The workes of that famous chirurgion Ambrose Parey translated out of Latin and compared with the French. by Tho: Johnson. Whereunto are added three tractates our of Adrianus Spigelius of the veines, arteries, & nerves, with large figures. Also a table of the bookes and chapters.

The FOURTEENTH BOOK: Of Bandages, or Ligatures. (Book 14)

CHAP. I. Of the differences of Bandages.

BAndages, wherewith we use to binde, do much differ amongst themselves:* 1.1 But their differences (in Galens opinion) are chiefly drawn from six things; to wit, their matter, figure, length, breadth, making, and parts whereof they consist. Now the matter of Bandages is threefold; Membranous or of skins, which is accommoda∣ted peculiarly to the fractured grisles of the Nose; of Woollen, proper to inflamed parts, as those which have need of no astriction; of Linnen, as when any thing is to be fast bound; and of Linnen cloaths, some are made of flax, other some of hemp, as Hippocrates observes.* 1.2 But Ban∣dages do thus differ amongst themselves in structure, for that some thereof consist of that matter which is sufficiently close and strong of it self, such are the membranous; others are woven, as the linnen ones. But that Linnen is to be made choice of for this use, and judged the best,* 1.3 not which is new & never formerly used, but that which hath already been worn, and served for other uses; that so the Bandages made thereof, may be the more soft and pliable: yet must they be of such strength, that they may not break with stretching, and that they may straitly contain and repell the humor ready to flow down, and so hinder it from entring the part. These, besides, must not be hemmed nor stitched, must have no lace nor seam; for hems and seams by their hardness press into, and hurt the flesh that lies under them. Lace, whether in the midst or edges of the rowler, makes the Ligature unequal. For the Member where it is touched with the lace, as that which will not yield, is pressed more hard; but with the cloth in the middle more gently, as that which is more lax. Furthermore, these Ligatures must be of clean cloth, that if occasion be, they may be moistened or steeped in liquor appropriate to the disease, and that they may not corrupt, or make worse that liquor by their moistening therein. Now the Bandages which are made of Linnen clothes must be cut long-wayes, and not athwart, for so they shall keep more firm and strong that which they bind, and besides, they will be alwayes alike, and not broader in one place then in another: But they thus differ in figure, for that some of them are rolled up, to which nothing must be sowed, for that they ought to be of a due length to bind up the member: others are cut or divided, which truely consist of one piece, but that divided in the end (such are usually taken to binde up the breasts) or else in the midst; others are sowed together, which consist of many branches sowed together, and ending in divers heads, and representing divers figures, such are the Bandages ap∣propriated to the head. But they thus differ in length, for that some of them are shorter, others longer: so in like sort for breadth; for some are broader, others narrower. Yet we cannot cer∣tainly define nor set down, neither the length nor breadth of Rowlers, for that they must be vari∣ous, according to the different length and thickness of the members or parts. Generally they ought both in length and breadth to fit the parts, whereunto they are used. For these parts re∣quire a binding different each from other, the head, the neck, shoulders, arms, breasts, groins, testicles, fundament, hips, thighs, legs, feet and toes. For the parts of Bandages, we tearm one part their body, another their heads. By the body we mean their due length and breadth;* 1.4 but their ends, whether they run long-wayes or a-cross, we according to Galen, tearm them their heads.

CHAP. II. Sheweth the Indications and general precepts of fitting of Bandages and Ligatures.

THere are, in Hippocrates opinion, two indications of fitting Bandages or Ligatures;* 1.5 the one whereof is taken from the part affected; the other from the affect it self. From the part affected: so the leg, if you at any time binde it up, must be bound long-wayes, for if you binde it over-thwart, the binding will loosen as soon as the Patient begins to go, and put forth his leg, for then the muscles take upon them another figure. On the contrary, the Arm or Elbow must be bound up, bending in and turned to the breast; for otherwise at the first bending, if it be bound when it is stretched forth, the Ligature will be slacked, for that (as we formerly said) the figure of the muscles is perverted. Now for this indication, let each one perswade him∣self thus much, that the part must be bound up in that figure, wherein we would have it re∣main.

Now for that Indication which is drawn from the disease, if there be a hollow Ulcer, sinuous

and cuniculous,* 1.6 casting forth great store of Sanies; then must you begin the ligature and binding from the bottom of the sinus, and end at the orifice of the Ulcer; and this Precept must you al∣wayes observe, whether the sinus be sealed in the top, bottom, middle, or sides of the Ulcer: For thus the filth therein contained shall be emptied and cast forth, and the lips of the Ulcer too far separated, shall be joined together; otherwise the contained filth will eat into all that lyes neer it, increase the Ulcer, and make it uncurable, by rotting the bones which lye under it with this acrid sanies or filth. But some Ligatures are remedies of themselves; as those which perform their duties of themselves, and whereto the cure is committed; as are these which restore their native unity, those parts which are disjoyned: others are not used for their own sakes, but only to serve to hold fast such medicins as have a curative faculty. This kind of Ligature is either yet a doing,* 1.7 and is termed by Hippocrates, Deligatio operans; or else done and finished, and is called, De∣ligatio operata: For the first, that the Ligature may be well made, it is fit that it be close rowled to∣gether; and besides, that the Surgeon hold it stiffe and strait in his hand, and not carelesly; for so he shall binde up the member the better. Also he must in the binding observe, that the ends of the Rowler, and consequently their fastning, may not fall to be on the affected or grieved part; for it is better that they come above or below, or else on the side: Besides also, he must have a special care, that there be no knot tied upon the same place, or upon the region of the back, buttocks, sides, joints, or back-part of the head, or to conclude in any other part upon which the Patient uses to lean, rest or lye. Also on that part where we intend to sow or fasten the Rowlers, you must double in their ends, that so the fastning or suture may be the stronger, otherwise how close soever they shall be wrapped or rowled about the member,* 1.8 yet will they not remain firm, especially if they be of a great breadth. For the second kind of Ligature, to wit, that which is already done and fi∣nished; the Surgeon, the performer thereof, must consider to what end it was done, and whether he hath performed it well and fitly, as also neatly and elegantly, to the satisfaction both of himself and the beholders. For it is the part of a skilfull Workman every where handsomely and rightly to perform that which may so be done.

In fractures and luxations and all dislocations of bones, as also in wounds and contusions, you must begin your bandage with two or three windings, or wraps about upon the place, and that (if you can) more straitly than in other places, that so the set bones may be the better kept in their places, and that the humors, if any be already fallen thither, may by this strait compression be pressed forth; as also to hinder and prevent the entrance in of any other, which may be ready to fall down. But in fractures (as those which never happen without contusion) the blood flowes, and is pressed forth of its proper vessels; as those which are violently battered and torn, which causes sugillation in the neighbouring flesh, which first looks red, but afterwards black and blew, by reason of the corruption of the blood poured forth under the skin. Wherefore after these first windings, which I formerly mentioned, you must continue your rowling a great way from the bro∣ken or luxated part; he which does otherwise, will more and more draw the blood and humors into the affected part,* 1.9 and cause Impostumes, and other malign accidents. Now the blood which flowes, goes but one way downwards, but that which is pressed, is carryed as it were in two paths, to wit, from above downwards, and from below upwards. Yet you must have a care that you ra∣ther drive it back into the body and bowels, then towards the extremities thereof, as being parts which are uncapable of so much matter, and not furnished with sufficient strength to suffer that burden, which threatens to fall upon it, without danger, and the increase of preternatural acci∣dents. But when this mass and burden of humors is thrust back into the body, it is then ruled and kept from doing harm by the strength and benefit of the faculties remaining in the bowels, and the native heat.

CHAP. III. Of the three kinds of Bandages necessary in Fractures.

* 1.10TWo sorts of Ligatures are principally necessary for the Surgeon, according to Hippocrates, by which the bones as well broken as dislocated may be held firm when they are resto∣red to their natural place.

* 1.11Of these, some are called Hypodesmides, that is, Under-binders: others, Epidesmi, that is, Over-binders. There are sometimes but two under-binders used, but more commonly three. The first must first of all be cast over the fracture, and wrapped there some three or four times about, then the Surgeon must mark and observe the figure of the fracture; for as that shall be, so must he vary the manner of his binding: For the Ligature must be drawn strait upon the side opposite to that whereto the luxation or fracture most inclines; that so the bone which stands forth may be forced into its seat, and so forced may be the more firmly there contained. Therefore, if the right side be the more prominent or standing forth, thence must you begin your ligation, and so draw your ligature to the left side. On the contrary, if the left side be more prominent, begin∣ning there, you shall goe towards the opposite side in binding and rowling it. Here therefore would I require a Surgeon to be Ambidexter, (i. e.) having both his hands at command, that so he may the more exquisitely perform such variety of ligations: But let him in rowling, bend or move this first ligature upwards, that is, towards the body, for the former reasons. But neither is this manner of ligation peculiar to fractures, but common to them with luxations: for, into what part

soever the luxated bone flew; then when it is restored, that side must be bound the more loosly and gently whence it departed, and that on the contrary more hard unto which it went: Therefore the ligature must be drawn from the side whereunto the bone went; so that on this side it be more loose and soft, and not straitly pressed with bolsters or rowlers, that so it may be more inclined to the side opposite to the luxation. If the ligation be otherwise performed, it succeeds not well; for the part is relaxed, and moved out of its natural seat: wherefore there will be no small dan∣ger, lest the bone be forced out again, and removed from its place, whereinto it was restored by Art and the hand: Which thing Hippocrates so much feared, that on the contrary he willed that the set bone should be drawn somewhat more unto the part contrary to that whereunto it was driven by force, than the natural and proper site thereof should require. But to return to our former discourse of the three Ligatures: The first under-binder being put on, we then take the second, with which we in like sort begin at the fracture; but having wrapped it once or twice about there, for that, as we formerly said, we must not force back, and press so much blood towards the extre∣mities, as we must do towards the body and bowels: Wherefore this Ligature shall be drawn from above downwards, gently straining it to press forth the blood contained in the wounded part: When by rowling you shall come to the end of the part, then you shall carry back again that which remains thereof, to wit, upwards; But otherwise you may take the third under-binder,* 1.12 wherewith you may begin to rowle, whereas you left with the second, and you may carry it thus, rowling it from below upwards. These under-bindings thus finished, apply your boulsters, after them your over or upper-bindings, which are oft-times two, but sometimes three.* 1.13 The first hath two heads, & is wrapped both from the right hand and the left, for the preservation of the first un∣derbinder and the boulsters, and restoring the muscles to their native figure. The two other which remain, consist of one head, and the one of them must be rowled from below upwards, the other from above downwards, after such a manner, that they may be directly contrary to the under-binders; as if they were rowled from the right hand, then these must be from the left. Now this is the manner of Hippocrates his Ligation, which, for that it is now grown out of use, we must here set down that which is in common use. They do not at this time use any over-binders,* 1.14 but that which we termed the third under-binder, serves our Surgeons instead of the three forementioned over-binders. Wherefore they carry this third under-binder, wrapped from below upwards (as we formerly said) contrary to the first and second under-binder; as if these begun on the right side, this shall be rowled from the left, and shall end whereas the first under-binder ended. And you must not only draw it indifferently hard, but also make the spires and windings more rare. This third rowler is of this use in this manner of Ligation; that is, it restores the muscles to their native figure, from whence they were somewhat altered by the drawing and rowling of the two former Ligatures. But you must alwayes have regard,* 1.15 that you observe that measure in wrapping your Ligatures, which reason, with the sense of the Patient, and ease in suffering, prescribes; ha∣ving regard, that the tumor become not inflamed. Also the habit of the body ought to prescribe a measure in Ligation: for tender bodies cannot away with so hard binding as hard. Verily, in fractures and luxations, the humors by too strait binding are pressed into the extreme parts of the body; whence grievous and oft-times enormous Oedemaes proceed; for healing whereof the Ligature must be loosed, and then the tumified parts pressed by a new rowling, which must be performed from below upwards, and so, by forcing the matter of the tumor thither, it may be helped; for there is no other hope or way to drive the humor back again. He which doth this, forsakes the proper cure of the disease, so to resist the symptom, which the Surgeon shall never refuse to do, as often as any necessary cause shall require it. For this cause Hippocrates bids,* 1.16 that the bandages be loosed every three dayes, and then to foment the part with hot water, that so the humors, which (drawn thither by the vehemency of pain) have setled in the part, may be dissol∣ved and dispersed; and itching and other such like symptomes prevented. The fear of all acci∣dents being past, let the Ligation be sooner or later loosed, and more slacked than it formerly was accustomed; that so the blood and laudable matter, whereof a Callus may ensue, may flow more freely to the affected part.

CHAP. IV. Of the binding up of Fractures associated with a Wound.

IT sometimes happens that a Fracture is associated by a wound,* 1.17 and yet for all this it is fit to binde the part with a Ligature; otherwise there will be no small danger of swelling, inflam∣mation, and other ill accidents, by reason of the too plentifull afflux of humors from the neighbouring parts. But it is not fit to endeavour to use that kind of binding which is performed with many circumvolutions or wrappings about. For seeing the wound must be dressed every day, the part must each day necessarily be stirred, and the Ligature consisting of so many windings, loosed; which thing will cause pain, and consequently hinder the knitting and uniting, which is performed by rest: Therefore this kind of binding may be performed by one only rowling about the wound, and that with a rowler which consists of a twice or thrice doubled cloth, made in manner of a boulster, and sewed with as much conveniency as you can, that it may be so large as to encompass and cover all the wound, for these reasons, which shall be delivered at large in our Treatise of Fractures. But if the wound run long-wayes, let the boulsters and splints be applyed

to the sides of the wound, that so the lips of the wound may be pressed together, and the con∣tained filth pressed forth.* 1.18 But if it be made overthwart, we must abstain from boulsters and splints: for that in Galens opinion, they would dilate the wound, and the purulent matter would be pressed out, and cast back into the wound.

CHAP. V. Certain common precepts of the binding up of Fractures and Luxations.

IN every Fracture and Luxation, the depressed, hollow and extenuated parts, such as are neer unto the joints, ought to be filled up with boulsters, or clothes put about them, so to make the part equal, that so they may be equally and on every side pressed by the splints, and the bones more firmly contained in their seats. So when the knee is bound up, you must fill the ham or that cavity which is there, that so the ligation may be the better and speedilier performed. The same must be done under the arm-pits,* 1.19 above the heel, in the arm neer the wrist; and to conclude, in all other parts which have a conspicuous inequality by reason of some manifest cavi∣ty. When you have finished your binding, then enquire of the Patient, whether the member seem not to be bound too strait. For if he say that he is unable to endure it so hard bound, then must the binding be somewhat flackned.* 1.20 For, too strait binding causes pain, heat, defluxion, a gangrene, and lastly, a sphacel or mortification: but too loose is unprofitable, for that it doth not contain the parts in that state we desire. It is a sign of a just ligation that is neither too strait nor too loose, if the ensuing day the part be swoln with an oedematous tumor, caused by the blood pressed forth of the broken place; but of too strait ligation, if the part be hard swoln; and of too loose, if it be no whit swoln, as that which hath pressed no blood out of the affected part. Now if a hard tumor, caused by too strait binding, trouble the Patient, it must presently be loosed for fear of more grievous symptoms, and the part must be fomented with warm Hydraeleum, and another in∣different, yea verily, more loose ligature must be made instead thereof, as long as the pain and in∣flammation shall continue; in which time and for which cause, you shall lay nothing upon the part which is any thing burdensome. When the Patient begins to recover, for three or four dayes space, especially if you find him of a more compact habit and a strong man, the ligature must be kept firm and not loosed. If on the third day, and so untill the seventh, the spires or windings be found more loose, and the part affected more slender; then we must judge it to be for the better. For hence you may gather, that there is an expression and digestion of the humors, causing the tumor made by force of the ligation. Verily, broken bones fitly bound up, are better set, and more firmly agglutinated, which is the cause, why in the place of the fracture, the ligation must be made the straiter,* 1.21 in other places more loosly. If the fractured bone stand forth in any part, it must there be more straitly pressed with boulsters and splints. To conclude, the seventh day being past, we must bind the part more straitly then before: for that then inflamation, pain and the like accidents are not to be feared. But these things which we have hitherto spoken of, the three kinds of Ligatures, cannot take place in each fractured part of the body, as in the chaps, collar-bones, head, nose, ribs: For, seeing such parts are not round and long, a Ligature can∣not be wrapped about them, as it may on the arms, thighs, and legs, but only be put on their outsides.

CHAP. VI. The uses for which Ligatures serve.

* 1.22BY that which we have formerly delivered, you may understand that Ligatures are of use to restore those things which are separated and moved forth of their places, and joyn toge∣ther those which gape; as in fractures, wounds, contusions, sinewous Ulcers, and other like affects against nature, in which the solution of continuity stands in need of the help of Bandages, for the reparation thereof.* 1.23 Besides also, by the help of Bandages these things are kept asunder or separated, which otherwise would grow together against nature; as in Burns, wherein the fingers and the hams would mutually grow together; as also the Arm-pits to the Chest, the Chin to the Breast,* 1.24 unless they be hindred by due ligation. Bandages do also conduce to refresh emaciated parts: wherefore if the right leg waste for want of nourishment, the left leg, beginning at the foot, may be conveniently rowled up even to the groin. If the right arm consume, binde the left with a strait Ligature, beginning at the hand, and ending at the arm-pit. For thus a great porti∣on of bloud from the bound-up part is sent back into the vena cava, from whence it regurgi∣tates into the almost empty vessels of the emaciated part. But I would have the sound part to be so bound, that thereby it become not painfull; for a dolorifick ligation causes a greater attractati∣on of blood and spirits, as also exercise: wherefore I would have it during that time to be at rest, and keep holy-day.* 1.25 Ligatures also conduce to the stopping of bleedings: which you may per∣ceive by this, that when you open a vein with your lancet, the blood is presently stayed, laying on a boulster and making a Ligature.* 1.26 Also Ligatures, are usefull for women presently after their de∣livery; for their womb being bound about with Ligatures, the blood wherewith their womb was too much moistened, is expelled, the strength of the expulsive faculty being by this means stirred

up to the expulsion thereof: and it also hinders the empty womb from being swoln up with wind, which otherwise would presently enter thereinto.* 1.27 This same Ligature is a help to such as are with childe, for the more easie carrying of their burden; especially those whose Childe lyes so far downwards, that lying as it were in the den of the hips, it hangs between the thighs, and so hin∣ders the free going of the mother. Therefore the woman with childe is not only eased by this binding of her womb with this Ligature, which is commonly tearmed, the Navil-ligature; but also, her childe being held up higher in her womb, she hath freer and more liberty to walk.* 1.28 Ligatures are in like sort good for revulsion and derivation: as also for holding of medicins which are laid to a part, as the neck, breast, or belly. Lastly,* 1.29 there is a triple use of Ligatures in amputation of members, as arms and legs. The first to draw and hold upwards the skin and muscles lying under it, that the operation being performed, they may, by their falling down again, cover the ends of the cut-off bones; and so by that means help forwards the agglutination and cicatrization; and when it is healed up, cause the lame member to move more freely, and with less pain; and also to perform the former actions, this, as it were, cushion or boulster of musculous flesh lying there∣under. The second is, they hinder the bleeding by pressing together the veins and arteries. The third is, they by strait binding intercept the free passage of the animal spirits, and so deprive the part which lyes thereunder of the sense of feeling, by making it, as it were, stupid or num.

CHAP. VII. Of Boulsters or Compresses.

BOulsters have a double use,* 1.30 the first is to fill up the cavities and those parts which are not of an equal thickness to their end. We have examples of cavities in the Arm-pits, Clavicles, Hams and Groins; and of parts which grow small towards their ends, in the arms towards the wrists, in the legs towards the feet, in the thighs towards the knees. Therefore you must fill these parts with Boulsters and Linnen cloths, that so they may be all of one bigness to their ends.

The second use of Boulsters,* 1.31 is to defend and preserve the first two or three Rowlers or Under-binders, the which we said before must be applyed immediately to the fractured part. Boulsters, according to this twofold use, differ amongst themselves, for that when they are used in the first mentioned kind, they must be applyed athwart; but when in the latter, long-wayes or downright.

You may also use Boulsters,* 1.32 lest the too strait binding of the Ligatures cause pain and trouble to the new-set bones. A three or four times doubled cloth will serve for the thickness of your Boulsters, but the length and breadth must be more or less, according to the condition of the parts and disease for which they must be applyed.

CHAP. VIII. Of the use of Splints, Junks, and Cases.

HAving delivered the uses of Ligatures and Boulsters, it remains that we say somewhat of the other things, which serve to hold the Bones in their places; as Splints, Junks, Cases, and such other like. Splints are made and composed of past-board,* 1.33 of thin splinters of wood, of leather, such as shoo-soals are made with; of the rindes of trees, or plates of latin, or lead, and such other like, which have a gentle and yielding stiffness; yet would I have them made as light as may be, lest they by their weight become troublesome to the affected part. But for their length, breadth, and number, let them be fitted, agreeable to the part whereto they must be used. Let also their figure be streight or crooked according to the condition of the member whereto they must be applyed. You must have a special care, that they run not so far as the swellings out, or eminencies of the bones; as the ankles, knees, elbows, and the like, lest they hurt them by their pressure: also you must have a care, that they be smaller at their ends, and thicker in their middles, whereas they lye upon the broken bone. The use of splints is,* 1.34 to hold fast and firm, that they may stir no way the broken and luxated bones, after they be set and resto∣red to their places. That they perform this use, it is fit there be no thick boulsters under them, nor over many rowlers, for so through so thick a space, they would not so straitly press the part. Junks are made of sticks, the bigness of ones finger, wrapped about with rushes,* 1.35 and then with linnen cloth: they are principally used in fractures of the thighs and legs. Cases are made of plates of latin, or else some light wood; their use is, to contain the bones in their due figure,* 1.36 when the Patient is to be carried out of one bed or chamber into another, or else hath need to go to stool: lastly, if we must rest somewhat more strongly upon the broken or luxated members, these Cases will hinder the bones from stirring or flying out on the right side or left, above or below, we sleeping or waking, being willing or unwilling; and in like sort lest being not as yet well knit, or more loosly bound up for fear of pain, inflammation, or a gangrene, they hang down, fall, or fly in sunder by reason of the inequalities of the bed. Such Cases, Junks, and the like,* 1.37 which serve for restoring and fast holding of broken and luxated bones, we may according to Hippocrates his minde, call them in generall Glossocomia. All which things, the young Surgeon, which is not as yet exercised in the works of Art, can scarce tell what they are. But in the mean time, whilest that he may come to be exercised therein, or see others perform these operations, I, as plainly as possibly I could, have in words given him their portraiture or shape.

The End of the Fourteenth Book.

Notes

• * 1.1

  Lib. de fasciis.
• * 1.2

  Sect. 3. de Chir. offic.
• * 1.3

  What cloth best for rowlers.
• * 1.4

  Com. ad sect. 22. sect. 2. de offic. chir.
• * 1.5

  1 & 2 sect. lib. de fract.
• * 1.6

  We must al∣wayes begin our ligatures at the bottom of a sinus.
• * 1.7

  Hip. cent. 4. Sect. 2. offic. Initio 2. sect. off.
• * 1.8

  Ligatures must not be only lightly, but also neatly per∣formed.
• * 1.9

  Gal. com. ad sent. 25. sect. 1. lib. de fract.
• * 1.10

  Sent. 24. sect. 2. offic.
• * 1.11

  Hypodesmides.
• * 1.12

  When the third under-binder is necessary.
• * 1.13

  Epidesmi.
• * 1.14

  The manner of binding now in use.
• * 1.15

  What mean to be observed in wrapping the Ligatures.
• * 1.16

  Why Hippoc. bids to loose the Ligatures every third day.
• * 1.17

  How to bind up a Fracture with a wound.
• * 1.18

  Ad sent. 12. sect. de fract.
• * 1.19

  Hipp. sent. 37. & 38. sect. 1. de fract.
• * 1.20

  The signs of too strait and loose binding up.
• * 1.21

  Why we must make more strait ligation on the broken part.
• * 1.22

  The first bene∣fit of Ligatures.
• * 1.23

  The second.
• * 1.24

  The third.
• * 1.25

  The fourth.
• * 1.26

  The fifth.
• * 1.27

  The sixth.
• * 1.28

  The seventh.
• * 1.29

  The eighth, the particular use of ligatures in the amputation of members.
• * 1.30

  The first use of Boulsters.
• * 1.31

  The second use of them.
• * 1.32

  The third use of them.
• * 1.33

  The matter of Splints.
• * 1.34

  Their use.
• * 1.35

  What Junks are.
• * 1.36

  The matter and use of Cases.
• * 1.37

  Glossocomium, a general name for such things.