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.

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

As Galen remarks in his Commentary, our author adverts to this subject in his work on Fractures. It is, no doubt, a very important practical observation that, although inability to place the limb in its accustomed attitudes be an inseparable symptom of dislocations, it sometimes happens that patients, from pains or other causes, lose this faculty without there being any displacement of the bone. The symptoms of dislocation at the shoulder-joint, as given in the remainder of the paragraph, are remarkably accurate.

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.

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 reverse of what is proper. For many physicians have burned the shoulders subject to dislocation, at the top of the shoulder, at the anterior part were 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

1 Our author, it will be recollected, applies this remark to the Nomadic Scythians, in his work On Airs, Waters, etc.

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 will 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

1I need scarcely remark here that the work, On the Glands, which we now possess, is not the promised work of our author. See an analysis of the other work in the second section of the Preliminary Discourse. Galen, in his Commentary on this passage, states distinctly that the work which is contained in the Hippocratic Collection is supposititious, and unworthy of our author. Those, he adds, who made out the Tables (of the Hippocratic treatises) do not recognize it. I may be allowed to remark again in this place, that if our author had not practiced human dissection he could not have been so well acquainted, as he here shows him to be, with the situation of the blood-vessels, nerves, and glands, situated in the axillary region.

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.'1

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,'

1 For the other ancient authorities on this operation, see PAULUS ÆGINETA, B. VI., 42.

2 Galen professes not to think it worth his while to determine whether or not the term which is here translated weasel-armed (yañíáукveç) be derived from yaλñ, (mustela vulgaris?) He adds there can be no doubt that it signifies“ shortarmed."

Our author here evidently alludes to congenital dislocation at the shoulderjoint, a malformation which we know does occur, although I never met with a case of it. I have seen cases, however, of congenital dislocation at the hip-joint, and several such have been described of late years. Dr. Heine, of Stuttgart, has observed nine cases in female, aud two in male children. See Forbes's British and Foreign Medical Review, No. xxxii., p. 489. Baron Dupuytren has also treated of this subject with his usual ability, in his work, On Fractures and Dislocations, lately reprinted by the Sydenham Society. In this work, he gives an interesting case of congenital dislocation of the upper extremity of the radius on the humerus (p. 117). He makes no mention, however, of congenital dislocation at the shoulder-joint. By far the most interesting and instructive account of this subject which we possess, is that given by Dr. R. W. Smith, in the Dublin Journal, Vol. xv., p. 236. He notices two kinds of congenital dislocations, viz., the subcoracoid and the subacromial dislocation. A few extracts from his description of the former of these, will show how well it agrees with that given by Hippocrates. "In the congenital subcoracoid dislocation, the head of the upper-arm bone, when the arm hangs down on the side, is situated beneath the coracoid process, and the outer part of the glenoid cavity can be felt beneath the projecting acromion; if the elbow be drawn forward over the chest, the head of the upper-arm bone slips backward over the acromion, and completely leaves the unnatural part of the articular surface, which can now be distinctly felt; the shoulder has not its natural rounded form, but is flattened. The muscles of the shoulder and arm are much shrunk, and also the muscles passing from the chest to the blade-bone and upper-arm, only the m. trapesius shows the least of this, and seems to be almost the only muscle, which still acts upon and moves the blade-bone, the diseased arm is nearly half an inch shorter. The motions of the arm are very much reduced: elevation and abduction are not possible, and even the forward and backward motions cannot be performed without a correspondent movement of the blade-bone." See, further, Chelius's System of Surgery, (Vol. I., p. 786.) The

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 below 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 hopes of succeeding, or committed the 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 suitaable 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

same subject is treated of in a very ingenious and interesting manner by Dr. R. M. Smith, in his recent publication "A Treatise of Fractures in the Vicinity of Joints," Dublin, 1847. He gives the histories of several cases of congenital luxation at the shoulder-joint, which, in the main, agree very well with the characters of this abnormal conformation as given by Hippocrates. M. Guerin has also recently written on this interesting subject. (Recherches sur les Luxations Congénitales.)

VOL. II.-7.