Ars chirurgica a compendium of the theory and practice of chirurgery in seven books ... shewing the names, causes, signs, differences, prognosticks, and various intentions of curing all kinds of chirurgick diseases ... : to which is added Pharmacopoeia chirurgica, or, The medical store, Latin and English ... / by William Salmon ...

CHAP. XXIII. Of GƲN-SHOT WOƲNDS in the LIMBS and JOINTS.

I. THese kinds of Wounds sel∣dom go without Fracture of the Bone; nor is there any of the five various kinds of Fra∣ctures which will not be made by Gun-shot.

II. The Signs. Now to disco∣ver a Fracture of a Bone, it will be well, as Hippocrates advises, to compare the sound Parts with the Parts affected, and to see whe∣ther there is any inequality, or not; for if broken, you will feel a Cavity, if you touch or press upon the Parts above or below.

III. There will be a vehemency of Pain, because of the divulsion of the Nerves, and distortion of the Tendinous Bodies, also a prick∣ing pain in the fleshy Parts by the pointed ends, or shivers of the Bone.

IV. The asperity and inequality of the Bone, also searching with your Probe, and handling the Fra∣ctured Member, wherein is per∣ceived a crashing of the Bones one against another: these, with the Impotency of the wounded Member, so that the Patient cannot lean or stand upon it, are all demonstrations that the Bone is broken.

V. The Prognosticks. Those Fractures are most dangerous, which are made so deep in the Flesh, that we cannot well come at them with our Hands, to extract the shivered Bones, and place the others right, and retain them so by Bandage, as those of the Pubes, Os Ilion, Os Sacrum, &c.

VI. Those Wounds in which there are many Splinters of Bones, wherein the Bone is generally shat∣tered to pieces, are extreamly dangerous, because their sharp points are apt to prick the Nerves, Tendons, &c. where∣by vehement Pain, Inflammati∣on, and Convulsions are excited, and many times Death follows, unless the Member is immedi∣ately Amputated.

VII. Tho' Amputation is not to be used upon every slight account, yet when the Case is so desperate, that the Cure cannot be done with∣out it, or when it is necessary to be done for preserving the Patient's Lise, it ought to be done at first, even upon the receiving of the Wound, whilst the Patient is heated, furious, and in Mettle, before his Courage decays, Spi∣rits languish, or Pain, flux of Humors, Inflammations, Fevers, or Convulsions, seize him, and not defer it to the next Day, at which time the Patient will chuse rather to Die, than to endure the Cruelty of the Ope∣ration.

VIII. If the Bone is broken in the middle, it is less dangerous than near the Joint, where it is

more hard to be restored; and being restored, more difficult to be kept in its place; besides the great number of Symptoms, which are apt to ensue, which cannot be cured without much difficulty.

IX. The Agglutination of Bones is more easily, and sooner per∣formed in young Persons, than in such as are old: so also in such as are of a Sanguin Complexion, rather than in such as are Cho∣lerick, Melancholick, or of a Cacochymick, or Scorbutick Habit of Body; because the former has much better Juices, Lympha, and Serum, for the generating of a Callus, than the latter have.

I. The Cure of Gunshot-Wounds in the Limbs.

X. Clear the Wound from all extraneous things; as Bullets, Rags, Splinters, Weapons, pieces of Bones, &c. and if need be, enlarge the Orifice of it; then dress it with Digestives and lenient Embrocations, after∣wards deterge it with Mundifi∣cativum Paracelsi; and hasten the Exfoliation of the Bones with Mel Rosarum and Spirit of Wine, or Tincture of Eu∣phorbium, &c.

XI. The Mundificative of Paracelsus. ℞ Honey ℥iv. Tur∣pentine ℥ ii. boil with a gentle heat, to the consistence of a soft Ointment; take it from the Fire, and mix with it the yolk of an Egg, red Precipitate levigated ℥i. stir them 'till they are well in∣corporated. It is said to excel all other Abstersives or Mundifi∣catives.

XII. If the Fracture is near a Joint, there may be many times thro' the violence of the Blow, a dislocation withal: in this case, you must first restore the Joint, before you meddle with the Fracture: you must also first reduce the Fracture, before you meddle with the Wound.

XIII. To reduce the Fracture, you must make Extension, and Coaptation, or Reposition, that the Bone may be restored to its proper place, which ought to be done with much steadiness and care; and not with such a force as is necessary in Fra∣ctures without a Wound, lest the Musculous or Nervous Parts should suffer vehement Pain, In∣flammation, Convulsions, &c.

XIV. When you begin the Work, if the Orifice is not large enough, widen it, for the Extraction of the Bullet, broken Bones, and other Extraneous Bodies; so will the Extension be the easier, and less subject to an Inflam∣mation, and a small extension will serve to restore the Bones to their former place.

XV. And indeed these Wounds require more dilatation than any other; that not only the cor∣rupted Blood, and other Excre∣ments may have a free passage out; but that also the Shivers of Bones, with which these kinds of Wounds usually a∣bound, may with less trouble be extracted by Instrument, or discharged by Nature.

XVI. If this Dilatation is not made at first, you may possibly

be forced to do it when the Part is afflicted with vehement Pain, Defluxion, and Inflamma∣tion; or when the Bones are corrupted by the retention of the Matter; which will be a great disadvantage to the Pa∣tient.

XVII. The Wound being laid open, see whether the Bone is bare, or not; which you may find out either with your Eye, Finger, or Probe: if it is bare, you must apply drying things to it, as dry Lint, pouders of Aloes, Birthwort-roots, Frankincense, Myrrh, Orrice-roots, Euphor∣bium, &c. forbearing all oily and greasy Medicines, because they foul the Bone, and hinder the Callus.

XVIII. But to the Fleshy Parts you must apply Digestives, because they require Digestion, without which no Cure will succeed: and therefore over the dry things laid upon the naked Bone, you may apply warm Suppuratives, such as we direct to in Simple Gunshot-Wounds.

XIX. Then lay over the Fra∣ctured Part Emplastr. Caesar, or E Bolo; or Catagmaticum ma∣laxed with Linseed-Oil, and Oil of Whelps: or this; Take Empl. Album ℥iv. Comfrey-roots in pouder, Terra sigillata, Catechu, Rosin, all in pouder, A. ℥ss. juice of Plantan ℥j. Oils of Myrtles and of Whelps, A. q.s. mix, and make an Emplaster.

XX. Apply over the Wound a Stuph, or double Cloths wrung out of a Decoction of Wormwood-tops, Myrtle-berries, Sumach, red Roses and Catechu made in Red-Wine; which Compress will serve to keep the lips of the Wound smooth, and defend it from the injury of the Bandage.

XXI. The next thing to be considered is the Bandage: for unless that is rightly and well done, no Unition, or Healing can be expected: and tho' in Simple Fractures without a Wound, all kinds of Bandage may be admitted, with ma∣ny circumvolutions about the Part, and once opening them in a Weeks time may be enough: in these Wounds it is not so, for the Bandage is to be daily loosned, and the Wounds to be opened and drest, for the dis∣charge of purulent and excre∣mentitious Matter, and exfo∣liation of carious Bones, which lying, would corrupt those which are sound.

XXII. But the Bandage ought to be such, as may the least shake or hurt the fractured Part: for being every day to be opened, the so often rowling the Wound up would cause much pain, and hinder the Unition; for which Reason, Authors have invented many kinds of Bandage, to answer all the Intentions of Dressing, and yet keep the Member immoveable.

XXIII. And therefore for this purpose, it ought to be made of soft Linnen Cloths; (broader than those we use in simple Fractures;) yet it may compre∣hend, or reach over, both the Fracture and the Wound, keep the Lips down and smooth, and not hurt them by its too hard compression.

XXIV. The Form of the Liga∣ture. Take a soft broad piece of Cloth, folded four times dou∣ble, to give it the more strength and firmness, and so broad as may reach over both the lips of the Wound, and the fractured Parts, and so long as to come once about the Fracture: it must have three slits, from the ends to the middle; which middle must be undivided under∣neath, to bear more equally the Member; and the ends must come over one another, with a Compress between or under them, over the Wound, to press the lips thereof equally down, which otherwise would swell or stick out with great brims.

XXV. The Compress is useful to receive the matter, and fill up the inequality; and the Slits or Straps are to be so fastned, that you may easily open them, and undress and dress the Wound, without disturbing the fractured Member.

XXVI. Now because thro' the great shattering of the Bones, and laceration of the fleshy Parts; as also by reason of the largeness of the Wound and Fracture, causing exceeding pain, the Member is made exceeding weak, that it cannot be kept steady by this Ban∣dange, you ought to make use of Ferulae or Splints; but they are not to be used 'till the Flux of Humors and Inflammation cease, which will be about the seventh day; and 'till then, you may make use of Splenia, which are folded Linnen Cloths four times double, and cut or made in length and bredth like to the Ferulae.

XXVII. These Splenia are to be spread with Galen's Cerat, or any proper Ointment, whereby they may adhere to the Part, 'till you have put the Bandage over it. They strengthen the Part, and make such an equal compression, as to keep the Bones in their pla∣ces, press the Serous Humors out of the Wound, and cause the Member to lie soft.

XXVIII. The Pain and Inflam∣mation being thus gone off, and the Wound digested, you may (if you think fit) use pliable Pastbords cut into like pieces, to lay over these Splenia. Or, having fast∣ned the Splenia, by the broad Bandage with three Slits, or Straps, cut a piece of Pastbord, fit to receive the lower part of the Member, and leave a place large enough for dressing of the Wound: and over the other part of the fractured Member you must lay another piece of Pastbord, to answer to the former; which ought to be wet, that they may be the more pliant.

XXIX. And about the Past-bord make a Bandage with three Ligatures, which you are to fasten in the most fit place for the ease of the Patient: if the Splenia also are made wet with whites of Eggs, and so applied, they will very much strengthen the Member, and also keep it steady without those other.

XXX. You may make the Past-board over the first Bandage, to en∣compass so much of the lower parts, as may support the Fracture, and come within an Inch of the Wound: and over the Wound it self you

may fasten a Splenium of Cloth four times double, or a Ferula∣like piece of Copper, Pewter, Tin, or Pastbord, lined as you see the Part can bear it, which may be taken off at each dressing.

XXXI. The first Bandage next to the Cerate, makes an equal compression, by three Heads, meeting one over another: the lowermost presses the Humors or Recrements from below up∣wards, and with the help of its next fellow, keeps the Bones in their right places, and forces the Pus out of the Wound; and by the help the middle Bracer has from the uppermost, the matter is prest out of the up∣per parts of the Fracture and Wound, to the mouth of the Orifice: it also restrains the Influx of Humors from above, by virtue of the Defensative lying under it.

XXXII. And in the dressing of these Wounds, you are only to undo the middle Binder, to come at the Sore; but in doing it up again, you must take great heed, that you make it not too hard nor too slack, but draw it strait in a mean, that it may not in the least hurt the Patient.

XXXIII. The convenient Position of the Membeer, is next to be con∣sidered; which ought to be so, 1. As it may lye soft and easy; lest the compression should offend the wounded Parts, and cause Pain, or Inflammation. 2. That it may lye equal or smooth; for otherwise the Limb will be distorted, or the Operation ill performed. 3. That it may lye higher than the parts next the Body, especially for the first three or four days: because if it inclines down∣wards, it may be apt to induce an afflux of Humors. Now how this Position is exactly to be per∣formed, we shall teach in Lib. 6. of Fractures, following.

XXXIV. The Bones being thus restored, the Wound digested, and the Inflammation or other Accidents gone off, which is about the se∣venth or ninth day, unloose the Bandage, take off your Astrin∣gent or Restrictive Applica∣tions, and impose Empl. Cata∣gmaticum, or some such like, over the broken Bones.

XXXV. Or this following. Take Frankincense, Wax, A. lbi. Catechu in fine pouder ℥iv. juice of Comfrey, of Doves-foot, A. ℥iij. mix, and melt, reducing it to the consistence of a Cerat.

XXXVI. Or, Take mucilage of Comfrey-roots, birdlime, juice of Doves-foot, or Bistort, of Poplar∣buds, A. ℥iv. mucilage of Traga∣canth, Osteocolla in fine pouder, Catechu in fine pouder, A. ℥ iij. yolks of Eggs N^o xx. Turpentine lbjss. Oil of Whelps ℥iv. mix, and boil all well; adding afterwards Wax, enough to bring it to the consistency of a Cerat.

XXXVII. Some use instead of these, Empl. Sticticum Paracelsi ℥iv. Empl. Album ℥ij. mixing them together; and over this, or one of the former Empla∣sters, apply a double Cloth dipt in Decoction of Wormwood, Southernwood, Sumach, and Red-Roses, made with Red-Wine.

XXXVIII. Which done, fit to

the wounded Part the former Bandage again; and over it ei∣ther some Plates of Tin or Copper, or otherwise Splenia of double Cloths dipt in whites of Eggs, and wrung out hard: these latter will lye close to the Part, and after they are dry will admirably well strengthen the Member.

XXXIX. In about nine days time the Wound will be digested, after which Maturatives or Sup∣puratives are to be forborn, and Abstersives or Cleansers are to be used; as the Mundisicati∣vum Paracelsi, at Sect. 11. afore-going; or Ʋnguentum Nicotianae; or this, Take Tobacco, Perwinkle, A. M. ij. Hypericon Mj. roots of round Birthwort ℥jss. of Floren∣tine-Orrice ʒ vj. Frankincense, Myrrh, Sarcocol, A. ʒiii. White-VVine q.s. boil, and strain out, and dissolve therein Honey of Roses ℥iv, vel vi. Inject this with a Syringe, and it will both cleanse, and breed Flesh.

XL. If there is a caries, or rottenness of the Bone, make a Decoction of Orrice-root, Gen∣tian, Cortex Guajaci, Scordium, Perwinkle, Hog-fennel and Myrrh, in Wine; adding Tin∣cture of Euphorbium to it, Cam∣phorated S.V. or Extract of Scordium.

XLI. If the Caries will not yield to the former Medica∣ment, touch it now and then with this. Take Oil of Myrrh, distilled per descensum, and acuated with S.V. ʒiv. Oil of Cloves ʒi. Oil of Sulphur ʒjss. mix them. Or you may use Tinct. Euphorbii, alone: these will in a short time remove the Cariosity; after which, you may pursue the ordinary Method of Cure.

XLII. While these things are doing outwardly, you may administer inwardly this fol∣lowing Wound-Drink. Take round Birthwort-roots, A. ℥ss. the Herbs, Angelica, Avens, Bistort, Comfrey, Doves-foot, Perwinkle, Self-heal, Scordium, Speedwel, Ladies-mantle, A. M. j. VVine lbxii. boil them in a Vessel close stopt for half an hour, or better; strain out, and let the Patient take ℥iv, ad vi. morning and evening, with Osteocolla ʒi. in fine pouder, every time. Or you may make a Decoction of Perwinkle in Wine, in which you may give Osteocolla, as before directed.

XLIII. Now in Dressing these kinds of VVounds, you are to ob∣serve, that if the Quittor is but little, it is enough to dress them once in 24 hours time: but if much Pus flows forth, or there is great Pain, or the Patient is feverish, they ought to be drest once every 12 hours.

XLIV. Cooling and Astringent Medicines are not to be used in the first Dressing; because the first extinguish the Natural Heat; the latter keep in putrid Vapors, and may induce a Gangren.

XLV. For this cause Anodyns, Emollients, and Suppuratives are convenient; as Oils of Linseed, of Hempseed, of Lillies, of Eggs, of Hypericon, of Elder, of Whelps, of Earthworms, and of Camomil; which may be mixt with yolks of Eggs and

Saffron, 'till the Wound comes to Digestion, which may be about the fourth or fifth day. Or this: Take Crums of Bread ℥iv. Milk ℥xii. Barley and Bean meal, A. ℥j. flowers of Camomil and Melilot, A. P.ij. boil all to the consistence of a Cataplasm, adding at last yolks of Eggs N^o ij. Oil of Whelps and of Hypericon, A. ℥jss. mix them.

XLVI. If Putrifaction is feared, some use Vitriol calcined, and dissolved in Aqua Vitae; tho' it is not suppurative, because it resists Putrifaction.

XLVII. Tents, if any are used, may be at first made greater and longer, that the Wound may be sufficiently dilated: but Escaro∣ticks are not to be used, without great necessity; 1. By reason they cause Pain, Inflammation, and Fevers, &c. 2. Because they hinder Suppuration. 3. Be∣cause the Escar keeps in putrid Vapors, which may pass from the lesser to the greater Vessels, and so to the Principal Parts, and cause a Fever.

XLVIII. If there is any Burn∣ing, then such Medicines which are good against Burning are to be used: as, Take Oils of Linseed and white Lillies, A. ℥ii. Ung. Album ℥jss. Ung. Nico∣tianae ℥i. juices of Housleek, of Plantan, of Elder-leaves, and of green Tobacco, A. ℥ii. Saccharum Saturni ʒiv. boil with a gentle Fire to the consumption of the Juices, and add Oil of Whelps ℥i. purified Verdigrise ʒj.

XLIX. If the Contusion is very great, and possesses much of the adjacent Parts, they are to be Scarified, to discharge part of the coagulated Blood, which is apt to putrify.

L. If by the Signs the Bullet seems to have been poisoned, the brims are to be scarified, Ventoses to be applied, Antidotes are to be inwardly given, and Alexiphar∣micks applied outwardly. In∣wardly give Sal Viperarum, or Our Theriaca Chymica, taking after it a spoonful or two of Our Aqua Bezoartica, or Spiritus Cordialis.

LI. And outwardly apply to the Wound this Mixture. Take juices of Scordium, Tobacco, and Angelica, Vinegar of Roses and of Squills, Honey, A. lbss. Sal Gem, Alum, A. ℥i. Verdigrise purified ℥ss. mix, and boil to a consistence; adding at the end of the boiling, Mithridate, Venice Treacle, A. ℥i. or of Our Theriaca Chymica ℥ii. apply this either upon Tents, or Pledgets, or by way of In∣jection, as you see fit. See more of this Subject in Chap. 18. afore-going.

LII. If the softer Spermatick Parts are lacerated, you may apply this. Take Strasburgh or Cypress Turpentine, Oils of Turpen∣tine and Hypericon, A.℥ii. Tur∣bith-mineral ʒss. Calx vive, Eu∣phorbium, Tutty, all in fine pouder, A. ʒi. mix them.

LIII. But if the harder Sper∣matick Parts, as the Cartilages and Bones are shivered, then, ℞ Of the former Composition ℥ijss. Oils of Hypericon and Juniper-berries, A. ℥ii. pouders of round Birthwort roots, of Cloves, of Tobacco, A. ʒi. mix them, and let it be applied hot: this will

procure the Scaling of the Bone, and preserve the sound Part from Cariosity.

II. Of Gunshot-Wounds in the Joints.

LIV. These Wounds are subject to more grievous and vehement Accidents or Symptoms, than the former: there are Tendons and Ligaments inserted near the Joints, for their motion; and Membranes, to make them of a very exquisit sense: the Trunk of Nerves in every great Joint passes thro' it, for the use of the Member beyond it; and Joints being exsanguous Parts, the Natural Balsam of the Blood and Lympha is more spa∣ringly supplied, for the help of the Cure.

LV. The Prognosticks. Great Wounds in the greater Joints, are accompanied with more vehement pain, than Wounds out of the Joint; and also with Inflam∣mations, Delirium, Convulsions, and Gangren, which are for the most part mortal.

LVI. The Cure. In these, the extraneous Bodies, and Splinters of Bones, are immediatly to be taken forth; for which reason, the Orifice, if it be not large enough, is to be made so: but in doing this, in the lower parts in the hollow of the Ham, Arm, Armpit, or Groin, be cautious, because those Parts are subject to great Hemorrhages.

LVII. The Extraneous Bo∣dies, &c. being removed, you must with all speed hasten Digestion by dropping, or applying warm upon Tents, Dossels, or Pledgets, proper Digestives, such as the following: but Tents are to be used with much caution in these kinds of Wounds.

LVIII. Take Turpentine washed in S.V. ℥iv. Oil of Hypericon ℥ii. yolks of Eggs N^o ii. Frankincense, Mastich, Olibanum, Myrrh, Saf∣fron, A. ʒi. mix them.

LIX. Or, Take Turpentine ℥ii. yolks of Eggs N^o ii. Oils of Scor∣pions, of Castor, of Earthworms, and of Whelps, A. ℥ss. Frankin∣cense, Myrrh, Harts-horn burnt, A. ʒiss. mix them.

LX. But if a stronger Dige∣stive is required; then, Take Oils of Turpentine and of Spike, A. ℥i. Oils of Castor, and of Hype∣ricon with Gums, A.℥jss. Euphor∣bium in pouder ʒjss. mix them: this is to be dropt very hot in∣to the Wound, and one of the afore-mentioned Digestives is to be applied over all.

LXI. Then the Parts adjacent are to be Embrocated with Oils of Whelps and of Hypericon, over which this Cataplasm may be applied. Take Barley and Bean meals, A. lbj. flowers of Camomil and Melilot, red Roses, tops of Wormwood and Scordium, all in pouder, A. ℥i. Broth of a Sheeps-head, (if you would have it Lenitive, otherwise in Oxymel) q.s. boil to a consistency; adding, Oils of Whelps and Linseed, A.q.s.

LXII. Or, Take mucilages of Altbea and Comfrey roots, A. ℥iv. Barley and Bean meals, A. ℥vi. meals of Linseed and Fenugreek-seed, A. ℥iv. Zedoary in pouder ℥jss. Wine, q.s. boil to a consi∣stency: and add, Oils of Hypericon

and Whelps, Honey, A. ℥ii. yolks of Eggs N^o ii. mix them for a Digestive.

LXIII. Then deterge with this Abstersive. Take Turpentine, Ho∣ney, Orobus-meal, A. ℥ii. Orrice-root, Frankincense, round Birth∣wort-root, A. ℥jss. juice of Smal∣lage ℥ iii. mix, and make an Ointment.

LXIV. The Wound being cleansed, Inearnate with Sarco∣ticks: as, Take Beef-suet ℥iv. Earthworms washed, Oil of Ma∣stich, A. ℥ii. roots of Comfrey and Tormentil, A. ℥ ss. tops of Hyperi∣con, Betony, Horse-tail, Plantain, A. M. ss. Wine, q.s. boil to the consumption of the VVine; strain out by strong expression, and add thereto VVax ℥ iv. Pine-Rosin ℥i. Aloes, Frankin∣cense, Mastich, Myrrh, A. ℥ss. mix, and make an Ointment. Wiseman.

LXV. If the pain is violent, and yields not to Anodyns, cut off the affected Tendon, and whatever corrupts, lest it taints the rest: and if the Bone is bare, you must be careful not to foul it by applying greasy Medicines: also in great Wounds of this kind, you ought always to con∣sider first, whether they are curable or not; that by a timely Extirpation, you may save the Life of your Patient.