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.
