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Technology, Social Change
and Human Behavior
Influence for Impact
Cornelia C. Walther
 Technology, Social Change and Human Behavior

“Using technology to crush the cycle of greed and inertia and help us achieve a state
of ‘Augmented Humanity’ founded in generosity, compassion, honesty and courage
is a beautifully hopeful idea. In these anxious and uncertain times, it offers a
much needed, enticing and ultimately achievable vision of a new utopia. Reading
this book makes you feel better, but it does much more. It takes you on a journey
of imagination, from the closed-mindedness of hyper-individualism to the joys of
authentic human connection, with self and others. Read it and you will discover
more of who you truly are. In doing so you will feel more awake, more purposeful
and more alive.”
—Gareth Owen OBE, Humanitarian Director, Save the Children UK
International, London

***
“Cornelia Walther’s book arrives at an important time as Covid19 has accelerated
the digital transformation of many elements of our society. Using technology to
encourage humans to embrace digital technology and use it for social change is a
brilliant concept and one that needs to be explored further. Never has the world
been more connected and yet strangely at isolated at the same time. The author
explores how technology could be used to bring about real social change at a time
when a global population is looking for direction.”
—John E. Roche, CMC. Global Strategy Director, Enablement. SAP Premium
Services. New York

***
“The truth is that we live in a networked world, interconnected. Thus, the challenge
is to ensure that technological advance is at the service of improving people´s quality
of life. This is possible if we consider that personal well-being is the result of collective
well-being and then no one can achieve their well-being in isolation from what
happens in their context. This book invites you to discover how to enhance social
change dynamics, and in this sense improve people’s quality of life, using technology
overtime to make it sustainable. If you are interested in these topics, you cannot
stop reading this new and compelling book by Cornelia Walther.”
—Dr. Graciela H. Tonon, Director Master of Social Sciences and Center for
Research in Social Sciences (CICS-UP). Faculty of Social Sciences. University of
Palermo, Buenos Aires

***
“Cornelia Walther takes a refreshingly original look at the relationship between
technology and social change, incorporating the Poze methodology, which she devel-
oped after working for UNICEF and the World Food Program in a number of
countries, including Haiti, Chad, Afghanistan and the Democratic Republic of the
Congo. Her latest book is an invaluable tool for promoting tolerance and societal
transformation throughout the world.”
—Dr. Joann Halpern, Director, Hasso Plattner Institute, New York. Adjunct
Professor of International Education, New York University

***
“Imagine a world where technology is designed to elevate your consciousness, point
you towards your highest self and most noble aspirations. This is not about the
future; this technology is already here, but what intention do we collectively as a
species bring to our creations? Our challenge today is to understand that with every
choice we make to adapt to new technology, our world is changed. Thus, it becomes
increasingly important to make sure that our choices are mindful. This book opens
a world of possibilities and poses important questions about who we are and how
we can be nudged to interact with technology as it evolves. It is essential reading
for the curious mind and highly recommended for those among us with the power
to shape the future of the technology that will shape how we evolve as a species.”
—Marielle Sander, UNFPA Representative. Papua New Guinea. Port Moresby

***
“The future is uncertain. Nevertheless, with solid theory and a good model, it is
possible to peek and discern probable trends. This book provides a superb model that
not only does exactly that but also delivers tools and practical ideas to use technology
for the betterment of life.”
—Enrique Delamonica, Senior Adviser Statistics and Monitoring (Child Poverty
and Gender Equality), United Nations Children’s Emergency Fund (UNICEF)

***
 Cornelia C. Walther

Technology, Social
Change and Human
Behavior
Influence for Impact
Cornelia C. Walther
POZE
Tuebingen, Germany

ISBN 978-3-030-70001-0 ISBN 978-3-030-70002-7 (eBook)

https://doi.org/10.1007/978-3-030-70002-7

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights
of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and
retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc.
in this publication does not imply, even in the absence of a specific statement, that such
names are exempt from the relevant protective laws and regulations and therefore free for
general use.
The publisher, the authors and the editors are safe to assume that the advice and informa-
tion in this book are believed to be true and accurate at the date of publication. Neither
the publisher nor the authors or the editors give a warranty, expressed or implied, with
respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps
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Cover illustration: © Melisa Hasan

This Palgrave Macmillan imprint is published by the registered company Springer Nature
Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 Preface

The central argument of this book is that society can be shaped to lift indi-
viduals to fulfill their potential, if those who constitute Society (Us) aspire
to that objective and act accordingly. Technology can help us to make that
happen. It cannot do it for us. To serve the Common Good 1 technology must
be designed, delivered, and used with this goal in (the human) mind. That
feedback loop of human aspirations and artificial intelligence is one of the
central messages of this book. It is not a technical book and the cited exam-
ples are not an extensive inventory of the technological prowess that the world
disposes of. The aim is not to draw an inventory but to show certain patterns
that affect society.
Humanity is ready to take a leap from bigger to better to brighter;
from catering to a culture of cash and casual carelessness to collective
consciousness. This leap is not quantitative but qualitative. Societies that
nurture quality of life for all while protecting the environment become
possible when humans adopt the understanding that their own wellbeing,
and that of others, is not only connected but represents two sides of the
same coin. A state of Augmented Humanity (AH) is within reach when
individuals realize that sharing and caring enhance their own lives, and act
accordingly because they want to.
Technology can contribute to the concretization of AH in our lifetime.
But, to nurture AH, technology must be both designed and used with a
particular mindset. The outcomes of technology depend on the attitudes
and aspirations that underpin it. Fire can serve to cook a meal, or to burn

v
vi PREFACE

a village—the end is not conditioned by the mean itself. Furthermore, it

is merely a mean to an end not an end by itself. Impressive as the tech-
nological progress is, it does not free us from the responsibility of making
the right choices.
We shape the technology that shapes us. Millions of customers and
CEOs, consumer consortia and communities have been pondering which
impact Artificial Intelligence (AI) and ancillary technologies will have on
our future; whether they will be beneficial or detrimental. The answer to
that interrogation does not reside with the sophistication of algorithms,
nor the development of ever more capable devices or the mining of ever
bigger quantities of data. The impact of technology on this (and future)
generations and on the Planet depends on those who live, think, and
feel—and act, today (Us).
To optimize the positive influence of technology on individuals and
institutions, the intentions that precede the design and implementation
of hard and software must be geared toward collective progression, not
personal profitability. Conceived with the understanding of intercon-
nected impact, technology may compensate for limitations of human
nature; starting with our tendency to biased judgments, willful blindness,
inertia, and greed. As we will see over the course of this book, technology
can accompany the human journey to a higher self. It represents neither
the path nor the traveler.
Depending on the mindset of engineers and entrepreneurs, of users
and utility managers technology may be refined ever further. We have just
begun to explore the potential of mind-oriented technology; the question
is to move from Artificial Intelligence (AI) to Artificial Emotional Intelli-
gence (AEI) to Aspirational Algorithms (AA) in order to nurture a state
of Augmented Humanity (AH). The last stage entails machines which
are programmed with human values and directed toward the achievement
of human aspirations. Undeterred by greed and jealousy, AA endowed
machines can influence, or take over, decision-making processes in which
humans traditionally succumb to their lower instincts. In other words,
technology can help us on the path to AH if it is designed with that
purpose—however, it will not be designed with that purpose unless we are
already on that path. This is not a tautological argument, nor a catch-22.
 PREFACE vii

Technology Can Crush the Cycle of Greed

and Inertia---If We Design It to Do So
Well-intentioned individuals and institutions have tried for centuries to
stop and reverse trends that lead to an imbalance of needs and means—
poverty. The status quo, in which, globally, inequity has been on the rise
for decades, illustrates that their efforts have at best alleviated the suffering
that derives from that situation. More candidly spoken—the thinkers and
doers of the past and present failed to end avoidable deprivation. Blaming
‘the system’ for this failure means falling prey to the chicken and egg
conundrum. Cause and consequence often appear indistinguishable but
blaming ‘the system’ equals shaming us, individually and collectively, as
we perpetrate the ‘system’ that we are part of. Aspirational Algorithms
(AA), a type of technology designed to nurture the common good, may
help us to break the cycle and move toward AH.
A futuristic scenario where the world is ruled by robots is often
portrayed as an apocalypse. To be fair in this debate, it is worth looking
at the world that is emerging from millennia of a human regime. The
pace of human evolution has been extraordinary. We know and possess
more, while living longer to enjoy it. However, war and pollution, climate
change and the exploitation of people and planet meander in parallel
to that progress.2 Nature is declining at rates unprecedented in human
history, with up to 1 million species at risk of extinction due to human
activity (Kailash and Lambertini 2020). The World Economic Forum’s
Global Risks Report 2020 ranked biodiversity loss as one of the top
five risks in terms of impact and likelihood over the coming decade. For
the first time in history, humans are the drivers of climate and environ-
mental change—we live in the Anthropocene, with devastating conse-
quences. If the current rate of destruction continues unabated, some
biomes (e.g. tundra, grasslands, coral reefs, forests) will cross irreversible
tipping points. The impact may make the world uninhabitable for humans.
This book does neither argue in favor of robotic empires nor advocate to
outlaw machines. It merely looks at options to make the best of a future
where technology will be part of our life.
Reversing the current trend starts with a shift in human perspective—
from closed-mindedness to connection, from constraining mindsets to
organic changes, from categories that parcel and judge experiences to a
continuum of humanness. A shift from competition to complementarity.
Much good has happened over the past centuries and is happening right
viii PREFACE

now. Much more is needed, quickly. We have a solid point of depar-

ture, both in terms of means and motivation. We must not wait while
the momentum slips away.
The technological assets that we now take for granted would have
appeared like magic centuries (even decades) ago—from cellphones over
computers down to AI. The present pages seek to disperse the magical
dust to distill the human outcomes. Paradoxically, technology can serve
us in these endeavors if it is built and used by humans who aspire to that
outcome. If human engineers and users do justice to their innate ability
of generosity, compassion, honesty, and courage, technology will reflect
these traits.

Individual wellbeing is the cause and consequence of collective welfare. One

without the other is unsustainable. Together they condition the transition from
now to Augmented Humanity.

Anchored in the understanding that everything operates in a constant

interplay which can be influenced, we look at intrapersonal dynamics,
from small to large-scale flows. Change starts from the inside out with the
aspiration of human beings. It is nurtured from the outside in, with action
that makes the best use of tools and techniques. The POZE paradigm3
offers a multidimensional perspective that can be used to understand and
promote social change, via personal transformation and vice versa.
The changeover involves 4 stages that complement each other: A
new PERSPECTIVE on who we are, individually and collectively; which
enables us to pursue an OPTIMIZATION of the factors that condition
our behavior, as well as the influence of these factors on technology and
conversely the influence of technology on them. Once a fresh dynamic
is initiated it gradually dismantles the cycle of inequity. The journeys of
personal change and social transformation propel each other; taking the
individual traveler and humanity altogether forward to the best version of
itself, a ZENITH. We may never reach the final stage; because once we
reach what we thought was the ultimate goal, we find that the finishing
line has shifted. Rather than one zenith, there are many; we grow to grow
further, from one milestone to the next. Along the way we come closer to
our highest self. As we learn more about ourselves our perspective on life
changes; mental filters and misperceptions dissolve. The consequence is
EXPOSURE to reality as it is, including our own nature. This book looks
at the 4 phases that are involved in this process:
 PREFACE ix

Chapter 1 establishes the parameters of a PERSPECTIVE that is used

in the rest of the book. It presents the 4 dimensions that underpin indi-
vidual existence (soul, heart, mind, body), the 4 dimensions that deter-
mine society (individuals, communities, countries, planet), as well as 4
principles that rule throughout these dimensions (connection, change,
continuum, complementarity). Awareness of their existence and their
mutual influence conditions the outcomes of this journey. Once we know
what influences us, we can shape that influence in view of the desired
outcomes.
Chapter 2 investigates technological advances that may be conducive
or detrimental to the OPTIMIZATION of individual and collective
life-determinants. We look at the role that recent advances in high-
end technology may play to accelerate positive influence within and
among multiple dimensions. Because Acceptance of the dynamics that
underpin such influence conditions their optimization, which determines
the gradual fulfillment of our potential.
Chapter 3 goes into the undercurrents that influence the move from
complacency to compassion to change, or the ZENITH of humanity.
Certain aspects of our unexplored humanpotential in the context of high-
tech changes will be looked at from the micro (individual), meso (commu-
nity), macro (country) and meta (global) angles. Alignment is investi-
gated as both, a process and an outcome. Because the gradual alignment
(process) of the dimensions that shape our individual experience eventu-
ally leads to the Alignment (outcome) of individuals among each other,
and thus the overall synchronization of society. It should be mentioned
that the word ‘ZENITH’ is used here not as an ultimate point, but one
of many successive peaks along a path of continued improvement. Over
the course of our individual existence, as well as from one generation to
the next, many ZENITHs can be pursued—as with each stride “the head
above the line shifts, and the horizon expands” (Corominas 1987).
Chapter 4 concludes with a set of recommendations to increase the
likelihood of positive outcomes. The latter depend on EXPOSURE, to
reality as it is; including our own human nature. Knowledge is power,
and the latter entails Accountability. Once we are aware of the circum-
stances that influence our life, we are responsible to use that awareness
to optimize our internal and external influence for the betterment of
society. Awareness of the dynamics that underpin who we are, combined
with the aspiration of the common good, makes it then possible to
x PREFACE

create Aspirational Algorithms (AA); a type of technology that maxi-

mizes the benefits for all parties. The concluding recommendations relate
to the feedback-loop that causes and conditions human aspirations and
aspirational technology.
Differently said, the first chapter offers a new perspective or frame-
work to understand human beings and society. The second chapter looks
at technology, pointing out certain cornerstones of the tools that are of
interest in the ambition of optimizing social outcomes. The third chapter
brings both together and illustrates how the interplay of technology and
humanity may be beneficial. The fourth chapter concludes with a set of
suggestions that put human beings and Planet Earth front and center in
a future with technology. While the accent is herein put on offline/low-
tech solutions, two illustrations of the type of technology that makes the
best of artificial and natural assets for the common good of humanity are
offered.
The symmetry that underpins the POZE paradigm is reflected in the
structure of this book. It connects the different stages of personal change
(awareness, acceptance, alignment, accountability) to the 4 pillars of
social transformation (perspective, optimization, zenith, exposure). These
two sets of elements mirror the 4 dimensions of every individual (soul,
heart, mind, body) which relate to 4 complementary values that matter
for sustainable change (generosity, compassion, honesty, courage). The
schema below captures the terms that will be used in this book and their
interconnected logic. It is a snapshot that will be unpacked as we move
through the chapters (Fig. 1).

Tuebingen, Germany Cornelia C. Walther

 PREFACE xi

Perspective Optimization Zenith Exposure

Awareness Acceptance Alignment Accountability Individual and

collective wellbeing

Generosity Compassion Honesty Courage

Soul Heart Mind Body

internal external

Fig. 1 Interrelated stages of being and becoming. The symmetry that under-
pins the POZE paradigm is reflected in the logic that connects different stages of
personal change (awareness, acceptance, alignment, accountability) to 4 pillars of
social transformation (perspective, optimization, zenith, exposure). They mirror
the 4 dimensions of every individual (soul, heart, mind, body). In addition,
they echo 4 complementary values that matter for sustainable change (generosity,
compassion, honesty, courage)

Notes
1. In the present context we refer to the Common Good as that as attitudes
and actions that benefit society as a whole, in contrast to the private good
of individuals and sections of society (Encyclopedia Britannica).
2. This is in line with the paradox of progress that as stated by Nell (2019)
and described almost 150 years ago by George (1879).
3. POZE is based on the understanding that change starts from the inside out
and is nurtured from the outside in—as we will see in Chapter 1. POZE has
different meanings, it: (i) represents the 4 outcomes of the logic that under-
pins it (Perspective, Optimization, Zenith, Exposure); (ii) is an acronym
that encompasses the 4 core concepts of the paradigm (Purpose, Om,
Zoom, Expression); (iii) translates as ‘inner peace’ from Haitian Creole,
country where the dynamic began in 2017; and (iv) illustrates an exer-
cise to nurture inner peace daily (Pause, Observe, Zoom in, Experience).
Walther 2020-a. Furthermore, it stands for is the description of a move-
ment: People On Zenith Exploration. And, as will be seen in Chapter 4,
it reflects the layers of optimization covering Purpose orientation that tran-
scends personal interest, Optimism for the future; Zeal to achieve the best
xii PREFACE

outcomes for humanity; and Exploration of opportunities with the ambi-

tion to move beyond forgone conclusions. These relate to the overall aim
of OPTIMIZATION, yet they go deeper by establishing a more granular
mental matrix.

References
Corominas, J. (1987). Breve diccionario etimológico de la lengua castellana (in
Spanish) (3rd ed., p. 144). Madrid. ISBN 978-8-42492-364-8.
Encyclopedia Britannica. The common good. Retrieved November 2020, from
https://www.britannica.com/topic/common-good.
George, H. (1879). Progress and poverty: An inquiry into the cause of indus-
trial depressions and of increase of want with increase of wealth. New York:
Doubleday & McClure Co.
Kailash, D., & Lambertini, M. (2020). Why 2020 is the year to reset humani-
ty’s relationship with nature. Retrieved November 2020, from https://rb.gy/
iqfs3m.
Nell, E. (2019). Henry George and how growth in real estate contributes to
inequality and financial instability. Palgrave Macmillan.
 Acknowledgements

This book has organically arisen from the past four decades of my life, and
the millennia that preceded them. It combines past and future, applying
the POZE paradigm to an issue that is all-pervasive, and influences us
mostly under the radar. Technology is everywhere. It has been illustrating
human ingenuity since the onset of times, with a slim line to separate
danger from delight, and destruction from realizing the dream of a better
Society.
Every generation felt like the cusp of innovation, the peak of
humanity—and always more was to come. Today technology confronts us
yet again with the onset of radical transformation. And with it, the chal-
lenge to acknowledge and reconcile the two streams of human nature—
personal interest and the common good. Whether we zoom in on the
former or zoom out to embrace the latter, our choices influence the future
of technology and thus the course of society from hereafter.
Our understanding of the world is an organically evolving kaleidoscope,
ever changing. Thus, I am writing this book to honor many individuals—
those who travelled the road of questions before me; who walked with
me; and who will come later.
I am indebted to the thinkers whose discoveries led to the technology
that this book is about, with gratitude to those who remained unacknowl-
edged because they worked backstage. Scientific exploration would not be
possible without the unnamed who produce the hardware, the coders who

xiii
xiv ACKNOWLEDGEMENTS

translate overarching objectives into everyday scripts, the research assis-

tants who test and refine. Their efforts and sacrifices happen in silence, yet
the sum of their contributions is an inherent part of the scientific prowess
that we admire today.
It is impossible to list all of those who helped me along my journey in
writing this book. However, my parents, Barbara and Manfred Walther,
must be named as I would not be who I am without them being who
they are. Furthermore, I am grateful to Enrique Delamonica for his kind
and candid review of the manuscripts that led up to this book. Lastly,
I am grateful to Alina Yurova and Anne-Kathrine Bircher my fabulous
editors at Palgrave Macmillan and their entire team, especially Aishwarya
Balachandar for their continued support.
Finally, and foremost, Thank You—for choosing this book. Time is
rare, and mental real estate precious. I appreciate that you give me a
chance. Without you the content of these present pages will be forgotten
soon, drifting away with the trickle of time. If you find the present propo-
sitions valid, your action can make a difference for the dissemination of the
present perspective, and for those whose life is on the line as technology
moves ahead in gigantic strides. Us.
As always, I am eager to hear your feedback. Please get in touch via
LinkedIn or via the Contact section on https://www.poze.cc.
 Scope

This book looks at the changing continuum that links individuals, communi-
ties and society. An outline of Aspirational Algorithms (AA) and Valuable
Wearables is presented as tools to shift from an AI culture to the cultivation
of Augmented Humanity (AH).
The human mindset that is behind the design and use of technology deter-
mines the outcomes of technology. If the intended outcome is the common
good, then the preceding human aspiration must be geared towards that
goal. Only a technology that is conceived with the aspiration of a society that
lifts individuals to fulfill their potential can be a gamechanger for good.
Based on an understanding of the constant interplay between the 4
levels of human existence—soul, heart, mind, body, expressed as aspirations,
emotions and thoughts and sensations—technology may serve to systemat-
ically sway individuals from inspiration to desire, from informing to the
ignition of tangible transformation. This transition is explained along the
Scale of influence.
Two convergent and mutually influencing dynamics are analyzed: (1)
the influence of values and aspirations on the impact of technology; and (2)
the influence of technology on the attitude and action of users, and thus
the Society they evolve in. Both assess how hardware and software can serve
everyone to live a meaningful happy life.

xv
 Contents

1 Perspective 1
1.1 Principles 3
1.2 Individuals 4
1.2.1 The Body—Interface Between the Inner
and Outer Realms, Between the Self and Others 6
1.2.2 The Mind—From Mindless to ‘Mindfull’
to Mindful 7
1.2.2.1 Ir-Rationality: Thoughts, Errors,
Biases, and Decisions 8
1.2.3 The Heart—Harbor of Emotions 10
1.2.3.1 Thought/Bias > Bias/Emotion
> Emotion/Decision >
Decision/Behavior 11
1.2.3.2 Empathy Versus Compassion 12
1.2.4 The Soul—Essence of Who We Are 13
1.2.4.1 Values—The Anchor of Aspirations 13
1.2.4.2 The Golden Rule—A Golden
Standard 16
1.2.4.3 Mind and Matter 17
1.2.4.4 Purpose and Passion 18
1.2.4.5 Happiness and Meaning 18
1.3 Society 19
1.4 Influence 23

xvii
xviii CONTENTS

1.4.1 The Scale of Influence 23

1.4.2 Influencing Mindsets 26
1.4.3 The Inside-Out and Outside-in Principles 28
1.4.4 Why It Matters—The Common Good 31
References 35
2 Optimization 41
2.1 Technology: Treasure Chest—Black Box—Pandora’s Box 44
2.1.1 What Is the Role of Technology in the Quest
for Wellbeing? 45
2.1.2 From Blessing to Burden 47
2.2 Artificial Awareness 48
2.3 Algorithmic Influence 50
2.3.1 Priming Power 51
2.3.2 Facts Versus Opinions 52
2.4 Technological Treasure Hunt 55
2.4.1 Body—Overcoming Physiological Limitations 57
2.4.1.1 The Line Between Body and Brain,
Mind and Matter, Real
and Imagined Becomes Blurry 58
2.4.1.2 Human—Machine Transitions 60
2.4.2 Mind—Thinking Re-Thought 62
2.4.2.1 Quantity Enhances Quality 63
2.4.2.2 Quality Increases Quantity 63
2.4.2.3 Gather and Use 64
2.4.3 Heart—The Oxymoron of Artificial Emotions 66
2.4.4 Soul—Meaning-Making Machines 68
2.4.4.1 Riding the Curve of Challenges 70
2.4.4.2 From Self-Interest to the Common
Good 71
References 77
3 Zeniths 85
3.1 Micro—What Do We Value? 89
3.1.1 Under-Utilized Micro-Potential 91
3.1.2 The 4 Layers of Attitude 94
3.2 Meso—What Is the Role of Institutions in the Pursuit
of Human Values? 96
3.2.1 Under-Utilized Meso-Potential 98
 CONTENTS xix

3.3 Macro—What Is the Place of Culture and Legislation

in the Upholding of Values? 101
3.3.1 Under-Utilized Macro-Potential 103
3.4 Meta—What Position Hold Supranational
Institutions, Given the Global Reach of Technology? 105
3.4.1 Under-Utilized Meta-Potential 106
References 114
4 Exposure 121
4.1 Valuable Wearables. Digital Coaches 124
4.1.1 Digital Coaches 126
4.2 Aspirational Algorithms (AA) 128
4.2.1 Added Value of AA Versus AI 128
4.2.2 AA Prototype 133
4.3 From Potential to Personal Power 136
4.3.1 Micro-Dimension 137
4.3.1.1 Mind Muscles 137
4.3.1.2 Connection 137
4.3.1.3 Perspective Polishing 138
4.3.2 Meso-Dimension 138
4.3.2.1 Inspiration Islands 138
4.3.2.2 Compassion for Change 139
4.3.3 Macro-Dimension 140
4.3.3.1 Socratic Schooling—Reshaping
the Education System 140
4.3.3.2 Purpose for Power 140
4.3.3.3 Generalized Generosity 141
4.3.4 Meta-Dimension 142
4.4 Conclusion—Manifesting Augmented Humanity 143
References 156

Index 161
 About the Author

Cornelia C. Walther combines praxis and research. As a humanitarian

practitioner, Cornelia worked for nearly two decades with UNICEF
and the World Food Program in large-scale emergencies in West Africa,
South Asia and Latin America, mostly operating as head of communi-
cation. As coach and researcher, she collaborates since 2018 with the
Center for humanitarian leadership at Deakin University and serves as a
mentor within the Harvard Women in Defense and Diplomacy network.
Being part of the European Union’s Network on humanitarian assistance
(NOHA), she lectured for five years at Aix-Marseille’s Law faculty.
Aside from her interest in the multiple shapes of influence, Cornelia’s
focus is on social transformation from the inside out, looking at indi-
vidual aspirations as the point of departure. In 2017, she initiated the
POZE (Purpose, Om, Zoom, Expression) dynamic in Haiti, offering indi-
viduals tools to identify and pursue their aspirations. The network is
now expanding into the Americas, Africa, and Europe. Her objective is
to refine a methodology that influences people toward wanting to get
involved in social change processes, rather than obliging them to act for
the sake of others. She holds a Ph.D. in Law and is a certified yoga and
meditation teacher.
Books published by Macmillan Palgrave/Springer in 2020, include
‘Development, Humanitarian Action and Social Welfare’; ‘Humanitarian

xxi
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Fig. 333 Fig. 334 Fig. 335
 Fracture of upper end of Transverse fracture, with Line of fracture at junction
tibia. anterior displacement. of lower and middle thirds
(From the Buffalo of tibia.
Museum.)

While wire sutures may be used as freely as may be indicated it

will be well, at least in the majority of cases, to leave the ends
protruding in such a way that they can later be untwisted and
removed. The presence of wire after a certain length of time rather
interferes with the process of ossification than helps it.
Fractures of the lower end of the leg nearly always involve the
joint, to some extent at least, in respect of being accompanied by
sprain if nothing else. They are accompanied by displacement of the
foot, and are produced by violence, which first involves the foot. The
term “Pott’s fracture” is meant to include the injury originally
described by Pott himself. In the typical Pott’s fracture, as shown in
Figs. 336 and 337, there are a chipping off of the internal malleolus,
of the outer portion of the articular end of the tibia, and fracture of the
fibula a little above the joint. In spite of the classical description
which Pott gave fractures of the fibula alone, those accompanied by
tearing of the internal lateral ligament, or chipping off of the
malleolus, are frequently referred to under the same term. The more
complete the injury the greater the possibility for displacement.
Eversion and outward displacement, of course, are conspicuous.
Lesser degrees of injury are accompanied by less displacement, but
all of these injuries will be followed by extreme swelling of the ankle-
joint, which may at first make diagnosis somewhat difficult, because
of the extreme tenderness which prevents the handling necessary
for careful determination. It is not always easy to so completely
replace the bones, when we have the combination of three fractures
as above, as to get an ideal result. Nevertheless with suitable
treatment usually very useful limbs are secured. When the injury has
been made compound the difficulties are increased. Such a result
will not be obtained, however, unless the tendency to backward and
lateral displacement be overcome, when the limb is placed in its
permanent plaster-of-Paris splint, as it should be after a few days.
Great care should be given to this point in the management.

Fig. 336 Fig. 337

Pott’s fracture. (Hoffa.) Exaggerated deformity in Pott’s fracture.

 —Nearly all these fractures
Treatment of Fractures of the Leg.are likely to be followed by
swelling, even to a degree which makes it impracticable to put them
up in permanent dressing until the swelling has subsided. This
means a period of two to several days, during which the limb should
be kept absolutely at rest, and the bones maintained in apposition by
side splints, while the limb is restrained within a folded pillow or other
comfortable cushion. More frequently here than in any other part of
the body there will form blebs or large blisters, which are most liable
to occur in alcoholic subjects. The leg should be scrubbed and
shaved before putting on dressings, in order that the skin may be
reasonably clean before its surface epithelium is raised. Ecchymosis,
infiltration, and sometimes general edema may become somewhat
pronounced, and the splint which would be required to fit a limb
under these circumstances would soon be too large when this
disturbance has subsided. The limb should not, therefore, be placed
in a fixed or permanent dressing until it is in every respect ready.
While these disturbances are subsiding, or perhaps being
encouraged to subside by the use of an ice-bag or of cold wet
applications, extreme care should be taken that proper position and
apposition are maintained. This will at times need considerable
ingenuity. A delirious or maniacal patient would need restraint far
beyond that required for one who is rational and docile. Moreover in
all of these fracture cases which entail confinement to bed there is a
tendency to deficiency of elimination which will require judicious use
of laxatives and other eliminatives.
The writer prefers a well-molded set of side splints, properly
padded, to any other first dressing for fractures of the leg. A limb
thus dressed may be supported on a pillow and even made
adaptable for transportation should it be necessary to remove the
patient from one place to another. The fracture box can be well
superseded by this method.
So soon as swelling has subsided, plaster of Paris should be used
for a fixed dressing. The limb should be enveloped in a layer of
cotton, by which the skin is protected, within which swelling may
occur without much strangulation. Over this and down the front of the
leg a strip of thick pasteboard should be placed, which can be
moistened and made to adapt itself, or a strip of sheet tin, an inch
wide, which can be made to fit the part, and upon which one may cut
down later in removing the splint. This refers especially to the use of
the roller bandage saturated with plaster of Paris. Molded splints can
be made, as recommended for the upper extremity, out of surgeons’
lint, canton flannel, or old blanketing, while at the lower end of these
splints may be incorporated, with the plaster, a strip of bandage or
other material, by which a loop is formed beneath the foot, which
may be utilized for the purpose of traction.
The foot should always be placed at a right angle to the leg. If
there be too much muscle spasm to permit this, or make it too
uncomfortable, the tendo Achillis may be divided. This position
should be maintained during the period of repair, in order that so
soon as one resumes the use of the limb the foot may be planted
naturally upon the ground. In addition to this precaution it must be
noted that backward displacement is completely overcome, and that
eversion is perhaps a trifle overcorrected.
In all fractures of the lower end of the leg the foot and entire leg
should be enclosed in a bandage. In fractures near or above the
middle not only the leg but the lower part of the thigh should be
immobilized if the promptest and most satisfactory results are to be
obtained.
The limb being immobilized it soon becomes a question as to how
quickly the patient can leave the bed and begin to move about on
crutches. This will depend to some extent on the patient’s
temperament. Timid women are less desirous of getting out of bed
than are active men and children. Some patients acquire facility with
crutches very slowly. Others are so tenderly built that crutches give
pain and even produce crutch paralysis. It is advisable to get
patients at least into the sitting posture so soon as the immobilization
has been secured, while those inclined may be encouraged to use
the uninjured limb and move about with crutches. A foot and leg too
long kept off the ground will swell when again lowered. The later this
dependent position is attained the greater the liability to edema.
Patients should be cautioned about this.
The so-called ambulatory method of treatment has found favor
with some surgeons. This implies something more than merely
permitting motion with crutches; it means really such dressing as to
permit use of the injured limb in locomotion. The various forms of
splints used for immobilizing the limb in hip-joint disease may be
used in this way. A useful splint is made with body and perineal
bands, or an inside steel bar with ischiatic crutch and a cross-bar
below the sole of the foot, on which the weight of the body may be
supported. This is to be combined with a plaster-of-Paris support.
The ambulatory treatment is occasionally of value, but the
advantages claimed for it have not been generally sustained.

FRACTURES OF THE FOOT.

The astragalus and the calcis suffer more often than the other
tarsal bones, partly because of their size and partly because they are
in the line of transmission of force as usually directed after accident.
When the posterior end of the calcis is broken off there remains a
fragment which is easily palpated, and which would be displaced
backward and upward by the tendo Achillis were it not for the plantar
fascial fibers which are inserted into it. The bone may also be
comminuted, in which case that part of the foot will lose much of its
shape and distinctive peculiarities. The sole will be flattened, but
swelling and hemorrhage will at first be so great that there will be
much difficulty in recognizing the exact nature of the injury.
The astragalus is usually broken by being caught between the
calcis and the lower end of the leg. It is generally broken through the
line of its so-called neck. Not infrequently one or more of the
fragments is forced out of place, usually beneath the anterior
tendons. When such extensive displacement occurs the fragments
should be removed if the fracture is compound. In both of these
bones results are generally satisfactory when displacement is not
marked, also after removal of the entire astragalus. The foot and leg
should be immobilized in the best possible position, and this can be
best accomplished within a plaster-of-Paris dressing.
In regard to the tarsal bones, diagnosis can now be made
accurately by the use of the x-rays. These bones, according to
Eisendrath, may be fractured in any one of the following ways: (1)
Compression, as when the weight of the body is violently thrown
upon the feet; (2) sudden dorsal flexion, often with fracture of the
inner malleolus; (3) forced supination or pronation, the interosseous
ligaments being stronger, the bones forcibly pulling the latter apart;
(4) violent traction upon the heel through the calf muscles, by which
the tuberosity of the calcis may be torn from the rest of the bone; (5)
extensive crushing injuries, in which several tarsal bones may be
involved; (6) gunshot fractures. Some assistance in diagnosis may
be obtained by computing the distance from the malleoli to the
bottom of the heel, which will be shortened when the bones are
compressed; or shortening of the length of the foot, or by fixed
abnormal positions.
The metatarsal bones are broken by direct violence, the first and
fifth being most exposed. As in other fractures of the foot contusion
will be a serious feature, and swelling and laceration will frequently
seriously complicate, while the fractures themselves may be
compound. The same is true, also, of fractures of the phalanges,
crushing and comminution being common. The matter of treatment
often includes an estimation of the blood supply and of the vitality of
the distal portion. The operator may sometimes temporize with an
antiseptic dressing until this matter is settled. Simple fractures
require only immobilization in good position.
 C H A P T E R X X X V.
DISLOCATIONS.
A sprain has already been described as a momentary change of
emplacement or disturbance of the normal relations between joint
surfaces, which, so far as displacement is concerned, is but a
momentary affair and is promptly overcome. The term dislocation
implies something more permanent as well as complete in both
respects. It indicates an absolute and direct separation of articular
surfaces of much more than momentary duration and requiring
skilled assistance for its reduction. It pertains to articular surfaces
which are enclosed within a capsule. The term luxation is
synonymous with dislocation. When the condition is evidently partial
or incomplete it is often referred to as subluxation. As compared with
fracture dislocations are about one-tenth as frequent.
Dislocations are described as compound when through a co-
existing wound air may enter the cavity of the joint, and as
complicated when accompanied by other lacerations or injuries.
When unaccompanied by these conditions they are described as
simple.
To dislocations which result from external violence or from sudden
muscular action is given the term traumatic. Pathological dislocations
are those which are brought about by slow morbid processes,
muscle spasm being the most prominent factor in their production. A
third variety of dislocations, the so-called congenital, do not belong
strictly in this class; by common consent the term is applied to
congenital abnormalities where, from errors in development, normal
emplacements and relations are altered.
The distal bone is the one described as that which is dislocated;
thus we speak of dislocations of the forearm upon the arm, of the leg
upon the thigh, etc.
Subluxations or incomplete dislocations are frequently
accompanied by fracture of a bony prominence, e. g., the rim of the
acetabulum, the coronoid process of the ulna, etc. The direction in
which the distal member of the joint has been displaced is indicated
by one of the common terms, as forward, inward. A consecutive or
secondary dislocation implies a shifting of position from that at first
occupied by the displaced bone end. These injuries may occur at
any age, although usually during the more active period of life, from
childhood to middle age, when mankind are more subject to injuries.
Certain conditions predispose to dislocations. Abnormalities or
previous injury or disease of joint structures figure especially in this
respect. A joint already relaxed by hydrarthrosis will exercise a
relatively small restraining influence and a subluxation, at least, may
easily occur.
The immediate cause is violence, either from without or within,
generally the former. This may be direct, as from a blow, or
transmitted, as when the shoulder is displaced by a fall upon the
open hand. It occasionally happens that the component bones of a
dislocated joint were in a position of extreme flexion or extension at
the time of injury. The factors of leverage and spiral tension or
wrenching are also important ones. Luxation from muscular activity
is occasionally met with; most frequently when the lower jaw is
dislocated by the act of yawning or violent laughter. The shoulder
has been displaced in a violent effort at throwing or pitching a ball, or
in wild gesticulation.
A few individuals have been in the habit of exhibiting themselves
whose normal ligament and joint arrangements are so lax that they
can voluntarily displace one or more of them and as easily replace
them. These may be spoken of as instances of voluntary dislocation.
A joint once displaced may never fully recover its normal degree of
tension, and will yield more readily to subsequent similar injuries. In
this way there may occur so-called recurrent or habitual dislocations.
Expressions of this kind are seen most often in the lower jaw and in
the patella.
Actual injury to tissues is to some extent unavoidable. In arthrodial
joints the capsule is nearly always lacerated, at least upon one side.
In hinge joints both lateral ligaments are likely to be ruptured. It is
probable, however, that about the maxillary joints the ligaments may
stretch without tearing to any extent. Not only are ligaments torn, but
bony prominences are frequently detached, while sometimes there is
extensive tearing away of tissue.
In connection with these injuries to joints proper other
complications may occur, such as fractures of prominences about
joints and epiphyseal separations, or such injuries as compound
fracture of the neck of the humerus with dislocation of its head.
Furthermore, bloodvessels are occasionally lacerated and nerves
are frequently injured. This latter lesion is liable to occur after
shoulder dislocations, the head of the bone injuring the circumflex
nerve, paralysis of the deltoid being the consequence. This is a
feature of the injury, and yet the result has often been unjustly
imputed to the physician in attendance. Even a momentary
contusion of the nerve may be followed by lasting effects, for which
the medical attendant should be held blameless. Other injuries, e. g.,
contusions or lacerations of nerves, may occur about any of the
joints.
Dislocations of the spine subject the cord to a special class of
injuries which will be dealt with later in this work. In very rare
instances the head of the humerus has been forced within the thorax
or the head of the femur within the pelvis, these, injuries being
practically always fatal.
Compound dislocations rarely occur about the jaw or shoulder.
They pertain usually to the joints below. In every case of such
character the question will be promptly raised whether a more or less
complete exsection of the joint will not be preferable to mere
reduction with the ensuing probability of ankylosis. Such injuries will,
under all circumstances, require aseptic measures.
So far as repair is concerned, dislocations by themselves are so
rarely fatal that there have been but few opportunities for a study of
tissue recovery under these circumstances. It is apparent that repair
is complete, for after almost any simple dislocation there is
restoration of function.
The obstacles to reduction are spasm of muscles pertaining to the
injured limb, by which the dislocated bone end is firmly held in its
abnormal position, and, in those joints provided with a capsule, the
fact that the head of the bone is frequently forced out through a
comparatively small opening, through which it is only with the
greatest difficulty reduced. It is a part of the manipulation in most
cases to enlarge this rent in the capsule, after which reduction is
comparatively easy, although impossible until it is accomplished.
Dislocations which have long gone unreduced are called old,
inveterate, or ancient. By common consent a period of six weeks has
been fixed, beyond which the dislocation is spoken of as old or
ancient; up to that time it is usually described as unreduced. In
proportion to the length of this period the difficulties of reduction are
materially enhanced. So soon as a dislocated joint has been put at
rest, i. e., fixed by muscle spasm and by the timidity of the patient,
the blood which has been poured out will begin to coagulate and
conditions are soon favorable for organization of clot and formation
of adhesions in abnormal position. In the course of a few weeks
these adhesions become strong, and in the course of months they
are frequently stronger than the bone itself, which has been disused
and has undergone a certain amount of fatty atrophy. Thus it
happens that even with well-directed effort the bone will yield before
the adhesions, and thus, in spite of every precaution, fracture
sometimes complicates the effort to reduce these ancient
dislocations.
So generally is this fact now recognized that surgeons do not
hesitate to make open incisions for the purpose of separating
adhesions and reopening what remains of the capsule in the
endeavor to replace the head of a bone. Nor do they hesitate
sometimes to cut down upon the latter and exsect rather than run the
risk of more extensive injury.
Efforts at reduction under these circumstances subject the patient
not only to risk of failure, or of fracture of bone ends, but to rupture of
vessels or laceration of nerve trunks. I recall seeing one case of
enormous traumatic aneurysm of the axillary artery which was
brought about by unsuccessful attempt in this direction.

SYMPTOMS AND DIAGNOSIS OF DISLOCATIONS.

The cardinal indications of a dislocation are deformity with
alteration in contour and position of the affected joint. It usually
happens that the dislocated bone ends cannot be felt in normal
position, but are felt somewhere else in the vicinity. About the
shoulder and hip of stout or fat individuals it may not be easy to feel
the head of the bone, but unless the case be complicated by a
fracture it can usually be detected by aid of anesthesia. The
deformity may include a lengthening or shortening of the limb,
apparent or real, as well as abnormal eversion or inversion, or other
peculiarity of position.
Whatever alterations in position appear will be accentuated by
spasm of the muscles which pertain to the movement of the affected
joint or even of the entire limb. These are usually so tightly
contracted as to form a complicating feature of such cases and to
lead to that loss of mobility which is diagnostic of every dislocation.
Limitation of motion is not entirely a matter of muscle spasm. It is not
under voluntary control and subsides only under anesthesia. To
some extent motion may be limited by escape of the head of a bone
through a small rent in the enveloping capsule, by which it is
afterward tightly clasped. This is particularly true of the shoulder and
hip. Certain dislocations of the fingers or thumbs are also made
more rigid by fixation of the tendons, which become tightly stretched
within the neighboring tendon sheaths.
A sort of crepitus, which may be easily mistaken for that of
fracture, is occasionally detected during the examination of a
dislocated joint. It lacks the peculiar grating character of true bony
crepitus.
In addition to these features there are certain subjective
symptoms, of which loss of function is the most prominent, while
pain is a more or less frequent but variable accompaniment, and
dependent on the amount of tissue injury or pressure upon nerves.
Moreover, the displacement once completely rectified (“reduced”)
does not tend to recur, as is the case with fractures.

PATHOLOGICAL AND CONGENITAL LUXATIONS.

The statements made above refer almost entirely to recent and
traumatic dislocations.
Pathological dislocations are those which are produced gradually
and through the mechanism of disease affecting the joint structures.
The head of the bone is gradually drawn out of the acetabulum, in
tonic spasm of hip-joint disease, by the continuous action of
muscles, the result being the complete displacement of the bone
from its original socket, or what is known, at the hip, as the migration
of the acetabulum, where its upper margin, being softened by
disease, is gradually extended and altered, so that the femoral head
rests an inch or more higher upon the side of the pelvis than is
normal. Pathological dislocations, then, may occur both in the course
of the infectious joint diseases as well as in the neuropathic.
Congenital luxations are those which occur from defect in the
shape or arrangement of joint structures, permitting a departure from
the normal standard. While no joint in the body is exempt from
abnormalities of this description, the congenital hip dislocations are
those which have attracted attention by their frequency and the
disability which they produce.
While the general character of these changes is easily made out
by the ordinary methods of examination, coupled with a suitable
history, a well-made skiagram will tell at a glance a story which it
may take some effort to elicit by other means; hence radiography
has here been of great value to the surgeon. Congenital dislocations
are devoid of nearly all the features which characterize traumatic
dislocations, and their consideration will be found in the chapter on
Orthopedics.
Differential diagnosis as between fractures and dislocations is not
always easy. Furthermore it is frequently the separation of a
prominence by fracture which permits of dislocation, this being
particularly true of the elbow and the ankle. The extent of a fracture
may seriously complicate the problem of treatment, as, for instance,
when the head of the humerus is not only dislocated below the
clavicle but separated from the shaft by fracture at the surgical neck.
A dislocation made possible only by fracture will not remain reduced
as will one which is simple and uncomplicated, while it will display
even a greater amount of motility and displacement. Other
complications may occur, many of which are common both to
dislocations and to fractures in the vicinity of joints, such as
lacerations of bloodvessels or nerve trunks, pressure upon the latter,
compound injuries with infections, etc.
 TREATMENT OF DISLOCATIONS.
The essential requisite of every case is complete reduction or
replacement of the dislocated bone end. The earlier this is attempted
the better the result. Brief as such a statement is, dislocations
frequently offer considerable difficulties, both in reduction and in
maintenance in proper position with the necessary physiological rest
of the injured part. Thus dislocations of the clavicle, which can hardly
occur without considerable injury to the ligaments, may be reduced
with slight effort, but are kept in place with difficulty. The simplicity of
the after-treatment is proportionate to the difficulty experienced in
reduction, so that while “to put the part in place and keep it there”
sounds very simple, it will often perplex the ingenuity of the surgeon.
Reduction having been effected, rest is the essential feature of the
after-treatment, which should be absolute for a few weeks and
relative for many months. Should reaction be extreme, ice-cold
applications will afford relief.
The causes which prevent reduction of dislocation are either those
attributable to ignorance, carelessness, or failure in diagnosis on one
hand, or, on the other, mechanical difficulties, including “button-
holing” of the capsule around the expanded end of a bone or the
interposition of some of the adjoining tissues. Dislocations of the
class referred to above as unreduced or ancient, offer great
difficulties, proportionate to their duration, which are due to the
formation of adhesions that sometimes take place and become very
dense. Judgment, skill, and effort are needed in their management.
A dislocation which has become unreducible is only to be treated by
arthrectomy and the establishment of a false joint. Nevertheless in a
small proportion of cases, especially of the hip and shoulder
dislocations, the adhesions which first form gradually relax, and in
time there is formed a natural substitute for a joint which may be
regarded as a nearthrosis, and which will sometimes prove as
serviceable as any result afforded by arthrectomy. The duration of
time after which reduction is impossible or impracticable varies so
widely with different cases that it can scarcely be stated. It rarely is
more than a few months and often but a few weeks. It is greater
when it is a ball-and-socket joint which is affected.
 Nearly everything that has been stated in the previous chapter
concerning compound fractures applies here to compound
dislocations. They are subject to the same dangers, both of infection
and of injury to important adjoining structures. There is the same
necessity for aseptic management if the case be seen early, and for
antiseptic treatment, including drainage, if seen late. In many
instances there is so much liability to subsequent ankylosis that the
first treatment may well be made to include an arthrectomy, or the
total removal of a small bone, e. g., the astragalus. Fortunately
compound features are less frequent in dislocations than in
fractures.

SPECIAL DISLOCATIONS.

DISLOCATIONS OF THE LOWER JAW.

Unless accompanied by fracture there is but one direction in which
the condyle of the inferior maxilla can be dislocated, i. e., forward.
One side or both may be affected, i. e., dislocation may be unilateral
or bilateral, the latter being more frequent. It is rare during the
extremes of age, and most common during middle life. There is
considerable variation in the degree of tension of the capsule of the
maxillary joint. In some it is so loose that dislocation may occur
during the act of yawning or vomiting. Ordinarily it occurs only as an
expression of violence from without. By a blow which shall thrust the
jaw forward, whether the mouth be closed or open, the ramus may
be made to carry the condyle over the articular eminence. The
capsule is not necessarily torn, but is always tightly stretched, while
as a reflex result the temporal muscle is thrown into a condition of
tonic spasm by which the jaw is fixed and firmly held in its abnormal
position. This produces the symptoms, then, of a more or less widely
opened mouth, with rigidity and inability to close it, with protrusion of
the chin and tense contraction of the temporal muscle, which can be
easily recognized. When the dislocation is unilateral the symptoms
are essentially the same, save that the protrusion is toward the side
that is injured.
 Treatment.—The method of reduction is simple and consists in
depressing the angle of the jaw, while, at the same
time, the chin is supported and carried both upward and backward. If
temporal spasm be not too pronounced the reduction is rather easy
and may be effected while the patient is seated in a chair, the
surgeon standing in front of him and grasping the jaw with the fingers
of each hand, while the thumb is utilized within the mouth to press
the angle of the jaw downward and backward. At the same time the
fingers should lift the chin. The operator should protect his thumbs
by wrapping them with some material in order that they may not be
injured by the patient’s teeth. Should muscle spasm offer much
resistance it would be well to administer nitrous oxide or one of the
other anesthetics, at least to the point of primary anesthesia, with
sufficient relaxation of muscle to make reduction easy. When once
this has been effected the lower jaw should be bound to the upper
and kept at rest for at least two weeks. When this injury has taken
place it is likely to recur with much less effort until it becomes almost
a habit.

Fig. 338 Fig. 339

Reduction of dislocation of lower jaw.

 There is a condition of relaxation of the capsule and elongation,
with abnormal loosening of the interarticular fibrocartilage, peculiar to
this joint, by which it has too free play, to such an extent that a
clicking sound in its movements may be frequently heard by others
than the patient. This condition is either congenital or the result of
previous injury, and is one for which little can be done, although this
explanation should be afforded to all who suffer from it.

DISLOCATIONS OF THE LARYNX.

The cartilages of the larynx are sometimes displaced as the result
of direct violence applied to the anterior region of the neck. Almost
any lesion of this character may take place between the independent
cartilages of the larynx or the attachments of the larynx to the hyoid.
The injury may simply give rise to pain and soreness, or may cause
so much interior damage as to be quickly followed by edema of the
glottis and suffocation. If the latter be impending a quick tracheotomy
should be done, after which time may be afforded for such
replacement as may be required, by manipulation, and subsidence
of swelling with relief from occlusion of the respiratory tract.

DISLOCATIONS OF THE STERNUM.

The various portions of the sternum, especially the upper and the
lower, may be displaced as the result either of direct violence by
forcible backward flexion, or by muscular action accompanied by
flexion of the trunk and neck. When the latter, it is usually forward;
when produced by violence, it is usually backward.
These displacements are sometimes so easily reduced by mere
pressure as to make it almost impossible to retain them. At other
times anesthesia with firm pressure, accompanied by flexion of the
trunk backward or forward, may be required; reduction has been
possible sometimes only through incision and by the use of
instruments applied as levers, or by the use of a screw driven into
one of the fragments, thus affording a handle by which to manage it.
Serious dislocations are frequently accompanied by fractures of the
ribs or of the sternum. The same fixation of the thorax is required as
in fractures of these parts, and should be conducted in the simplest
manner possible.

DISLOCATIONS OF THE RIBS.

To displace a rib from its sternal connections requires actual
fracture of bone or cartilage. Forward dislocation at its posterior and
spinal connection, especially of the eleventh and twelfth ribs, has
been described. Considerable effort is necessary for its production,
and the case should be treated on its individual merits.

DISLOCATIONS OF THE CLAVICLE.

Either end or both ends of the clavicle may be dislocated. Its
sternal end may be thrown in any direction but downward; its
acromial end in any direction, although usually upward. Dislocations
of the sternal end can only occur in consequence of serious damage
to the sternoclavicular ligaments, because of which, and in the
absence of a socket, it is extremely difficult to maintain the parts
when restored to position. Violent backward traction upon the
shoulder permits anterior displacement when the joint is thus
weakened. Backward displacement is usually the result of indirect
violence when the shoulder is forced forward and inward, while
upward displacement is the result of tilting which occurs when the
shoulder is violently depressed. Respiration is generally more or less
disturbed, while in backward luxations deglutition may be made
difficult and painful.
Reduction is not difficult to effect, but extremely difficult to
maintain. Pressure in the proper direction, accompanied by traction
upon the shoulder, suffices for the former. For the latter there should
be a combination of fixation of the shoulder and arm with proper
traction, and at the same time pressure upon the end of the clavicle.
For all of the clavicular dislocations the dressing and position
advised by Dr. Moore, of Rochester, and referred to in the chapter on
Fractures as his double figure-of-eight, serves admirably for
maintaining the proper position of the shoulder, while pressure can
be made by a pad, retained either by adhesive plaster or by some
further addition to the dressing itself. (See p. 494.) Acromial
dislocation is usually in the upward direction, and is produced by
violence upon the shoulder, which has expended itself in rupturing
ligaments rather than in fracturing the acromion process. The
indication here is to keep the shoulder elevated by any dressing
which will accomplish the purpose and the clavicle bound down.

Fig. 340

Position of clavicle in dislocation of sternal end upward.

Dislocation of both ends, i. e., complete loosening of the bone,

occurs occasionally, in which case the indications already given are
reinforced, while the difficulties of treatment are considerably
aggravated. Here the shoulder should be kept upward, outward, and
backward, and the clavicle retained by pressure or some other
means.
Treatment.—Clavicular dislocations yield fair results to intelligent
treatment. Ideal results are difficult to secure without
coöperation on the part of the patient. Functional results, however,
are usually satisfactory.

DISLOCATIONS OF THE SHOULDER-JOINT.

The upper end of the humerus is attached to the margin of the
glenoid cavity by a capsule which has a certain degree of elasticity,
and which resembles a short section of a sleeve or a cuff. It is
sufficiently loose to permit a wide range of motion, and were it not for
the acromial process above it there would be as much motility in the
upward direction as in any other. It is not the capsule which keeps
the articular surfaces together, but the tension of the muscles which
are wrapped around the shoulder-joint, all of which contribute to this
effect. The glenoid cavity is made a more complete socket by a
fibrocartilaginous rim. Thus a certain degree of subluxation or
displacement may be permitted without very serious damage to this
rim and capsule, but a complete dislocation is hardly possible
without more or less laceration. The prominence and exposure of the
joint and its natural freedom of motion help to account for the fact
that more than half of all dislocations occur here, and that this rarely
ever occurs in children or in the aged, in whom the violence which
may be expanded produces either epiphyseal separations or
fractures of the surgical neck. The relation of structure to function
also accounts for their far greater frequency (i. e., four to one) in men
than in women. The influence of atmospheric pressure should not be
forgotten, as in the shoulder this affords a force of some fifty pounds,
and in the hip of nearly double that amount, of pressure.