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. V. Of a FRACTƲRE with a WOƲND.

I. WHAT the Greeks call, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. and the Latins, Fractura cum Vulnere; we in English call, A Fracture with a Wound.

II. This comes to pass, when the sharp eminencies or points of the fractured Bones do perforate the Flesh which lies upon them; making thereby the Member shorter than it was before.

III. The Causes are from vari∣ous things; sometimes these Fra∣ctures happen by means of some cutting Weapon, which not only cuts the Flesh, but even the Bone it self.

IV. The Prognosticks. If such a Fracture as this is made, where the Flesh and Skin lying over are still whole and sound, it is more dangerous than where the Wound is open; because in the former a Pain and Inflammation are excited, and the Muscles thus affected, suffer a double Extension, the one from the In∣flammation, the other from the Extension in order to the Re∣duction.

V. And this danger is so much the greater, by how much the Parts fractured are greater, or more no∣ble and principal, as the Arteries, Veins, Nerves, Tendons and Muscles.

VI. A Fracture with a Wound made with a cutting Weapon, is dangerous, if the Bone that is cut is great, such as that of the Shoul∣der, or Thigh; for in these, if the Incision is direct and straight, the Bones will very difficultly be brought to grow together again; partly, because by the Cut the Pores are obstru∣cted, thro' which the Juice ge∣nerating the Callus did former∣ly pass; and partly, because the ends of the Bones being equal and smooth, cannot easily be kept fixt, till the Coalition is perfected.

VII. A Fracture in the Thigh and Shoulder, with a Wound and falling out of a Bone, is the most dangerous of all; and this in re∣spect to the magnitude of the Part, and greatness of the Ves∣sels.

VIII. Celsus, lib. 8. cap. 10. saith, That it is yet more grievous, when unto the Fracture of a Bone, there is added likewise a Wound of the Flesh; and especially if the Muscles of the Thigh, or of the Shoulder be sensible thereof; for these have always much the more dangerous Inflammations, and they have also Gangrenes more apt and ready to seize up∣on them.

IX. Hippocrates, de Fracturis lib. 3. text. 47. says, They sel∣dom or never escape, the Bones of whose Arms or Thighs, have fallen out outwardly; for as these Bones

are great, and full of Marrow, so there are many other Parts of great moment wounded; as the Muscles, Nerves, Arteries and Veins: whereupon if you reduce them, Convulsions are wont to be excited; if you do not reduce them, acute and cholerick Fevers are excited, with sighing, and blackness of the place affected; so that these do not yet less escape than the other.

X. But (says he) they are in less danger, or more likely, to escape, who have the lower Bone fallen out, than those who have the upper Bone fallen forth outwardly: and they do sometimes escape with Life, who have these Bones redu∣ced or replaced; but this is very rare.

XI. But if the Bone of the Shoul∣der or Thigh fall forth, to the inward parts of those Members, the danger is yet more augmented; because in the inner or under parts of those Limbs, there are Vessels of far greater magnitude and account.

XII. And in Text 41. he says, that if those Bones be reduced, or restored, Convulsions are rather produced, than if they be not redu∣ced, or in a possibility of being restored.

XIII. The Cure. The Indi∣cations of Cure are twofold: 1. That the Bones may be restored to their places, if possible; and exactly joined together again. 2. That the Wound may be healed. But as to this latter Indication, we shall refer you to what we have already written of Wounds.

XIV. The replacing of bones here is difficult, because of the Wound, and great pain, which may hazard a Convulsion, if the Parts be extended. Therefore the Ex∣tension is immediately to be made, (before an Inflammation has (••era'd the Part) but not with violence.

XV. If this cannot be done you must have in readiness some ••trong Iron Levers of different bignesses, out of which one that is convenient is to be chosen; which is to be applied to the lower part of the broken Bone, where pressing upon the lower Bone, it may lift up the upper part, and so slide it into its place.

XVI. But, says Hippocrates, de Fracturis, lib. 3. text, 12. if the Bone which is fallen forth over another, leaves not any place fit for the Lever to enter; or if it is so sharp, as that it starts away from it; we must with a File take away some of the broken Bone; or make it hollow, 'till room is made for the Iron Lever, so as to lay hold upon it.

XVII. But truly these things are are to be done instantly, before any Inflammation arises; for then no extension, or any such put∣ting forth of the Bone can be attempted without danger: but it is to be deferred 'till the Inflammation is abated and gone.

XVIII. If any small part of the Bone so stick out, that it cannot easily be put back again into its true place; but that one part of it may be a stop to another, and that it seems not fit strongly to extend the soft parts, lest pain and convulsion ensue, be∣cause some fragments, or sharp

ends of Bones, may by their eduction tear or hurt those parts which lye near them: in all these Cases, you must by the advice of Hippocrates, de Fract. Lib. 3. Text. 4. Cut them off, either with the Cutting-File, or with the Saw, as you shall see most convenient, as may be done with the best opportunity.

XIX. So likewise, if any part of the Bone break the Flesh, and excite pains; the reduction of them it not to be attempted, because it will induce the highest tortour imaginable: but that part of the Bone is to be cut off; but al∣ways with this Prognostick to the By-standers, that that Limb will be shorter than before, or shorter than its fellow; as our Hippocrates, de Fract. Lib. 3. Text. 46. has assured us.

XX. But in Fracturs with a Wound, the Skin and Flesh being yet fast to them; you must be cautious, that before reduction there is nothing at all sticking between the said broken Bones, for that will hinder their con∣glutination.

XXI. If any thing is sticking there, as a small part of a Bone, or Flesh, or any thing else, it is immediately to be taken forth, but without violence; lest vehement Pain, Inflammation, or Convul∣sions should be induced.

XXII. But if this is not done at first, even in the very beginning, or it cannot be done without vio∣lence and pain, you must defer it; for Nature her self will at length expel whatever is forein or extraneous; but withal you ought to assist her all you can, by applying proper Attractive Medicaments.

XXIII. The Fracture being set, or the Bones replaced, the lips of the Wound are to be closed up, and things must be applied to keep the substance of the fractured and wounded Part sound; and which may ease the Pain, and prevent Inflammation, repel a Flux of Humors, dry up what is there already, and press out what is gathered into the Part: and such are Astringents and Gluti∣natives, of which we have for∣merly spoken.

XXIV. If there is Pain in Winter-time, Ceratum Picatum is to be applied, which Hippocra∣tes says, eases Pain; but in Sum∣mer, a simple Cerat of Wax, Oil, and Vinegar: if there is no Pain, you must endeavour the strengthning of the Fracture, and prevent Inflammation, by applying fine Tow dipt in whites of Eggs; or a linnen Cloth, dipt in and wrung out of a mixture of rough Red-wine and Oil of Roses: Astringent Pouders may also be mixed with whites of Eggs.

XXV. The Bandage, or Way of binding up. The Fracture is to be bound up, as we shewed be∣fore; but the Rowlers ought to be softer, and broader, than in a Fracture without a Wound, that they may reach over the edges of the Wound on each side; and so may close, not press the edges of the Wound.

XXVI. Nor are the Rowlers to be drawn so hard, as in a Fracture without a Wound, lest by squeezing the Wound, Pain and Inflammation

should ensue: for which reason, the Ancients, as Hippocrates and Celsus, used many circumvolu∣tions; it being better to winde often about, than to bind too hard.

XXVII. Some bind this Fra∣cture up, as that without a Wound, so that the Wound may be covered, and they loose this Binding every third day: some rowl about the Swaths so, as that the Wound is not at all comprehended within them, but left naked: so that from day to day, all fit means may be used for curing thereof, without frequent binding up, and unbinding the Fracture.

XXVIII. Others use fewer Swaths, and bind up the Fracture after the usual and ordinary man∣ner; others again use broader, and more Rowlers; that so by their number, they may accom∣plish that which might have been done with fewer, when harder rowled: some use Splints, others slight them: and they that use them, apply them at a good distance from the Wound; some near, or upon the Wound; but it is then with some trouble.

XXIX. Now tho' by all these Ways, you may attain to the same desired End; yet Hippocrates, and all the more skilful Artists, will have it as undoubted Truth; That in the first Binding, the Wound ought not to be left naked; but is to be compre∣hended within the Swath or Rowler.

XXX. And therefore the Swath is first of all to be put upon the Wound it self, (for otherwise, the Humors will be pressed forth from the upper parts upon the Wound, and many dangerous Symptoms may thence arise:) and what is necessary of the Limb, is to be rowled up within the Swaths; nor from this Bandage need you fear any kind of danger; for that for the first three days, little Sanies or Pus will flow forth.

XXXI. Now tho' this Bandage ought not to be too hard, and ought to be somewhat less, than if there was no Wound: yet there ought to be a sufficient compression made, so as to retain and keep the Bones together.

XXXII. And the number of Rowlers may in some sort compen∣sate for the more loose and easy binding of them; since it is far more safe to rowl about the Swaths oftner, than in the least to hurt the Part by a too hard comprehension: for which rea∣son, Celsus his. Bandage with Six Rowlers, is the most excellent in this kind of Fracture.

XXXIII. Every third day the Fracture is to unbound, and then it is again to be dressed after the first manner; save that now a Hole may be made or cut thro' the Emplaster or Cataplasin, which is imposed on the Fracture, and on the Wound: and in the midst also of the very Swaths a Hole is to be left, that so fitting Medicines may be applied unto the Wound, that it may be throughly di∣gested and deterged, without any loosning of the Bandage; as Paraeus, lib. 14. Cap. 18. & 23. has directed.

XXXIV. As oft as the Wound is dressed, it may be covered with

a new Rowler, which may contain •…•…th, the Medicaments, and the Splenia, to defend the Wound from the external Air; which is to be loosned as oft as need shall require: but Ferulae or Splints are here not very profitable, be∣cause they are apt to beget Pain and Inflammation; and for that the number of the Rowlers may very well supply their places.