on the articulations-第12章

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will　do　any　good；　though　administered　the　same　day；　and　the　draught
repeated；　and　yet　it　is　the　most　likely　means；　if　any　such　there　be；
but　I　am　of　opinion　that　not　even　it　will　be　of　service。　But　if　not
reduced；　nor　any　attempts　at　first　made　to　reduce　them；　most　of　such
cases　recover。　The　leg　and　foot　are　to　be　arranged　as　the　patient
wishes；　only　they　must　not　be　put　in　a　dependent　position；　nor　moved
about；　and　they　are　to　be　treated　with　pitched　cerate；　a　few
compresses　dipped　in　wine；　and　not　very　cold；　for　cold　in　such　cases
induces　convulsions；　the　leaves　also　of　beet；　or　of　colt's　foot；　of
any　such；　when　boiled　in　dark…colored　austere　wine；　form　a　suitable
application　to　the　wound　and　the　surrounding　parts；　and　the　wound
may　further　be　anointed　with　cerate　in　a　tepid　state。　But　if　it　be　the
winter　season；　the　part　is　to　be　covered　with　unscoured　wool；　which　is
to　be　sprinkled　from　above　with　tepid　wine　and　oil；　but　on　no
account　is　either　bandage　or　compress　to　be　applied；　for　this　should
be　known　most　especially；　that　whatever　compresses；　or　is　heavy；
does　mischief　in　such　cases。　And　certain　of　the　dressings　used　to
recent　wounds　are　suitable　in　such　cases；　and　wool　may　be　laid　upon
the　sore；　and　sprinkled　with　wine；　and　allowed　to　remain　for　a
considerable　time；　but　those　dressings　for　recent　wounds　which　only
last　for　a　few　days；　and　into　which　resin　enters　as　an　ingredient；
do　not　agree　with　them；　for　the　cleansing　of　the　sores　is　a　slow
process；　and　the　sore　has　a　copious　discharge　for　a　long　time。　Certain
of　these　cases　it　may　be　advantageous　to　bandage。　It　ought　also　to
be　well　understood；　that　the　patient　must　necessarily　be　much　maimed
and　deformed；　for　the　foot　is　retracted　outward；　and　the　bones　which
have　been　displaced　outward　protrude：　these　bones；　in　fact；　not
being　generally　laid　bare；　unless　to　a　small　extent；　neither　do　they
exfoliate；　but　they　heal　by　thin　and　feeble　cicatrices；　provided　the
patient　keeps　quiet　for　a　length　of　time；　but　otherwise　there　is
danger　that　a　small　ulcer　may　remain　incurable。　And　yet　in　the　case　we
are　treating　of；　those　who　are　thus　treated　are　saved；　whereas；　when
the　parts　are　reduced　and　allowed　to　remain　in　place；　the　patients
die。

　　64。　The　same　rule　applies　to　dislocations　at　the　wrist；　attended
with　a　wound　and　projection　of　the　bone；　whether　the　bones　of　the
arm　be　displaced　inward　or　outward。　For　this　should　be　well
understood；　that　the　patient　will　die　in　the　course　of　a　few　days；
by　the　same　mode　of　death　as　formerly　described；　if　the　bone　be
reduced；　and　allowed　to　remain　so。　But　in　those　cases　in　which　they
are　not　reduced；　nor　any　attempt　made　to　reduce　them；　the　patients；
for　the　most　part；　recover；　and　the　same　mode　of　treatment　as　has　been
described　will　be　applicable；　but　the　deformity　and　impediment　of
the　limb　must　necessarily　be　great；　and　the　fingers　of　the　hand　will
be　weak　and　useless；　for　if　the　bones　have　slipped　inward；　they　cannot
bend　the　fingers；　or　if　outward；　they　cannot　extend　them。

　　65。　When　the　os　tibiae；　having　made　a　wound　at　the　knee；　has
protruded　through　the　skin；　whether　the　dislocation　be　outward　or
inward；　in　such　a　case；　if　the　bone　be　reduced；　death　will　be　even
more　speedy　than　in　the　other　cases；　although　speedy　also　in　them。　But
the　only　hope　of　recovery　is　if　you　treat　them　without　reduction。
These　cases　are　more　dangerous　than　the　others；　as　being　so　much
higher　up；　as　being　so　much　stronger　joints；　and　displaced　from
bones　which　are　so　much　stronger。　But　if　the　os　femoris　form　a　wound
at　the　knee；　and　slip　through　it；　provided　it　be　reduced　and　left
so；　it　will　occasion　a　still　more　violent　and　speedy　death　than　in　the
cases　formerly　described；　but　if　not　reduced；　it　will　be　much　more
dangerous　than　those　cases　mentioned　before；　and　yet　this　is　the
only　hope　of　recovery。

　　66。　The　same　rule　applies　to　the　elbow…joint；　and　with　regard　to　the
bones　of　the　fore…arm　and　arm。　For　when　these　bones　protrude　through　a
wound　which　they　have　made　in　the　skin；　all　cases　in　which　they　are
reduced　prove　fatal；　but　if　not　reduced；　there　is　a　chance　of
recovery；　but　to　those　that　survive　there　is　certain　impediment。　And
if　in　any　instance　the　bones　of　the　upper　articulations
（shoulder…joint？）；　should　be　dislocated；　and　project　through　a　wound
which　they　have　made　in　the　skin；　these；　if　reduced；　are　followed　by
more　speedy　death；　and　if　not　reduced；　they　are　more　dangerous　than
the　others。　But　the　mode　of　treatment　which　appears　to　me　most
suitable　has　been　already　described。

　　67。　When　the　joints　of　the　toes　or　hands　are　dislocated；　and　the
bones　protrude　through　a　wound　which　they　have　made；　and　when　there　is
no　fracture　of　the　bone；　but　merely　displacement　of　the　joint；　in
these　cases；　if　the　reduction　be　made　and　allowed　to　remain；　there
is　some　danger　of　spasms　（tetanus？）　if　not　properly　treated；　and　yet
it　may　be　worth　while　to　reduce　them；　having　warned　the　patient
beforehand　that　much　caution　and　care　will　be　required。　The　easiest；
the　most　efficient　method；　and　the　one　most　conformable　to　art；　is
that　by　the　lever；　as　formerly　described　when　treating　of　bones
which　have　been　fractured　and　protruded；　then　the　patient　must　be　as
quiet　as　possible；　lie　in　a　recumbent　position；　and　observe　a
restricted　regimen。　And　it　will　be　better　also　that　he　should　get　some
gentle　emetics。　The　sore　is　to　be　treated　with　dressings　for　fresh
wounds；　which　permit　of　allusions；　or　with　the　leaves　of　camomile；
or　with　the　applications　for　fractured　bones　of　the　head；　but
nothing　very　cold　must　be　applied。　The　first　（most　distant？）　joints
are　least　dangerous；　but　those　still　higher；　are　more　so。　Reduction
should　be　made　the　same　day；　or　the　next；　but　by　no　means　on　the　third
or　fourth；　for　it　is　on　the　fourth　day　that　exacerbations　especially
attack。　In　those　cases；　then；　where　immediate　reduction　cannot　be
accomplished；　we　must　wait　until　after　the　aforesaid　days；　for
whatever　you　reduce　within　ten　days；　may　be　expected　to　induce
spasm。　But　if　the　spasm　supervene　on　its　being　reduced；　the　joint
should　be　quickly　displaced；　and　bathed　frequently　with　warm　water；
and　the　whole　body　should　be　kept　in　a　warm；　soft；　and　easy　condition；
and　more　especially　about　the　joints；　for　the　whole　body　should　rather
be　in　a　bent　than　in　an　extended　state。　Moreover；　it　is　to　be
expected；　that　the　articular　extremities　of　the　bones　of　the　fingers
will　for　this　generally　happens；　if　even　the　least　degree　of
inflammation　take　place；　so　that　if　it　were　not　that　the　physician
would　be　exposed　to　censure；　owing　to　the　ignorance　of　the　common
people；　no　reduction　should　be　made　at　all。　The　reduction　of　the　bones
of　joints　which　have　protruded　through　the　skin；　is　attended　with
the　dangers　which　have　been　described。

　　68。　When　the　articular　bones　of　the　fingers　are　fairly　chopped
off；　these　cases　are　mostly　unattended　with　danger；　unless　deliquium
come　on　in　consequence　of　the　injury；　and　ordinary　treatment　will　be
sufficient　to　such　sores。　But　when　resection　is　made；　not　at　the
articulations；　but　at　some　other　point　in　the　bones；　these　cases
also　are　free　from　danger；　and　are　still　more　easily　cured　than　the
others；　and　the　fractured　bones　of　the　fingers　which　protrude
otherwise　than　at　the　joint　admit　of　reduction　without　danger。
Complete　resections　of　bones　at　the　joints；　whether　the　foot；　the
hand；　the　leg；　the　ankle；　the　forearm；　the　wrist；　for　the　most　part；
are　not　unattended　with　danger；　unless　one　be　cut　off　at　once　by
deliquium　animi；　or　if　continual　fever　supervene　on　the　fourth　day。

　　69。　With　regard　to　the　sphacelus　of　fleshy　parts；　it　takes　place
in　wounds　where　there　are　large　blood…vessels；　which　have　been
strongly　compressed；　and　in　fractures　of　bones　which　have　been　bound
too　tight；　and　in　other　cases　of　immoderate　constriction；　when　the
parts　which　have　been　strangulated　generally　drop　off；　and　the　most　of
such　patients　recover；　even　when　a　portion　of　the　thigh　comes　away；　or
of　the　arm；　both　bones　and　flesh；　but　less　so　in　this　case；　and　when
the　fore…arm　and　leg　drop　off；　the　patients　readily　recover。　In
cases　then；　of　fracture　of　the　bones；　when　strangulation　and
blackening　of　the　parts　take　place　at　first；　the　separation　of　the
dead　and　living　parts　quickly　occurs；　and　the　parts　speedily　drop　off；
as　the　bones　have　already　given　way；　but　when　the　blackening
（mortification）　takes　place　while　the　bones　are　entire；　the　fleshy
parts；　in　this　case；　also　quickly　die；　but　the　bones　are　slow　in
separating　at　the　boundary　of　the　blackening；　and　where　the　bones
are　laid　bare。　Those　parts　of　the　body　which　are　below　the
boundaries　of　the　blackening　are　to　be　removed　at　the　joint；　as　soon
as　they　are　fairly　dead　and　have　lost　their　sensibility；　care　being
taken　not　to　wound　any　living　part；　for　if　the　part　which　is　cut　off
give　pain；　and　if　it　prove　not　to　be　quite　dead；　there　is　great　danger
lest　the　patient　may　swoon　away　from　the　pain；　and　such　swoonings
often　are　immediately　fatal。　I　have　known　the　thigh…bones；　when
denuded　in　this　manner；　drop　off　on　the　eightieth　day；　but　in　the　case
of　this　patient；　the　parts　below　were　separated　at　the　knee　on　the
twentieth　day；　and；　as　I　thought；　too　early；　for　it　appeared　to　me
that　this　should　be　done　more　guardedly。　In　a　case　which　I　had　of　such
blackening　in　the　leg；　the　bones　of　the　leg；　as　far　as　they　were
denuded；　separated　at　its　middle　on　the　sixtieth　day。　But　the
separation　of　denuded　bones　is　quicker　or　slower；　according　to　the
mode　of　treatment；　something；　too；　depends　upon　whether　the
compression　be　stronger　or　weaker；　and　whether　the　nerves；　flesh；
arteries；　and　veins　are　quicker　or　slower　in　becoming　blackened　and　in
dying；　since；　when　the　parts　are　not　strongly　compressed；　the
separation　is　more　superficial；　and　does　not　go　the　length　of　laying
the　bones　bare；　and　in　some　cases　it　is　still　more　superficial；　so
as　not　even　to　expose　the　nerves。　For　the　reasons　now　stated；　it　is
impossible　to　define　accurately　the　time　at　which　each　of　these
cases　will　terminate。　The　treatment　of　such　cases；　however；　is　to　be
readily　undertaken；　for　they　are　more　formidable　to　look　at　than　to
treat；　and　a　mild　treatment　is　sufficient　in　all　such　cases；　for
they　come　to　a　crisis　of　themselves；　only　the　diet　must　be　attended
to；　so　that　it　may　be　as　little　calculated　to　create　fever　as
possible；　and　the　body　is　to　be　placed　in　the　proper　positions：
these　are；　neither　raised　very　high　up；　nor　inclined　much　downward；
but　rather　upward；　until　the　separation　be　completed；　for　at　that　time
there　is　most　danger　of　hemorrhage；　on　this　account；　wounds　should　not
be　laid　in　a　declining　position；　but　the　contrary。　But　after　a
while；　and　when　the　sores　have　become　clean；　the　same　positions　will
no　longer　be　appropriate；　but　a　straight　position；　and　one　inclining
downward；　may　be　proper；　and　in　the　course　of　time；　in　some　of　these
cases；　abscesses　form；　and　require　bandages。　One　may　also　expect
that　such　patients　will　be　attacked　with　dysentery；　for　dysentery
usually　supervenes　in　cases　of　mortification　and　of　hemorrhage　from
wounds；　it　comes　on　generally　when　the　blackening　and