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.
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
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,
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-
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
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.
19 Now the fingers can be dislocated in almost as many ways as the hand and the signs are the same. But in stretching these less force is required, for the joints are shorter and the sinews less strong. They only need to be stretched out on a table, when the dislocation is forwards or backwards; then reduction is made with the palm of the hand; but when the displacement is to one side, by means of the surgeon's fingers.
20 Since I have described the above, I can be held also to have described displacements in the legs: for in this kind of accident also there is some similarity between the thigh and upper arm, between the tibia and ulna, between the foot and the hand. But there are also some special points to note about the legs.
The thigh-bone may be moved out of place in all four directions, oftenest inwards, next outwards, very rarely forwards or backwards. If it has been dislocated inwards, the leg is longer than the other, and is bowed; for the point of the foot looks outwards;
21 It is very well known that the knee is put out externally and internally and backwards. Many have written that it does not slip out forwards; and this may be very near the truth, for the knee-cap
22 The ankle can be dislocated in all fought directions. When it slips inwards, the sole of the foot is turned outwards; when outwards, the contrary sign is exhibited. If the ankle is dislocated forwards, the broad sinew behind is hard and tense, and in those cases manipulation is required; if backwards, the heel is almost hidden and the sole is elongated. But this is also replaced by manipulation, the foot and leg first being stretched in opposite directions. And after this kind of accident also, the patient should stay for a long while in because, lest the ankle, which sustains the whole weight of the body, should give way and again be displaced if the sinews have not gained strength enough for bearing the weight. At first low shoes should be worn, so that the ankle may not be injured by tight lacing.
23 The bones of the sole of the foot may come out like those of the hand, and are set after the same fashion. Only the bandage should also include the
24 For the toes the same treatment is required as was laid down for the fingers. But the middle or end joint when replaced may be fixed in some kind of gutter splint.
25 This is the treatment for those cases in which no wound accompanies the dislocation. . . . In these cases too there is not only great danger but it is more serious, the larger the limb, and the more powerful the sinews and muscles controlling it. Hence in the case of the shoulder and hip joints there is risk of death: and if the bones are set, there is no hope at all; if not, there is still some danger, and in either case the nearer the wound is to the joint the greater the cause for anxiety. Hippocrates said that no such dislocation could be replaced safely except those of fingers and toes, and feet and hands, and even in these cases it was best not to be in a hurry. Some have also replaced elbows and knees; and have then let blood at the elbow, lest gangrene and spasm should arise, after which generally in such cases an early death follows. Even a finger, in which the damage and therefore the damage is least, ought not to be reset whilst there is inflammation, or indeed at a later stage when the condition is of long standing. Moreover, when after replacement the sinews become tense, the bone should at once be put out again. Where there is a dislocation and a wound as well, the limb which has not been seet should lie in the position easiest