on the articulations-第14节

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all；　and　yet　these　bones　admit　of　being　displaced　to　a　greater　or　less
extent；　and　the　thigh　is　more　subject　to　these　differences　than　the
arm。

　　62。　Wherefore；　then；　some　of　these　congenital　displacements；　if　to　a
small　extent；　may　be　reduced　to　their　natural　condition；　and
especially　those　at　the　ankle…joint。　Most　cases　of　congenital
club…foot　are　remediable；　unless　the　declination　be　very　great；　or
when　the　affection　occurs　at　an　advanced　period　of　youth。　The　best
plan；　then；　is　to　treat　such　cases　at　as　early　a　period　as　possible；
before　the　deficiency　of　the　bones　of　the　foot　is　very　great；　and
before　there　is　any　great　wasting　of　the　flesh　of　the　leg。　There　is
more　than　one　variety　of　club…foot；　the　most　of　them　being　not
complete　dislocations；　but　impairments　connected　with　the　habitual
maintenance　of　the　limb　in　a　certain　position。　In　conducting　the
treatment；　attention　must　be　paid　to　the　following　points：　to　push
back　and　rectify　the　bone　of　the　leg　at　the　ankle　from　without　inward；
and　to　make　counter…pressure　on　the　bone　of　the　heel　in　an　outward
direction；　so　as　to　bring　it　bring　it　into　line；　in　order　that　the
displaced　bones　may　meet　at　the　middle　and　side　of　the　foot；　and　the
mass　of　the　toes；　with　the　great　toe；　are　to　be　inclined　inward；　and
retained　so；　and　the　parts　are　to　be　secured；　with　cerate　containing　a
full　proportion　of　resin；　with　compresses；　and　soft　bandages
insufficient　quantity；　but　not　applied　too　tight；　and　the　turns　of　the
bandages　should　be　in　the　same　direction　as　the　rectifying　of　the　foot
with　the　hand；　so　that　the　foot　may　appear　to　incline　a　little
outward。　And　a　sole　made　of　leather　not　very　hard；　or　of　lead；　is　to
be　bound　on；　and　it　is　not　to　be　applied　to　the　skin　but　when　you
are　about　to　make　the　last　turns　of　the　bandages。　And　when　it　is　all
bandaged；　you　must　attach　the　end　of　one　of　the　bandages　that　are　used
to　the　bandages　applied　to　the　inferior　part　of　the　foot　on　the　line
of　the　little　toe；　and　then　this　bandage　is　to　be　rolled　upward　in
what　is　considered　to　be　a　sufficient　degree；　to　above　the　calf　of　the
leg；　so　that　it　may　remain　firm　when　thus　arranged。　In　a　word；　as　if
moulding　a　wax　model；　you　must　bring　to　their　natural　position　the
parts　which　were　abnormally　displaced　and　contracted　together；　so
rectifying　them　with　your　hands；　and　with　the　bandaging　in　like
manner；　as　to　bring　them　into　their　position；　not　by　force；　but
gently；　and　the　bandages　are　to　be　stitched　so　as　to　suit　the　position
in　which　the　limb　is　to　be　placed；　for　different　modes　of　the
deformity　require　different　positions。　And　a　small　shoe　made　of　lead
is　to　be　bound　on　externally　to　the　bandaging；　having　the　same　shape
as　the　Chian　slippers　had。　But　there　is　no　necessity　for　it　if　the
parts　be　properly　adjusted　with　the　hands；　properly　secured　with　the
bandages；　and　properly　disposed　of　afterward。　This；　then；　is　the
mode　of　cure；　and　it　neither　requires　cutting；　burning；　nor　any
other　complex　means；　for　such　cases　yield　sooner　to　treatment　than　one
would　believe。　However；　they　are　to　be　fairly　mastered　only　by　time；
and　not　until　the　body　has　grown　up　in　the　natural　shape；　when
recourse　is　had　to　a　shoe；　the　most　suitable　are　the　buskins；　which
derive　their　name　from　being　used　in　traveling　through　mud；　for　this
sort　of　shoe　does　not　yield　to　the　foot；　but　the　foot　yields　to　it。
A　shoe　shaped　like　the　Cretan　is　also　suitable。

　　63。　In　cases　of　complete　dislocation　at　the　ankle…joint；　complicated
with　an　external　wound；　whether　the　displacement　be　inward　or　outward；
you　are　not　to　reduce　the　parts；　but　let　any　other　physician　reduce
them　if　he　choose。　For　this　you　should　know　for　certain；　that　the
patient　will　die　if　the　parts　are　allowed　to　remain　reduced；　and
that　he　will　not　survive　more　than　a　few　days；　for　few　of　them　pass
the　seventh　day；　being　cut　off　by　convulsions；　and　sometimes　the　leg
and　foot　are　seized　with　gangrene。　It　should　be　well　known　that　such
will　be　the　results；　and　it　does　not　appear　to　me　that　hellebore
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