De Medicina

Celsus, Aulus Cornelius

Celsus, Aulus Cornelius. De Medicina. Spencer, Walter George, translator. Cambridge, MA: Harvard University; London, England: W. Heinemann Ltd, 1935-1938.

12 The lower jaw is displaced forwards, sometimes on one side, sometimes on both. If on one side, it inclines with the chin to the opposite side, the teeth do not correspond with their fellows, but the canine are under the incisors. But if on both sides, the whole chin is moved forwards, and the lower teeth stick out beyond the upper ones; and the muscles above appear tense. As soon as possible the patient is to be seated on a stool, with an assistant behind holding his head, or with his

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back against a wall and a hard leather cushion between the wall and the back of his head, against which his head is firmly pushed by the assistant, to keep it from moving. Then the surgeon's thumbs, which have been wrapped round with strips of linen or bandages so that they may not slip, are inserted into the mouth whilst the fingers are applied outside. When the jaw has been grasped firmly, if it has slipped forwards to one side, the chin is to be pressed down towards the throat with a jerk. Then simultaneously the head is firmly held, and the chin being raised the jaw is forced back to its place, and the mouth is closed so that all this is done almost with one movement. If it has been dislocated on both sides all the same movements are to be done except that the jaw is forced straight backwards. When the bone is in its place, if the accident has been attended with pain in the eyes and neck, blood is to be let from the arm. For all patients with dislocated bones, a more liquid diet is proper at first, but especially in this case, since even talking, as it causes constant movement of the mouth by means of the sinews, is harmful.

13 As I stated in the first part, the head is held by two processes, inserted into two cups in the highest vertebra. These processes sometimes slip out backwards; with the result that the sinews under the occiput are stretched, and the chin fixed to the chest; the man cannot drink or speak, and sometimes has involuntary emission of semen; upon these symptoms death very quickly supervenes. Now I

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thought this condition should be described, not that there is any treatment for it, but that it may be recognized by these indications, and that those who have lost someone in this way may not deem the medical man to have been at fault.

14 The same fate awaits those whose spinal vertebrae have been dislocated; for this cannot happen without rupture of the marrow in the middle of them, and of the two little membranes which pass oust between the two processes at the side, and of the sinews which hold them together. But the vertebrae may slip pout both backwards and forwards, above the diaphragm or below it. The direction of the displacement is indicated either by a swelling or by a hollow at the back. If it happens above the diaphragm, there is paralysis of the arms, and vomiting or spasm follow, breathing is difficult, pain is severe, and hearing blunted. If below the diaphragm, the lower limbs are paralysed, the urine is suppressed, or sometimes is passed involuntarily. From such accidents the man dies more slowly than when the head is displaced, yet within three days. As for what Hippocrates said, that when a vertebra has been displaced backwards, the man is to be laid out on his face, and stretched out, while an assistant presses his heel upon the displaced bone and pushes it inwards, that procedure is only to be adopted when the bone has slipped out a little, not if there is a total displacement. For occasionally weakness of the sinews causes a vertebra, although not displaced, to project a little, either backwards or forwards. This is not a fatal accident, but we cannot press upon a vertebra from within; it cannot even be touched; and if it is pressed upon from outside,

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it generally slips back again, unless, as very rarely happens, the strength of the sinews is renewed.

15 Passing to the humerus, it is sometimes put out into the armpit, sometimes forwards. If it is dislocated into the armpit, the elbow stands out from the side; again, this elbow, together with the upper arm, cannot be raised to the level of the ear on the same side, and that forearm is longer than the other. But if forwards, the upper forearm can be stretched out, but not to its full extent; and it is more difficult to stretch out the elbow forwards than backwards.

So if the upper bone has slipped out into the armpit and the patient is still young or supple, at any rate if the sinews are not very powerful, it is sufficient to have him held on a stool; one of the two assistants is directed to press gently upon the head of the blade-bone, while the other stretches the forearm; then the surgeon seated behind thrusts one hand into the point's armpit, presses the bone up with this hand, and with the other presses the elbow to the side. But for a more powerful patient, with stronger sinews, a wooden board is required, two fingers thick, and lon enough to reach from the armpit to the fingers; the upper end is rounded and slightly hollowed to admit a small part of the head of the humerus. In three places in this, with a space between, are two slots through which soft straps are passed. And this board, covered with bandage to avoid injury by contact, is so applied from the forearm to the armpit, that its upper end is put under the armpit: it is then tied to the limb by its

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straps, one just below the head of the humerus, the second a little above the elbow, the third short of the wrist, to which purpose the two spaces between the six holes are adapted. The limb so fixed is passed over a rung of a poultry ladder at such a height that the patient himself cannot stand firmly; and whilst his body is allowed to sink down to one side, the limb is stretched on the other side; and thus it comes about that the top of the humerus is forced upwards into place by the top of the board, sometimes with, sometimes without a sound. It is easy to learn that there are many other methods by reading Hippocrates alone, but no other has met with more approval in practice.

But if the humerus is put out forwards, the man is laid on his back and a bandage or a leather strap passed under his armpit, the ends of which are handed to one assistant behind the man's head and his forearm to another assistant; and it must be arranged that the former pulls the strap, the latter the forearm. Then the surgeon should thrust back the man's head with his left hand, whilst with his right he raises the elbow together with the upper arm and forces the bone back into place; and reduction is easier in this case than in the previous one.

When the bone has been replaced, the armpit is filled with wool; if the bone had moved backwards, to prevent it from slipping back; if forwards, to make the bandaging more effective. Then the bandage must first pass under the armpit and control the head of the bone, then stretch across the chest under the opposite armpit, next over the shoulder-blades and again back to the head of the same arm-bone,

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and it is to be carried round several times in the same way until bone is well held. The bone when bandaged in this way is held in place more comfortably if it is also bandaged close to the side.

16 From what was said at the beginning of this book, it can be understood how the three bones, humerus, radius and ulna, meet together at the elbow. If the ulna which is connected to the upper arm slips away from it, the radius which is joined to the ulna is sometimes dragged with it, sometimes remains in position. The ulna can slip out in all four directions: but if it is dislocated forwards, the forearm is extended and cannot be flexed; if backwards, the forearm is flexed and cannot be extended, and it is shorter than on the opposite side; sometimes this causes fever and bilious vomiting. If the ulna has been dislocated outwards or inwards, the forearm is stretched but a little bent towards the part from which the bone has receded. Whatever has happened, there is one method of treatment which holds good not only for the ulna but also for all long bones which are connected at their articulation by a long head. Each limb is to be pulled in opposite directions until there is a gap between the bones. Then the bone which has fallen out of place is forced into the opposite direction from the position into which it has slipped. The methods of extension, however, are various according to the strength of the sinews, and the direction in which the bones have given way. And sometimes only the hands are used, sometimes other means have to be applied. Thus if the ulna has slipped for-

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wards, extension by two hands, at times aided by straps, is sufficient; then some round object is to be put in front of the biceps and the ulna suddenly flexed over it towards the upper arm. But in other forms of displacement, it is best to stretch the forearm as described above for fracture of the elbow and then to replace the bones. The rest of the treatment is the same as in all other cases; only the dressing must be taken off more quickly and more often and there must be more plentiful fomentations with hot water, and more prolonged rubbing with oil, nitre and salt. For whether the elbow remains out of place or is put back again, callus forms more quickly round it than round any other joint, and if this callus has grown through resting the joint it prevents flexion afterwards.

17 The hand also may be dislocated in all four directions. If it has slipped out backwards, the fingers cannot be stretched out; if forwards, they do not bend; if to either side, the hand is turned in the opposite direction either towards the thumb or towards the little finger. It can be replaced without difficulty. The hand, supported on a hard and resistant object, must be stretched one way, the forearm the other, in such a way that the hand is palm downwards if the bone has slipped out backwards, palm upwards if forwards; if the displacement is inwards or outwards, upon the side. When the sinews are sufficiently stretched, the surgeon's hands push back the bone, in the opposite direction to the side to which it has slipped. Where

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the dislocation is forwards or backwards, some hard object is placed upon the hand, and pressed on the projecting bone, and by this additional force the bone is more readily pushed back into place.

18 In the palm also bones are sometimes moved from their places, either forwards or backwards; for they cannot move sideways because of the bones on either side. There is but one sign, and that common to all, a swelling over the displacement, a hollow at the spot from which the bone has receded. But without extension the bone is returned into its place imply by firm pressure with a finger.