Severall chirurgicall treatises by Richard Wiseman ...

OF FRACTURES. (Book 7)

The Seventh Book. (Book 7)

CHAP. I. Of Fractures.

A Bone is a similar Part of the Body, and the hardest and driest of all.* 1.1 The generall Use of which is, Stabilimentum ac fundamentum reliquis omnibus Partibus largiri, to be a firm Prop and Foundation, upon the strength whereof all the rest of the Parts are built. The whole Sceleton con∣sidered joyntly, may be looked upon as performing that office to the Little world, that Atlas hath been fabulously reported to doe to the Great one: it bears the whole bulk of it, and sustains it in all its motions; none of which could be performed, if either the Bones were not, or not so articulated and joynted as upon defection they appear to be. Nam si ossa abessent, non flecte∣remus manus, non nervos & fibras. Nay, if the least Bone be but a little mai∣med, the use of the Part is hindred. But they are not onely Fulcimenta, as Galen says De Ʋsu partium, sed etiam Defensio, but also a Defence. The Cra∣nium, veluti Galea, as a Helmet defends the Brain from externall injuries. So Pectus Ossibus clauditur; the Heart, Lungs, and great Vessells of the Thorax, are guarded by a Wall of Ribs. The Spina is a Bulwark to the Marrow in∣cluded in it: and such a defence is the Os pubis and the Os coxae and Ileon to the Womb and Bladder. Others otherwise serve the uses of Nature. As the three little Bones in meatu Auditorio, by firming the Tympanum, are a great help to the Hearing: the Os hyoïdes assisteth the swallowing, by managing the Root of the tongue and the Epiglottis: the Rotula serves the motions of the Knee: and the Teeth prepare the Meat by Mastication. Not a Bone but hath its particular end set out. There was a reason of the Temper, of the Magnitude, of the Number, of the Substance, of the Situation, of the Con∣nexion of them; the wise Creatour as much shunning superfluity as deficiency. Indeed, the whole Fabrick is so full of Excellency, that it would take up much time to expresse it. But that is not my businesse. The Subject I have undertaken to treat of is their Misfortune: and that is twofold; to

be fractured, and dislocated. That of Fractures I have proposed for the first part of my present Discourse; and that onely in generall, it being suf∣ficient for my design.

To proceed methodically,* 1.2 I shall begin with their Definition of a Fracture, who, according to Galen de Methodo medendi, make it to be Ʋnitionis sive continuitatis solutio quaecunque in osse. But this being too generall, and ta∣king in all Cariosity and Ulcers of the Bones, which hardly belong to this Head of Chirurgery, the Moderns have more closely defined it to be, Ossis divisio seu ruptura à causa violenter irruente. But this likewise seems to me to be liable to many Exceptions. I shall name onely this, viz. That a Cut made into a Bone by a Sword or a sharp Instrument seems to be rather a Wound, then a Fracture. And for this reason Guido de Cauliaco makes it to be continuitatis solutio in osse non à re qualibet facta, sed ab ea quae contundit. But I must still beg pardon, if I be not yet satisfied with this Description, because it leaves out all such Fractures as are made by any accidental bowing of a Bone, either in a Wrench, or any other case where, without any Blow or Con∣tusion of Parts, the Bone snaps in sunder, and then wounds the neighbouring Muscles, even to the thrusting of it self very often quite through the Skin. These are (cases of Battel excepted) the most frequent of all Fractures; yet not without some violence to be reduced to any of these latter Definitions. I shall therefore chuse to define a Fracture in the following words;* 1.3 It is a So∣lution of continuity in a Bone, suddenly made, either by Contusion or Flexure. By Contusion I mean, either a Blow by a blunt Instrument, or a Pressure by a great Weight; either of which usually bruiseth the Flesh about the Bone, as well as the Bone it self. In Contrafissures indeed the Bruise is not imme∣diately upon the Fracture, but in the place where the Blow is given. In Flexure there is seldome any Bruise, but what is made by the edges of the Bone it self after it is snapped in sunder. All other Fractures are reducible to these.

Amongst the Greeks it was commonly known by the name of Catagma. I purpose not to trouble you with the nice Distinctions in Fractures, nor yet with their various Names. Galen in his Book de Method. medendi complains thus in his time: Non desunt ex Medicis junioribus, qui ambitiose omnes Fracturarum differentias propriis nominibus interpretantur; There want not (saith he) young Physicians who affect to give proper names to all the se∣verall kinds of Fractures: At non Hippocrates hujus fuit sententiae; nor shall I spend my time so, but, according to Galen, do take the Difference in Fractures to arise,* 1.4 1. à figura, 2. à magnitudine, 3. ab ossium fractorum varietate. First, from their Figure: and that is either right, quae fit per longitudinem; or transverse, per latitudinem; or oblique, which is as it were compounded out of the two former. Secondly, à magnitudine, according as the Fracture is greater, or less. The third Difference is, ab ossibus ipsis, that is, from the Bones themselves that are broken, whether it be the Arm, Leg, Ribs, &c.

Causes of Fractures internall there are none,* 1.5 unless they proceed ab humo∣ribus corporis erodentibus; and of that sort you may read many in Schenckius, Fabr. Hildanus, and others. I my self have seen some, and lately. But these, being from Erosion, are rather to be called Ulcers with Caries, and therefore more fit to be discourst of amongst Ulcers of that kind, to which I refer you.

Of Causes externall there are many; as the too violent Assaults or Stroaks of all externall things, which may bruise, break, shatter, or bend. In this number of Causes may also be reckoned Falls from on high, &c.

The Signs of a Fracture without a Wound are for the most part very evi∣dent.* 1.6

The first and most certain is, when in our handling the Part we feel the pieces of Bones severed asunder, and hear them crackle. Secondly, the Impotency of the Member. Thirdly, vehement Pain. Fourthly, a Distortion of the Part. It may also be discovered by comparing the one Member with the other; the fractured being the shorter. But if there be a Wound joined to the Fracture, then if the Bones thrust themselves not forth, yet you may easily know the Member to be fractured, if you search with your finger or Probe. There is also a Curvednesse, which may be reduced to a Fracture. I have seen it in Children often, as in D. C's little Daughter in the Old Baily, and Mr. N's Son in Black-friers, and others. It is as it were when you break a green Stick; it breaks, but separates not: so is cured by a due Extension, with little Trouble to the Chirurgeon, or Pain to the Patient af∣ter the Extension is made.

If the Fracture be secundum longitudinem, it will appear first by the unna∣turall thicknesse of the Member, then by the Pain and Inequality of the Part.

As to the Prognostick or Presage,* 1.7 a Fracture of the Bones cannot be without danger: for of necessity the Solution of continuity must be great. If a Wound be made in a Fleshy part, it is then proportionable to the Weapon that made it, & non ultra: but if the Bone be broken, propter rigiditatem & continuitatem non potest frangi, nisi totum frangatur. The Fracture is more dangerous in a great Bone then in a small; and the greater, if both the Bones be broken, as the two Focills in the Leg, or if it be the Arm, where the Radius and Ʋlna are: yet if it happen in the middle of the Bones, it is the lesse dange∣rous. Those in or near the Joynt are more painfull, and difficultly cured: and if any Shivers presse upon the Nervous parts, ill Accidents commonly follow; but of all the Fractures that with a Wound is most dangerous.

As to the time of Cure, the lesser Bones are perfected in fourteen, eighteen,* 1.8 or twenty five days, the bigger in fourty or fifty, according to Guido. Yet let me advise you not to be too hasty in taking the Patients out of their Beds; for in some Bodies the generation of Callus is very slow, and a new Distor∣tion may happen, and ill Accidents follow. I have been called into Con∣sultation upon such an Accident, the Patient did recover, but by lying very long within doors contracted such an ill Habit of body, as was not got off in a long while after.

In the Cure of Fractures Unition is required: but that cannot be made, unlesse Pain and Inflammation be prevented. For a Fracture of the Bones is not made without an internall wounding of the Periosteum and Parts next to it, whence grievous Pain arises, which stirs up Defluxion, and is attended often with great Inflammation; and from the weaknesse of the Member many Excrements are made and received, which it is neither capable to as∣similate, nor yet expell. And the mischief is so much the greater, by how much the Bones lie deeper under the Muscles, where they cannot be set, by reason of the great quantity of Flesh interposing between them and the hand of the Artist. The Intention pursued in this case is the Union of Bones, as I have already said; which is not performed by the first Intention, unlesse it be in little Children, but by the second, viz. an intervening of Callus.

The Method I thereto propose is, first, to joyn the fractured Parts together;* 1.9 secondly, to keep them so joyned: thirdly, to preserve the Tone of the Part; fourthly, to generate Callus; fifthly, to correct Accidents.

That the Parts may be rightly joyned together, there is need of Extension,* 1.10 and Coaptation. For in Fractures, especially transverse ones, the Bones

are commonly distorted, the rectitude of the Member lost, some Parts are pro∣minent, and others hollow, the fractured Bones lying one upon another; and so the Member is made short: & quia musculi perpetuò membra trahunt versus suum principium;* 1.11 therefore Extension is necessary, that the Parts which are indirect may be brought right, and the Parts that stick out may be re∣duced to their Cavities. And although sometimes the Member seemeth not to be short, as if it consists of two Bones, and one broken, or that the fractu∣red Bones do not lie one over another; neverthelesse you ought to make due Extension in all Fractures, because the Bones never lie exactly equal, and most frequently they ride one over another. The want of which Exten∣sion is one reason why the fractured Thigh-bones happen to be so often shorter then they should be, as Celsus hath it in these words; Si femur per∣fractum fuerit, breve erit; his reason is, quia nunquam in antiquum statum revertitur. And I find in Galen, that Hippocrates saies the same of the Leg and Arm; and withall tells us, it is so, nisi ante confirmationem extensio debita abhibeatur, & commodâ deligatione ossium coaptatio servetur. By which you may observe, the fault is want of good Extension, and keeping the Part in its right seat: for unlesse that be done, you shall hazzard the starting again of the Bones, and thereby their fractured ends may happen to be broken off by mutuall Attrition in the act of joyning together: and if those pieces do chance to fall in between the main Bones, they will then hinder their uniting: and if those Shivers slide outwardly towards the Membranes, they will cause extreme Pain. This inconvenience is therefore to be shunned by the help of Extension. But again in Extension there must be observed a mean, as Vigo notes: Ad magnam quidem Extensionem futurus Spasmus valde suspectus est. Yea sometimes the very Muscles are torn asunder, as Galen tells us: and Albucasius cries out, Cave Extensionem vehementem & Compressionem for∣tem, sicut faciunt multi stolidorum: multoties enim faciunt Apostema calidum & contractionem in membro. By which it seems in his time there were such people, who thereby drew sad Accidents, as Convulsions and Inflammations, upon their Patients. But if the Extension be less then it should, then, as I said before, the ends of the Bones rub one against another, and are broken, or not seated in their proper place. Therefore the bigger Bones having large Muscles, which draw the Member forcibly to their Originall, do require the stronger Extension; and such are those of the Thighs, Legs and Arms. And if both the Focills of the Arm be broken, the Radius requires the more Extension, because it hath no Muscles to draw it upwards, its motion being onely secundùm pro∣num & supinum. In Extension it behoves us to observe debitam figu∣rationem, that the Member be extended in ea figura quae minimum facit dolorem, saith Galen: which is done, if the Fibres of the Muscles be stretcht according to their rectitude. Children, and such as are of a soft Ha∣bit of body, do best suffer Extension: elderly and dry Bodies the con∣trary.

In the next place is to be considered the most reasonable time wherein to re∣duce the Fractures. And herein we all agree, the sooner the better, and that to avoid Inflammation; and according to Celsus, Si in primis diebus non restauratur, inflammatio oritur, &c. If at the first or second day the Frac∣ture be not reduced, it is in danger of Inflammation and Mortification: for indeed after the second day, it is supposed the Fracture is accompanied with great Defluxion, and so yields not to Extension without hazzard of drawing such ill Accidents upon it self.

Therefore Fallopius in his Exposition upon Hippocrates De Capitis vulne∣ribus, and by his authority, tells us what we shall doe in such a case. Si os

non fuerit in suo loco, saies he, ideo ad septimam, qui est primus terminus Inflam∣mationis, vel usque ad nonam, qui est secundus, debemus bene advertere: & o∣portet impedire inflammationem. If the Bone was not restored before the time of Inflammation, then we ought to attend till the seventh day, which is the first period of Inflammation, or untill the ninth day, which is the second period: and all this time we ought to restrain the Defluxion, vel per lenitionem doloris, vel expressionem & deligationem loci. Lenimus autem medicamentis oleo∣sis, quae habent vim refrigerandi, vel per deligationem pluribus fasciis; either by lenient Medicines, or by Deligation. We lenifie with soft cooling Oils: we make our Deligation or Bandage by many turns of the Rowlers. These are to be done untill the seventh or ninth day. Inflammation abating gives you opportunity for reducing the Fracture.* 1.12 The Instruments for Extension are threefold. First, the Chirurgeon's Hand, for gentle Extension: and let him place his Hand near the Fracture; otherwise he shall hurt the sound Part by too much Compression, and not avail himself much in his Extension. Secondly, for the middle Extension there are Funes and Habenae, a sort of Bandage fit to pluck at in order to Extension. Thirdly, there are Organa and Machinamenta, Engines used often by us, but invented by the Ancients: and they are for the most strong Extension. But before you make your Extension, consider whether the Member be not fractured in more places then one. An old Gentleman came out of the Countrey, and by a Fall going down Ludgate-hill brake his right Arm a little above the Wrist transverse; and near the bending of the Arm was a second Fracture oblique. This dou∣ble Fracture hath happened to others in the Leg. It requires your circum∣spection, lest the one escape your sight, and the Member be left deformed, and weakned in its action.

The Extension made, the Extenders are to be loosened gently,* 1.13 and the O∣peratour must with his hand endeavour as gently to presse down the ends of the Bones, and joyn them smooth and even together. And if there be any little Shiver that will not be placed even with its fellows, cut upon it, and take it out. You shall know the perfect Coaptation of Parts by these Signs.* 1.14 First, if the fractured Member answer to the sound; secondly, if by your handling of it you feel no Inequality; and thirdly, if Pain be abated.

The second Intention in curing of Fractures is,* 1.15 that the Parts brought together may so be preserved: and that is performed by Bandage, which ought to be so made, as not onely to keep the Parts so joyned together, but to de∣fend them from Inflammation. And to this purpose I commend to you that of Hippocrates from my own practice. It consists of three Rowlers made of linen Cloath, not too course, lest thereby it should offend the fractured Member; nor yet too soft and fine, lest it break.

With the first Rowler you are to begin upon the Fracture,* 1.16 and take three Turns there. Then rowl upward to the sound part, and so a little high∣er, and there end this Rowler. It will keep the Fracture a little steady, untill the other Bandage be made, and restrain the influx of Humours which might cause Inflammation.

The second Rowler ought to be as long again as the first,* 1.17 and must be rowled contrary to the first; as for instance, if the first was made to the right hand, this must be turned to the left: so that if the Muscles by the first Bandage were wreathed too much on one side, they now may be restored again to the other. This second Rowler must begin upon the Fracture, and after a Turn or two there, must be carried downwards, that so you may presse the influx of Humours from the fractured part. And so having made three or four Turns downwards upon the sound part, you may rowl upwards

again by the Fracture, and making a Circumvolution upon the Fracture it self, passe upwards, untill you come to the end of the first Rowler. And there Hippocrates terminates this second Bandage, because there is fear of the de∣scent of Humours à parte superiori: and these two Bandages do more de∣fend the Part from Inflammation, then strengthen the Fracture. But they being made,* 1.18 Hippocrates puts over them Compresses of linen Cloath three or four times doubled, of such length as to reach over the Frac∣ture; but so narrow, as that five or six might be placed round about the Fracture, the distance of a finger one from another. These are to be spred with a little Cerote, onely to make them stick. They are called Plagulae and Splenia from their figure, and do supply the defect of agglutinative Me∣dicaments, and lessen the Pain, by hindering the Compression of the Ban∣dage.

The third Rowler of Hippocrates fastens the said Compresses;* 1.19 and its first Turn is made upon the Fracture, the one head being carried upwards, and the other downwards. And you are to take notice, that the Bandages are to be drawn more streight upon the fractured Parts then elsewhere, that the said Parts being more weak, may be kept from Defluxions.

Celsus in his eighth Book,* 1.20 and tenth Chapter, proposes another way of Ban∣dage. First, he dipt a Cloath in Red wine and Oil, and applied it over and about the Fracture, and over that he brought six Rowlers, his two first being those of Hippocrates, and so he rowled them; then he used a broad double li∣nen Cloath, spred with Cerote, to keep them close down. And his reason is, because the fractured Bone hath always a propensity that way whither it tended when fractured; therefore, saith he, you are always to put a Compresse of linen Cloath, dipt in Wine and Oil, ei parti quae contraria est parti in quam membrum inclinat. And over this he brings the four remaining Rowlers; so as the following Rowler be rowled contrary to the former, and the third end in inferiori parte, in the lower part, reliquae omnes in superiori terminum habeant, all the rest end above.

These are the Bandages of Hippocrates and Celsus, men of the greatest Au∣thority in Chirurgery, and are followed almost by all that have writ since, and are of excellent use in Fractures in and near the Joynts, where there is fear of Inflammation. But then in your Binding you must observe such a mean as confists with the ease of the Member bound.* 1.21 A small and lax Tumour appearing at the extremity of the Member a day after, is a sign of good Bandage; but if there appear no Tumour, or if the Swelling be great and hard, then the Bandage is naught; the first shewing the Bandage not to be streight enough, and the last too streight. Therefore you should often visit your Patient, to inform your self how the Bandage is.

But if no Accident happen,* 1.22 you shall not unbind the Fracture untill the seventh day: and then, if all be well, the Bandage will begin to slacken of it self; and if it be not well, you may then see your errour, and timely help it. And that is one reason, why Fractures should be opened about that time. Another may be, for that often in Fractures there is an intole∣rable Itching, through the detention of Humours, which are made sharp by Deligation, (Perspiration being thereby hindred,) and that is wont to termi∣nate in a most painfull Excoriation and inflamed Rednesse. In which case you are to bath the affected Part with warm Water, that the Matter may be evaporated: and then the Member is to be bound up again. But here you are to put Ferulae or Splints in stead of the Splenia or Compresses. Whereas in Fractures with great Contusion, or in and near the Joints, I have continued the use of Compresses wet in Whites of eggs during the whole Cure with

good successe. And lately a Youth about ten years of age,* 1.23 labouring under a carious Ulcer in his Foot, the last great Frost brake his Thigh-bone ac∣cording to the length of the Member. This Fracture was covered with empl. è bolo and Splenia moistened in album. ovor. with Bandage, &c. as is proposed in this Treatise; by which the fractured Bones were kept even and close to∣gether with much ease to the Child, and agglutinated firmly by the Callus in∣tervening. Mr. Yowel, sometimes a Servant of mine, set his Thigh-bone for me, I being at that present otherwise imployed.

But all the Ancients after the seventh day did use Splints; and so have I where they might safely be used: for they not onely keep the Member steady, but straight. And of these some are made of Tin, others of Scabbard, Past∣board, and of Wood, sowed up in linen Cloaths. Those of Tin do very well, by reason of their lightnesse. Those of Scabbards are apt to bow, and so those of the thickest Pastboard, especially if they chance to be wet. And those of Wood are heavy, and apt to inflame the Member. Yet through the Artist's care they may be all used with good successe, yea from the first day of the Fracture. As in the case of a Reverend Divine, who brake both the Focills of his left Leg within a few fingers breadth of the Ancle. This person laboured under an Asthma, which grievously shook the fractured Member; wherefore I was necessitated to put on Ferulae the very first dres∣sing, which I continued the use of during the whole time of his Cure. He lately told me, that he never felt the least pain in that Leg since I took off the last Plaister, which is more then ten years since. But Hippocrates used them not untill the seventh day. For before that day there was more need of hindring the Inflammation, then of strengthening the Fracture; post septimam contra, but afterward the contrary is required.

The third Intention in curing of Fractures is,* 1.24 in preserving the Tone of the Part. Natura enim os unire nequit, nisi pars sit sana; Nature cannot knit the Bones while the Parts are under a Distemper: and that cannot presently be removed. For though fractured Bones be very well set, yet there will remain some Cavernulae, which will be apt to fill with Sanies, which the Part through its weaknesse can neither well assimilate nor expell, and so is like to be burthened with excrementitious Humours. Therefore Phlebotomy may be here of special use, and the keeping of the Belly soluble by Clysters, or otherwise, and a slender Diet must be prescribed. This is the work of the Physicians. But they not being always at hand, I thought fit to mention it, and so to proceed to our own work, in keeping up the Tone of the Part. And hereto we have need of such Medicines quae materiam influxam desiccant, & inflammationem repellunt, which dry up Serosities, and repell Inflammation. And these in a word are Astringentia, of which we have choice. Hippocra∣tes used Cerote, then Red wine: Celsus, as you have heard, used Oil of Myrtills and Roses, Red wine, and Whites of eggs together: others again used Whites of eggs alone; and others added Oil of Myrtill, balaust. ros. rubr. sang. dracon. bol. Armen. and with a little Wine made it up to the con∣sistence of a Liniment, and applied it upon Cloaths over the Fracture. By the use of this latter Medicament I cured a man whose Arm was soar bruised, and fractured in many pieces, by the fall of a piece of Cannon, which brake loose in a Storm, while we were preparing to lay aboard our Enemy. Over this Restrictive I applied Splenia of double soft Linen with Bandage, as in Compound Fractures, and happily cured him. If the Inflammation be not great, I then take empl. diapalmae, and some of the forementioned Powders, with a little Oil of Myrtill and Vinegar, made up to the consistence of an Emplaster, which I spread upon Cloath pretty thick, and apply over the

Fracture. It not onely restrains the Defluxion, but strengthens the Fracture. The Medicaments proposed are all very good, and excellently preserve the Tone of the Part, if they be proportioned according to the greatnesse of the Malady.

There is yet farther requisite to the performance of this Intention,* 1.25 a right Position of the Member: and that, according to Galen, debet esse mollis; the hurt Part ought to lie soft: for that hard lying presses upon the bruised Bones and Flesh, and causes Pain and Inflammation. Debet esse aequalis, nè distorqueat; It must lie smooth or equall, because an uneven placing distorts or draws awry the Part. Sursum versus, nè humores descendant; It should lie somewhat high, lest a painfull Defluxion fall upon it. Oportet congruam membri figurationem considerare: It behoves, saith Hildanus, to consider the convenient figure of the Member, that the Muscles be kept in their right Site, which is most free from Pain. Haec autem est figura media; which if it be not observed, exiguo post tempore membrum dolere solet. What those Pains are, you may possibly guesse, but no tongue can expresse. Therefore you ought to handle the Member very tenderly; and if the Fracture be made in cubito, place it in a Case made of Pastboard, with a soft Pillow under it, and bring it up to the Breast with a fine Towell, or the like. But if it be the Leg that is fractured, we then place it in a Bed, or in a Cradle, or upon a Pil∣low quilted in the midst with Junks to support it; having a speciall care that the Hollow of the Ham and Heel be filled up, lest the weight of the Foot hurt the Heel, from whence grievous Pain doth ensue, and sad Acci∣dents may follow, as at large you may reade in Fabr. Hildanus.

The fourth Intention is,* 1.26 Callum generare, to make Callus; which is to be endeavoured after the fear of Inflammation is over, quia natura partis laesa non potest Callum generare; and that ceaseth circa diem septimam, about the seventh day, sooner or later. And if after that time the Fracture be to be set, possunt diversa & mala accidentia generari, saith Vigo. Yet after the seven∣teenth day of the Fracture I have set the Thigh-bone, and cured the Patient, without any ill Accidents: he is yet living to testifie it.

How the Callus is made, you may reade at large in Fallopius, in his Ex∣position of Hippocrates. And though it be not Bone, it is so hard, saith he, that if the Member hap again to be broke, potiùs in alia parte frangitur, quàm ubi Callus est genitus, it breaks anywhere rather then in the Callus.

Two things are therefore required: first, that it be supplied with fit mat∣ter; secondly, that that matter be not washed from the edges of the fractured Bones, aut foras evocetur, saith Galen. As for the matter to make Callus, most Authours do agree,* 1.27 that there be a greater liberty in Diet. At quo tempore (saith Galen) Callus gignitur, nutriendum corpus est cibis boni succi, & qui multùm nutriant. And that must be viscous: his reason is, quia ossis alimentum crassum. And for that reason Authours commend at this time Offall of Flesh, and Broths of Kid and Veal, and the like, boiled with Rice or Wheat. They also allow sweet Wines. But this liberty in Diet I think is better forborn, for thereby we often see great Obstructions arise, especially there where our Patients are inclinable to feed plentifully. Therefore in such Fractures where the Patient is constrained to keep his Bed, I propose a slen∣der Diet, and of such things as are of easie Digestion. For without that liber∣ty surely we cannot fail to compleat our Cure; the Bones having naturally a Porinesse in them, in which is always contained a matter fit for their Nou∣rishment; and ex illo ipso nutrimento in fracturis generatur Callus, of that Nourishment Callus is made. So if we be carefull to prevent Inflammation, and the like Mischiefs, which disturb Nature in her actions, and apply such Remedies as may dry the proper Nourishment into Callus, we shall not

fail then of our desire: and those remedies, according to Galen, ought to be Emplastick and moderately hot. For, saith he, ea Callos tum promovent, tum augent: quae digerendi vim obtinent, ea magnos jam Callos diminuunt. There∣fore it behoves us with care to fit our Medicines to the Age and Constitution of our Patients. For those which are proper for Men of ripe age, if applied to Children and tender Bodies, would so dry the Callus, that they would quite diminish it, and frustrate our Cure. In Children Albucasius commends to us the application of Whites of eggs alone, or with a little farina volatilis: in those of more years, pulv. myrrhae, aloes, acaciae, gum. tragacanth. thus, lab∣danum, &c. Emplastrum stict. Paracels. diapalm. oxycroceum, severally or mixt, are proper. But this latter Vigo is very angry with, and says it is a Diabolicall Emplaster, too hot for the Summer, and not very proper for Win∣ter. Vigo's emplastr. ad ossium fracturas is excellent; and so is our Catag∣maticum in the London Dispensatory. As to internall Medicines, there are many; but I shall onely recommend to you osteocolla, and that by the autho∣rity of Fabr. Hildanus, who often experienced it. The Dose was ʒ j. in aq. rad. symphyti: and with this so given he cured a compound Fracture in one above sixty years of age. At in juvenibus & succulentis non putat convenire osteocollam.

Thus I have proposed fit materialls for the generation of Callus: now lest that the matter of which it is to be generated should be hindred from thru∣sting forth, it behoveth you to alter the Bandage, the Member not requiring to be rowled now so streight; by which means the nutritious Juices will have liberty to flow in, and there by graduall Digestion to thicken into a Cal∣lus. In taking off your Dressings, you are to consider whether the Callus genera∣ted be such as is required. how the fault of the Callus is to be remedied, if it be greater or lesse then it should be, you shall hear presently.

If the Fractures be simple, whether transverse or secundum longitudinein, they are cured by the same methods; onely these latter require a more strict Ban∣dage, otherwise the Bones will be apt to rise and make a gibbous Member.

The fifth Intention is,* 1.28 the correcting of those Accidents which happening in Fractures retard their Cure: and they are many; as Pain, Inflammation, Apostemation, Gangrene, Itching, Excoriation, Callus more or lesse then should be, Weakness of the Member, and depraved Figure. If Pain invade the place, then Lenients are proper, and such Remedies as restrain Defluxion, and hinder Inflammation; of which sort I have mentioned some, and for more variety refer you to those which are set down in the Chapter of Phlegmon. If Gangrene appear, slacken your Bandage, and foment the Part with a Lixivium in which have been boiled scordium, absinth. centaur. and the like. You may also apply over all a Cataplasm of Barley-meal, Lupines, with the addition of such Ingredients as have been prescribed in the Chapter of Gangrae∣nae. But if Itching affect the Part, then foment it with warm Water, which will give a breathing to it by the Pores; or with Salt-water, quae propter salem ex∣purgat, & poros aperit. The Itching neglected is wont to terminate in exco∣riationem dolorosam, in a very painfull Excoriation, cui occurrendum est exsic∣cantibus & refrigerantibus; such are unguent. alb. camph. nutritum, popu∣leon, &c.

As to the Callus, it is sometimes just, sometimes greater or lesser then it ought.* 1.29 If it be too great, you will perceive it by its bunching out; as also it will be painfull to the touch or pressure; and besides it renders the Part unapt for motion. In this case abate the Patient's Diet, make your Bandage more strict, and foment with Discutients, also apply empl. de cicuta, de ranis cum Mer∣curio, &c.

But if the Callus bel ess then fit,* 1.30 the signs are, quòd ad motum redditur debi∣lis, the Bone is weak, and if the Part be toucht you scarce feel the Callus. And this was thought by the Ancients to proceed from slenderness of Diet, or that it was not enough incrassating. But I think it rather proceeds from im∣proper Applications, or too streight Bandage. Yet if the Patient be in years, and of a spare Body, you may both increase and incrassate his Diet: but with∣all slacken your Bandage, and invite forth the Humours by warm Water, not too hot, donec pars rubescat, & in tumorem attollatur, untill the fractured Parts a little swell; tunc enim defistendum. But if the Member be extenuated, it is either from the too streight Bandage, or over-much bathing with warm Wa∣ter: therefore you must now bath with fresh Broths, and other good Embro∣cations. Also a Pitch-plaister applied, and presently pulled off again, will by its adhesion to the Hair and Skin cause Pain, and likewise an attraction of Aliment to the Part, and so the Member may be nourished.

Sometimes also after the Fracture is cured, the Member is found to be of a depraved Figure, by reason the Bones were not well set, or through ill Ban∣dage, or some inordinate motion, aut propter inscitiam Chirurgi. To resolve this Callus, some Authours have adventured to prescribe sundry Medicaments; but they have hitherto proved unsuccessful. Yet if it be true what a Chirurgeon lately affirmed of empl. de minio, the work would be very facil. But Celsus and Fabr. ab Aquapend. after the prescribing various Remedies conclude at last thus: If the Patient be young and lusty, and the Callus but six months old, there is yet one refuge, that is, fracturam de novo rumpere: and in order thereunto, you are to foment the Part with Decoctions ex althaea, rad. lilior. fol. malvar. taps. barbat. cicuta, &c. and then rursus os frangitur manibus vel digitis, impellendo seu com∣primendo. But if the Callus be so hard that it yields not to your hands, then says Fab. ab Aquapend. frango eum instrumento attrahente in diversas partes. But this, Albucasius, a Chirurgeon as hold as any, and one that had seen the effects of such rash undertakings, utterly condemns, saying, it is operatio valde vitupe∣rabilis, perducens ad mortem: therefore he adviseth the Patient not to give ear to such vain people, but rather content himself with such help as emollient De∣coctions, Liniments, and Emplasters may effect. Which in truth is safer, if you consider, that after the Callus is so confirmed that it will not yield to Ex∣tension, then if you should break it anew, or any other way separate it; yet it would no more yield to a right Coaptation, then a Hair-lip or my two Fingers will to Agglutination without separating the Callosity; which is not possible to be done in Bones.

I could have here inserted many Instances of my work in the Cure of the severall Fractures of particular Parts: but it would signifie little more then I have already written, their Cure consisting in the very same Extension and Coaptation, and they being subject to no other Accidents then what I have set down: all which I have writ as plainly and feelingly, as if I had been performing the work in your presence. Yet as a rarity I shall give you one Instance.

SOme years before the Fire,* 1.31 I was sent for to a poor Widow inhabiting near Bridewell, whose little Son, of about eight years of age, playing about the Wharf, was struck by one of those great Cart-horses full in the Face, beating the Ethmoïdes quite in from the Os cribriforme, without any great Wound. The Boy lay for dead a while, and dozed longer. It appeared a strange sight at first to me, his Face being beaten in, and the lower Jaw stickling out: nor did I presently know how to help him, or by what art to make my Extension. But after a while, he a little recovering his Senses, was perswaded to open his

Mouth. And there I saw the Os palati and Ʋvula beaten so close backwards, that it was not possible for me to get my finger behind, as I designed; and other way of Extension there was none. Upon which I presently formed an Instrument bended up at one end, by which I got up behind the Ʋvula; then raising it a little upward, pulled it forward with the Bone into its former place very easily. But I no sooner let go my Extender then the fractured body returned back again. I then contented my self in dressing up the Face with a restrictive Cerote, to prevent the Influx of Humours, and let him bloud, and within a few hours after caused an Instrument to be made, whereby the great fractured body was more easily brought into its naturall place, and also kept there by the hand of the Child, his Mother and my Servants helping him some while: other way there was none. Thus by their and our care, the Tone of the Part was preserved, and a Callus thrust forth, which as it hardened, the Part grew stronger, and the Face was restored to a good shape, better then could have been hoped for from such a Distortion in that place. The Patient is yet alive and well.

A Page attending a Noble Family, riding behind the Coach, fell down,* 1.32 bruised his Face, and broke his right Collar-bone. He was taken up and car∣ried to the next Pretender to Chirurgery, who seeing his Face much swelled, and his Nose bloudy, concluded it fractured, and fill'd up his Nostrills with Tents, binding them up with Plaisters; and finding his lower Jaws standing unequally with the upper, concluded them luxated, and that part of the Sternon under the Collar-bone was broken down. Things being thus represented, I was sent to view this Youth: and pulling off the Plaister, and the Tents out of his Nose, I saw nei∣ther Wound nor Fracture. His Jaws did not answer equally to one another; but by his frequent motion and champing with them, it was evident they were nei∣ther luxated nor fractured. But by his Fall the Bones of his Face seemed to be pressed inward, and the uppermost Jaws were crushed nearer one another then they should: and this made the Inequality which our Chirurgeon thought a fault in the lower Jaws, and by his pulling them had like to have broken or dislocated them. The next day he called in a Chirurgeon to justifie his proceedings. But there appearing nothing of Luxation or Fracture in the Jaws, we looked upon the Sternon, and found it well; but that Collar-bone was broken oblique, which we set and bound up, with resolution not to open it till it should be united. All things being in this hopefull condition, we advised him to keep his Bed, and left him to observe the Directions of his Physician, by whose prescription a Clyster was administred that evening, which he voided into a white earthen Chamber∣pot, which his Chirurgeon looking into call'd it bloud, and alarm'd his Friends. But a discreet person looking afterward upon it, concluded it onely the Clyster tinctured with red Sugar, Hiera picra, &c. I being soon after fetched, confirmed the same, and appeased that clamour. About the tenth day our Chirurgeon, con∣trary to former order, undressed the fractured Clavicle: upon whose binding it too slack the Bone started, and from that time it grew painfull; so that he dres∣sed it again four or five days after: but the Pain increasing the more, I was fetched, and upon opening saw one end of the Clavicle riding over the other, and pric∣king against the Skin. The Callus being confirmed, the Patient was removed from his Chirurgeon's house to his Mother's in the City, where being in great Pain, his Chirurgeon dressed him again; and the streighter he made the Ban∣dage, the greater was the Pain. He not imagining the cause, imputed the fault to the unruliness of the Patient, and declared that the Fracture was yet in the Bone, and that it was incapable of Cure. Upon which I was sent for, and seeing the Pain to proceed from the end of the fractured Bone pricking in the Skin, and the more when it was bound, I caused half a Wallnut-shell to be plaistered over

it: and having thereby defended it from Pressure, he made use of his Arm, and complained no more of Pain. I then designed to cut off that end of the Bone, if it again pained him: but from that time it continued easy, and he recovered the use of that Arm very well.

Thus have I done with that which concerns Simple Fractures.* 1.33 In a Fracture with a Wound, if neither the Bone be bare, nor yet prominent through the Skin, then you are by Extension to bring the fractured ends of the Bone toge∣ther, as was proposed in the first and second Intentions of Simple Fractures. And the Lips of the Wound are likewise to be brought together by Suture, if it be any whit large, and not too much contused. Which manner of dressing is contrary to what is taught in Gun-shot Wounds with Fracture; the method being to be altered upon that occasion for the reasons there alleaged. Then endeavour, as in our third Intention, to keep the fractured and wounded Parts together by Dressings, which may as well mitigate the Pain, as keep off Apostemation, by repelling the Matter flowing to the Parts, and drying up that which already affecteth the Fracture and wound: qualia sunt Astringen∣tia, that is by Astringents; with which I have sufficiently furnished you in the Discourse of Simple Fractures Galen, by the authority of Hippocrates, re∣commends Cerote of Roses. But if there be no Pain, you are to endeavour the strengthening of the Fracture, and preventing Defluxions, by Cloaths spred with that Composition of astringent Powders, mixt with the Whites of eggs and Red wine, which is already proposed. Then follows Deligation of the Part: and in this case Bandages are to be made of softer and broader Linen then we use in Fractures without a Wound, that they may comprehend both the Lips of the Wound, and keep them down, yet not hurt them by too hard Compression. Minùs astringendae sunt fasciae quàm si vulnus non adesset, says Celsus. And therefore it is that Hippocrates and Celsus make so many Circum∣volutions; cùm melius sit saepe circumire quàm astringere, saith Celsus again. The third day they loosen the Bandage: then ferulae vel non apponendae, nè vul∣nus comprimant, saith Albucasius; or if they be put on, super vulnus apponi non debent. Rather in these Fractures do we use Deligation, pluribus fasciis, with many Rowlers, saith Albucasius. And so all along he proceeds in his Discourses of Fractures, as if he had been rather bred under Hippocrates or Celsus, in Greece or Italy, then where he was. But in truth this way of Deligation is not onely very troublesome to the Chirurgeon, to put on and off, but so very painful to the Patient, that it is almost impossible that he should ever be with∣out a Fever, if his Wound be every day to be so rowled and unrowled. There∣fore in these Compound Fractures we chuse rather to follow the method of some of the Moderns, who, in stead of these many long Rowlers, make choice of two or three short Cloaths, folded three or four times double, to give them the more strength. We also make them of such breadth, as to encompass the Lips of the Wound and the fractured Parts; and of that length, as to come once about the Fracture, and so stitch together on the most convenient side. And under these may be placed Compresses of fine Tow, or double Cloaths; which will not onely keep the Lips of the Wound down, but fill up the In∣equality, and further the expulsion of Matter. And so the Wound may be drest, and the fractured Member relieved at your pleasure, without giving the Patient the pain to have the fractured Member removed, or your self the trouble of rowling and unrowling so many long Rowlers as the Ancients proposed. With this method I have cured Arms and Legs, so shattered by Splinters from Cannon-shot, and with such loss of Substance, that I even de∣spaired of their Cure. But in some of these I have made use of Hippocrates's

Plagulae; and often, for the more strengthening the shattered Member, have been glad to make use of some Splints from the first day; but so as their com∣pression was gentle and equall, and so placed that the Lips of the Wound might be kept even, and that the discharge of Matter was by them furthered. But if the Wound be transverse, it then requires more caution, lest the Matter should at any time be prest back into the Wound, and so not onely dilate it, but foul the Bones.

Thus much for a Fracture with a Wound where the Bones are not exposed to the Air. But if the Bone be bare, and thrust it self out of the Wound, you shall endeavour presently to reduce it; and after it is restored to its naturall place, let the Wound be stitcht and drest, as I proposed to you even now in the Compound Fracture.

A Commander at Sea,* 1.34 valiantly fighting in the midst of the Enemie's Fleet, had his Leg fractured by the fall of his Mizzen-top-mast, it breaking his Leg transverse near the Ancle, the edge of the Bond thrusting out through the Skin. He not suffering the Bone then presently to be set while it was warm, afterwards, when it was swelled and stiff, it did not yield to Extension, but became painfull and inflamed. After some few days he was brought to Lon∣don, and I was sent to him. He was of an ill Habit of body, subject to the Gout and Dysenterie; and the Fracture being accompanied with great De∣fluxion was not in a condition to admit of Extension. Therefore, according to Fallopius and Hippocrates, before cited by me in this Treatise, I proposed to his Chirurgeon to proceed by Lenients, to mitigate Pain, Inflammation, &c. and by Bandage to hinder Defluxion. Which we did; and his Chirurgeon continued that method a few days, by which the Accidents were remitted. When we met again, finding the Patient in ease, we took off the Dressings, and agreed to make Extension, and reduce the Fracture. The Patient was of a dry tough Body, and the Member yielded difficultly to the Stretch: upon which consideration we satisfied our selves with a moderate Extension, doubting that upon a more forcible one ill Accidents might follow, (as an Inflammation presently did. (We drest it up as a compound Fracture: and after some days dressing a Callus thrust forth, and united the Bones. That Callus being confirmed and dried, we hasten'd the Exfoliation of the foul Bone by a little Aegyptiacum and pulv. myrrhae dissolved in spir. vini, applied hot upon an armed Probe. Thus the Bone was exfoliated, and the Ulcer cured by the ordinary Intentions in such cases. Yet the inward leaning of the Bone conti∣nued a weakness in the Member a long time, as is usuall where the Fracture hath not been timely or well reduced. To remedy this, I caused a Bar of Steel to be fixed in his Shoe with joints, and by a Bracer of Cloath to be la∣ced on, or tied with Ribbons on the outside of his Leg; by which it was mar∣vellously strengthened.

But if the end of the bared Bone do chance to thrust it self so out, as that without great force it cannot be restored to its place; tunc è duobus malis minus est eligendum; then that end of the Bone which hath thrust it self so far out is to be sawed off: and if this be done timely, before a Gangrene hath seized upon the Part, it may be performed with good success.

In St.* 1.35 Clement's Parish behind the Church, some years since, while I was one evening preparing my Dressings for the setting a fractured Thigh-bone in a little Child, I was hastily fetcht to assist one Mr. Powell, a Barber-chirur∣geon, in the setting a Fracture of both the Focills of the Leg in a Man about sixty years of age, of a tough dry Body. There I met Mr. Tatham, an in∣dustrious knowing Chirurgeon. The Fracture was oblique, almost secundum

longitudinem; and the Os tibiae or greater Focill had shot it self out by the in∣side of the Ancle a great length. We endeavoured by a strong Extension to reduce this fractured Bone into its place; but it yielded very difficultly to our endeavour: yet we reduce it, and afterwards cleansed the Wound of what Shivers or pieces of Bones we met with, and brought the Lips of the Wound together by Suture, hoping thereby to keep the fractured Bone the closer. Then we drest the Wound with our Digestive warm, and with an empl. diachalcit. malaxt with ol. ros. and over the fractured Parts we ap∣plied the Mixture following spred upon a double Cloath: ℞ flor. ros. rubr. balaust. baccar. myrtill. bol. Armen. sang. dracon. an. q. s. pulveriz. cum albu∣min. ovor. ol. ros. & acet. Misc. ad consist. mellis. This we fastned by Bandage, as hath been shewed in Compound Fractures: and for the more strengthening the fractured Member, we placed Splenia over that Bandage, with Ferulae upon them; and having fastened them by three Ligatures, we placed the Member as much to the ease of the Patient as we could contrive, upon a Pillow quilted in the middle, with Junks to keep it steady. But these great Fractures with large Wounds, and near the Joint, are always subject to grievous Pain; and this much more, for that the Tendons and Musculous flesh were soarly torn, and stretcht by the great Extension: so it was not likely to be attended with lesse mischief then afterward befell it. We let him bloud that night, and gave him an Anodyne draught to dispose him to rest. But he slept little, his Pain continuing with much disturbance: a Fever also fol∣lowed, and within two or three days he became delirous, and in the absence of his Attendents got out of his Bed; upon which the great Focil flew out as at first, and the poor man fell down on the floor as half dead. We were both presently fetcht, and taking off the Dressings, we saw the Bone distorted, the lower Stitches broken, and the Wound of an ill aspect, as it were tending to Mortification; also the Bone thrust out so far, that there was no hopes of its being any more reduced by a new Extension. Upon which considera∣tion we resolved to saw off the end of it: and to that purpose having pre∣pared all things ready, we cut out the remaining Stitches, and turned the Foot on one side towards the Small of the leg, thrusting the Bone more out; the one sawing the end off, whilst the other with a Spatula defended the Ten∣donous flesh underneath from being wounded by the Saw. That done, we cleansed the Wound from the Saw-dust, as also from the Shivers of little Bones which we had not discovered in our first dressing, they lying pricking the Periosteum, between the fractured Bones and Membranes, by which those sad Accidents had been hastened. The Wound thus cleansed, we turned the Foot right into its naturall place, there being no need of Extension: which being done, we scarified the Lips of the Wound, and washt them cum spir. vini, with a little Aegyptiac. dissolved in it, and applied to the ends of the Bones Pledgits dipt in the same, and prest out. We also drest the rest of the Wound cum unguent basilic. with a little ol. terebinth. warm, and ap∣plied a Mixture of an Emplastrum Paracels. and diachalcit. over the Wound and Parts about, and then a Compresse and Bandage over that, as in Com∣pound Fractures. The great work was now, how to support the Foot, and keep it even with the rest of the Leg, there being so great a distance between them without any Bone. But we having placed the Leg upon a quilted Pil∣low, laid him again in his Bed, and fitted it in a Wainscot-case, where it was kept steady and equall, and lay conveniently for our daily dressing him. This done, we committed him to the care of his Friends to keep him there quiet, and ordered him cordiall Juleps, &c. After some hours we let him bloud again. From that time his Pains lessened, and his Fever and other

ill Symptoms went off as the Wound digested. But after some days the Heel became very painfull, and a Slough was discovered to us inflamed with an Ulceration sticking to the very Bone. The Patient not permitting to have the Case, wherein his Foot and Leg was, stirred, it had not been raised up, as for perspiration it ought to have been; whence this Ulcer became very troublesome to us. For a present Relief, we laid him upon his Side, and drest the Ulcer with Lenients, to hasten separation of that Escar. And be∣cause the Patient grew soon weary of this Position, which also was inconve∣nient for our dressing the great Wound, we therefore designed an Instru∣ment of Tin to receive his Foot and Let, this Heel to lie hollow in a place cut for that purpose, whereby we could daily dresse it without disturbing the Patient, onely placing him down lower towards the Bed's feet, that the Heel might lie over it. The side of this Instrument, that came up by the Wound, was to be taken off at the time of dressing his Wound, and af∣terward placed close again; whereby he was drest without disturbing the weak Member. It lay also soft, by reason of the Folds of Linen we placed under and between the Leg and Instrument: it was also kept straight, in hopes it might be supplied with Callus. But the Wound became sinuous, and the Matter fouling the Bones hindred the growth of Callus; and while we waited for Exfoliation, the Lips of the Ulcer became callous, which pro∣longed the Cure. The Ulcer in the Heel we digested: and after we found the Bone would not incarn, we drest it with unguent. Aegyptiac. with a little Merc. subl. dissolved in it; by which dressing we hastened the Exfoliation of the Bone, and cured the Ulcer. The Wound above was a larger work: but after the generation of Callus it cured as a Fistula with carious Bones. The Pa∣tient lived many years after: but through the ill disposition of the Ulcer, the callus was hindred in its growth, whereby the Leg remained the shorter, almost as much as had been sawed off of the Bone. Yet this was better, I suppose, then to leave the Bone distorted untill Digestion, as in such like case I have seen done. But if the Bone be not so much distorted as that you may come to saw off the end of it, or if you cannot reduce it after the ordinary way; then you may with a Chizell-like instrument thrust between the fractured ends of the Bone, and use it after the manner of a Lever, for the reduction of the Prominencies. But then it is supposed these fractured ends of them are within the Wound, and have not much over-shot one another, and the Fracture is transverse or oblique: otherwise this may will doe little good; nay may possibly rive up the piece of Bone, and make another kind of Fracture, and grievously pain the Patient to no purpose. And that you may easily do, if the ends break off upon your hard and unsteady Ex∣tension. Therefore it becomes you to be very wary in making this Ex∣tension; else, I say, you may put the Patient to sad Pain, and doe him little good.

But to conclude, after your Extension is made, and the Bone reduced, you are to feel if there be any Shivers of Bones loose, and pull them out. And if you perform this Operation in a Fracture newly made, then you are to prevent Inflammation, and all other Accidents, by dressing up the Patient with such Medicines as have been proposed in Compound Fractures; and make your Bandage so, that you may come to dresse the Wound, as occasion shall offer, with as little molestation of the fractured Member as is possible; having a care you grieve not the tender Parts with Splints, untill the In∣flammation be over, and the Wound well digested.

Then afterwards 'tis to be endeavoured, that the Bones robb'd of their Periosteum may again be incarned or exfoliated; which is the work of Na∣ture,

yet ought to be helpt by Medicines which have a manifest hot and drying quality, and a peculiar faculty thereto, of which there are enough set down in the Treatise of Gun-shot Wounds.

The Bones exfoliated, and Cure of the Ulcer will succeed of course, or may be performed by Epuloticks, of which you may have choice in this Book.

CHAP. II. Of Luxations in generall.

IN severall Observations in this Book I have had occasion to take notice of the inconvenience many people have fallen into through the wickedness of those who pretend to the reducing luxated Joints by the peculiar name of Bone-setters: who, (that they may not want imployment) do usually repre∣sent every Bone dislocated they are called to look upon; though possibly it be but a Ganglion, or other crude Tumour or preternatural Protuberance of some part of a Joint. In which cases their rash Extensions do frequently cause sad Accidents. But their more gainfull way is, by extending and dressing up Joints rather wrencht then dislocated: in which if they escape undetected, they must needs reap great credit, the Patient recovering so soon the ease and use of them. Whereas if the Joints happen really to be luxated, scarce one of them knoweth how to reduce them. In consideration of this daily abuse, and the inadvertency of the young Chirurgeon, whose not timely dis∣cerning the Luxation renders it more difficult to reduce, I have thought fit to say somewhat to this part of Chirurgery; and first in generall.

He that will give an account of Luxations,* 1.36 and the manner of their Cure, ought first to describe the Connexion of the Bones to each other: on the divers manners of which depend the great variety of methods in reducing and han∣dling of them. These Connexions we find to be of two sorts; 1. Symphysis, 2. Articulatio.

• I. Symphysis in its originall signification denotes a Connascency or Growing together;* 1.37 and perhaps is meant of those Bones which in young Children are distinct, but after some years unite and consolidate into one Bone. So the Os ileon and Os pubis are two distinct Bones in a Child, but unite into one in a Man: the Epiphysis of the Os femoris is a distinct Bone from it in a Child, whereas in a Man they do intirely unite. But custome and the usage of Au∣thours hath found out another sense of the word, fitted to adult persons; in whom it is used to mean such a Connexion, or two Bones together as is im∣movable: and of these there are two sorts.
  • 1. An immediate Conjunction, or Juxtaposition, (if I may so call it,) without the interposition of any other Body. Of which we find three Spe∣cies.
    • First, Sutura, or the indented Conjunction of Bones in the Scull.

• ...
  • ...
    • Secondly, Harmonia, when without toothing or interfearing they do joyn immovably in a straight line: as the Bones in the upper Jaw.
    • Thirdly, Gomphosis, or the Connexion of a Tooth to its Socket.
  • 2. Mediate, where the Connexion is made by interposition of another Bo∣dy. Of these we likewise find three sorts: which notwithstanding are not so peculiar to the Symphysis as it is opposed to Articulatio, but that they may be found in that also. They are these that follow.
    • First, Syssarcosis, when two Bones are joyned together by the intervention of Flesh. An instance of this in the Symphysis is, the Conjunction of the Teeth to the Mandible by the Flesh of the Gums. In Articulations we see it in the Elbow or any other Joint, where one Bone is connected to another by Muscles.
    • Secondly, Synneurosis, when the Connexion is made by a Ligament. Of this in Symphysis we find instances in the Connexion of the Ossa pubis to∣gether, especially in Women, by a ligamentous substance. In Articula∣tions it is either round, as that which unites the head of the Os femoris to the Coxa; or broad, as the Tendon of the Patella, which unites it to the Os tibiae.
    • Thirdly, Synchondrosis, which is an Union by Gristles. A Symphysis of this kind we have of the Sternon to the Ribs. Articulations are most of them so joyned, there being few Bones destin'd for motion which have not cartila∣ginous heads for the facility thereof. These two latter sorts of Union are com∣pounded in some Articulations; as in the Ossa coxae, where you have Ten∣dons and Gristles both to joyn them together. This is by Galen called Neu∣rochondrosis.
• II.* 1.38 Articulatio is a Connexion of Bones with aptnesse of Motion. Some∣thing hath been anticipated already concerning this Head, because of its coincidence with Symphysis, in the forementioned instances. But take it as it is in it self, and you will find it to have this difference. There is,
  • 1. A conspicuous Motion, which where it happens, the Conjunction is called Diarthrosis; as in the Elbow, Thigh, and Knee.
  • 2. An obscure one, where the Conjunction is called Synarthrosis; as in the joyning the Carpus to the Metacarpus, the Tarsus to the Metatarsus. And both these are divided into the three following Species.
    • First, Enarthrosis, where a good round Head enters into a Cavity: whether it be Cotyla, or profound Cavity, as that of the Os coxae receiving the head of the Os femoris, or Glene, which is more shallow, as in the Scapula where it receives the Humerus. Of more obscure motion is that Connexion of the Os tali with the Cymbiformis, which is an Enarthrosis.
    • Secondly, Arthrodia, where the Cavity is very superficiall: as between the head and the first Vertebra of the Neck, in Diarthrosis; and between the Carpus and Metacarpus, in Synarthrosis.
    • Thirdly, Ginglymus, which is a mutuall Indenting of two Bones into each other's Cavity: of which the Elbow is an instance, in Diarthrosis; the Vertebrae of the Back, in Synarthrosis.

Many other things might be said on this subject, were it pertinent to my present design, which is onely to regard the Union and due Conformity of Joints, in order to the Doctrine of Luxations, in which the Articulations are chiefly concerned. For when those that are united by Symphysis, as the Sutures of the Head, and the Bones of the Maxilla superior, are dislocated, there is always a Fracture concomitant, and the whole is treated as a Fracture. When the Teeth are dislocated, or to the dislocated, a Tooth-drawer is con∣sulted.

Articulations therefore, whether by Diarthrosis or Synarthrosis, are the Sub∣ject on which my present Discourse concerning Luxations is founded.

When therefore two Bones,* 1.39 which being naturally united make up a Joint, are separated from each other, we call it a Luxation.

The Ancients called it a Slipping of the Head of a Bone out of its Cavity. Which is true of the great Joints, but not of all: for the broad end of the Clavicle, where it resteth upon the Scapula, hath neither Head nor Cavity, yet is capable of Luxation.

Luxations admit of severall Differences.* 1.40

• 1. From the Subject; viz. whether it be a place of obscure motion, or a manifest one. An instance of one is, when the Clavicle recedes from the Scapula; which the Arabians call a Disjunction. Of the other, where an Elbow, Shoulder, &c. is disjointed; which is most properly termed Luxati∣on. There is also a peculiar Luxation proper to Children, viz. when the Epiphysis of a Bone separateth from the Bone, they being not throughly con∣solidated into one; which however is treated like a Fracture, and consequent∣ly deserveth no place in this Discourse.
• 2. From the Degree of it; viz. whether it slip out wholly, or onely in part, viz. to the margin of the Cavity that containeth it. To this latter sort may be referred those Elongations which are the effect of an Humour soaking upon a Ligament, (as that of the Coxa,) thereby making it liable to be stretcht, and to be thrust quite out upon every little force.
• 3. From the Situation and Figure of the Part, as whether upward, down∣ward, forward, backward, on the right side, left side, &c. of which more in the following Chapters.
• 4. Differences may also be taken from Accidents attending them; as In∣flammations, Wounds, Fractures, &c.

Causes of Luxations are internall,* 1.41 or externall. The internall are the Hu∣mours which affect the Joints, and either by relaxing the Ligaments give way to the Bone to depart from its naturall seat; or by a contraction of the Tendons put it upwards out of the Cavity. Both these sorts I have seen in Children, and it's likely it was in some of them hereditary; as Sennertus hath well observed, à gibbosis gibbosos, à claudis claudos generari. The ex∣ternall Causes are, Blows, Falls, violent Extension: in which latter cases Infants sometimes suffer by the hands of Midwifes, or at more age by the negligence of Nurses.

The Signs of Luxation may be taken from the losse or imperfect motion of the Joint,* 1.42 and from the different resemblance it hath with the contrary sound Member; there appearing to the eies or touch a Cavity in the Part whence it receded, and a Protuberance where it is lodged: the Member is also rendred longer or shorter, according as the Bone is distorted.

The Signs of Reduction are the contrary to what have been before deli∣vered.* 1.43 There is also a crashing noise made by the Bone in its return to the Cavity. But this is not always a certain sign; for it may proceed from an Eruption of some part of the margin of the Cup or Cavity. In which case the Luxation is for the most part rendered incapable of Restitution. But this Fracture maketh a different noise from the other, and may be easily distinguished by the discerning Artist.

In Children and moist Bodies luxated Bones are easiest reduced,* 1.44 but are with great difficulty retained: in elderly and dry Bodies the contrary hap∣peneth.

Luxations of long continuance are difficultly reduced, and are for the most part as hardly retained, the parts growing emaciated. Those of the Vertebrae

occasion'd by externall Accidents are for the most part mortall: whereas some of those by Congestion are frequently cured.

The Bone luxated maketh compression on the neighbouring Parts whither it slippeth;* 1.45 and accordingly as those Parts are of more or less sense, so are the Pain and Accidents that attend it. You ought to hasten the restoring it to its place as soon as may be. The work is purely Chirurgicall, it having no dependency upon Nature, but the Extension and forcing back of the Bone into its proper seat is done by the Hands of the Artist. There are four Intentions necessary to the Cure: 1. Extension, 2. Reposition, 3. Deligation, 4. Collo∣cation, or placing of the Member in a right Position.

Extension is first required,* 1.46 because of the situation of the Bone, which be∣ing out of its due Socket rendreth the motion of the Muscles useless, or rather hurtfull, which the more they pull the Bone, the more they distort it, and con∣tract the Joint. This therefore cannot be committed to Nature, but requireth manuall Operation.

The Extension being well made,* 1.47 you are at the same instant to restore it to the place it fell from. And to doe this, you must consider well the luxated Joint, and which way it slipped out; for it requireth to be returned in the same manner. If it lie on the right Side, it must be prest back to the left: and so if it be luxated forwards, it must be forced backwards. The Shoul∣der requireth one way, the Elbow another, and the Knee or Ancle another. If the Luxation hath been of any continuance, or if the contraction of the Muscles be great, it will be reasonable that you first relax them by emollient Embrocations, viz. unguent. dialthaeae, axung, human. &c. lest by your vio∣lent forcing in the Bone you affect the Nerves, and cause a Paralysis, &c.

Being satisfied in the Reposition of the Bone,* 1.48 you shall then take care to keep it so: and that is performed by Deligation. But before make the Bandage, you ought to apply such Medicaments as have virtue to resist the Influx of Humours, and strengthen the Part: and those are Astringents, and such as have been proposed in the foregoing Chapter of Fractures; viz. bol. Armen. sang. dracon. farin. volatil. balaust. flor. ros. rub. cum albumine ovi, aceto, aut vino rub. If there be great Pain, you may embrocate cum ol. ros. lumbricor. mastichin. and apply empl. è bolo, diapalm. de minio, &c. Then place a Compresse wrung out of some of the aforesaid Liquours on that Part whi∣ther you suspect the Bone may again tend, and rowl it on close accordingly as you see occasion.

The last Intention is Collocation,* 1.49 or placing of the Member; and that ought, for the ease of the Patient, to lie soft, and somewhat raised up, neither much extended, nor too much bent, a middle figure being best to prevent Pain. Yet if it be the Shoulder that is luxated, the Elbow ought to be kept to the Side, and the Hand upon the Breast. If no Accident happen, you must not dresse it again till the seventh day; and then you may alter the Po∣sition, and move the Joint a little to and fro, and dresse it up with such Me∣dicaments as may give a breathing to the Humour, and corroborate the weak Joint. In case it itch, bath it with Salt-water; otherwise with a De∣coction ex summitat. absinth. flor. cham. ros. rub. balaust. bacc. myrtill. juniperi, nuc. cupress. &c. to which may be added spir. vini. All greazy Applications relax the Tendons, and prolong the Cure.

Luxations made by Congestion do require Emollients to resolve and breath forth the crude Humour affecting the Joint, Ligaments and Tendons: to which purpose ℞ rad. althaeae ℥vj. rad. cucumeris asinini ℥iij. summitat. majoran. Mij. coctis in brodio ex pedibus vitul. & contusis adde pulv. sem. foenugraeci & lini an. ℥j. ol. lilior. axung. human. an. part. aeq. fiat Cataplasma. You may

also use emplast. diachyl. cum gummi, de mucilaginibus, de ranis cum Mer∣curio, &c. That Matter being thus resolved, you may then proceed in the Reduction of the relaxed Bone: and after you have reduced it, apply such Medicaments to it as may dry up the superfluous Humidity, and strengthen the Joint: of which sort I have given you an example in the fourth Inten∣tion. There will also be required some extraordinary Bandage to retain the Bone in its place: but of that I shall have more fitly occasion to discourse in some of the following Observations, as also of Paralysis, &c. which fre∣quently attend great Luxations.

CHAP. III. Of Luxation of the lower Jaws.

THE Processes of lower Jaws are two on each side.* 1.50

• 1. One more acute, called by Anatomists Corona; which hath no Socket properly so called, but playeth in the Hollow of the Cheek according to the motion of the Temporall Muscles, whose Tendon is inserted in∣to it.
• 2. Another more obtuse, with a roundish Head, called Condylus. This hath for its Socket the first Sinus of the Os temporum, in which it moves; and is kept close to it by the Muscles which lay hold either of the Corona before mentioned, as the Temporall, or of the outward broad Angle, as the Masseter, or the inside of the broad part of the Jaw, as the Pterygoïdes. These Muscles, by their perpetuall tendency to a contraction, (which is the nature of all Muscles,) keep the Bone steady in its situation; but much more so when they are voluntarily contracted for Mastication, Speech, &c.

It is remarkable, that though Nature hath made other Muscles to open the Jaws, as well as these to shut them, yet they are in themselves slender, and not inserted into this part of the Jaw, but quite before at the Chin; so that in their motion they do not pull down this part of the Jaw, but the fore∣part onely: whereas the attollent Muscles being laid nearer to the Condyli on each side, keep them so close to their Sockets as to make them a Joint, or cen∣ter of motion: from whence, according to the custome of Levers and Ba∣lances, it falleth out, that those little diagastrick Muscles, by being applied to the remoter part of the Jaw, which maketh the circumference, become equi∣pollent to all the bigger Muscles before mentioned; nay, are sometimes so va∣lid, that upon over-stretching, as in Gaping and Yawning, they pull the Condylus out of its Socket. Sometimes the attollent Muscles themselves do pull it, when we violently gnaw any large Bone, Gristle, or other thing that is hard, and withall so big as to be necessarily detained in the fore-part of the Mouth.

This Luxation can be made but one way, viz. when it slippeth over the fore-side of the Sinus, and passeth into the Cavity of the Cheek under the

Os jugale; it being so defended by Bones, that other waies are impossible with∣out a Fracture.

When this Luxation happeneth,* 1.51 the lower Jaw is thrust forward, the Teeth are prominent beyond those of the upper, the Patient can neither swallow nor speak nor chew, nor indeed shut his Chaps. If you see him presently before any Tumour supervene, you will find the Temporall Muscle rigid. If one side onely be dislocated, the Mouth is distorted, as if the Patient had a Spas∣mus; the fore-part of the Jaw is thrust down on one side, &c.

The Reduction of the Jaws is said to be difficult,* 1.52 and that if they be not timely reduced, ill Accidents do happen, viz. Paralysis, Strangulation, &c. To which I can onely say, that I never met with any difficulty in the re∣placing them, nor yet saw any such Accidents as by Authours are mentioned: but certainly they are in danger of famishing, for they can neither eat nor drink while the Jaws are luxated.

In order to the Reposition of the Jaws,* 1.53 the Patient ought to be seated firm, and his Head held steady, lest it start back in the time of Reduction. Then place a couple of Wedges of Wood close between his great Teeth, as far as you can thrust them, and your Thumbs close by them, and your Fingers externally under both the Jaws, extending them moderately; and at the same instant presse the farther parts of his Jaws downwards, and raise up the fore part. If his Teeth be too sharp for your Thumbs, put a fold of Linen between. If onely one of the Jaws be luxated, move it to the contrary side, and keeping it in that posture, place your Hand as aforesaid, with your Thumb upon his great Teeth, pressing that part downwards, and raise the fore-part upwards by a quick moderate Extension, and you shall feel it re∣duced, and may conclude it so by the equall meeting of his Teeth, and by the opening and shutting of his Mouth, also by his ready Speech. If after Reduction you suspect his Jaws may prolapse, you may apply a Defensative with Bandage; or in case of Pain, embrocate the Temporall Muscles and Parts about with ol. lumbricor. mastichin. &c. But hitherto I never saw occa∣sion to apply any thing.

A Woman aged about fifty six years was sent to me from a worthy Lady in a neighbouring County:* 1.54 both her Jaws were luxated, the obtuse Proces∣ses of them were slipt forward and shot under the Os jugale, and her Chin was thrust forward and inclining down towards her Collar-bone. She had been so three days, during which she could neither eat, drink, nor speak. I placed her in a Chair, and Dr. Lenthall, who came with her, held her Head. Then I placed my Hands on the outside and under her Jaws, and my Thumbs upon her great Teeth, with a Compresse of soft Linen under each; and whilst I pressed hard down the farther parts of the Jaws, I raised up her Chin, and reduced them in a moment: and to satisfie her that they would not slip down again upon an ordinary motion of them, I perswaded her to eat and drink; then dismissed her without application of Plaister or Bandage.

A Gentleman of about fourty years of age,* 1.55 of a sickly weak Constitution, had his right Jaw distorted, by which his Mouth being drawn awry, it was supposed a Spasmus, and various Applications had been made to that purpose. One morning, walking amongst my Patients, I met his Apothecary, who telling me the case his Patient was in, I replied, his Jaw was certainly luxated: upon which I was the next day consulted, and saw it so. I laid my Hand on the outside of that distorted Jaw, and placed my Thumb with a Rag wound about it upon his great Teeth as far as I could thrust it, and laying my other Hand upon his sound Jaw, I drew the distorted one straight out; and

whilst I pressed down the hinder part, I made Extension, raised up his Chin, and reduced it. He did not at that instant believe it, but he was soon after confirmed by the use he had of it. It continued well without any manner of Application to it.

CHAP. IV. Of Luxation of the Clavicle, or the Collar∣bone.

THE Clavicle is a crooked Bone made in the figure of an s. one end of which being thicker,* 1.56 and almost three square, is inserted into a Cavity purposely fitted for it in the first Bone of the Sternon, and bound in by a strong ligamentous Membrane. The other end, being broad and flat, is joyned to the Acromium, where it not onely serveth to keep the Shoulder at due distance from the Sternon, but also assisteth those severall Processes which are provided by Nature to preserve the Shoulder-bone from slipping up∣wards from its Cavity.

This Bone is capable of a double Luxation, one at the Sternon, and that onely outwardly, where it riseth from the Breast, and lieth like a Lump. The broad end near the Acromium is also subject to a twofold Luxation, viz. upward, and forward; being defended from all other Distortions by its neighbouring Bones.

This Luxation is for the most part occasioned by a Fall and pitching upon the Shoulder.* 1.57 It is discerned by the Prominence it maketh.

The Clavicle is not so subject to Luxation as other Bones; but being luxa∣ted, it is most difficultly retained after Restitution, by reason of the smoothnesse of its heads, and the little hold they have upon the Acromium and Sternon: and if it be not restored, the use of the Arm is impaired in some of its motions.

The Reduction of the Clavicle,* 1.58 which end soever of it be luxated, must be made by drawing that Shoulder backwards, and by pressing the luxated end even with the Acromium, or to the Cavity of the Bone of the Sternon, whence it departed. Neither of the places affordeth it much room, there∣fore 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, the Scabbard of a Sword, or Tin. The Bandage ought to be a Rowler with two heads to come over the Shoulders, and under the Arm-pit, making so many Circumvolutions as may retain the Dressings close. This being well made, his Arm must be kept up with a Nap∣kin or Towell, and his Hand placed upon his Breast. If all be well, you ought not to loosen the Bandage till you judge it united, which may be guessed at by the ease and use of that Arm.

I Was fetched to a young Fellow,* 1.59 who by a Fall from his Horse was sup∣posed to have broken his left Shoulder. Upon view of it, I saw the end of the Clavicle separated from the Acromium, and lying prominent without any manner of Fracture; but the head of the Os humeri was bruised, and remained sugillated long after. I caused one standing behind him to pull back the Scapula, and with my hands forced down the end of the Clavicle, and placed it to the Acromium; then applied an Emplaster of astringent Pow∣ders mixt cum album. ovor. &c. over the Clavicle and Shoulder, with a piece of Pastboard wet in aceto and Whites of eggs; over which I applied a dry one, and upon that a Compress wet with some of the former Liquour, and rowled it on with Bandage as above said; then wet that part of it over the Clavicle with Whites of eggs, to strengthen it and retain it firm. That done, his Shirt and Doublet were put on, and his Arm tied up, as hath been said. Then I put him to bed, and let him bloud in the other Arm, and kept his Body soluble by lenient Purgatives. After he had lain four or five days in bed, I observing the Bandage tight, and the Pain and Accidents di∣minished, permitted him to rise, and walk up and down in the house. About the eighteenth day I took of Dressings, and saw te Bone right in its place, the Parts about being onely marked with the extravasated bloud. I embro∣cated them with ol. lumbric. & spir. vini, and applied an empl. stict. Para∣celsi & diapalmae, rowling it up as before, and from that time dressed it no more, but saw him afterwards well abroad.

Another having by accident of a Fall in wrastling started the end of the Clavicle from the Sternon,* 1.60 I made Extension after the same manner as a∣bove said, by pulling his Shoulders backwards, and pressing the while with my hands upon that end of the Collar-bone, till I had replaced it, then dres∣sed it as afore said. But the next day, finding the Patient in Pain, and the Dressings raised up, I concluded the Bone distorted. Whereupon I caused a Tin-plate to be made in the form of the Clavicle, and to reach form one Shoulder to the other, cut at the ends, to receive the fore-parts of the Shoul∣ders, and keep them out. Then I took off Dressings, and restored the Bone again to its place, and repeating the former Applications, placed the Tin-plate over the Compresse, and rowled it on close. This Plate sate easy, and served to keep out his Shoulders, also retained the Bone in its place, whereby he was happily cured without more dressing.

CHAP. V. Of Luxation of the Shoulder.

THE head of the Shoulder-bone being round is inserted into so shallow a Cavity in the Scapula,* 1.61 that were there no other Guards for it, it would fall out or be thrust out almost upon every occasion. But Nature, that found that Shallownesse necessary to the variety of motions which is intended for the Joint, found other ways of securing it from running out. Viz. 1. upwards it is prohibited from an excursion by the Acromium, the Processe anchriformis, and the broad end of the Clavicle, which reaching over the latter to the edge of the former, addeth to the strength of the place. Nor is this all, for Nature hath made a strong Ligament which reacheth transverse from the Processe anchriformis to the Acromium; and to confirm all, hath laid under∣neath these not onely a strong circular Ligament, which involveth the whole head of the Shoulder, (being indeed a collection of the Tendons or the Mu∣scles, which lying under and upon the Scapula particularly serve for the mo∣tion of the Humerus, or else lying upon the Humerus, do take their origine from the Scapula,) but also a Tendon of one of the heads of the Biceps, which passing through a peculiar Notch or Trench of the Humerus inserteth it self into the head of the Scapula. Over all these lieth the Musculus deltoïdes, binding all in so strongly, that if the Elbow chance to be so pushed that it forceth the Os humeri upon this Fortresse, it sooner breaketh into shivers then maketh a way through. 2. The principall Guard it hath from falling inwards and downwards is its pendulous posture, together with the many Mu∣scles that keep it in that posture, and chiefly the Tendon of the Biceps externus, (as it is called in our Hall,) and of the subscapularis, with the rotundus minor. Yet are not these so strong, but that between the Tendon of the subscapularis and the Biceps externus it is apt to flie out into the Axilla. All other ways are so barricadoed with Bones or Tendons, that the Luxation is very diffi∣cult: yet I have seen it lie forward somewhat under the Pectorall Muscle; but whether it was forced thither in their attempting to reduce it out of the Axilla, I cannot certainly say, but do suppose it might.

The Causes of this Luxation are for the most part externall,* 1.62 by some violent force, either in Wrastling, Running, or by a Fall from a Horse, or the like. In the time of War it may happen by the force of great Shot or Splinters. Some instances whereof you may see in the Treatise of Gun-shot. But it sometimes happeneth from an internall Cause, viz. a Catarrh or Fluxion of Humours upon the Muscles or Tendons, which gradually relaxeth them to such a degree, that the head of the Os humeri slideth down into the Axilla.

Its descent into the Axilla appeareth by an unusuall Cavity in the head of the Scapula,* 1.63 where it naturally is full and round. You may also feel the head of the Os humeri lying in the Axilla hard and round: the Patient's El∣bow hangs from his Side, and cannot be brought so close as the sound with∣out great Pain, nor can he bring his Hand to his Mouth, or stretch it upright against a Wall. If the head of the Shoulder be distorted forward, that part

will appear prominent, with an unwonted Cavity behind, if you compare it strictly with the other Shoulder: the Elbow also hangeth backwards, and will not endure to be brought forwards.

If the Luxation be made by a Relaxation of the Tendons, the Patient's complaint will inform you, and the Emaciation of the Arm will make the foresaid Symptoms more apparent.

A Luxation of the Os humeri from an externall Cause is not very hard to reduce in Children or soft Bodies, if timely undertaken:* 1.64 but contrary in el∣derly people and tough musculous Bodies: and such are frequently slow in recovery of their former strength and motion. Sometimes a Paralysis sei∣zeth them, and they emaciate: but by timely Endeavours they do recover. If in the Reduction or otherwise any part of the Cupula chance to be frac∣tured, the retention of the Os humeri is not an easie task. Luxations made by Fluxion may be easily reduced, but are most difficultly retained in the Capsula.

The Reposition of the luxated Shoulder is performed either by the Hand,* 1.65 Bandage, or force of Instruments. He that will reduce it by Hand must put it in a motion contrary to that it went out by. In its going out, it is first thrust or pulled forwards, till it come beyond the edges of the Cupula; then it falleth down below the Cupula, and is by the Muscles pulled backward. He that will reduce the Bone this first way must reverse these motions; viz. first bring it forward, then upward, then thrust it in. By the observing this me∣thod I have reduced the Shoulders of Infants and little Children so soon, that the Standers by have hard them knap in before they knew they were out. But the way of reducing the Shoulder in those of more growth must be, if done by one man alone, by placing the Patient in a low Seat, and clapping his Fingers under his Arm-pit, his Knee or Thighs to the outside of his Elbow, and his Head to the point of his Shoulder. By his Fingers strongly bent to∣gether, he pulleth the Bone both forward and upward. By his Thigh or Knee pressing his Elbow to his Side, he doth likewise help to raise it and bring it forward. The pressure of his Head keepeth down the Scapula, that it may not rise with the Bone. But because this application of the Knee, Head, &c. is not easily practicable but upon little and slender men, we generally commit the pressing of the Elbow toward the Ribs to another man.

After this manner the Elbow is brought quite back to the Spine: which being done, his other Hand must be placed under the Axilla, to raise the head of the Humerus forward and upward, whilst the Chirurgeon with his hands presseth down the Scapula to receive the Bone.

When the head of the Os humeri lieth distorted forwards under part of the Pectorall Muscle, the Patient's Elbow must be drawn backward, and held close to the Spine, whilst the Chirurgeon presseth with both his Hands for∣cibly upon the head of the Bone.

There is yet another way of restoring the luxated Shoulder by the Hand thus: You are to make choice of a proper lusty Fellow on whose shoulder you must hang the Patient by the luxated Arm, bringing his Hand over to the Fellow's Breast. If the weight of the Patient be not sufficient to make the Extension, some other body may hang upon him, or pull him by the Legs downward.

But because these ways of Reduction by the the Hand are not always fecible,* 1.66 especially in strong muscular people, we therefore make use of Bandage and severall sorts of Engins. The most common way of Bandage is by that of the Girt, which Girt hath a Boulster in the middle, and the ends are tackt firmly together. In the use of it the Patient must be placed so, that part

of the Girt with the Boulster is to be placed under the Arm-pit, and the other part over the Chirurgeon's Neck, that he may thereby with all his force raise up the head of the Humerus: which that he may the better doe, his Assistent must sit behind the Patient, and pull his Arm backward with all his might; and if the Chirurgeon presseth with his Hands upon the head of the Scapula at the same time he raiseth up the Humerus, he shall reduce it more easily.

There is another way of Reduction by Bandage, and that is, by laying the Patient flat on his Back on the ground, the Chirurgeon sitting behind him, and making Extension by the foresaid Girt or other Bandage placed under the Axilla, whilst his Assistent lieth along at the Patient's Side, and presseth with his Heel upon the foresaid Bandage, and at the same instant taketh the Patient by the Hand, and pulleth his Arm with all his force. Thus by their severall Extensions the head of the Shoulder-bone may be rai∣sed and reduced.

Instruments proper for the Reduction of the luxated Shoulder are,* 1.67 Ladder, Coulstaffe, Pulleys, Glossocomium, &c.

The way of Extension by a Ladder is, that the Patient climbe 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 backward, whilst the Pa∣tient hangeth by it.

The way by a Coulstaffe is safer. The Staffe must have a Bunch in the middle somewhat Wedge-like, and covered with a soft Boulster fit to place under the Patient's Arm-pit. In order to the Extension, the Patient must be seated near some Post or Pillar, in which the Pulley must be fastened to extend his Arm; and the Bandage must be made a little above the Elbow: which being fastned, and the Coulstaffe placed, and supported by a couple of Fellows, the Chirurgeon must stand on the contrary side, with his Hands on each side of the Scapula, to presse it downward, and keep the Patient firm in his Seat, and govern the Operation, taking care that the Wedge be placed right whilst the Extension is making, lest they break the Bone, or otherwise 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 Extension. There ought to be great care in the use of it, for many shrewd Accidents have happened thereby.

The Humerus luxated by Relaxation of the Ligaments and Tendons is restored to its place after some of the was above said, but doth require your industry to retain it after it is reduced: more of which by and by.

A Lady going on evening out of her Coach into her house,* 1.68 trode upon her Gown, and fell down. I being fetcht, found her sitting in the same room grievously complaining of her right Shoulder. Lookig upon it, and feeling the head of the Humerus lying in her Arm-pit, I endeavoured to re∣duce it by Circumrotation: but it not yielding thereto, I caused one of her Servants to pull her Elbow back towards the Spine, then to thrust it for∣ward. During which I stood on the contrary side, with one of my Hands upon the head of the Scapula, and the other under the Os humeri; and at the same instant my Assistent thrust it forward. I forced it into its place: the people standing by heard it knap in, and the Patient declared it by the ease she felt. Then I applied an empl. è bolo round the weak Joint, with a proportionable Compresse wrung out of Oxycrate, and rowled it on. After

which her Servants led her to her Chamber to bed. The next morning I visited her. She had rested well, and was so easiy, that her Physician, Sir William Gideon, would scarce believe that the Bone had been luxated. The Lady prepared to remove to her Country-house, and undertook the Cure her self by some Plaisters of her own. But during the application of them her Arm grew weaker, and emaciated very much, and was painfull about the in∣sertion of the Muscle Deltoïdes, and so to her Hand, with a nummednesse in some of her Fingers. Whereupon she returned back, and consulted Physicians. One whereof, supposing the Bone still dislocated, advised the consulting a Bone-setter. I being present, he acknowledged the Bone well set. What he would have said had I been absent, may easily be guessed by his former dealing with others of my Profession. From that time Antiparalyticks were prescribed, a Fontanell was made in that Arm near the Muscle Deltoïdes, also Embrocations and Plaisters were externally applied; whereby she recovered the use of her Arm.

A Nobleman who was a Commander of Horse in that Army which came out of Scotland into England,* 1.69 was by some accident thrown off his Horse, and would not be raised off the ground till I came. He complained of his right Shoulder. I looking upon it, felt the head of the Humerus lie distorted in his Arm-pit. I endeavoured to reduce it by my Hands, as above in the former Observation: but it not yielding thereto, I caused Mr. James Davies, who was Chirurgeon to those Guards, to pull off his Boot from his right Leg, and to lie along upon the ground by his Lordship, to make Extension that way. Whilst he was making ready, I clapt a Compresse under the Pa∣tient's Arm-pit, with a Towell over it, and placed my self at his Lordship's Shoulder, and made Extension by the Towell, whilst my Assistent took the Patient by the Hand, and thrust his Heel into his Arm-pit with all his might. We having thus reduced the Bone into its place, I applied an emplastrum è bolo over the Shoulder, and a Compresse of Tow prest out of acetum un∣der the Arm-pit, and rowled them on. That done, his Servants made him ready, and helpt him upon his Horse. I made him a visit that night at his Quarters, designing to let him bloud in the contrary Arm: but his Shoulder being easy, and not hurt in any other part, I took my leave of him, tellig him his Shoulder ought not to be dressed till after six or seven days. But this person forgetting what I had said, thought himself neglected, and com∣plained to his superiour Officers of me. Whereas in truth, if the Bone be well set and bound up, it is not materiall whether it be any more dressed or no. Thus in an Army we are frequently rewarded, if we do not attend them as their meniall Servants.

One morning Mr. Faucett, Chirurgeon to his Royall Highnesse,* 1.70 sent to my house, when I lived in the Old-Baily, to come to him into Black-friers, to help him to reduce a luxated Shoulder of a man lodged there. The head of the Humerus was fallen down into his Arm-pit. The way of Reduction pro∣posed by Mr. Faucett was by a Girt. We placed the man on the ground, and that part with the Boulster under the man's Arm-pit, and put the Girt about Mr. Faucett's Neck, who stood over him with his Hands upon the Scapula; and whilst I drew the Patient's Elbow backward close to his Spine, and thrust the head of the Humerus upward, Mr. Faucett raised up the head of the Bone with all his force, and it knapt in. The Bone being thus reduced, Mr. Faucett slipt the Girt off his Neck, and dressed up the man's Shoulder with Astringents and Bandage as hath been said.* 1.71

In the year 1657. whilst I was riding to a Noble Family in the North, I was desired upon the Road to make a visit to a man who had some days

before put his Shoulder out of joint. I did so, and saw his Arm miserably stript of its Cuticula by the Bandage which the severall Bone-setters had en∣deavoured to make the Extension by; yet the Bone lay lodged in his Arm-pit. I applied over the Arm cerat. Galeni, and gave direction to have a Coulstaffe made ready against next morning, with a Wedge-like prominence in the middle of it, covered with soft Cloaths; and that the Bone-setters should meet me at the Patient's house. The next morning we met, and having all things ready, I caused the Patient to be seated with his luxated Arm near a strong Pillar, which supported part of a Mantle-tree; then took off the Dressings, and fomented and embrocated his Shoulder with Emollients; then folded a Cloath about his Arm a little above his Elbow, and fastned a Bed-cord over that, and tied the ends of it about the Pillar, and with a Bed-staff twisted it, shewing one of the company how to twist it, and make Extension of the Arm by it. Then I placed the Coulstaffe with its Wedge close under the prolapsed head of the Humerus, two strong men the while supporting the ends of the Staffe proportionably high, I standing on the con∣trary side with my Hands on the Scapula to draw it back, and presse it down∣ward to receive the head of the Humerus, and to govern the Operation, the Bone-setters looking on. All things being thus ready, the one twisted the Cord, and thereby extended the Arm; the other held the Coulstaffe firm and close to his Side. During the Extension our Patient roared, and one Bone-setter called to me to forbear the Extension, saying, Why will you strive against the Lord? and turned from us, declaring that I would kill the man. But the head of the Humerus was then moving; upon which consideration I bid the man twist on: and at that instant the Bone knapt in, and we loosened the Bandage; then dressed it up with empl. è bolo with Bandage, and put him to Bed. There being little more required, I went on my journey.

In the year of the great Sicknesse,* 1.72 whilst I was in the North-country, a Gentleman sent his Servant to me, who had some half a year before luxated his right Shoulder. He had been with a Bone-setter, who took some pains in stretching it, and made him believe he had set it: but upon sight of it, I concluded it luxated, and felt the head of the Humerus lying in his Arm-pit. I being then lame of my fractured Leg, and indisposed with coughing bloud, advised the man to return to his Bone-setter, and tell him what I had said. He did so, and travelled from one Bone-setter to another. Every one of them attempted the Reduction, and pretended they had set it. But the Patient returning still to me with it unset, I sent for a Pulley, and causing it to be fixed to a strong Post, and a Coulstaffe to be held under his Arm-pit by two strong people, we made Extension of the Arm, and reduced the Shoulder, as in the former Observation hath been shewed, without much difficulty. Then I dressed it up with a restrictive Emplaster and Bandage as above said, and he recovered the use of his Arm.

The deceased Mr. Edward Molins and my self were sent for to a Fencer who had put his Shoulder out of joint.* 1.73 We endeavoured to reduce it by the help of the Girt and our Hands: but he being of a strong muscular Body, we could not move it. We therefore embrocated the Shoulder cum oleo ex ped. bovinis, and dressed it up with cerat. dialthaeae. The next day we came prepared with a Glossocomium, well known to the young Chirurgeons by the name of a Commander, and reduced the luxated Bone; then dressed up his Shoulder as above said. This foresaid Instrument is frequently used in re∣ducing these Bones in strong tough Bodies, and where the Luxation hath been of long continuance: but the use thereof requireth great caution, for some∣times sad Accidents have happened theregby.

Luxations from internall causes are for the most part irremediable: yet I shall give you a couple of Instances of my attempts therein.

A young Woman having been long diseased with a Pain in her right Shoul∣der,* 1.74 with an Emaciation of that Arm, came to me recommended by Doctour Chamberlain Sen. Her Shoulder seemed to me luxated; but her Chirurgeon not being of that opinion, I declined the meddling with her: yet being af∣terwards solicited by some of her Friends, I sent her to a Chirurgeon's house, who was one of the Masters of Anatomy, whither I followed, and met seve∣rall Masters of that Faculty there at a private Dissection. They together viewed and felt her Shoulder, and unanimously concluding it luxated, pre∣pared for the Reduction of it; and having reduced it by Pulley and Coulstaffe, dressed it up accordingly. But the Ligaments and Tendons were so relaxed, that afterward upon slackning the Bandage it relapsed.

A Child of about four years of age having had his left Shoulder luxated from his infancy, the Arm emaciated and grown uselesse,* 1.75 I being at last con∣sulted did presently reduce it by lifting up the head of the Humerus with my Fingers: but the Tendons being extreamly relaxed, the Bone slipt down again as soon as I removed my Fingers. Wherefore I sent for Mr. Smith a Trusse-maker, and appointed him to fit the Child with a pair of Bodies stiffened on the lame side, wherein was fixt a Bar of Steel with a head like a Souldier's Rest, which by a Screw was raised proportionably to support the head of the Humerus. This being made, I placed a Fontanell in that Arm, and rowled up the other Arm from the Hand to the Shoulder, and braced it to his Breast, designing thereby to force Nourishment into the lame Arm, and necessitate him to use it. But the Child growing froward, they set it again at liberty. Upon notice thereof I deferred farther proceeding in the Cure, till the Child should be more governable; advising the Parents to repeat the use of the former Prescriptions of their Physicians as they should see occasion.

CHAP. VI. Of Luxation of the Elbow-joint.

THE Joint of the Elbow is made by the concurrence of three severall Bones:* 1.76 1. the Os humeri, 2. the Ʋlna, 3. the Radius. The Os humeri endeth broad towards the Cubit with a double head, the inward fitted for the recep∣tion of the Ʋlna, the outward for the Radius. The inward head is exactly shaped, and covered with a Gristle, which rendreth it smooth, and fit for the motions of the Ʋlna, which with a sutable Cavity plaieth about it, inser∣ting upon every extension of the Arm its utmost Processe (called the Olecra∣non of Ancon) in the large Cavity that is situate on the back-side of the Hu∣merus. In every Flexure its lesser Protuberance plaieth into a lesser Cavity in the exteriour part of the said Humerus. The Radius meanwhile, being

round and flat, with a very small Excavation doth play upon the outer head. These Heads have yet a farther use, viz. by their respective Processes to make a station for severall Muscles: the outer Protuberance giving originall to all the Extensors of the Hand and Fingers; the innermost to all the Flex∣ors of the same. The Joint it self, besides the Ginglymoïde connexion of the Ʋlna to the Humerus, is tied fast by a strong Ligament, and well bound in with Muscles. Viz. on the inside it is lined with the strong and thick, but very soft, end of the Brachiaeus internus, whose Ligament, though hard and thick enough, yet hath a soft Pillow of Flesh interposed between it and the Joint, that so the pressure may not hinder the motion thereof, but rather give way to it. Yet is the pressure strong enough to keep the place firm, which the accession of the Tendon of the Biceps doth much more corroborate; so do the Pronator radii teres and Supinator longus, &c. The outer part is well guarded by that great strong Muscle which usually is reckoned for two, viz. the Biceps, and Brachiaeus externus, which uniting together have a fleshy soft inside, but with a strong broad Ligament fixt on the outside to the Olecranon. There is also a little Muscle called Anconeus, which reaching from the end of the Humerus obliquely transverse doth insert it self into the Ʋlna corro∣borating the Joint.

The Radius also is bound close to the side of the Ʋlna and to the Humerus by two remarkable Ligaments; viz. the circular one that involveth the Joint, and the broad one that uniteth it and the Ʋlna together: it is also bound down by the neighbouring Muscles, especially the two Supinators and the Pro∣nator teres.

He that considereth the figure of the Ʋlna, and the strength whereby it is tied to the Humerus, will think the Luxation of it almost impossible: Yet even this also is sometimes made by the force that may be put upon it, and that four severall ways, if we may believe Authours; as ouotwardly, inwardly, and to each side.

If the Luxation be forward,* 1.77 the Arm hangeth straight out, or rather outward, and he cannot bend it; a Prominence appeareth in the Bout or inside of it, and an unwonted Cavity where the Elbow should be. But if the Luxation be backward, the Cavity will be in the fore-part, and the Arm curved. If the Luxation be on the inside, the Cavity will be on the outside; and so the contrary, if it be externally distorted.

The perfect Luxations of this Joint do rarely happen.* 1.78 When they do, they are difficultly restored: and if there be a Fracture of any of the Processes of the Joint, the case is deplorable.

If the Cubit be luxated forwards,* 1.79 the Arm must be extended, but not in a straight line, lest you break the tip of the Ʋlna, but obliquely. To which end, two persons being employed, one to hold the Humerus, the other to pull the Arm below, a third person must guide the Elbow so as to keep it bent, and to direct the Bone. Which is done by pressing a Boulster upon the bend of the Joint, or by a Girt or other Bandage pulled behind, or by one in the nature of a Stirrup, in which the Chirurgeon may put his foot, and make Extension that way.

If the Luxation be backwards, the Extension being made obliquely as be∣fore, the Reposition is easily guided by the Chirurgeon's Hand. Yet since the extending Muscles of the Cubit are very strong, it will be necessary that the Muscles serving the Cubit be first well embrocated with lenient Oint∣ments: but if notwithstanding you cannot reduce it by Hand, the Ladder or other Engines must be used. And after Reduction applie Restrictives, &c. for these Luxations are subject to great Fluxion, Inflammation, &c.

THE former of these Luxations happened to a Servant-maid in White∣friers carrying a Pail of water. Her Feet slipping,* 1.80 she endeavoured to save her self; but falling backward, she pitcht upon her right Hand, and dis∣torted the head of the Bone inward a great way. The poor creature was car∣ried into the next house, being an Ale-house, and Mr. Clarke a neighbouring Chirurgeon and my self were fetched. Dressings being made ready, and the Wench seated, one of the company stood on the contrary side of her, with both his Hands upon that Arm below the Shoulder, and held her firm. Mr. Clarks made Extension below the Cubit, and my self with a boulstered Girt upon the prominent Bone in the Bout of the Arm pulled it backward. After we had thus come to the very brink of the Joint, Mr. Clarke bowing the Arm suddenly forward, I drew it back into the place; then embrocated it cum ol. ros. myrtill. & aceto, and applied empl. è bolo with Bandage, and left her Hand upon her Breast. But she was lame long after.

If the Cubit-slip out side-way, the Reduction may be made by Extension and impulse of the Hand.

That of the Radius is also reduced by the like means; so that examples need not be given: onely in the other of a curved Wrist, I shall give one In∣stance.

A Lady being overthrown in her Coach,* 1.81 the lower Process of the Ʋlna cal∣led Styloïdes was distorted from the Radius, and one of the Bones of the Car∣pus shoved between. I made Extension of the Wrist, and prest that Bone of the Carpus to its fellows smooth, then thrust the Processe of the Ʋlna close to the Radius, and applied round the luxated Joint an Emplaster of a stringent Powders cum album. ovi, Splints, and Bandage, as in a fractured Bone, and pla∣ced it on her Breast, and thereby restored it to good use and its naturall figure.

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

THE Carpus is composed of divers Bones. One lieth out of order. Three of them are joined to the Processes of the Radius and Ʋlna, four to the Metacarpus, and all of them bound in by a strong Ligament, by the strength of which the Joint is made more firm. Yet these Bones may be all thrust out together, or any one of them single, inwardly, outwardly, also towards either side.

This Luxation is discovered by the Tumour it maketh in the place where it lieth distorted; also by the Flexure or Extension of the Fingers.* 1.82 Viz. if the Bones be moved inward, the Flexors of those Fingers are so stretcht, that the Extensors cannot stir them: and so contrary, if the Bones start outward,

the Extensors are immovable: and if they be luxated sideways, the Hand leans either to the Thumb or little Finger.

The way of Reduction is,* 1.83 to lay the Hand and that part of the Arm flat up∣on a Table, and make Extension above and below: during which the Chi∣rurgeon presseth down the prominent Bones with his Hands into their severall Cavities. The Bones reduced, remove the Hand, and place it upon a Ferula, and dress it up with Restrictives, Compresse and Bandage.

The Fingers may be luxated backward,* 1.84 forward, or on either side. The single Luxation of the severall Bones may be demonstrated by their Protube∣rance, and by the complaint of the Patient. They may be easily reduced by Extension, they having no Process to hinder: and being reduced, the common Restrictive and Bandage will retain them so.

CHAP. VIII. Of Luxation of the Hip.

THE Joint of the Hip is a Connexion of the head of the Os femoris to the Acetabulum of the Os ischion,* 1.85 which is done by two strong Ligaments: one outward and membranous, encompassing the whole head of the Femur, from the edges of the Acetabulum to the farther end of the neck, where it toucheth the great Trochanter: the other inward, of a round figure, like a Cord tying the utmost apex of the Caput femoris to the inner side of the Acetabulum near the center. This Articulation is confirmed and strengthe∣ned by great strong Muscles; viz. on the outside by the three Glutes, on the inside by the Triceps, together with the Levidus, and the four little Rotators. All which being duly considered, it must needs follow, that the force must be great that doth drive this out of its place. Yet when the weight of the Body and the undue position of the Thigh do concur, they frequently make that Luxation: so likewise doth sometime externall force.

It is remarkable, that this place admitteth not of a Semi-luxation as others do; the head being so round, and the Cavity so glib, and deep, that what∣ever the force be, if the head be not thrust quite out, it will slip in again as soon as the force ceaseth. It doth slip out four severall ways, outwardly, inwardly, forward, and backward. Yet these two latter I never saw; but by Congestion the Ligaments and Tendons may be so relaxed, that it may fall out either way.

If the Luxation be inward,* 1.86 the head of the Femur may be felt round and hard a little beneath the Groin. But if the Patient be in bed, you may judge of it by turning up the cloaths at the bed's feet; the Leg will appear longer then the other, and the Knee and Foot lie turned outward. If the Luxation be outward, that Leg will be much shorter then the sound one, and the Toes truned inward.

In a relaxation of the Hip, the Leg hangs for the most part directly down and loose, is weak, turneth either way, and is much emaciated.

Luxations of the Hip are difficultly reduced, and being so,* 1.87 are extreme apt to prolapse, by reason of the over-great Extension or Ruption of the in∣ternall Ligament, which should hold the Bone in its Acetabulum. And if it be not reduced, it will be subject to great Pain and Fluxion from the over-stret∣ching of the Muscles, and pressure upon them with its great head: yet after some months those Muscles become callous, and having yielded to the Exten∣sion, the Patient makes a shift to go upon it, though lamely. But the Mem∣ber suffereth an Atrophia, and is shorter then the other.

When the Luxation happeneth by Congestion, it is subject to Apostemati∣ons, and the head of the Bone corrupts by lying slabb'd in the Humour, and the Patient languishes and dies emaciated.

If the Thigh-bone be luxated inward,* 1.88 and the Patient young and of a tender Constitution, it may be reduced by the Hand of the Chirurgeon: viz. he must lay one Hand upon the Thigh, and the other upon the Patient's Leg; and having somewhat extended it towards the sound Leg, he must suddenly force the Knee up towards the Belly, and press back the head of the Fe∣mur into its Acetabulum, and it will knap in. For there is no need of so great Extension in this kind of Luxation; for the most considerable Muscles being upon the stretch, the bowing of the Knee as afore said reduceth it. Yet in tough Bodies it may require stronger Extension: and in that case the Patient must be laid upon a Table flat on his Back; and a Pin of a good thickness ought to be fixt in the middle of the Table, to stand up between his Legs close to that Inguen, that the Extension may be made thereby. During which, the Extension must be made by two men, the one pulling him by that Arm-pit, the other by the Leg: which latter Extension must be made obliquely towards the sound Leg.

If the Luxation be backward, he must be then laid upon his Belly, and the Pin placed as aforesaid in his Twist: it ought to be as thick as a Rowling∣pin, and covered with Cotton, that its hardness may not be offensive. The Extension may also be made upward by a Towell or Girt between his Thighs: and the while that Leg must be stretcht by Pulleys or such like strength, and the Bandage fastened above the Knee.

The Bone once reduced, dress it up with Restrictives and good Compresse and Bandage, then bind it to the other Leg, and keep him in bed: for these Bones are apt to start, especially if the Ligamentum teres be broken. If after Reduction and such Regulation the Bone do start again, I should forbear any farther forcing it, to avoid the danger of Apostemation, &c. For, as I have said, they may recover strength to goe on it, though it be never reduced.

A Luxation made by Relaxation or Resolution requireth good drying and corroborating Fomentations, Emplasters, Epispasticks, Fontanells, &c. The Habit of body ought also to be treated by Internalls as in the King's Evill; and if it apostemate, to be dressed as such Abscesses.

CHAP. IX. Of Luxation of the Knee.

THE Joynt of the Knee is made by the connexion of the lower head of the Femur and the upper head of the Tibia and the Patella.* 1.89 The first of these by a double Protuberance is inserted into the double Cavity of the latter, and suffers constriction on the anteriour part from the great and large Muscles, which running to and beyond the Patella, join that to the Os tibiae, and bind it down upon the Articulation, so as of the whole to make a Joint. On the hinder side it is guarded with the two Ham-strings so called, viz. the Tendon of the Biceps outwardly, and of the sartorius, gracilis, semimembra∣nosus & seminervosus inwardly: between which, through a little Cavity made for that purpose, all the great Vessells have their passage to the Legs. Now the Joint being thus strengthned doth scarce admit of any Luxation forward, unlesse the cause be exceeding violent. Backward and on each side it is subject to both Luxation and Semiluxation.

The Signs of the severall Luxations of the Knee are apparent to the eye,* 1.90 by the Protuberance in the one part, and Cavity on the contrary.

They are not difficult to reduce, nor subject to such Accidents as those of the Elbow.

Those Luxations which happen on either side of the Knee may be reduced by a moderate Extension with your Hands. The Luxation backward is restored by extending it a little: then bend the Leg suddenly backward, bringing his Heel to his Buttock, and you shall hear it knap in to its place. It being so, stretch it out again, and embrocate the Joints and Parts affected, and apply Astringents with a Compresse in the Ham, with good Bandage. I shall shew you the manner of reducing the perfect Luxation more particu∣larly as followeth.

A Gentleman of about 30 years of age,* 1.91 riding upon the Road some few miles out of Town, was by the rushing of a Cart tumbled with his horse into a Ditch, and brought back to London extremely lame and brui∣sed. I being fetcht to him found him in bed. The head of the Os tibiae was shot under the Thigh-bone, and lay stretcht out straight, exceedingly swelled, and much bloud extravasated amongst the Muscles of the Calf of his leg. I caused the Patient to be laid on the contrary side: then one of the com∣pany held him down, and kept that Thigh steady, whilst I took him by the Foot and Calf of his leg: and after I had a little drawn it to me, I forced it backward towards his Buttock; by which very motion it knapt into its place. That done, I extended it again, placing the while my Hand in the Hollow of his Knee. The motion of that Joint to and fro, and the filling up that Cavity under the Rotula, were certain signs of its Reduction. I embroca∣ted the Leg cum albumine ov. ol. ros. myrtill. & aceto, and applied empl. è bolo over all, with a Compresse in his Ham, then rowled it up, and laid his Leg upon a Pillow to the ease of the Patient. That done, I let him bloud in his

Arm, prescribed him an Emulsion of the cold Seeds, &c. and kept his Body soluble by Clysters, and advised him a slender Diet. The third day I re∣peated Embrocations with the foresaid Oils cum aceto, and thereby repelled the Humour so, that there onely remained some remarques of the extravasa∣ted bloud. I then embrocated those Parts cum ol. cham. lumbric. spir. vini, and applied empl. stict. Paracels. & diapalmae on the weak Joint. From the first application he grew daily easier, and by these latter the Joint waxed strong, and he rose and walkt with a Crutch in his Chamber: and some time afterwards I saw him walking abroad with a Stick in his hand.

CHAP. X. Of Luxation of the Ancle-bones.

THE lower end of the Tibia being joyned to the Fibula maketh a gin∣glymoïde Cavity in which the Os tali is inserted:* 1.92 the two Ancles being on the inside the Product of the Os tibiae, make the outer on the Fibula. Underneath lie all the Ossa tarsi in order; viz. the Os calcis under the Talus, the Os cymbi∣forme before it. Outward of that, joyning to the Os calcis, is the Os cubiforme; and between the Os cymbiforme and the Metatarsus lie the three Ossa cùnei∣formia.

This Joint is involved in strong Membranes and Ligaments, and bound in by divers strong Tendons: viz. behind by the Tendon of the Gastrocne∣mius, and yet close underneath in the Hollow of the Calcaneum by the Flexores pollicis & tertii internodii digitorum lateralis; inward by the tibialis posticus; outward by the preconei; forward by the tibialis anticus. These joined to the strong Ligaments that every-where bind up the Part, and assisted by the figure of the Bones, do make a Joint that would not easily be dislocated, did not so great a weight lie thereupon. But from great weight and force it suffereth four ways.

If the luxated Bone be distorted inward,* 1.93 the Sole of the foot lieth turned outward; so likewise if the Luxation be in the exteriour part. If the Luxa∣tion be forward, the broad Tendon of the Heel lieth hard and stretcht out, and the Foot appeareth shorter, because the Joint is moved forward, and pos∣sesseth most part of the Foot. But if the luxated Bone be distorted back∣ward, it lieth over the Heel-bone, in which case the Sole of the foot seemeth bigger and longer. Accordingly as these Signs are evident, the Luxation is perfect or imperfect.

The Reduction is not difficult;* 1.94 yet these Luxations are subject to great Pain, and are accompanied with Tumour and Ecchymosis, and the Patients are long lame of them.

The way of Reduction in tender Constitutions may be by Extension with your Hands, the one taking hold of the Leg, the other of the Foot.* 1.95 During which Extension, the Chirurgeon must presse the Bone the contrary way to which it was fallen. In case the Extension by your Hands suffice not,

you may make use of Pulleys or other Engine. The Bone being reduced, ap∣ply Restrictives with Bandage as above said.

Sometimes the Ancle-bone is apt to turn out on either side, by reason of Relaxation of the Tendons: in which case, though you do reduce it, yet upon the least walking on it the Bone slips out again. Some years agoe such a one was brought to me; I reduced it easily, and it as soon slipt out again: whereupon I caused a Shoe to be made by which the Ancle was kept steady, and at length by application of Astringents, &c. it recovered strength.

The Bones of the Metatarsus and Toes are frequently fractured, but rarely luxated, by reason of their strong Ligation by so many Tendons. But if it so happen, their Cure is the same with that of the Fingers and Hand.

CHAP. XI. Of Luxation of the Spine.

LUXations of the Spine, which are most usually from inward Causes, as in Rickety Children, also in the King's Evill, and other Tumours hap∣pening upon those Bones, require internall Remedies, so are referrable to a Physician. The Chirurgicall part consisteth in the application of Plaisters, as hath been shewed in the Treatise of the King's Evill; also in good Bandage, which chiefly belongs to the Bodies-maker.

When it happeneth from force, a speedy Reposition is required, about which Galen, Hippocrates, Oribafius, Celsus, &c. speak much, who all may be con∣sulted. The case is so rare, that I think it not needfull to adde any Dis∣course here; much lesse that of Hildanus, about reducing the Spine when luxated inwardly. He that pleaseth may look into the Authour.

Notes

• * 1.1

  The Office and Use of Bones.
• * 1.2

  Definitions of Fractures.
• * 1.3

  The Au∣thour's Defi∣nition of Fractures.
• * 1.4

  Differences.
• * 1.5

  Causes.
• * 1.6

  Signs.
• * 1.7

  Progno∣sticks.
• * 1.8

  Cure.
• * 1.9

  Intentions of Cure.
• * 1.10

  1. Intention.
• * 1.11

  Extension.
• * 1.12

  Instruments of extension.
• * 1.13

  Coaptation.
• * 1.14

  Signs of good Coap∣tation.
• * 1.15

  2. Intention.
• * 1.16

  1. Rowler.
• * 1.17

  2. Rowler.
• * 1.18

  Splenia.
• * 1.19

  3. Rowler.
• * 1.20

  Celsus's way of Rowling.
• * 1.21

  Signs of good Ban∣dage.
• * 1.22

  When to loosen Bandage.
• * 1.23

  Observation.
• * 1.24

  3. Intention.
• * 1.25

  Position of the member.
• * 1.26

  4. Intention.
• * 1.27

  Diet for the ingendring of Callus.
• * 1.28

  5. Intention.
• * 1.29

  To lessen Callus.
• * 1.30

  To encrease Callus.
• * 1.31

  1. Observat. of a fractu∣red Face.
• * 1.32

  2. Observat. of a fractu∣red Cla∣vicle, &c.
• * 1.33

  Compound Fractures.
• * 1.34

  2. Observat. of a fractu∣red Leg.
• * 1.35

  4. Observat. of both the Focills of the Leg fractured.
• * 1.36

  Connexion of Bones.
• * 1.37

  Symphysis.
• * 1.38

  Articulatio.
• * 1.39

  Definition of a Luxation.
• * 1.40

  Differences.
• * 1.41

  Causes.
• * 1.42

  Signs.
• * 1.43

  Signs of Re∣duction.
• * 1.44

  Prognostick.
• * 1.45

  Cure.
• * 1.46

  1. Intention.
• * 1.47

  2. Intention.
• * 1.48

  3. Intention.
• * 1.49

  4. Intention.
• * 1.50

  Processes of the Jaws de∣scribed.
• * 1.51

  Signs of Jaws lux∣ated.
• * 1.52

  Prognostick.
• * 1.53

  Reduction.
• * 1.54

  1. Observat. of a Lux∣ation of both Jaws.
• * 1.55

  2. Observat. of a Luxati∣on of the right Jaw.
• * 1.56

  The Clavicle described.
• * 1.57

  Cause and Sign of a luxated Cla∣vicle. Progno∣sticks.
• * 1.58

  Reduction.
• * 1.59

  1. Observat. of a Clavi∣cle luxated.
• * 1.60

  2. Observat. of a Luxati∣on of the Clavicle.
• * 1.61

  Description of the Shoul∣der-bones.
• * 1.62

  Causes of Luxation the Shoul∣der.
• * 1.63

  Signs.
• * 1.64

  Prognostick.
• * 1.65

  Reduction by the Hand.
• * 1.66

  Reduction by Bandage.
• * 1.67

  Reduction by Instru∣ments.
• * 1.68

  1. Observat. of a luxated Shoulder.
• * 1.69

  2. Observat. of Reduction by the Foot.
• * 1.70

  3. Observat. of Reduction by the Hand.
• * 1.71

  4. Observat. of Reduction by the Coul∣staff.
• * 1.72

  5. Observat. of Reduction by a Pulley and Coul∣staffe.
• * 1.73

  6. Observat. of Reduction by Glossoco∣mium.
• * 1.74

  7. Observat. of luxation by Con∣gestion.
• * 1.75

  8. Observat. of Luxation by Conge∣stion.
• * 1.76

  Description of the El∣bow-joint.
• * 1.77

  Signs of the Elbow luxa∣ted.
• * 1.78

  Prognostick.
• * 1.79

  Cure.
• * 1.80

  1. Observat. of a luxated Elbow.
• * 1.81

  2. Observat.
• * 1.82

  Signs of the Carpus luxa∣ted.
• * 1.83

  Reduction.
• * 1.84

  Luxated Fingers.
• * 1.85

  Description of the Hip.
• * 1.86

  Signs of a Hip luxa∣ted.
• * 1.87

  Progno∣stick.
• * 1.88

  Reduction of the Os fe∣moris.
• * 1.89

  Description of the Knee∣joynt.
• * 1.90

  Signs of a luxated Knee. Reduction.
• * 1.91

  Observation of a luxated Knee.
• * 1.92

  Description of the Ancle-bones.
• * 1.93

  Signs of a luxated Ancle.
• * 1.94

  Prognostick.
• * 1.95

  Reduction.