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. I. Of DISLOCATIONS in General.

I. WHAT the Greeks call, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, vel, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉. the Latins call, Disloca∣tio, vel Luxatio; and we in Eng∣lish, A Dislocation, or Luxati∣on, or Bone out of Joint.

II. It is the displacing or slip∣ping of the head of some Limb or Bone out of its proper Acetabulum or Sinus, into another place.

III. And it is either compleat, when it is wholly out of its place; or incompleat, when it is but a little out, or distorted.

IV. Now a Joint which is de∣signed for motion, consists of the head of a Bone, and a Sinus or Cavity: in the head, all Bones which have a round head, have all motions, as the Shoulder and Thigh: in the Sinus, all which have a deep Sinus, are not so apt to be thrust out of Joint, as the Os Coxendicis; and contrari∣wise, where the Sinus is shal∣low, as in the Scapula.

V. But in order to the full un∣derstanding of the Doctrine of Dislo∣cations, it is necessary to know how Bones are joined together, which is, 1. Per Symphysin. 2. Per Arthrosin.

VI. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Coalescentia, is a close growing of Bones together, and this is either immediate, or mediate.

VII. Immediate Conjunction of Bones is also threefold; 1. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Sutura, or indented Conjuncti∣on, as in the Bones of the Scull. 2. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Harmonia, when joined in a straight line, without indenting. 3. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Gom∣phosis, by entering into a Si∣nus, as a Tooth in its hole or socket.

VIII. Mediate Conjunction of Bones is also threefold; 1. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Syssarcosis, when two Bones are joined by a Medium of Flesh; as the joining of the Teeth to the Jaw, by the Gums. 2. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Synneurosis, when the Connexion is made by a Li∣gament, as the Ossa Pubis in Wo∣men: in Articulation, it is ei∣ther round, as that which joins the head of the Os Femoris to the Coxa: or broad, as the Tendon of the Patella, which unites it to the Os Tibiae. 3. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Synchondrosis, when there is a Union made by Gristles; and by this Medium, the Sternon is joined to the Ribs.

IX. 2. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Articulatio, a Ʋnition by jointing; and this it either, 1. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Diar∣throsis, a manifest Articulation; as in the Joints of the Elbow, Thigh, Knee, &c. 2. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Synarthrosis, an obscure Articulation; as in the Conjun∣ction of the Carpus with the Me∣tacarpus, and the Tarsus with the Metatarsus. Both these are divided into three several Spe∣cies,

viz. Enarthrosis, Arthrodia, and Ginglymus.

X. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Enarthrosis, is where a large round Head en∣ters into Cotyla, a deep or pro∣found Cavity, as the head of Os Femoris into that of the Os C•…•…: or into Glene, a shallow Cavity, as the head of the Os Humeri into the Scapula.

XI. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Arthrodia, is where the Cavity is very super∣ficial, as in Diarthrosis, between the head and first Vertebra of the Neck; and in Synarthrosis, between the Carpus and Meta∣carpus.

XII. 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Ginglymus, is where there is a mutual in∣denting of two Bones in a Joint, into each others Cavity, as in Diarthrosis, in the juncture of the Elbow: and in Synarthrosis, in the Vertebrae of the Back.

XIII. It is good for an ••rtist to know all the various kinds of unition of Bones; but notwith∣standing all that has been said of that Matter, Diarthrosis and Synarthrosis are the chief subjects upon which this our present Discourse of Luxations is built.

XIV. Now lest the Bones should easily slip out of the Joint, they are held fast with Ligaments: some of them are orbicular, which in all Joints encompass round the head and Sinus: others are round, and are only in such Joints, as are made for strong Motions, as in the Thigh and Knee: these out of a deep Cavity, are inserted into the head of the Bone.

XV. Now the Joints which have both sorts of Ligaments, at least the orbicular, and are very close, are with much difficulty put out of Joint.

XVI. The Kinds. There are two kinds of Dislocations, 1. When the •…•…d of the Bone slipt totally out of its proper Sinus: and this is that which is specially called Exarthrosis, or Exarthroma, Dis∣location.

XVII. 2. When the head of the Bone starts a little out of the Si∣nus, but is not quite out; and this is called, 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉 vel 〈 in non-Latin alphabet 〉〈 in non-Latin alphabet 〉, Luxatio, a loosening, or distortion of the Joint: and this may sometimes come to pass, when the Bones are length∣ned thro' a laxity or distention of the Ligaments, from a weak∣ness of the Part, or a flux of Humors. Yet Dislocatio and Luxatio are generally taken in one and the same acceptation.

XVIII. To these some add a third Species, viz. when such Bones shall gape, which were be∣fore joined; and this happens in three places, 1. When the Sca∣pula parts from the Clavicula or Humerus. 2. The Radius from the Cubitus. 3. The Fibula from the Tibia; and this they call a Divulsion or Disjunction, or Disjoining. See Celsus, lib. 8. cap. 10.

XIX. The Differences. They arise first from the Situation and Figure of the Part, as upwards, downwards, forward, back∣ward, to the right side, or left side.

XX. Secondly, from Accidents or Symptoms attending them, as, vehement Pain, Inflammation,

flux of Humors, Wounds, Fra∣ctures, &c.

XXI. The Causes. They are either Procatartick or Antecedent: The Procatartick or External, are Falls, Blows, violent Extensi∣on, (in which latter Case, In∣fants are sometimes hurt by the Hands of the Midwife.)

XXII. The Antecedent or In∣ternal, are from Humors affect∣ing the Joints, which flowing down upon them, do by their Quantity or Quality either relax the Ligaments; and so cause the Bones to slip out of their pro∣per places; or else contract the Tendons, and so pluck them out of their natural seats.

XXIII. The Signs. A Dislo∣cation is known by the extraordina∣ry Tumor of the Part where the Bone is lodged, emptiness of the place where the Bone was, and privation of Motion, accompanied with Pain; as also by comparing it with its fellow, which is not dislocated: the Member is also rendred longer or shorter, ac∣cordingly as the Bone is out of its place.

XXIV. These things then are to be observed, 1. That as long as the motion of the Member is not lost, tho' there may be sus∣picion of a Dislocation, yet there is none. 2. That the Tu∣mor or Swelling is always on that side unto which the Bone is slipt, and the hollowness on that side from whence it is fal∣len. 3. That the Bone being out of its place, and finding no resistance, the Muscles will draw it upwards, and so make the Limb shorter, 4. That it will be unlike to its fellow, which is not dislocated.

XXV. A Dislocation may be di∣stinguished from a Luxation, by the inte••s••ess of the signs aforesaid; for if all the motions of the Limb is lost; if it is indeed shorter, and there is a great Eminence and Gavity, and it is very unlike to the found one, it is a Distocation: & 〈◊〉〈◊〉 contrar••, it is a Luxation.

XXVI. If the Part is thicker than it ought to be; if where the Bones should meet, there is a grea∣ter, extubera••ce; and if withal the Bones gape, there is a dis∣juncture.

XXVII. That sort of Luxati∣on, wherein the Limb is made lon∣ger, is known by these signs, 1. Be∣cause the Limb looks as if it were hung on, dangling this way and that way, by reason of the re∣laxation of the Ligaments, and the Bones not touching one ano∣ther. 2. When the Bone is re∣duced to its place, it will not stay there, but fall out present∣ly of its own accord. 3. There is a cavity or hollowness quite round the Joint, so big some∣times, as almost to put ones lit∣tle Finger into it.

XXVIII. The signs that the Bone is well set, are the just con∣trary to these which shew it to be dislocated: Avicenna, and others, have another sign also, which is a Crashing noise, or a kind of Snap, which the By-standers hear, upon the reduction.

XXIX. But says Wiseman, this is not always a certain sign, nor indeed is it a very good sign: for it may be made by the head

of the Bone cubbing against, and breaking the Cartilaginous edges of the Acetabulum or Sinus; part of which may go into the cavity before the Bone, and then no good Reposition can be made, but the Patient will always be lame, because the Head cannot turn round in the Sinus.

XXX. Or, the noise may come from the head of the Bone striking against the bottom of the Cavity, which sometimes may hazard a bruising of the Cartilages, tho' many times it is without any such Accident: however this noise is easie to be distinguish∣ed from the other, where the Cartilage is broken.

XXXI. The Prognosticks. In Children, and such as have very maist Bodies, Bones are easiest re∣duced, but they are with much difficulty retained in their places; and contrariwise in elderly Per∣sons, and dry Bodies.

XXXII. A Dislocation not re∣cent, or of song-continuance, is with great difficulty and pain re∣stored: and when restored, it is kept in its place with great trouble, because of the weak∣ness of the Part, and of the Li∣gaments, the whole growing emaciated.

XXXIII. A Dislocation of the Vertebrae, occasioned by External Atoi•…•… or •…•…elente, is for the most part Mortal; but if it is caused by Congestion, it is ma∣ny times Gur••d.

XXXIV. A Dislocation, with a Wound, is more difficult to be cured than without; so also, if it is with a Fracture: but if it is with Wound and Fracture both it is harder yet to be performed, and with a great deal of trouble and difficulty.

XXXV. Luxations or Disloca∣tions, in which the edges of the Acetabulum are broken off, are worst of all; for tho' the Joint is restored to its place, yet it continues not long, but falls out again upon the stightest cause.

XXXVI. Old Dislocations, which are grown hard with a Callus, and have a clammy or gelly-like Humor filling up the Gavities, are never, or very rarely, cured; for which reason, every Dislocation or Luxation ought presently to be replaced.

XXXVII. A Dislocation in Childhood, if not reduced, it causes the Member or Limb to grow less than the other.

XXXVIII. A Dislocation or Luxation of the Head from the Vertebrae of the Neck, is Mor∣tal; because it compresses the Spinal Marrow at its Original, or first Rise, and so hinders the Influx of the Animal Spirits.

XXXIX. A Dislocation with great Pain, flux of Humors, In∣semination, or Wound, is hard to be cured, and is not without dan∣ger; nor can it be restored with∣out danger of Convulsions, or Death.

XL. For which reason, Celsus advises, that if the Bone being re∣duced, there is an extension of the ••erves (with vehement Pain) It must presently be put out of Joint again.

XLI. The farther any Bone is fallen forth our of its Sinus, so much the more difficultly will it be

restored again; by how much the nearer, by so much the sooner and easier.

XLII. A Dislocation of long con∣tinuance, by how much it is less able to be moved by a natural motion; by so much the more it will be extenuated and wasted, and affected with an Atrophia.

XLIII. And the reason is mani∣fest; for because of the intermission of motion, the native heat of the Part will be dulled, and wasted also: and because the Vessels are comprest by the luxated Bone, the necessary Influx of the Blood and Spirits will be prohibited or hindred.

XLIV. The Cure. In the Cure of a Dislocation, there are (ac∣cording to Scultetus) Five Inten∣tions; viz. Extension, Reposition, Deligation, Deposition, and Reli∣gation.

XLV. In Extension, four things are to be considered; viz. 1. The Time. 2. The Instruments. 3. The manner of the Extension. 4. And the Quantity of the Extension.

XLVI. As to Time, (says Hip∣pocrates) it is to be done presently after it is put out of Joint, whil'st the Party is yet hot: but if it cannot be done presently, by reason no Physician (so I call every good or skilful Chirur∣gian) is near, it must be done on the second or third day, except Inflammation hinder it.

XLVII. On the Fourth Day, no∣thing is to be attempted, because of great paint; for it would not succeed well, but many ill Sym∣ptoms would follow: and there∣fore the Term of the Inflamma∣tion must be expected; which is the seventh, eighth, or ninth Day.

XLVIII. For so Hippocrates, de Articulis, Text. 65. says; unless it can be reduced in the first three days, it is not to be medied withal: nor on the tenth, ele∣venth, or twelfth day is it safe, because the Callus is bred.

XLIX. But before Extension, let the Joint be fomented with warm Water and Oil; or Wine and Oil; or a Decoction of Althea, or Mallows. Spigelius says, that nothing is better than a Bath of fair Water.

L. The Instruments of Extension are, our Hands, for small Dislo∣cations; Bands, for such as are mean; and Engins or Instru∣ments, for such as are great.

LI. The Bands ought to be strong, soft, and tractable; such as are Buck-skins dressed soft; or, for want of Leather, Linnen-cloth rubbed: you must fasten them on the part which is farthest from the Joint dislocated; lest the Muscles should be bound, or else torn by violent Extension.

LII. As for the Engins or In∣struments, they are such as we have described in Lib. 6. Cap. 2. Sect. 12. ad Sect. 47. viz. the Ambi of Hippocrates; the Glossocomon of Galen; the Reductive Ladder; and the Table of Hippocrates.

LIII. The Manner of Extension. This we have sufficiently taught in the former Book of Fractures; however, it ought to be as straight as possibly it can, viz. in a right line; for so Extension is made with as little pain and difficulty as may be.

LIV. The Quantity of the Ex∣tension:

This is known, from the Place where the Dislocation or Lineation is: the Way that the Bone slipt forth: the Place to which it is fallen: and the Place in which it rests.

LV. When Extension is almost made, the Swooning of the Sick, or of the Standers by, must by no means under the Ope∣ration.

LVI. Reposition. It is done by the Hands of the Artist, which ought to be anointed with Oil of Roses: and it is either made by circumgyration; or by forcing it back, to the opposit part, to which it is fallen.

LVII. But these Motions are not always necessary: because that sometimes when Extension is made, the Muscles are only re∣laxed, (not contracted) so that the Joint will slip into its natu∣ral placeo, f its own accord.

LVIII. Now if it is well Set, you may know it by the natural shape of the Member; when nei∣ther hollowness for swelilng appears about the Joint, as it did before it was set.

LIX. Also by the abatement of the Fair, which is always an inse∣pay able sign, that the Bone is reduced; but the Pain may not be ••aded, because the Museles may be very much 〈◊〉〈◊〉 and and sometimes by a crank, or small blow, which the Bone make••, when it falls into its Socket.

LX. You are to consider, which 〈◊〉〈◊〉 it is stipt out; for by the same way it must be reduce back again, if it slipt to the right side, it must be prest to the lest; if it is luxated forwards, it must be forced backwards.

LXI. The Shoulder requires one way, the Elbow another, and the Knee or Ancle another: if the Luxation is not recent, or the Muscles be much contracted, you must relax them by Emollient Embrocations of Oil of Ben, Rears Oil, Mans or Vipers Grease; or with Ʋng. Dialthaeae, lest by too great violence you affect the Nerves, and cause a Raralisis.

LXII. Deligation. This is con∣sidered from the Figure of the Part affected, and the Ligature it self; which may preserve the Joint being reduced, and pre∣vent Inflammation.

LXIII. In the Figure, you must consider the Form both of the Joint reduced and also of the whole Part: some Figures are natural, and without Pain; and some are unnatural, and with Pain.

LXIV. The Figure of the Arm without pain, is bended; of the Foot, perfect extension: now the figure in which the Part must stand, must be ordered before it be bound up, that the binding may be neither too loose, nor too hard.

LXV. The Ligature must be made of Linnen Swaths or Bands, and soft; that they may cause to pain they must be equal, that they may bind equally every where 〈◊〉〈◊〉 and they ought to be white and clean, that the Hu∣mors, issuing forth (if any be) may be known by their Colours.

LXVI. The breadth of the Swath or Rowle•• must be according to the Part to be bound up: for the

thinner or smaller Parts, they may be the narrower: in the Thigh and Knee they may be near four Inches broad: in the Arm and Hand, about three Inches: in the Fingers, about an Inch, or better.

LXVII. Galen divides them in∣to inner Bands, to wit, such as bind the Joint under the Plasters; and outward Bands, as those which are put above the Plasters: Hip∣pocrates uses two inward Bands, and two outward; but one may may do, where the Joint is not easy to be slipt out.

LXVIII. The length of the Swath is various, in respect to the variety of Parts to be bound. Upon the Thighs they must be six Yards in length; for the Shoulder, four Yards and half long; for the Arms and Legs, about two or three Yards in length.

LXiX. Now that the Swaths may hinder Inflammation, they must be wet in sowr or astringent Wine, mixed with Oil of Roses; or an∣ointed with Hippocrates his Ca∣taplasm or Cerate, made of Oil of Roses p. ii. Wax p. i.

LXX. Some allow not here of Astringent Pouders mixed with the white of an Egg; because they either cool, dry, and bind the Joint too much, hindering the bending of the Joint; or pro∣hibit the flowing forth of the Humors which are flowed into it.

LXXI. Yet Sennertus, Med. Pract. lib. 5. part. 6. cap. 1. al∣lows of Astringent Medicaments. First of all, (says he) before bind∣ing up, Astringent Medicaments are to be laid on, which hinder a Flux of Humors, and Inflamma∣tion, contract the Ligaments re∣lax'd, and withal strengthen the Part.

LXXII. These may be made of fine Bole, Dragons-blood, Ba∣laustians, Pomgranate-peels, red Roses, Frankincense, fine Flower, and the like, mixed with the white of an Egg. To these things you may add, Acacia, Comfrey-roots, Catechu, Myrtle-berries, Saccharum Saturni, Sumach, Crocus Martis, &c.

LXXIII. If there is great Pain, you may embrocate with Oils of Roses, of Earthworms, of Whelps, or of Mastich. Or you may mix some of those Oils with your Astringents afore-named; and apply over Empl. Album, è Bolo, or de Minio.

LXXIV. Sennertus commends this Emplaster. ℞ Fine Bole, Bean-flower, Comfrey-roots in pou∣der, A. ℥iii. mix; steep them in Vinegar, and dry them: to which add Litharge, Wax, Rosin, A. ℥iii. melt these three over the Fire, then add to them the former three things; and with two Ounces of Gum-Tragacanth, make an Em∣plaster.

LXXV. Or, ℞ Fine Bole, Com∣frey-roots, Dragons-blood, Frank∣incense, Mastich, A. ℥ss. fine Wheat-flower ℥i. Sheep-suet ℥iii. Wax q.s. mix, and make a Plaster.

LXXVI. Or, ℞ Birdlime, Ma∣stich, Pine-Rosin, A. ℥ss. new Wax ℥iii. mix, and make a Plaster. Or you may apply Empl. Barba∣rum, or Catagmaticum, malaxed with a little Oil of Roses Om∣phacine.

LXXVII. Or, ℞ fine Bole, Catechu, Dragons-blood, Myrtle-berries,

Pomgranate peels, Sumach, Saccharum Saturni, A ℥ss. whites of Eggs, q.s. mix, and apply. These things being laid on, the Member must be conveniently bound up with Swaths or Row∣lers, and Bolsters, in the same manner as we have taught con∣cerning Fractures: and if need be, and the figure and nature of the Part will admit of it, Splints, or such like, made of Paste∣board, Leather, &c. may be laid on.

LXXVIII. Deposition. This is threefold. 1. Alligation; as in a Dislocation of the Shoulder or Arm, where the Arm is bound to the Thorax. 2. Suspension; as when the Arm is hanged by a Scarf or Linnen-cloth, put about the Neck. 3. Collocation; when we place the Part affected in a certain situation or rest: as the Arm upon the Thorax, or in a Capsula, and the Thigh or Leg in a Trunk or Case, of Straw or Wood.

LXXIX. And herein you must note, that the Collocation must be, 1. After the mean Figure of the Part. 2. Soft; that the Sick may lye at ease; therefore is the Case filled with Hurds or Tow. 3. Equal, or rather a little upwards; that the Humors may not so easily flow to the Part affected, and cause Inflammation. 4. At Rest; for which Reason, the Ancients used to make a Hole thro' the Bed and Blankets, that the Sick in voiding their Excrements, might not be forced to move.

LXXX. Religation. This is of Ʋse, 1. Where the Part is bound too fast, or too loose. 2. If there is Itching, or Pain.

LXXXI. If the Ligature is bound too strait, a hard Tumor arise•• in the Extream Parts dis∣located: if too loose, there is no Tumor at all: if it is too strait, you must loosen it the second day: but if too loose, you must straiten it the third day.

LXXXII. If there is Itching or Pain, the Swaths are to be loosned, and fair warm Water to be poured upon the Part; not only to abate the Itching, and discuss the sharp watery Humors, but also that the Ligaments may be corrobo∣rated.

LXXXIII. But unless the Liga∣ture is made ill, or the Itching is troublesom, let the Part remain as it was first bound up, 'till the se∣venth day: if there is an Itching, you must loosen it on the third or fourth day, and bathe with fair Water, as aforesaid: but Wiseman says, with Salt-water, or a Decoction of tops of Worm∣wood, Camomil-flowers, Red-Roses, Balaustians, Myrtle-berries, Juniper and Cypress-Nuts, adding a little S.V.

XXXIV. On the seventh day, which is the time that the Inflam∣mation should be past, the Liga∣ture must be let loose again; and lukewarm Water poured on again; (but not too hot, for that loosens the Ligaments: so also all Greasy Medicaments re∣lax the Tendons, and prolong the Cure.)

XXXV. But the Swaths are no more to be wet, nor to be sineared with the Cerate of Roses, by reason the Inflammation is over: but

upon the Joint, Empl. Catagmati∣cum softned with Cerate of Roses, or Oil of Myrtles, or some of the afore-prescribed Medi∣caments are to be applied; which may be also applied at first binding-up, if no evil Symptoms are present.

LXXXVI. After the seventh day, the Ligature ought to be made somewhat straiter than before: and after this second binding-up, the Part ought not to be loosned until the end of the Cure.