Chirurgorum comes, or, The whole practice of chirurgery begun by the learned Dr. Read ; continued and completed by a Member of the College of physicians in London.

THE PRACTICE OF CHIRURGERY. BOOK V.

CHAP. I.

Of the definition, differences, causes and signs of Luxations in general.

LUxation, or putting out of joynt, is called Dislocation. It is the slipping of the Head of some Limb out of its proper Sinus, into another place. For Dearti∣culation, or a Joynt, which is de∣signed for motion, consists of the head of a Bone, and a Sinus; In the head it is observable, that all Bones which have a round head, have all motions, as in the Thigh and Shoulder: In the Sinus, that all which have a deep Sinus, as the Os coxendicis, are not so apt to be put out of Joynt; on the contrary, in such as have a shallow Cavity, as in the Scapula. But lest the Bones might easily slip out of their Cavities, there are also Li∣gaments: and some of them are orbicular, which in all Joynts en∣compass the head and Sinus round: others are round, and are only in such Joynts as are made for strong motions, as in the Thigh and Knee. These out of a deep Ca∣vity, are inserted into the head of the Bone. Now the Joynts that have both sorts of Ligaments, or that have only the orbicular, but

very close, are difficultly disloca∣ted. In the Joynts there is a sort of unctuous and viscid Humor, lest the Bones by their perpetual motion should grow hot and dry.

In general there are three sorts of Luxations. First, when Bones gape, which before were joyned. This happens in three places; when the broad Blade-bone parts from the Humerus; or the Radius from the Cubitus, or the Sura from the Tibia, as Celsus writes, c. 10. l. 8. Rhases 15. contin. calls it Disjun∣ction. A Second sort is, when Bones are lengthened, through the laxity and distention of the Ligaments; whence it comes to pass, that the head of the Bone starts a little out of the Sinus; yet it is not quite out, but it may ea∣sily be put in. I have often ob∣served this Luxation in Beggars, in the Wrist and Elbow. The third sort is properly called Luxa∣tion, when the head slips out of its proper Sinus, of which there are no differences; but according as it is more or less, Paul c. 11. l. 6.

If then the head do wholly and perfectly slip out of its Sinus, it is called 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, by Rhases Dislocation: If in part, and but imperfectly, it is called 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉 by Rhases Distortura, or wrench∣ing. The Joynts of the Arm, Hand, Leg, Foot, Fingers and Toes suffer both sorts of Luxation; only the Thigh and Shoulder suf∣fer a perfect Luxation: the rea∣son whereof is the roundness of the heads, and thinness of the Ca∣vities; whence it comes to pass, that the heads do almost touch the edges in a point, and so either quite slip out of, or come in again to the Sinus. Yet Hippocrates says, the Shoulder and Thigh may be more or less luxated, which must be understood of perfect Luxation, while they are more less distant from their natural place. Moreover, this true Luxation may be made four ways, upwards or downwards, to the right hand or the left, Galen c. 4. l. de Con∣stit. Art. adds forwards or back∣wards.

The first sort of Luxation is oc∣casioned only by internal causes, i. e. by Humors, mollifying and relaxing the Ligaments. The other two sorts, namely; the wrenching and true Luxation, are occasioned both by an internal cause, to wit, the Humors, flow∣ing to the Joynts, which by de∣grees fill the Cavity, and thrust the head of the Bone out of its place: and by an external cause, which by violence moves the Bone out of its place, as leaping, a fall, and violent running. But we shall only treat of those Luxations that proceed from an external cause.

There are divers signs of Lux∣ation. First, when the motion of the Joynt is lost: for as long as motion is not lost, thô there be suspicion of a Luxation, yet there is no Luxation. But this sign is not enough, others must be ad∣ded. The Second therefore is an hollowness appearing in some un∣usual place, and on the contrary an eminence on the opposite side: for the Tumor is ever on that side unto which the Bone slipt; and the hollowness, from whence it is slipt: This sign is discovered by the sight and touch, in the Joynts,

which are either naturally without flesh, or emaciated. The third sign is, the Limb generally is short∣ned: for the Bone being slipt out of its place, since it finds no re∣sistance, is drawn upwards by the Muscles; this happens in a perfect Luxation. The fourth sign is; the Limb out of Joynt is unlike the found one in figure, site and longitude.

A perfect Luxation is distin∣guished from an imperfect one, by the intenseness of the aforesaid signs. For if all the motions of the Joynt be lost, if the Limb be short∣er, if there be a great Eminence, and a Cavity, if the Limb be un∣like the sound one, it is a perfect Luxation: On the contrary, when it is imperfect. The most cer∣tain sign of a disjunction, where the Bones gape, is the thickness of the Limb above its natural pitch; and where the heads of the Bones meet, the extuberance is greater. That sort of Luxation, wherein the Limbs are made long∣er, because of the softness of the Ligaments is known. First, be∣cause the Limb looks, as if it were hung on by thread, and it dangles disorderly this way and that, because the Ligaments are relaxed, and the Bones do not then touch one another. Secondly, when the head of the Bone is put up, the Limb returns to its natu∣ral length; and if it be let go, it returns to its accidental length. Lastly, there is a Cavity quite round the Joynt, into which one may sometimes put ones little Finger.

The signs of a Luxation being removed, i. e. of a Joynt well Self, are contrary, which shew the na∣tural state: If there be no more signs nor causes of Luxation. Be∣sides, Avicenna brings another sign, namely the crashing, or snap which both the Patient and the by-standers hear, when the Bone slips back again into its Cavity. But this is neither a good sign, nor much to be desired; because it has two bad causes. For either the noise is made while the head of the Bone rubs against the edges of the Sinus, whereby those thin and cartilaginous edges are broken, and so go into the Cavity before the Bone gets into it again: and therefore true reposition cannot be made; because the head can no more turn round in its Cavity, which makes Men lame. Or the noise is, because the head of the Bone beats against the Sinus; which may cause an Ulcer, and make the part putrefie, the Carti∣lages may grow hard, and be se∣parated from the Bone; and so the Bone remains rough, and dif∣ficulty in motion is occasioned.

CHAP. II.

The Cure of a Luxation in general.

THe Doctrine of Luxations is truly Chirurgical; because here all depends on the Chirurge∣on's Hand, and nothing on Nature. There are four scopes in a Luxa∣tion; Extension, Reposition, De∣ligation, Collocation. Extension is necessary; because the Muscles contract the slipt Bone, and make the Limb shorter; because then it finds no resistance. Deligation is necessary, lest, because of the Re∣laxation of the Ligaments, and the Extension of the Muscles, the Bone might slip out again.

And the four aforesaid things must be so administred, that the due figure of the Limb may be kept, and Inflammation may be prevented. The Limb must be put in such a Figure, as that it may be void of pain. In Extensi∣on the Muscles must on one side be kept as they are, lest the head of a Muscle should be in the inside, and the end on the outside. In Deli∣gation and placing of the Limb, we must observe such a figure or posture of the Limb, as is the mean between the two extreme motions of the Limb.

An Inflammation usually hap∣pens in Luxations by reason of the pain, that is caused, both when the Luxation is made, and after it is made; when the Bone, being out of its place, presses up∣on the nervous parts, and pain is caused in the Extension, when the Bone is replaced. And an Inflam∣mation must be prevented, in re∣spect of the part recipient, by pro∣per figuration or posture; in re∣spect of the part mittent. i. e. the whole Body, by Bleeding, Purging, and Diet.

First of all Extension must be made, as we have shewn in Fra∣ctures. Secondly, the Limb must be replaced gently, lest either Con∣tusion, or Attrition of the Head and the Sinus one against another should be made; also twining a∣bout of the head of the Bone must be avoided, lest the edge of the Sinus be broke. Thirdly the Limb must be bound, lest it slip out a∣gain. The binding must be so made, as to keep the natural po∣sture of the Limb, and prevent In∣flammation, by pressing out the Humors that are got in; and by hindring others from coming in. But before binding be made, Me∣dicines must be applied, which hin∣der Inflammation, namely Astrin∣gents, which besides this advan∣tage, do contract the relaxed Li∣gaments,

and strengthen the part, Such are Ceratum barbarum, Dia∣palma, de Minio, Oxycroceum, Ce∣ratum simplex, Ceratum rosaceum, Ʋnguentum rosaceum, Vinum, Pos∣ca, Vinum granatorum, Succus hypocystidos, decoctum corticum gra∣natorum; Balanstiorum, ovi Al∣bumen. A compound Medicine may also be made è bolo Armena, Sang. Drac. Myrtill. Cortic. Gra∣nat. pulverisatis, & mistis ovi Albumini ad mellis cunsistentiam, exceptum hoc stupis pexis circa ar∣ticulum imponitur. If there be pain, it indicates lenient and un∣ctuous Medicines, i. e. things con∣trary to an Inflammation: where∣fore we must proceed thus. If the pain be small, it must not be re∣garded, and astringents with un∣ctuous Medicines, as Flax with the white of an Egg, must be appli∣ed. But if pain divert the Cure to it self, the part must first be anointed with things that asswage pain, which yet must have an astringent Virtue in them, such as Oleum Rosatum, Oleum Myrtinum, Mastichinum; then the aforesaid Medicine must be applied, or a Linen cloth dipt in Ceratum Ro∣saceum, over which the aforesaid Stupes must be applied. Cerotes must not be used in the beginning; because by their hardness they press and cause Inflammation: for which reason Galen before bandage ap∣plies Linen clothes dipt in some juice, lest by pressure they should cause pain; When these things are done, the Limb must be laid in a middle figure, lest it should occasion pain, The Posture must be soft, smooth, and high.

The Limb thus bound, must (as much as may be) be kept im∣moveable for three or four days; But then the Rollers being slacken∣ed, and an itching arising from the detention of the Vapors, the bandage must be unbound, and the itching part must be bathed with warm water. Yet lest the warm water should loosen the Li∣gaments, which rather want astri∣ction, therefore, if there be no itching, we must not meddle with fomentation. At the Second De∣ligation, if there be no pain, we may apply some Ceratum, as in Winter. Ceratum barbarum: in Summer Ceratum de Minio, Dia∣palma. About the same time also, we may apply splints of Leather and thick Paper, to confirm the head of the Bone. And thus we must proceed, till the Limb seem strong enough: About this time it must be unbound, and fomented with a decoction of Wormwood, Roses, Chamaemel, white Oaken Moss, which do strengthen. Then having applied a Cerote, the Limb must be kept for some days with∣out binding, and the Patient must be ordered to use his wonted exer∣cises, but moderately. Thus much of the general cure of all fresh Lux∣ations.

Old Luxations have the same Indications. Yet these must be preceded by sostning and discus∣sing the matter, which is flowed into the Joynt, and about the Joynt. For which purpose, ℞ Rad. Althee ℥ vj. Rad. Cucum. asinini ℥ iij. fol. malvae M. ij. coctis in aqua & contusis adde farinae Faenugnec. & seminis lini ana ℥jss. Olei com∣munis ℥ vj. axungiae porcinae ℥ iiij. Decocti praedicti q. s. misce & siat

emplastrum. We likewise use Dia∣chylon simplex, & cum Gummi, when the Callus is great and hard: But first we must rub the part with our Fingers wet in moist Oesypus, and we apply thick Oesy∣pus. We often dip the Limb in the washing of Wooll warm, Morn∣ing and Evening for an hour or two. The Mud of hot Bathes is also good; Those are Emollients. After them we must use digesters, such as, in soft natures, Ceratum de betonica; in hard ones Empla∣strum sacrum. Before the applica∣tion of the Emplasters, Fomenta∣tion must be made è decocto Cha∣maemeli, Hyssopi, Betonicae, Stae∣chadis; also è vino albo generoso. When the Humors are much, and very hard, if they be first soften∣ed, we must use a Fumigation è lapide pyrite or molari: also a Fo∣mentation è decocto Rad. Cucum. asin. Altheae, ivae, colocynthidos; which both by their heat and dri∣ness discuss the matter, and by an innate property attract the Hu∣mors about the Joynt. The Limbs may be held in the water of hot Bathes, and in the steam of the same, which are very digerent: when these things are done, you may manage all the rest, as in a fresh Luxation.

CHAP. III.

Of particular Luxations: and First of Luxations of the Jaw-bone.

VVHen the Jaw-bone is out of joynt, Mastication and Speech are depraved. It is very seldom, that it is dislocated: be∣cause the head of the Jaw-bone, which is contained in the Cavity, is encompassed on every side with Bones. Then the Jaw-bone has many strong Muscles, which keep it in its proper place, and it has two heads, which are not so apt to slip out, as one is. Thirdly, it has two acute Processes. Fourthly, the Jaw-bone can only be dislocated one way, i. e. forwards, Fifthly, there are few causes of the Luxa∣tion of the Jaw-bone.

For the Jaw-bone can never be out, unless its acute Process slip under the Os jugale; and so can∣not get back again: But this Pro∣cess cannot slip downwards, unless the Mouth gape very wide, and it cannot get upwards except in a distortion of the Mouth. Yet I have often seen the Jaw-bone lux∣ated: the cause whereof may be a frequent and constant motion of

the Jaw-bone, both in Mastication and Speaking, whereby the Muscles are tired, debilitated, and so give frequent occasion to the luxation of the Jaw-bone.

Gulielmus de Saliceto, and some other Chirurgeons, not skilled in Anatomy, have written, that the Jaw-bone may be luxated to the left and right, but this is false; for behind, the Bone hinders, on the right, the left head of the Jaw∣bone hinders; on the left, the right head of the Jaw-bone hinders. It therefore follows, that the Jaw∣bone can be luxated only forwards.

And either both its heads are lux∣ated, or only one. If only one, 1. That part of the Jaw is promi∣nent only forwards. 2. The Chin enclines to the luxated part. 3. The Mouth is distorted towards the part, contrary to the luxated part, and the distorted Jaw-bone ap∣pears more eminent. 4. The Den∣tes canini stand underneath the fore-Teeth. 5. On the luxated side, the acute Process appears more eminent. 6. The Teeth cannot be shut. If the Jaw be out on both sides, these are the signs. 1. The whole Jaw is prominent forwards, and not distorted, but fore-right. 2. The Mouth keeps open. 3. The acute Process ap∣pears prominent on both sides. 4. The lower Teeth stand out far beyond the upper. 5. The tempo∣ral Muscles are very tight and hard.

Hippocrates writes, that unless it be replaced presently, there do arise continual Fevers, Sleepiness, Inflammation, Pain, Convulsion, voiding of Choler, and usually on the tenth day death. Thô I have had several such under cure, I never met with any that fared so: Yet I believe Hippocrates did; be∣cause it is rational enough, that such Symptoms may happen, by reason of the Muscles and Nerves being primarily affected, and the Brain by consent.

In the Reposition of the Jaw∣bone, motions must be made con∣trary to them, that the Jaw-bone made, when it slipt out of its Ca∣vity. First, the Jaw-bone slips forwards, it must therefore be thrust backwards. Secondly, in opening the Mouth it is drawn downwards; therefore it must be forced upwards. Thirdly, the Muscles draw the acute Process upwards; therefore the Jaw-bone must be drawn downwards.

If the Jaw be out only on one side; it must be forced to the con∣trary side. We must begin with the last motions first. Therefore if both sides of the Jaw be out; the first action of the Chirurgeon is Traction or Extension of it down∣wards; the Second backwards; the Third upwards. To do these things, he must put both his Thumbs in his Patient's Mouth, and with his Fingers he must take hold of the outside of his Chin: then the Jaw-bone must be forced downwards, backwards, and up∣wards. Thus it is easily and quick∣ly replaced. But the Patient's Head must be held fast, that it give not way, when the Jaw-bone is forced backwards.

When the Reposition is done, things must be applied to the heads of the Jaw-bone, i. e. to the Tem∣ples, which may prevent Inflam∣mation, such as Ceratum rosaceum:

In violent distention, where there is more need of astringence, we may apply Stupes wet in whites of Eggs, adding, if there be need, astringent Powders. We must al∣so anoint the parts of the Tem∣ples, i. e. the whole temporal Muscle, with Oleum Ros. lumbri∣catum.

Bandage is made in this manner; a Roller is applied to the Chin, where it must be slit a little, that it may take hold of the Chin on both sides; then on each side at the Ears, the Roller must be slit again, and the Ear must be drawn through; af∣terwards the Roller is to be faster∣ed at the Crown of the Head. And the Patient must be kept thus, till the Jaw-bone be strengthened, which it is in one, two, or at most three days time: All which time, if there be any danger, the Patient had best abstain from Meat; nor must he omit Bleeding, and those things we have mentioned in the general cure of Luxations. But to speak the truth, I ever used to apply Medicaments to the place affected, and when there was oc∣casion to eat, I ordered the Swathes to be loosened.

CHAP. IV.

Of a Luxation of the Shoulder.

THe Shoulder is a great Bone, with a round Head, which is inserted into the shallow Sinus of the Scapula. And this head is surrounded only with an orbicular Ligament, which is loose enough. This Sinus has some Buttresses; for on the outside of the Scapula it has a certain large Process, con∣sisting of the Spine of the Scapula: on the upper part it has partly the said Process, and partly the Clavicle: in the inside it has the Processus anchoroeides. Hence it is apparent, that the head of the Shoulder may easily slip out: for this Joynt is uniform and simple, not, as it is the Knee, double. Then the head of the Shoulder which is round, is deprived of a long neck, is inserted into a Sinus, that has no depth in it, and therefore is more easily put out of Joynt, then the Thigh, which has a long neck, and is inserted into a deep Cavity. 3. This Ligament is only simple, viz. orbicular, (not round as in the Thigh) and it is very lax. Fourthly, the Joynt of the Shoul∣der is without flesh, and there∣fore it is more apt to slip out of its place, than a fleshy Joynt. But the Shoulder can slip no way, ex∣cept into the Armpits downwards: because there are no Propugnacula there, as in other places, and the

Shoulder is apt by its own weight to slip downwards. Yet Galen says, that five times he saw the Shoulder slip forwards.

If the Shoulder be slipt under the Armpit, it is in figure very unlike the sound Shoulder. Secondly, on the top of the Shoulder there ap∣pears an unusual hollowness, and under the Armpit, the round hard head may be felt. Thirdly, if the Shoulder be in its natural place, the upper Process of the Scapula appears round; but when the Shoulder is out, it appears acute: because the head which made the roundness is slipt down. Fourth∣ly, the Arm sticks far from the Ribs, and cannot without much pain be brought to them. Fifthly, the Patient cannot carry his Arm to his Head, because the Humerus cannot move upwards: and seve∣ral other motions of the Shoulder are hindred. Sixthly, the disloca∣ted Arm is longer than the other, if the Shoulder only slip downwards; but it is shorter, if it be drawn up∣wards by the Muscles. Seventhly, the part is wrinkled at the end of the Axilla, in the luxated Shoul∣der, far lower, and both more forward and backward, than in the found Arm; which signifies that the head of the Shoulder is slipt downwards. If the Shoulder be luxated towards the fore-part, these are signs; in the fore-part there is an eminence, in the hind∣part an unusual hollowness: be∣sides the Cubitus enclines back∣wards, nor are there any signs of the Shoulder being out under the Arm.

Hippocrates says, that the Shoul∣der and Thigh can only be per∣fectly luxated: This is true, if the Luxation be occasioned by an ex∣ternal cause. But if there be in∣ternal causes, i.e. Humors gather∣ing and hardning by degrees, these, while they force the head to give way by little and little, may cause an imperfect Luxation.

The ways by which the Shoul∣der slipt into the Arm-pit is repla∣ced, are according to Hippocrates ten in number, l. 2. de art. but they may be very well reduced to three. The First way is by Cir∣cumrotation, or Circumvolution, while either the Patient or the Phy∣sician, puts the Hand clench't un∣der the Arm-pit, so that the mid∣dle knuckles of the Fingers may force the head of the Shoulder in∣to its Cavity. This way is used only in Children, and such as have very lax and moist Ligaments: But as by this way the Shoulder is easily reduced, so it easily slips back again. This way Hippocrates says, is not according to nature, because not so very safe. For while we turn round the head of the Shoulder upon the Scapula, some membranous and nervous bo∣dies may easily be torn, and so may the edges of the Sinus, where∣upon by reason of a conflux of Humors the Chirurgeon is frustra∣ted in Reposition.

The Second method is by a way contrary to that, by which it slipt out. If the head of the Shoulder be dislocated; First, it goes out of the Sinus, and so moves for∣wards. Secondly, it slips down∣wards. Thirdly, it is drawn back∣wards by the Muscles. This way differs from the first, because in the first, motion is made by Cir∣cumrotation

in crooked lines; in the Second, motion is made in right lines. In reposition there∣fore these three motions must be made by a way contrary to the slipping of it out. 1. From be∣hind forwards. 2. From the fore∣part upwards. 3. Back again. First of all therefore the Chirur∣geon puts his head to the Patient's Shoulder. Secondly, he puts his Fingers under his Armpits. Third∣ly, he must press the Patient's Elbow with his Knee, the Pati∣ent sitting all the while. Let us see now, how these operations an∣swer the foresaid Indications. The first motion, that must be made in reduction of the Shoulder, is forwards, and it is done by putting the Fingers under the Arm-pits. The Knee strengthens this motion, and makes it more easie, by pres∣sing the Elbow towards the Ribs, which by the dislocation stuck too far from it: For as when the head of the Shoulder slips into the Arm∣pit, the Elbow sticks out from the Ribs; so again, when the El∣bow is forced towards the Ribs, the Shoulder moves forwards. By the benefit therefore of the Fin∣gers and the Knee, the Shoulder is moved from behind forwards. And the Chirurgeon lays his Head on the Patient's Shoulder, lest, while with his Fingers he draws the Shoulder forwards, the rest of the Patient's Body might follow: Or rather (as I have learned by ex∣perience) lest the Scapula, which is moveable, should follow: for when the Shoulder is dislocated, if the Luxation be not new, it is ve∣ry difficultly replaced, for this ve∣ry reason, because when extension of the Shoulder is made, the Shoulder does not stir out of its praeternatural place, but rather the Scapula does move. Hippocrates therefore makes the first motion, i.e. he moves the Shoulder for∣wards: but he makes no menti∣on of the two other motions, be∣cause they are effected by the Muscles: For while the Muscles are sound, and the Luxation new∣ly made, they draw the Shoulder upwards, and restore it to its pro∣per place, if that the head of the Shoulder be not hindred, as it is, while it lies behind under the Arm∣pit. This way may also be ad∣ministred in another manner: for because we cannot so well with our Knee force the Elbow towards the Ribs, instead of the Knee we substitute a Servant, who with his Hand must take hold of the Elbow and force it towards the Ribs. And this second way may be admini∣stred in a third manner; the El∣bow may be brought back towards the Spina dorsi: for so the Shoul∣der is brought forwards: Then with one hand we must take hold of the Elbow, that motion may be made upwards; and we must lay the other hand hard upon the top of the Shoulder, lest the Sca∣pula might give way, as we said before.

The Third general way adds to the Second, Extension, which is very necessary, if the head of the Shoulder be confirmed out of place; moreover the Muscles always draw upwards, whence arises an Indica∣tion of drawing downwards by Ex∣tension. This way is performed either with instruments or with∣out.

Without instruments in a two∣fold manner. The First is, if the Patient lye, and the Chirurgeon sit upon the same level, taking hold of the luxated Arm with both his Hands, and putting his Heel under the Patient's Arm-pit (the right Heel, if the right Shoulder be out of Joynt, and the left, if the left be out) but before he put his Heel in his Arm-pit, it is ne∣cessary to put a hard Ball, like a Tennis-Ball under the Arm-pit. When this is done, a Servant must take hold of the opposite Arm, and draw it downwards: And an∣other having a strong Roller or Girt (broad enough to take hold of the Ball) must take hold of both its heads, and draw them up∣wards towards the Patient's Head; and with his other Foot lean upon the top of the luxated Shoulder. Now let us consider, how the Shoulder may be replaced by these operations. The First, who draws the Arm downwards, and the other, who pulls the string upwards, make extension and motion down∣wards. Motion forwards is made both by the Ball and the Heel: wherefore the Heel must be put between the Ribs and the head of the Shoulder, or the Ball, that the head of the Shoulder may be prest forward: And the reason why the Ball is used is, that whi∣ther the heel cannot reach, be∣cause of the hollowness of the Arm-pit (which is made by the Muscles and Tendons placed on all sides) yet there, by the benefit of the Ball, the Heel may operate. Two motions are therefore made by the Chirurgeon, the first down∣wards, and then forwards. The Servant, who draws the string up∣wards, makes motion upwards, and pressing the top of the Shoul∣der with his Foot, he keeps the Scapula from giving way. The third person, who draws the sound Shoulder downwards, keeps the whole body from giving way to the Extension.

The other way without instru∣ments is thus; A Man of a high∣er stature, than the Patient, must lift the Patient from the ground, and place his Arm-pit upon his own Shoulder, that so he may make Extension: Then he must bring the dislocated Arm towards his own Breast, that the Shoulder may move forwards. Afterwards a Servant putting both his hands behind him upon the Patients Shoulder, must draw and press that part, lest the Scapula might give way. Then a Boy must hang behind on the other side, so as his Feet may not touch the ground, that he may hinder the whole Bo∣dy from giving way. Thus far of the ways of doing it without in∣struments.

Instruments proper for the re∣duction of the luxated Shoulder are, the Ladder, Coulstaff, Pulleys, Glossocomium, &c.

The way of Extension by a Lad∣der is, that the Patient climb up three or four steps of it, and put his lame Arm over one of the Staves, placing it between his Side, and the head of the Humerus; and that a strong fellow take hold of that Arm, and pull it forcibly down backwards, whilst the Patient hangs by it.

The way by a Coulstaff is safer. The Staff must have a Bunch in

the middle, somewhat wedge-like, and be covered with a soft Boulster, fit to place under the Patient's Arm-pit. In order to the Exten∣sion, the Patient must be seated near some Post or Pillar, in which the Pulley must be fastned to ex∣tend his Arm; and the bandage must be made a little above the Elbow; which being fastned, and the Coul∣staff placed, and supported by a couple of fellows, the Chirurge∣on must stand on the contrary side, with his hands on each side of the Scapula, to press it downward, and keep the Patient firm in his seat, and govern the operation, taking care the edge be placed right whilst the Extension is making, lest they break the Bone, or other∣wise mischief him.

The Glossocomium, commonly called the Commander, is of use in the most strong tough Bodies, and where the luxation hath been of long continuance, and will not yield to the other ways of Exten∣sion. There ought to be great care in the use of it, for many shrewd accidents have happened thereby.

The Humerus luxated by relax∣ation of the Ligaments and Ten∣dons is restored to its place, after some of the ways abovesaid: but doth require your industry to re∣tain it, after it is reduced,

If the Humerus be to be redu∣ced, when it is luxated forward, the motion must be made contra∣ry. And thô the Limb be not made shorter; yet because we ease the head of the Bone, and dis∣intangle it, some little Extension must be made.

In general we must know, if the Shoulder be newly luxated, it may easily be replaced by the Fin∣gers. But when the Luxation is old, it is very difficultly reduced: because the Shoulder has fixt it self fast there, so that it is grown something callous; and besides, the Cavity it self is filled with flesh, which when the Bone is re∣duced, does nevertheless cause it to slip out of its proper Sinus.

When the Shoulder is reduced, we must bind it up. But before binding, we must apply things, which prevent Inflammation, and knit together the lax and distort∣ed Ligaments; such as we men∣tioned before; Bolus Armena, Sang. Draconis, Myrtilli, balaustia pul∣verisata ovi albumine subacta, ad mellis consistentiam, applied with Stupes or Clothes, And under the Shoulder-Joynt a Ball must be put, made of Linen or Tow wrapt together, it must be wet in the foresaid Medicines, and put un∣der the Arm-pit, lest the Shoul∣der, by reason of its weight, and the laxity of the Ligaments, might slip down again. Then a broad linen Cloth, wrung out of black austere Wine, must be applied. Thirdly, a Roller must be brought about it, which must keep fast the Ball, and always draw the Arm upwards, or at least keep it so. First of all therefore the middle of the Roller must go over the Ball, and be carried once or twice round the Joynt, then both the heads must be carried round the Neck on the other side. When three or four days are over, the bandage may be loosed: and if all fear of Inflam∣mation be not over, or if the Li∣gaments continue lax, the like

Medicine must be renewed, till all fear of Inflammation is over, and the Ligaments are strengthened. And then you may leave off the Roller, and the foresaid Medi∣cine, and apply some Plaster: in Winter Barbarum, and in Sum∣mer Diapalma.

CHAP. V.

Of Luxation of the Clavicle or Collar-bone.

THe Clavicle is a crooked Bone made in the figure of an S. one end of which be∣ing thicker, and almost three square, is inserted into a Cavity purposely sitted for it in the first bone of the Sternum, and bound in by a strong ligamentous Membrane. The o∣ther end being broad and flat, is joyned to the Acromium, where it not only serveth to keep the Shoul∣der at due distance from the Ster∣num, but also assists these several Processes, which are provided by nature to preserve the Shoulder-Bone from slipping upwards from its Cavity.

This Bone is capable of a dou∣ble Luxation, one at the Sternum, and that only outwardly, where it rises from the Breast, and lies like a lump. The other at the broad end near the Acromium, which is also subject to a twofold Luxati∣on, viz. upward and forward; be∣ing defended from all other distor∣tions by its neighbouring Bones.

This Luxation is for the most part occasioned by a fall, and pitch∣ing upon the Shoulder. It is dis∣cerned by the Prominence it makes.

The Clavicle is not so subject to Luxation as other Bones; but be∣ing luxated, it is most difficultly retained after restitution, by rea∣son of its smoothness of its heads, and the little hold they have up∣on the Acromium and Sternum. And if it be not restored, the use of the Arm is impaired in some of its motions.

The reduction of the Clavicle, which end soever of it is luxated, must be made by drawing that Shoulder backwards, and by pres∣sing the luxated end even with the Acromium, or to the Cavity of the Bone of the Sternum, whence it departed. Neither of the places affords it much room, therefore it will require your greater care: for if you place it not exactly, it will scarce hold right till you make your applications. Therefore you must have ready Emplasticks, Compresses and Bandage. Splints are also of use, whether they be of Pastboard, Scabbard; or Tin. The bandage ought to be a Roller

with two heads to come over the Shoulders, and under the Arm-pit, making so many circumvolu∣tions as may retain the Dressings close. This being well made, his Arm must be kept up with a Nap∣kin or Towel, and his hand pla∣ced under his Breast. If all be well you ought not to loosen the band∣age till you judge it united, which may be guessed at by the ease and use of the Arm.

CHAP. 〈◊〉〈◊〉

Of the Luxation of the Elbow.

THe Elbow is very difficultly both luxated and reduced, according to Hippoc. l. 2. de Ar∣tic. Gal. l. 1. de Fract. First, be∣cause it is multiform and various, not round. Secondly, the Bones that make up the Joynt, do mutu∣ally receive, and are received one of another; wherefore this Joynt is called Ginglymoeides, because it is made like hinges. Thirdly, the Ligaments of this Joynt are very tight. Lastly, the Bones are not two, as in most Articulations; but three, the Cubitus, Radius, and Humerus, which are mutually knit one to another by membranous Ligaments.

Unless the luxated Elbow be quickly replaced, most violent pain ensues; because its great head presses the circumjacent Muscles and Nerves that run to the Hands, and the deep and sharp edges prick the said part. Besides, the Radi∣us increases the pain; for if it be out, there are more pressures; if it be not out, there are great di∣stensions of the nervous bodies. This pain is usually attended with a Fever, vomiting of Bile, Numb∣ness, &c.

The Cubit is luxated forward or backward, outward or inward: and the Radius either follows, or abides in its place.

If the Radius follow, the part∣ing of the Radius from the Cubit may be felt by the touch. If the Cubit be luxated forward, these are the signs; we cannot bend the extended Cubit, the Cubit is made shorter, an unusual Tumor appears in the fore-part, and an unwont∣ed Cavity behind. If the Luxati∣on be made backward, the signs are the same; but that the Tu∣mor appears behind, and the Ca∣vity before. If it be luxated out∣ward, the signs are the same, but the Tumor appears outward, and the hollowness inward. If it be luxated inward, on the contrary.

The luxated Elbow must spee∣dily be replaced, otherwise a great Inflammation arises, because of the

pain, upon which the luxated El∣bow is quickly grown callous, the thin Matter being dispersed; but especially because the Elbow is less nervous, and of a cold temperament. When the Elbow is grown hard, it cannot be re∣placed, unless it be mollified with Medicines.

If the Cubit be luxa••••d for∣ward, First, Extensio•• ••••••st be made in a proper Figu•••• ••t di∣rectly, but obliquely, 〈◊〉〈◊〉 the Ca∣put humeri should touch the Cor∣nix, i. e. the high edge of the Cubit, and by Circumrotation it might be broken. When this is done, the luxated Cubit may be replaced four ways. First, if the Luxation be imperfect, it is repla∣ced by a quick bending of the Arm. Secondly, in a perfect Luxation, Extension must be made; then some hard and round body, as of linen Clothes wrapt up hard, must be put in the bending of the Arm, then the Elbow must be bent. Extension must be made by two Servants, one of which must draw the Humerus up, the other the Cubit down, but oblique∣ly. And the round body put in the bowt of the Elbow, must be prest, that when Inflexion is made, Reposition may be made also. Thirdly, two Servants must like∣wise extend, and a Girt must be applied to the luxated Arm, and bound so long hanging down, that the Chirurgeon may put his Foot into it, as into a Stirrup; Exten∣sion therefore being made, and the Girt drawn down by the Chirur∣geon's Foot, the Chirurgeon must then put his Hands to the Cubit, and pressing it backward must bend it. Fourthly, this is usually done with the Hands alone, ta∣king the Cubit in one Hand, and the Humerus in the Other, the Cu∣bit must be bended, and put into its place again.

If the Luxation be backwards, having made Extension obliquely, a fresh Luxation is easily replaced by the Hands alone. But because in this case extension uses to prove difficult (for the exteriour extend∣ing Muscles of the Cubit, are very strong) the Chirurgeon must anoint his Hands with Oyl, that the Muscles may be the more pliable: And if the Strength of the Hands be not sufficient to reduce the Cubit, we must use Hippocrates his Instruments, the Ladder, &c. If the Cubit slip inward or outward, it must be forced the contra∣ry way. When reduction is done, Medicines must be applied to as∣swage pain; to contract and strengthen the lax and distorted Ligaments, and to prevent Inflam∣mation: the first whereof is done by oyly things; the rest by astrin∣gents; where we must consider what is most urgent. If there be pain, we must mix Oleum Myrti∣num or Rosaceum with astringe•• Powders, and the white of an Egg. Or we must use Ceratum Rosace∣um, spread on a broad piece of Linen, and then Stupes must be ap∣plied dipt in a Medicine è pulveri∣bus astringentibus ovi albumine subactis. Then proper Bandage must be made, like that which we mentioned before in Fractures, always observing a middle po∣sture.

The Radius usually slips out∣ward. The Signs are, an apparent

Tumor outward, the Cubitus and Radius gape one from another. When extension is made, it is easi∣ly forced in again.

CHAP. VII.

Of the Luxation of the Carpus, Metacarpus, and Fingers.

THe whole Carpus, or Wrist, considered in it self, and joyned to the Arm by Diathrosis, may slip inward, outward, forward or backward, but principally for∣ward; the signs are a Tumor in the forepart, and the Fingers cannot be bent. If luxation be made backward, the Fingers cannot be extended, because the Tendons and Nerves are pressed upon by the Bones. If the Luxation be made either inward or outward, a swel∣ling appears on one side, and an hollowness on the opposite.

If then Luxation be made either forward or backward, the Hand must be laid on a Table, the back downwards, if Luxation be made forward; and the back upwards, if the Luxation be made back∣wards: then extension must be made by two Servants, one pulling at the Arm, and the other at the Hand. While extension is making, the Chirurgeon must force the luxated part the contrary way, either with the Hand, or in ro∣buft Bodies, by pressing it with the Heel. Celsus laies some linen Cloth rolled up hard, upon the Luxation, where it is to be prest most, that so the intrusion may be stronger, and the pain less. If the Luxation be outward or inward, as extension is making, the Chirur∣geon must force it the contrary way.

A Luxation of the Bones of the Carpus or Metacarpus is easily re∣placed, in the first by making no extension; in the second, by a mo∣derate extension, the Hand being placed on a Table, and some hard Body put under, and so the Bones being thrust by the Hand or Heel into their places, either forward or backward.

The Fingers are luxated either forward, backward, or to one side. The signs are very apparent, be∣cause the Joynts have but little Flesh on them. As extension is made upon a Table by two Ser∣vants, the Bone is easily thrust the contrary way. When reposition is made, Medicines must be applied, the Limb must be bound, put in a fitting posture, &c.

CHAP. VIII.

Of the Luxation of the Thigh.

THe Thigh has a round Head, growing in a long Neck, which is inserted into a very deep Sinus. The Thigh is bound to the Os Coxendicis by two Liga∣ments, the one orbicular, and the other round. Hence it is apparent that only a perfect Luxation can happen in the Thigh, and not an imperfect one, as we said before of the Shoulder. The Thigh slips forward, backward, outward or in∣ward. But it is done with great difficulty. First, because of the very strong Muscles, and abundance of Flesh upon those Muscles, which keep the Thigh in its proper Si∣nus. Secondly, because of the depth of the Acetebulum. Thirdly, because of two tight and short Ligaments. The Thigh is seldom luxated for∣ward or backward, because in these sides the edges of the Aceta∣bulum are highest; sometimes out∣ward, because there they are not so high; oftnest inward, because there the edge is lowest. And be∣sides the lowness of the edge I may add the round Ligament, which is inserted next the inside, and there∣fore will more easily give way to Luxation of the Thigh inward.

If the Thigh be luxated inward; it appears longer than the other, because the Thigh desconds. Also the Knee, Leg and Foot stand out∣ward; For if one end of a thing encline one way, the other end will encline the contrary: where∣fore if the Head of the Thigh be displaced inward, the Knee, Leg and Foot encline outward. Be∣sides, the Thigh cannot be brought toward the Groin; because the inflexor Muscles are straitned and hindred, that they can neither lift nor bend the Thigh. Another sign is, that on the Region be∣tween the Anus and the Testicles, a manifest Tumor appears in the outer side of the Sinus. If the Thigh slip outwards, the signs are contrary: for that Leg is shorter than the other, because the Head is more elate than its Sinus. Be∣tween the Scretum and the Anus there is a hollowness; and towards the Buttocks there is a swelling. The Knee, Leg and Foot stand in∣ward. The Heel cannot touch the ground, because the Leg is short∣ned: but the Patient can draw his Thigh upward, because the in∣flexor Muscles are not hindred. If the Knee slip forward, the extended Thigh cannot be bent, because the inflexor Muscles are hindred and pressed by the head of the Thigh.

Urine is stopt in such Persons, because the head of the Thigh presses upon the Bladder. The Groins swell, be cause the head of the Thigh is slipt into these parts. The Buttocks appear wrinkled and without Flesh; because the whole Thigh, toge∣ther with the Processes, is slipt for∣ward. If the Thigh be slipt back∣ward, there are the contrary signs. The Leg cannot be extended, be∣cause the extending Muscles, which are behind, are prest; wherefore they cannot be drawn toward their proper Principles; the Thigh af∣fected is shorter than the other, because the Head is got above the Sinus; the Heel cannot touch the ground. The Groin appears lax, and the head of the Thigh sticks out at the Buttocks.

It is very difficult to replace a dislocated Thigh; because, by reason of the very strong Muscles, extension cannot be made: and the difficulty is encreased, if the Luxation be not new, but callous by reason of Humors running to the Os Foemoris, and of the re∣pletion of the Sinus. The Thigh being replaced, it is apt to slip out again, because the Muscles are so weakned, that they are not able to keep the heavy Thigh in its Seat; and because the round Ligaments is either la••ated, or broken.

The Thigh may be replaced, either without or with extension. Without extension two ways, but never unless the Luxation be new, and moderate, i.e. standing but a little way from its Sinus, and in a Child's Body. The first way is, to turn round the head of the Thigh about the Hium (as we did when the Arm was out of Joynt) and not to separate it, if it get in∣to the Sinus. But this way is not safe, for fear lest the head of the Bone should rub against the edges of the Sinus, and so either bruise or break them. The other way is, to bend the Thigh suddenly: for so sometimes it is replaced accord∣ing to Paulus, c. 98. l. 6.

But the Thigh is best reduced with extension. If therefore the Thigh be slipt inward, thô there seems to be no need of extension, since the Leg is longer than it should be (not shorter, as in other Luxations, wherein the Muscles moving the head of the Bone, have their Original far above it, and so draw the head upwards) never∣theless a little extension must be made, as much as is sufficient to stir and extricate the fixt head. This may be done with the Hands, if the Luxation be new, moderate, and in a Child's Body. It must be performed in this manner; one Servant must hold the Patient's Body by the Armpits very fast; another must take hold of the Thigh with both his Hands above his Knee, and extend it. In the mean time, while extension is making, the Chirurgeon must with his Hands force the Thigh slipt inward, outward. When the Head is thus extricated by means of this impulsion, the Muscles that draw upwards, will easily put it into its place again; or, if the Muscles be weak, the Chirur∣geon may easily do it. If it be in a robust Body, we want stronger extension, which must be with Girts and Ropes. A Girt then

must be put on the space between the Genitals and the Anus; but so, as that it do not take hold of the head of the Bone. Then another Girt must be tied above the Knee, or another above the Ankle: and these Girts must be drawn by the two heads, either with the hands alone, or with a Ladder, to one of the staves whereof the up∣per Girt must be tied, and the Pa∣tient must be laid on the Ladder, and the other Girt must be drawn downward. You may also use the Scamnum Hippocratis. But these violent Extensions are most proper in other Luxations of the Thigh, when it is put outward, forward or backward: for when Extension is made, and the head is forced the contrary way, the Chirurgeon may easily reduce it. After reduction, Medicines must be applied, to pre∣vent Inflammation, asswage Pain, and to contract and strengthen the lax Ligaments.

CHAP. IX.

Of the Luxation of the Knee.

THe Knee is not easily put out of joynt: because it has two Ligaments, and it has a double head, and a Sinus. It un∣dergoes an imperfect and a perfect Luxation, and it slips outward, in∣ward, or backward: only Celsus adds forward; but so it is very hard for the Knee to be luxated, because of the Knee-pan, which be∣ing tied by very strong Tendons, does wonderfully strengthen the Knee forward, so that it cannot slip that way; unless there be a violent cause.

All the forts of this Luxati∣on are manifested to the Eyes; be∣cause it is a fleshless part: for there appears an unusual Tumor on one side, and a Cavity on the opposite; the Figure is depraved, Motion is weakned and abolished.

If the Luxation be imperfect, little or no Extension is required, but only forcing it to the contrary side. If it be perfect, Extension is necessary; which may be made by the hand in a fresh Luxation, and in Childhood. One Servant must draw upwards, and another below the Knee towards the Foot; and the Chirurgeon must force the Bone to the contrary side. In a grown Man, and a great Luxation, there is need of Girts or Engines, especially to draw downward, and make sufficient Extension, &c.

CHAP. X.

Of the Luxation of the Ankle and Toes.

THe Ankle may slip out in∣ward, outward, forward or backward. If inward, the Sole of the Foot turns outward: if outward, on the contrary. If forward, then the broad and strong Tendon in the Heel, is hard and tight: besides, that Foot is less; because the Leg and Joynt is mo∣ved forward, and takes up a great part of the Foot; whereupon the Foot is less and shorter. If back∣ward, the Heel is almost hid, be∣cause the Joynt is slipt to the Heel: besides, the Sole seems greater, and the Foot longer. If these signs be manifest, the Luxation is perfect; if they are obscure, it is imperfect.

The Cure is not difficult, if due Extension be used; with the Hands, if the Luxation be fresh, and in a Child, one Servant must take hold of the Foot, another of the Leg above the Ankle; and the Chirurgeon must force it unto the opposite part. If good Extension cannot be made by the Hands, we use Girts, to the Foot, and to the Leg above the Ankle; about the small. If very violent Extension be required, we may use the Scam∣nam Hippucratis; or Paulus his way, l. 6. c. 121. which is, to drive a stake deep into the ground; then to lay the Patient on his Back, astride the stake, which must be driven in so deep and firm, as not to give way, when Extension is made.

When the Joynt is reduced, the Patient must be kept longer in Bed, than for other Luxations, viz. Forty days; because the Ankle supports the whole Body, and therefore unless it be compleatly restored, that is, unless the lax Ligaments and distended Muscles acquire their pristine strength, the Patients do either relapse into the same Luxation upon every slight occasion; or they find their Foot very weak for a long time. We must therefore use aftringent Pow∣ders, mixt with whites of Eggs, applied about the Joynt with Tow. If there be pain, then Lenients are required.

The Bones of the Pedium and Tarsus are so strongly knit toge∣ther, that they never suffer Luxa∣tion. The Toes are seldom lux∣ated, because they are held by ma∣ny strong Ligaments and Ten∣dons. They are reduced as the Fin∣gers.