀρθῶς, παραξύνεσιν δὲ ἔχει πάνυ πολλήν· διὰ τὰ τοιαῦτα, καὶ οὐκ ἀρκέει μοῦνον λόγῳ εἰδέναι τὴν τέχνην ταύτην, ἀλλὰ καὶ ὁμιλίῃ ὁμιλέειν· πολλοὶ γὰρ ὑπὸ ὀδύνης, ἢ καὶ ὑπʼ ἀλλοίης προφάσιος, οὐκ ἐξεστεώτων αὐτέοισι τῶν ἄρθρων, ὅμως οὐ δύνανται ἐς τὰ ὅμοια σχήματα καθίστασθαι ἐς οἷά περ τὸ ὑγιαῖνον σῶμα σχηματίζεται· προσξυνιέναι μὲν οὖν, καὶ ἐννοεῖν καὶ τὸ τοιόνδε σχῆμα χρή. ἀτὰρ καὶ ἐν τῇ μασχάλῃ ἡ κεφαλὴ τοῦ βραχίονος φαίνεται ἐγκειμένη πολλῷ μᾶλλον τοῦ ἐκπεπτωκότος ἢ τοῦ ὑγιέος· τοῦτο δὲ, ἄνωθεν κατὰ τὴν ἐπωμίδα κοῖλον φαίνεται τὸ χωρίον, καὶ τὸ τοῦ ἀκρωμίου ὀστέον ἐξέχον φαίνεται, ἅτε ὑποδεδυκότος τοῦ ἄρθρου ἐς τὸ κάτω χωρίον· παραξύνεσιν μὴν καὶ ἐν τούτῳ ἔχει τινὰ, ἀλλʼ ὕστερον περὶ αὐτοῦ γεγράψεται, ἄξιον γὰρ γραφῆς ἐστιν· τοῦτο δὲ, τοῦ ἐκπεπτωκότος ὁ ἀγκὼν φαίνεται ἀφεστεὼς μᾶλλον ἀπὸ τῶν πλευρέων, ἢ τοῦ ἑτέρου· εἰ μέντοι τις προσαναγκάζοι, προσάγεται μὲν, ἐπιπόνως δέ· τοῦτο δὲ, ἄνω τὴν χεῖρα ἆραι εὐθεῖαν παρὰ τὸ οὖς, ἐκτεταμένου τοῦ ἀγκῶνος, οὐ μάλα δύνανται, ὥσπερ τὴν ὑγιέα, οὐδὲ παράγειν ἔνθα καὶ ἔνθα ὁμοίως. τά τε οὖν σημήϊα ταῦτά ἐστιν ὤμου ἐκπεπτωκότος· αἵ τε ἐμβολαὶ αἱ γεγραμμέναι, αἵ τε ἰητρεῖαι αὗται.
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.
11. 11. ἐπάξιον δὲ τὸ μάθημα, ὡς χρὴ ἰητρεύειν τοὺς πυκνὰ ἐκπίπτοντας ὤμους· πολλοὶ μὲν γὰρ ἤδη ἀγωνίης ἐκωλύθησανδιὰ ταύτην τὴν ξυμφορὴν, τἄλλα πάντα ἀξιόχρεοι ἐόντες· πολλοὶ δὲ ἐν πολεμικοῖσιν ἀχρήϊοι ἐγένοντο, καὶ διεφθάρησαν διὰ ταύτην τὴν ξυμφορήν· ἅμα δὲ ἐπάξιον καὶ διὰ τοῦτο, ὅτι οὐδένα οἶδα ὀρθῶς ἰητρεύοντα, ἀλλὰ τοὺς μὲν μηδὲ ἐγχειρέοντας, τοὺς δὲ τἀναντία τοῦ ξυμφέροντος φρονέοντάς τε καὶ ποιέοντας. συχνοὶ γὰρ ἤδη ἰητροὶ ἔκαυσαν ὤμους ἐκπίπτοντας, κατά τε τὴν ἐπωμίδα, κατά τε τὸ ἔμπροσθεν, ᾗ ἡ κεφαλὴ τοῦ βραχίονος ἐξογκέει, κατά τε τοὔπισθεν ὀλίγον τῆς ἐπωμίδος· αὗται οὖν αἱ καύσιες, εἰ μὲν ἐς τὸ ἄνω ἐξέπιπτεν ὁ βραχίων, ἢ ἐς τοὔμπροσθεν, ἢ ἐς τοὔπισθεν, ὀρθῶς ἂν ἔκαιον· νῦν δὲ δὴ, ὅτε ἐς τὸ κάτω ἐκπίπτει, ἐκβάλλουσιν αὗται αἱ καύσιες μᾶλλον, ἢ κωλύουσιν· ἀποκλείουσι γὰρ τῆς ἄνω εὐρυχωρίης τὴν κεφαλὴν τοῦ βραχίονος. χρὴ δὲ ὧδε καίειν ταῦτα· ἀπολαβόντα τοῖσι δακτύλοισι κατὰ τὴν μασχάλην τὸ δέρμα ἀφελκύσαι κατʼ αὐτὴν τὴν ἴξιν μάλιστα, καθʼ ἣν ἡ κεφαλὴ τοῦ βραχίονος ἐκπίπτει· ἔπειτα οὕτως ἀφελκυσάμενον τὸ δέρμα διακαῦσαι ἐς τὸ πέρην. σιδηρίοισι δὲ χρὴ ταῦτα καίειν, μὴ παχέσι, μηδὲ λίην φαλακροῖσιν, ἀλλὰ προμήκεσι (ταχυπορώτερα γὰρ), καὶ τῇ χειρὶ ἐπερείδειν· χρὴ δὲ καὶ διαφανέσι καίειν, ὡς ὅτι τάχιστα περαιωθῇ κατὰ δύναμιν· τὰ γὰρ παχέα, βραδέως περαιούμενα, πλατυτέρας τὰς ἐκπτώσιας τῶν ἐσχαρῶν ποιέεται, καὶ κίνδυνος ἂν εἴη ξυῤῥαγῆναι τὰς ὠτειλας· καὶ κάκιον μὲν οὐδὲν ἂν εἴη, αἴσχιον δὲ καὶ ἀτεχνότερον. ὅταν δὲ διακαύσῃς ἐς τὸ πέρην, τῶν μὲν πλείστων ἱκανῶς ἂν ἔχοι ἐν τῷ κάτω μέρεϊ τὰς ἐσχάρας ταύτας μόνας θεῖναι· ἢν δὲ μὴ κίνδυνος φαίνηται εἶναι ξυῤῥαγῆναι τὰς ὠτειλὰς, ἀλλὰ πολὺ τὸ διὰ μέσου ἔῃ, ὑπάλειπτρον χρὴ λεπτὸν διέρσαι διὰ τῶν καυμάτων, ἔτι ἀναλελαμμένου τοῦ δέρματος, οὐ γὰρ ἂν ἄλλως δύναιο διέρσαι· ἐπὴν δὲ διέρσῃς, ἀφεῖναι τὸ δέρμα, ἔπειτα μεσηγὺ τῶν ἐσχαρέων ἄλλην ἐσχάρην ἐμβάλλειν λεπτῷ σιδηρίῳ, καὶ διακαῦσαι, ἄχρις ἂν τῷ ὑπαλείπτρῳ ἐγκύρσῃ. ὁκόσον δέ τι χρὴ τὸ δέρμα τὸ ἀπὸ τῆς μασχάλης ἀπολαμβάνειν, τοισίδε χρὴ τεκμαίρεσθαι· ἀδένες ὕπεισιν ἢ ἐλάσσους ἢ μείζους πᾶσιν ὑπὸ τῇ μασχάλῃ, πολλαχῆ δὲ καὶ ἄλλῃ τοῦ σώματος. ἀλλὰ ἐν ἄλλῳ λόγῳ περὶ ἀδένων οὐλομελίης γεγράψεται, ὅ τι τέ εἰσι, καὶ οἷα ἐν οἵοισι σημαίνουσί τε καὶ δύνανται. τοὺς μὲν οὖν ἀδένας οὐ χρὴ προσαπολαμβάνειν, οὐδʼ ὅσα ἐσωτέρω τῶν ἀδένων· μέγας γὰρ ὁ κίνδυνος· τοῖσι γὰρ ἐπικαιροτάτοισι τόνοισι γειτονεύονται· ὅσον δὲ ἐξωτέρω τῶν ἀδένων, ἐπιπλεῖστον ἀπολαμβάνειν· ἀσινέα γάρ. γινώσκειν δὲ χρὴ. καὶ τάδε, ὅτι, ἢν μὲν ἰσχυρῶς τὸν βραχίονα ἀνατείνῃς, οὐ δυνήσῃ τοῦ δέρματος ἀπολαβεῖν οὐδὲν τοῦ ὑπὸ τῇ μασχάλῃ, ὅ τι καὶ ἄξιον λόγου· καταναισιμοῦται γὰρ ἐν τῇ ἀνατάσει· οἱ δʼ αὖ τόνοι, οὓς οὐδεμιῇ μηχανῇ δεῖ τιτρώσκειν, οὗτοι πρόχειροι γίνονται καὶ κατατεταμένοι ἐν τούτῳ τῷ σχήματι· ἢν δὲ μικρὸν ἐπάρῃς τὸν βραχίονα, πολὺ μὲν τοῦ δέρματος ἀπολήψῃ, οἱ δὲ τόνοι, ὧν δεῖ προμηθέεσθαι, εἴσω καὶ πρόσω τοῦ χειρίσματος γίνονται. ἆρʼ οὖν οὐκ ἐν πάσῃ τῇ τέχνῃ περὶ παντὸς χρὴ ποιέεσθαι, τὰ δίκαια σχήματα ἐξευρίσκειν ἐφʼ ἑκάστοισιν; ταῦτα μὲν τὰ κατὰ τὴν μασχάλην, καὶ ἱκαναὶ αὐταὶ αἱ καταλήψιες, ἢν ὀρθῶς τεθῶσιν αἱ ἐσχάραι. ἔκτοσθεν δὲ τῆς μασχάλης, δισσὰ μόνα ἐστὶ χωρία, ἵνα ἄν τις ἐσχάρας θείη, τιμωρεούσας τῷ παθήματι· μίαν μὲν ἐν τῷ ἔμπροσθεν μεσηγὺ τῆς τε κεφαλῆς τοῦ βραχίονος καὶ τοῦ τένοντος τοῦ κατὰ τὴν μασχάλην· καὶ ταύτῃ τὸ μὲν δέρμα τελέως διακαίειν χρὴ, βαθύτερον δὲ οὐ χρή· φλέψ τε γὰρ παχείη πλησίη, καὶ νεῖρα, ὧν οὐδέτερα θερμαντέα. ἔξωθεν δʼ αὖ ἄλλην ἐσχάρην ἐνδέχεται ἐνθεῖναι ἀνωτέρω μὲν συχνῷ τοῦ τένοντος τοῦ κατὰ τὴν μασχάλην, κατωτέρω δὲ ὀλίγῳ τῆς κεφαλῆς τοῦ βραχίονος· καὶ τὸ μὲν δέρμα τελέως χρὴ διακαίειν, βαθείην δὲ μηδὲ κάρτα ταύτην ποιέειν· πολέμιον γὰρ τὸ πῦρ νεύροισιν. ἰητρεύειν μὲν οὖν χρὴ διὰ πάσης τῆς ἰητρείης τὰ ἕλκεα, μηδέποτε ἰσχυρῶς ἀνατείνοντα τὸν βραχίονα, ἀλλὰ μετρίως, ὅσον τῶν ἑλκέων ἐπιμελείης εἵνεκα· ἧσσον μὲν γὰρ ἂν διαψύχοιτο (ξυμφέρει γὰρ πάντα τὰ καύματα σκέπειν, ὡς ἐπιεικέως ἰητρεύεσθαι)· ἧσσον δʼ ἂν ἐκπλίσσοιτο· ἧσσον δʼ ἂν αἱμοῤῥαγοίη· ἧσσον δʼ ἂν σπασμὸς ἐπιγένοιτο. ὅταν δὲ δὴ καθαρὰ γένηται τὰ ἕλκεα, ἐς ὠτειλάς τε ἴῃ, τότε δὴ καὶ παντάπασι χρὴ αἰεὶ τὸν βραχίονα πρὸς τῇσι πλευρῇσι προσδεδέσθαι, καὶ νύκτα καὶ ἡμέρην· ἀτὰρ καὶ ὅταν ὑγιέα γένηται τὰ ἕλκεα, ὁμοίως ἐπὶ πολὺν χρόνον χρὴ προσδεῖν τὸν βραχίονα πρὸς τὰς πλευράς· οὕτω γὰρ ἂν μάλιστα ἐπουλωθείη, καὶ ἀποληφθείη ἡ εὐρυχωρίη, καθʼ ἣν μάλιστα ὀλισθάνει ὁ βραχίων.
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.
12. 12. Ὅσοισι δʼ ἂν ὦμος καταπορηθῇ ἐμβληθῆναι, ἢν μὲν ἔτι ἐν αὐξήσει ἔωσιν, οὐκ ἐθέλει συναύξεσθαι τὸ ὀστέον τοῦ βραχίονος ὁμοίως τῷ ὑγιέϊ, ἀλλὰ αὔξεται μὲν ἐπί τι, βραχύτερον δὲ τοῦ ἑτέρου γίνεται καὶ οἱ καλεομενοι δὲ ἐκ γενεῆς γαλιάγκωνες· διὰ δισσὰς ξυμφορὰς ταύτας γίνονται, ἤν τέ τι τοιοῦτον αὐτοὺς ἐξάρθρημα καταλάβῃ ἐν τῇ γαστρὶ ἐόντας, διά τε ἄλλην ξυμφορὴν, περὶ ἧς ὕστερόν ποτε γεγράψεται· ἀτὰρ καὶ οἷσιν ἔτι νηπίοισιν ἐοῦσι κατὰ τὴν κεφαλὴν τοῦ βραχίονος βαθεῖαι καὶ ὑποβρύχιοι ἐκπυήσιες γίνονται, καὶ οὗτοι πάντες γαλιάγκωνες γίνονται· καὶ ἤν τε τμηθῶσιν, ἤν τε καυθῶσιν, ἤν τε αὐτόματόν σφιν ἐκραγῇ, εὖ εἰδέναι χρὴ, ὅτι ταῦτα οὕτως ἔχει. χρέεσθαι μέντοι τῇ χειρὶ δυνατώτατοί εἰσιν οἱ ἐκ γενεῆς γαλιάγκωνες, οὐ μὴν οὐδὲ ἐκεῖνοί γε ἀνατεῖναι παρὰ τὸ οὖς τὸν βραχίονα, ἐκτανύσαντες τὸν ἀγκῶνα, δύνανται, ἀλλὰ πολὺ ἐνδεεστέρως, ἢ τὴν ὑγιέα χεῖρα. οἷσι δʼ ἂν ἤδη ἀνδράσιν ἐοῦσιν ἐκπέσῃ ὁ ὦμος, καὶ μὴ ἐμβληθῇ, ἡ ἐπωμὶς ἀσαρκοτέρη γίνεται, καὶ ἡ ἕξις λεπτὴ ἡ κατὰ τοῦτο τὸ μέρος· ὅταν μέντοι ὀδυνώμενοι παύσωνται, ὁκόσα μὲν δεῖ ἐργάζεσθαι ἐπάραντας τὸν ἀγκῶνα ἀπὸ τῶν πλευρέων ἐς τὸ πλάγιον, ταῦτα μὲν οὐ δύνανται ἅπαντα ὁμοίως ἐργάζεσθαι· ὁκόσα δὲ δεῖ ἐργάζεσθαι, παραφέροντας τὸν βραχίονα παρὰ τὰς πλευρὰς, ἢ ἐς τοὐπίσω, ἢ ἐς τοὔμπροσθεν, ταῦτα δὲ δύνανται ἐργάζεσθαι· καὶ γὰρ ἂν ἀρίδα ἑλκύσαιεν, καὶ πρίονα, καὶ πελεκήσαιεν ἂν, καὶ σκάψαιεν ἂν, μὴ κάρτα ἄνω αἴροντες τὸν ἀγκῶνα, καὶ τἄλλα ὅσα ἐκ τῶν τοιούτων σχημάτων ἐργάζονται.
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.
13. 13. Ὅσοισι δʼ ἂν τὸ ἀκρώμιον ἀποσπασθῇ, τουτέοισι φαίνεται ἐξέχον τὸ ὀστέον τὸ ἀπεσπασμένον· ἔστι δὲ τοῦτο ὁ ξύνδεσμος τῆς κληῗδος καὶ τῆς ὠμοπλάτης· ἑτεροίη γὰρ ἡ φύσις ἀνθρώπου ταύτῃ, ἢ τῶν ἄλλων ζώων. οἱ οὖν ἰητροὶ μάλιστα ἐξαπατέονται ἐν τούτῳ τῷ τρώματι (ἅτε γὰρ ἀνασχόντος τοῦ ὀστέου τοῦ ἀποσπασθέντος, ἡ ἐπωμὶς φαίνεται χαμαιζήλη καὶ κοίλη), ὥστε καὶ προμηθέεσθαι τῶν ὤμων τῶν ἐκπεπτωκότων· πολλοὺς οὖν οἶδα ἰητροὺς, τἄλλα οὐ φλαύρους ἐόντας, οἳ πολλὰ ἤδη ἐλυμήναντο, ἐμβάλλειν πειρώμενοι τοὺς τοιούτους ὤμους, οὕτως οἰόμενοι ἐκπεπτωκέναι, καὶ οὐ πρόσθεν παύονται, πρὶν ἢ ἀπογνῶναι, ἢ ἀπορῆσαι, δοκέοντες αὐτοὶ σφέας αὐτοὺς ἐμβάλλειν τὸν ὦμον. τούτοισιν ἰητρείη μὲν, ἥπερ καὶ τοῖσιν ἄλλοισιν τοῖσι τοιούτοισι, κηρωτὴ καὶ σπλῆνες καὶ ὀθόνια, καὶ ἐπίδεσις τοιαύτη. καταναγκάζειν μέντοι τὸ ὑπερέχον χρὴ, καὶ τοὺς σπλῆνας κατὰ τοῦτο τιθέναι πλείστους, καὶ πιέζειν ταύτῃ μάλιστα, καὶ τὸν βραχίονα πρὸς τῇσι πλευρῇσι ποοσηρτημένον ἐς τὸ ἄνω μέρος ἔχειν· οὕτω γὰρ ἂν μάλιστα πλησιάζοι τὸ ἀπεσπασμένον. τάδε μὴν εὖ εἰδέναι χρὴ, καὶ προλέγειν ὡς ἀσφαλέα, εἰ ἄλλως ἐθέλοις, ὅτι βλάβη μὲν οὐδεμίη, οὔτε σμικρὴ, οὔτε μεγάλη, τῷ ὤμῳ γίνεται ἀπὸ τούτου τοῦ τρώματος, αἴσχιον δὲ τὸ χωρίον· οὐδὲ γὰρ τοῦτο τὸ ὀστέον ἐς τὴν ἀρχαίην ἕδρην ὁμοίως ἂν ἱδρυνθείη, ὥσπερ ἐπεφύκεεν, ἀλλʼ ἀνάγκη πλέον ἢ ἔλασσον ὀγκηρότερον εἶναι ἐς τὸ ἄνω. οὐδὲ γὰρ ἄλλο ὀστέον οὐδὲν ἐς τωὐτὸ καθίσταται, ὅ τι ἂν κοινωνέον ἔῃ ἑτέρῳ ὀστέῳ, καὶ προσπεφυκὸς ἀποσπασθῇ ἀπὸ τῆς ἀρχαίης φύσιος. ἀνώδυνον δὲ τὸ ἀκρώμιον ἐν ὀλίγῃσιν ἡμέρῃσι γίνεται, ἢν χρηστῶς ἐπιδέηται.