A treatise of wounds by Richard Wiseman.

A TREATISE OF Wounds . BY RICHARD WISEMAN , ONE OF His Majestie's Serjeant-Chirurgeons .

LONDON , Printed by R. Norton , for Richard Royston , Bookseller to His most Sacred MAJESTY , MDCLXXII .

Reader ,

HAving spent betwixt Thirty and Forty years in a plentiful exercise of my profession , and that in different Countries and Places , where I have been eye-witness of the variety of methods in Chirurgery , I think it is no great vanity for me by this time , to pretend to something of experience in the Faculty : Which how difficultly it is attained , I not only can testifie by my own frequent misadventures in this Imployment , but also do appeal to all others that have undertaken the Art. Vita brevis , Ars longa , Experimentum fallax , Judicium difficile , said the great Father both of Physick and Chirurgery , of which it is true , that the former hath more of uncertainty , because the diseases are hidden as well as their causes , and little of either lyeth open to the Eye : Yet ours also meets with many great difficulties , and very dubious cases , such as will sometimes puzzle an old Chirurgeon , but a young one would be quite lost in , without the assistance of an expert Guide . This is the Reason why I think all men , that have arrived to any thing of Knowledge or Experience , are obliged by the general debt they owe to mankind , to leave behind them such Monuments of it as may be useful to posterity . Thus our Art at first grew , when Apollo's Temple at Delphos received in Tables the Histories of particular cures consecrated by the Votaries , and when Fathers bred up their Children in their own profession , faithfully delivering to them such Rules and Maxims , as their frequent observations had both suggested and confirmed : Insomuch that the Art became Hereditary , and propagated in families . And it is the opinion of some learned men , that the so much admired Volume , that goes under the name of Hippocrates , was the product of such a succession of Communications , there being no less than seven of that Race that were in their several generations eminent that way : The world is since grown bigger , and the Art it self much inlarg'd , by the great accession both of Diseases and Remedies ; insomuch that Medicine , which heretofore was the work of one man , is now split into three parts , the Physician , Chirurgeon , and Apothecary ; each finding work enough for the whole man . Yet with all this encrease of Knowledge we do but encrease sorrow , and after whole Ages spent in Chirurgical and Medical Disquisitions , we find little advance towards the certainty of Cure , or the commanding of help in the necessities of nature : A great Reason of which I take to be the excess of Imployment , or ( which is worse ) disingenuity in great Practitioners , who have not often been free in communicating their Observations to the world , but have rather left that task to Sedentary men , who having Chairs in Universities , have more indulg'd themselves in the speculation of the Art , than in a diligent attendance to matter of fact ; who having reduced the Art into method , have spoken rather pursuantly to their own Rules , than agreeably to our Experience : Hence it is thought , that from Galen's days , who first drew Physick into a strict Body , we have found little Augmentation of Knowledge , till some bold adventurers in these latter Ages have made some fortunate Essays at farther discoveries .

For my own part , I shall not pretend to new Inventions , only what I have , I do here bring as my Mite to the Treasury of other mens Learning ; affecting more the praise of fidelity and easiness of being understood , than of having enriched my Faculty with any far-fetcht or novel additions : Our Art is rich enough already in that kind , Nature having plentifully supplied us with a Materia Medica in every field ; nor need we any other Instructions than in the use of that Store we find ready provided for us . In this such men as have spent their whole Time and Parts in a perpetual Practice , are the best Instructors , of which , whether I deserve to be reckoned for one , the ensuing Treatise must tell you : It being an Essay to a further work , which if this succeeds , may hereafter be offered to the use of the world . Why I have begun with a Treatise of Wounds , will easily be guessed by those who know me to have spent so much of my Time in Armies and Navies , in both which it was my chief business during my abode in that Imployment . I have observed many great Errors committed in dressings , very much to the damage , and often to the destruction of the Patient ; to which notwithstanding custome and frequency of example have given countenance . This very consideration did more excite me , when I once understood his Majesties design of a Navy Royal , where many young Chirurgeons being employed , and my Sickness of Body and my present relation to his Majesty render'd me not so fit for attendance there , as both my Genius and my desire of serving his Majesty makes me inclinable ; I thought it my duty to assist , at least with such directions as my Pen will afford , faithfully delivering those methods of Cures , which I my self have practised with success , and by giving early notice of such Errors as have been observed by me , either in my own , or other mens practice , arming them as well as I could against all misfortunes in the Faculty . I have therefore chosen the method that seemed to me the most easie and facil , and most accommodated to practice , still confirming Rules by Examples , and thereby illustrating what ever might else seem obscure . Not that I was ignorant how hard a task I have undertaken to speak of things of this nature , whilst so many both Chirurgeons and Patients who are therein concerned , are yet alive ; which is the reason why in some difficult cases , I have chosen to give so few Instances , as making use only of such as I was either concerned in my self alone , or such as might give least offence to others , which I have avoided as carefully as I could : For which cause I have made choice of such observations as may be rather for the Readers instruction than my own credit , mixing as well my unprosperous attempts as my succesful administrations .

The Lecture of Fractures was first written and read in the Chirurgeons and Barbers-Hall , and had been pursued by the rest , had not the Fire prevented us , and that occasion given a stop to a laudable custome . The Treatise of Gun-shot was afterwards compiled , and that of Simple wounds last , one thing begetting another , but when they were done , I put them into that order which did seem most agreeable to the design I now have in publishing them . I mention this here , that if any thing happen to be preposterous in the several Treatises , your charity may be furnished with an excuse for it .

It is true , that this discourse ( the former part of that of Simple wounds excepted ) were done long since for the use already mentioned , though since pollish't and fill'd up ; Several other little things , as of Tumors , Fistula's , and Lues venerea ( all which ly rough cast ) and may come to light , if the success of this small Tract encourage me : I have taken pains in one part of Tumors , which my relation to his Majesties service hath engaged me , viz. the Kings-Evil ; of which I wonder so little hath been written by the Chirurgeons of the English and French Courts , both which Kings do so publickly exercise themselves in the Cure of it : And though so many thousands of people pass through the hands of the Chirurgeons to be judg'd of , and presented to their Princes , yet excepting that of Laurentius , and an imperfect piece or two of our Countrey-men , there is nothing appeares in print concerning it . I therefore thought it worth my pains to write what I have observed in that disease , hoping withal to give so much credit to our Society in this Nation , as to let the world know , we do not all spend our time in talking in Coffee-houses , and drolling over the Accidents that befal one another in our profession ; but that some of us at least make it our business to Improve our Faculty and to give Strangers , pretenders to great things in Chirurgery , that come over to us ( and are so Wellcome to our Gentry , only upon the account of their being Strangers ) occasion of understanding , that they may whilst they are here , traffick for Skill as well as money , and carry that back with them , which may give the world some opinion of the Knowledge and Experience of our English Artists , as well as of the liberality of their Patients .

Reader ,

I do pretend to have spent my time in Armies , Navies , and Cities , not in Universities ; Nor to have been much conversant in Books , through my constant Employment in , and the little leisure I had from my Profession , till my want of health of late years enforced me to make them my diversion . Therefore thou must not expect a nice exactness in the disposition of the parts of this Book , which it may be from a perfect Logician thou wouldst ; yet I hope I have done so much that way as will excuse me from being altogether rude , and what it wants in that kind , will possibly be made up by its accommodation to the Chirurgeons hand in dressing , to which I have wholly applied my self ; as thinking it more profitable for the persons , to whose use I design it . The whole is contracted into a little bulk , and yet I hope nothing is wanting that is necessary to thy Instructions ; It becomes by this means cheaper and more portable , and if those conveniencies be accompanied with a sufficient perspicuity in delivering , and fulness in handling what I undertook , it is all that is desired by thy Friend to serve thee ,

R. W.

The Contents of Part I. CHAP. I. OF Wounds in General . Page 1. CHAP. II . Of the Second Intention . p. 7. CHAP. III . Of the Fourth and Fifth Intention and of Compound Wounds . p. 17. CHAP. IV . Wounds of Veins and Arteries . p. 34. Observation 1. Wound of the Internal Jugular . p. 37. Observat . 2. An Artery wounded p. 38. Observat . 3. An Artery wounded . p. 39. Observ . 4. Aneurisma p. 40. Observ . 5. Wound of the Sural Artery . p. ibid . Observ . 6. An Artery prickt by letting bloud , with the manner of Deligation . p. 43. CHAP. V. Wounds of the Nerves , Tendons and Ligaments , with Observations . p. 47. CHAP. VI . Wounds of the Face , with Observations . p. 56. CHAP. VII . Wounds of the Limbs . p. 61. Observat . 1. Puncture of the Arm. p. ibid . Observat . 2. Wounds in the Thigh . p. 62. Observ . 3. A wound in the Arm. p. 63. Observat . 4. Wound in the Leg . p. 64. CHAP. VIII . Wounds of the Breast . p. 66. Observation 1. p. 69. Observation 2. p. 70. Observation 3. p. 71. Observation 4. p. ibid . Observation 5. p. 73. CHAP. IX . Wounds of the Abdomen . p. 75. Observation 1. p. ibid . Observation 2. p. 78. CHAP. X. Of Wounds in the Head . p. 80. Observat . 1. Wound in the Temporal Muscle . p. 88. Observation 2. p. 98. Observations of the wounds of the Head . p. 107. Observat . 1. A large wound of the Calvaria . p. ibid . Observation 2. p. 108. Observat . 3. Of the Calvaria torn off . p. ibid . Observat . 4. A great contused wound . p. 110. Observ . 5. A Concussion . p. 111. Observat . 6. Another Concussion . p. 113. Observ . 7. A Fracture with a long fissure , and depression of the Cranium . p. 117. Observat . 8. A Contused wound by a blow on the Crown of the Head . p. 120. Observat . 9. A Concussion of the Brain . p. 123. Observ . 10. A large fissure , the Dura mater putrified . p. 126. Observat . 11. A Caries through the Cranium , wherein the Pericranium and dura mater become one Body . p. 128. An additional Discourse of Wounds of the Brain , with Observations . p. 131. The Contents of Part II . CHAP. I. OF Gun-shot-wounds in General , with an Observation . Page 1. CHAP. II . Of the Cure of Gun-shot-wounds ; and first of Extraction of Bullets , &c. with Observations . p. 4. CHAP. III . The first dressing after Extraction , with an Observation . p. 12. CHAP. IV . Of Accidents befalling Gun-shot-wounds , and of Sinuous Ulcers , with Observations . p. 19. CHAP. V. Of Gun-shot-wounds with Fracture , with Observations . p. 26. CHAP. VI . A Fracture made by a Splinter , with Observations . p. 41. CHAP. VII . Of Gun-shot-wounds in the Joynts with Fracture , with an Observation . p. 50. CHAP. VIII . Of Wounds of the Belly . p. 55. CHAP. IX . Of Gun-shot-wounds of the Thorax , with an Observation . p. 63. CHAP. X. Of Symptoms of Gun-shot , omitted in the fourth Chapter . Page 68. An Appendix to the Treatise of Gun-shot-wounds . p. 75. CHAP. I. De Ambustis , or Burning , with Observations . p. ibid . CHAP. II . De Gangraena & Sphacelo , with Observations . p. 81. What is to be considered by the Chirurgeon in the heat of Fight . p. 90. CHAP. III . Of Fistulae , with Observations . p. 103. CHAP. IV . Of Fractures in General , with several Observations . p. 110.

CHAP. I. Of Wounds in General .

A Wound is a solution of continuity in any part of the Body , A Wound defined . suddenly made by any thing that Cuts or Tears , with a division of the Skin .

THIS definition differs much from what is usually delivered by Authors , and it is fit it should , for they generally defining a Wound by a solution in parte molli , do thereby exclude a Cut made into a Bone ; as that into the Cranium by a Pole-Axe , &c. which why it should not be called a Wound I know not ? Secondly , I say it is made by any thing that Cuts or Tears ; other Authors define it to be made by an external Instrument , &c. How then do they call that fracturam cum vulnere , a fracture with a Wound , where the Bone from within makes the Wound , and thrusts it self quite through the flesh ? Sennertus adds to his Definition , that it be done à re secante & acutâ ; yet he reckons those for Wounds that are made by Bullets , although it be Canon-shot .

I do therefore think it fit to make my definition more comprehensive , and to take in whatsoever makes a sudden solution of continuity , at least immediately and by it self , on what part soever it lighteth ; so a Cut into a Bone is a Wound , tearing the Flesh , Nerve , Sinew , Tendon or Cartilage , by Bullet , Stone , Splinter , &c. is a Wound ; only I add this restriction , that the Skin must be likewise divided : By which last words I exclude fractures that come not through the skin and contusions , if the exterior parts be continuous . But by the word Skin , I understand not only the external cutis , but also the Inward membranes of the Gullet , Ventricle , Guts , Bladder , Urethra , Womb , all which are capable of Wounds from sharp Instruments , whether swallowed or thrust into them .

A Wound thus defined admits of many differences , Differences of Wounds . of which I know none that can be properly called essential . Great and small , deep and shallow , wide and narrow , streight and crooked , round and Angular , are but Accidental differences . Distinctions taken from the Weapons whether sharp or blunt ; Sword , Rapier or Bullet ; Cut , prick or Tearing , the likewise Accidental : Those that look most like essential differences are they which are taken from the subject in which the Wound ( which is it self but an Accident ) inhereth , viz. from the Flesh , Skin , Brain , Nerve , Tendon , Artery , Vein , Gristle , Bone &c. All which being the several subjects of Wounds may well be allowed to specifie them , and so much the rather , because from the nature of them we raise our greatest Indications of altering the method of Cure . To this head may also be referred the division of them into Simple or Compound .

Wounds are in themselves so visible , Signs and prognosticks . that they need no general marks to be known by . But the peculiar affections of the particular parts hurt , and the methods of discovering what Inward part is Wounded , by observation made of the symptomes that happen , are fully handled in the Treatise of Gun-shot-wounds , to which I refer you : And not they only , but the prognosticks also are there delivered , in which a Chirurgeon ought to be well versed , lest through ignorance of them he undertake the Cure of Wounds that are mortal . I therefore have translated them to that Treatise , because the difficulty of Knowing them in cases of Gun-shot , is much greater than in those of other Weapons . The greater symptoms likewise , Symptoms . as Gangrena , Paralysis , Spasmus , are there distinctly treated of , as being more frequent and important in Gun-shot-wounds than elsewhere ; Hemorrhagiae are spoken of in this present Treatise .

As to Intentions of Cure , Intentions of Cure . the Wound being a solution of continuity doth require to be made One again . Unity being the perfection of whatsoever hath a being . To effect this , is the work of Nature and Art : both must mutually joyn their helping hands , and unless both the vital faculties and nourishment of the part do assist the Art of the Chirurgeon , it will be lost labour , here must be a joynt meeting and agreement of all in one .

In Simple Wounds the Chirurgeon is to afford his assistance Five manner of ways , the omitting of any of which will render him negligent or ignorant in his Trade .

The first is in careful and diligent taking away all such extraneous Bodies , as by their interposition may hinder the true Agglutination of the disjoyned parts , whether they be concrete Bloud , Hair , Sand , Dust , pieces of Bones , Cartilages , or pieces of the Weapons , Rags , &c.

The second is performed in bringing the Lips of the Wound even together which were separated .

The third is in retaining the Lips so brought together , that they may be Consolidation be restored to their former Figure .

The fourth is in conserving the Temperament and Natural Heat of the part in order to Unition .

The fifth is to prevent ill Accidents , and to correct such as have already seized on the part .

Thus much is required of us if the Wound be only Simple ; What is required in Compound and Contused Wounds . but if it be a Compound Wound with loss of substance , or Contusion , then he hath somewhat more to do : as where there is loss of substance there he must assist Nature with his sarcotics , for regaining what is lost : And where there is Contusion , there he must promove the turning what is Contused into pus or Matter , which must be performed before there can possibly be Re-union .

As long as there is Alienum quid , The First Intention in taking out Extraneous Bodies . some strange Body or different substance to keep off the Unition , you must not hope to make any Cure of a Wound ; therefore if any such be to be drawn forth , before you attempt it , consider seriously ; first whether it can be done or no ; secondly , whether safely .

For first , sometimes the Weapon sticketh so fast , that by no Art it can be extracted ; then it is of necessity to be left to Nature , who this way sometimes worketh miracles : Mercatus in Lib . Institut . Chirurg . says , sometimes pieces of Weapons sticking so fast in the Inward parts have lain hid under the cicatrized Wound , and have a long time after upon the Apostemation of the part come forth of themselves .

Secondly , You are to consider whether you may with safety pluck out the Weapon or no ; some will live a day with the Weapon in their Bodies , which would expire upon the moment of extraction ; but if your judgment suggest to you that the Patient is recoverable , make haste out with it before the part be inflamed , or else you must stay until digestion .

If the Weapon have not pierced deep , Which way the Weapon is to be drawn out . and through great Vessels and Nervous places : If the part opposite be full of Veins , Arteries and Nerves , or have a Bone in it over against the Wound ; If there be no great fear of Laceration , pull it out the same way it went in ; for the effecting of which , our Masters have left us variety of Instruments , the figure and usage whereof you may see in Scultetus . But if the point of the Weapon have pierced above the half way , and there be no Bones nor notable Vessels to hinder you , ( here is use of your Anatomy , and exact Knowledge of the parts ) either thrust the Weapon through , or make way for it by incision on the contrary side ; but beware the Weapon be not too big , lest you do make two large Wounds for one .

If the Weapon stick in the Bone , Weapon stuck in a Bone . move it up and down to loosen its point , and then pluck it out ; but in case it will not move , cut away the Bone before you extract it .

If a Weapon be fastned betwixt two joynts , Weapon stuck between the Joynts . make an extension of the parts both ways , as it is the manner in Fractures and Dislocations , that so the Tendons and Ligaments being Elonged , the Weapon may with more ease come out ; but do this with moderation , lest you break some notable Vessels , and a flux of Bloud or some ill Accident befall you as you extract it . It will be necessary in this work that you consider the Position the part was in when the Wound was Inflicted . Gesner hath a story in his Observ . de Chirurgiae dignitate & praestantia , of a Chirurgeon , who when he could by no means get forth an Arrow , asked the wounded Patient in what Figure of his Body he received the Wound , understanding it was done on Horseback , he placed him in a riding posture , and immediately drew out the Weapon .

The Weapon thus drawn out , cleanse it from Rags or ought else , and permit the Wound to bleed accordingly , as you in your judgment shall think fit , you having respect to the constitution and habit of Body , that what is in the small Veins cut asunder may flow out as well to hinder Inflammation , as the generation of much Matter . The Bleeding stay'd , if there be Hair growing about the Wound , shave it off , then wipe away the clotted bloud with a Spunge dipt in Red-wine , Oxycrate or Water . But if it stick in the Wound deep , be not too busie with your armed Probe , for thereby you may stir up a new bleeding ; whereas this concreted , keeps the Wound warm , and defends it from the outward Air , and by digestion Nature will thrust it forth .

CHAP. II . THe Second Intention is performed by bringing the Lips of the Wound exactly together . The Second Intention .

THIS Intention is delivered in a few words , but they are as a Law to be observed , Unition is to be made . for without that reduction of the Lips a slow and deformed healing follows . Nature hath nothing to do here in bringing the Lips together , that is the sole work of the Chirurgeon , who must not lay a Pledgit , or croud a Dossel of Lint or Tent into a little Wound . No , that is the way to keep the Wound open , and make it painful , whereby defluxions are stirr'd up , the Temperament of the part weakned , and the Cure prolonged ; contrary to the Intention of all who have writ of them , and to the practice of our Knowing Chirurgeons here : But amongst the pretenders to that Art , we often meet with such work ; particularly in a young man Wounded near Highgate in the Back , Observation concerning Dossils in Simple Wounds . slanting under the right Scapula , another wound on the Back , and another through the upper part of the other Shoulder , with a long Gash over the forehead , and with other wounds , some whereof not considerable : The next day I was carried thither to Dress these Wounds , I found them all distended with Tents and Dossils of Lint , disposed to inflame and swell ; the Patient exceeding full of pain : after I had taken out these Extraneous Bodies , my endeavour was to Dress them so , as I might encline their up-heaved Lips to return to their Natural scite ; to which purpose I fomented them with Milk , and drest them with Pledgits spread with my digestive of Tereblnth . cum vitel . ovi , and Embrocated them with Ol. Ros . and by Empl. è Bolo , and Bandage with gentle compression I drest him up , and afterwards here in Town Cured him by Sarcotics and Epulotics , as in Compound Wounds , a longer work which at first ought to have been by Agglutination : Parts separated and disjoyned are to be brought together gently and equally , that they may touch one another , and so be prepared for Unition .

This must be done first gently sensim & sensim , as Fallopius hath it , by little and little , not hastily at one pluck : If the parts be equally soft bring them equally together : First Gently . if the one soft , the other hard , and not to be moved , but with difficulty , bring the soft part to the stubborn . If the part be grown stiff with cold , as if they had been left in the fields all night , which after a Battel hath often hapned , ( and particularly to a merry fellow , a common Souldier , that used to wear an Iron Skull under a Cap , and from thence was call'd by a Nick-name ; his wounds were large , and the Lips hardened with the cold , and it was well for him his bleeding being thereby stay'd ) in this case you are with Milk or warm-Water , and Oyle to supple them by Fomentation or Embrocation , till you perceive the Lips made soft enough for your purpose , before you endeavour Re-union .

Secondly Equally , that the parts cut asunder may answer one another , as well in profundo , as in superficie , the Top as the Bottom , Brim to Brim ; and , if possible , underneath Vessel to Vessel , Secondly , Equally . that Nature may be in a capacity of doing it is own work , and by vertue of its Balsam , Reunite , Agglutinate , Consolidate , and Heal the Wounds : In all which Intentions she is the Agent , and the Chirurgeon only the Assistant , which Assistence , that it may be more effectually given , we must go on to the Third .

THe Third Intention is Deligation , The Third Intention retaining the parts United . or Retaining the parts so joyned together .

For the effecting of this , our famous Masters have left us two principal means , fascias & suturas , Rowling and Stitching ; to which some , nay most of them added fibulas , or Clasps : But I will not put you upon that . If the Wound be small in parte molliore , in a fleshy part in the Limbs , and according to the length of the Fibres and Member ; if the Wound be Simple , and in a sound Body , you may perform the whole Cure only by Bandage , Bandage . for here Nature will truly act her part by application of Bloud and nourishment to both sides indifferently , and finish the Coalitus without your further assistance : this is that which gives such credit to the Sympathetick Powder . In the application of this , it becomes every Chirurgeon to be much experienced , in respect of the unspeakable commodities which the whole Art receiveth by them .

By them not only are parts dextrously accommodated for Union , Their Use . but such also as would unnaturally grow together kept asunder , in Burnings , Scaldings , &c. The Finger or Ham would many times grow together , the Chin would grow to the Breast , the Arms to the sides , were they not this way hindred . By them are fluxes averted , and the delapse of humors into the inferior parts forbidden , and being already lodged they are prest out . By these are good Juice wisely forced into parts Emaciated , as if the Right Arm pine away , Rowl up the Left from the hand to the arm-pit , that the bloud being prest out into the Vena Cava , or rather hindred to flow in so fast by the Artery , may with more eagerness flow into the other side where it was wanting : By these we see great fluxes of bloud , large Hemorrhages every day stayed : By them are ill shaped Ulcers brought into better figures , made more apt to be Cured : By them are the force of your application helpt and furthered , they keeping them close to their proper places , where your care hath bestowed them : By them is the true natural form and beauty of the part commonly preserved .

Three especial sorts of Fasciation or Rouling pertaining to our present work have the Worthies of our Profession commended to posterity ; Three sorts of Especial Use . the first they term Incarnatrix or Agglutinatrix , the Incarnative or Agglutinative : The second Retentrix , or Retentive : The third Expultrix , or Expulsive .

The Incarnative is that which brings the Lips of the Wound together , 1. Incarnative . and conserveth them in their right Figure ; it must be more strict than the Retentive , and more loose than the Expulsive , and is the most useful in simple , fresh , and yet bleeding wounds ; The manner of performing it is thus ,

Have in readiness a Rouler of such matter , length and breadth as I shall anon shew you , Roule it up at both ends firmly to the middle ; then lay the middle part of the Rouler on that part which is opposite , to prevent pain and Inflammation , and to cherish the heat of the part , you are , after you have made a turn upon the wound with both ends of the Roulers , to go up with the one and down with the other , and take so many turns about the part , according as may be requisite , for the restraining the flux of bloud , or according to the season of the year , to defend from Cold , and yet not keep the wound too hot , for that may weaken the part ; you must also be careful that your Bandage be not too hard so as to intercept the Spirits , your Bandage running downwards will press out the matter from the affected part , and by passing upward hinder the Influx of humours and Inflammation .

The Fascia retentrix , 2 Retentive . is used to keep on close Applications about the wound , for cure of the Patient ; and these are they that are only in use , in wounds of the Head : there must be a moderation of this Bandage .

Fascia Expulsiva is performed by a Rouler of one head , 3 Expulsive . the special use of it is to expell matter out of Fistula's , or the Sinuous Ulcers , and also to keep out and stay the descent of Humours , and to expel such as have already seated themselves upon the part wounded , or otherwise ; I do it in the manner following .

Begin in the sound part , beneath the seat of the Humours , and then Rowl hard at first , and by degrees , as you come nearer the mouth of the Wound gentler and gentler ; if you will press out the Matter contained in the Cavity about the Ulcer , Rowl loosely a turn or two , then harder , and yet a little streighter , the higher you go to hinder the descent of Humours , but not too hard for fear of harm , Terminus sit bona laborantis tolerantia , Celsus : How hard to bind . Let it be made with such moderation , as the Patient may well endure .

Hippocrates de offic . Medica ; Vinculorum aliud per se ( saith he ) Remedio est , aliud iis quae Remedio sunt subservit , amongst Ligatures , some of themselves are Remedies , others are servants to Remedies ; and true it is in this , for the Incarnative , and expulsive , are in themselves as you may perceive Remedies , and the Retentrix the common servant to them all .

To this Fallopius in Tract . de vulneribus in Genere , adds Four more , 4 Other Bandages added by Fallopius . viz. Fasciam disjunctionis ; Secondly , Fasciam directionis ; Thirdly , Fasciam facientem Apostema ; Fourthly , Fasciam prohibentem Apostema .

Fascia disjunctionis . by Rowling keepeth parts from joyning together , as the fingers when they are bared of the Cutis .

Fascia directionis , is that which assisteth in making a crooked part straight , or bendeth a part unnaturally straight to his proper figure .

Fascia faciens Apostema , is that which will procure an Apostem , by summoning the matter up into one Body , which might perhaps dangerously flow into many parts , and those more principal .

Fascia prohibens Apostema , is that which forbiddeth the collection of Matter , and by consequent hindereth the Generation of an Aposteme .

For the matter of your Rowlers , Of what Roulers are to be made . they must be fine and even Cloath , white , clean and gentle , but of strong Linnen without Hem , Seam or Threads hanging by .

Let the length be such as the Member affected and the multitude of Circumvolutions require , Their Leng h . longer in winter than in Summer : Hieme ( saith Celsus , ) saepius fascia circumire debet , Aestate quoties necesse est , Rowl on , on , and again in the winter , in the Summer no oftner than needs must ; his ground I suppose he had from our great Master , Sect . 5. Aphor . 20. Frigidum ulceribus mordax , cutem obdurat , dolorem insuppurabilem facit ; Cold nippeth a Wound , makes the Skin hard , and causeth pain , which cannot be digested for the breadth of the Rowler . Their Breadth . Petr . Pigreus lib . de vulneribus , is most punctual ; let them be for the Shoulder , saith he , of six Inches broad , for the Thighs of five Inches , for the Legs of four Inches , for the Arm of three Inches , for the Fingers and Toes of one Inch broad ; but this your judgment will teach you to Alter according to the conformation , shape , and positure of parts .

Fasten not your Rowler by tying a knot , How to be fastned . nor yet sew it upon the wound , or where you cannot easily come at it again , lest you hurt your Patient ; quickness and neatness distinguisheth the Workman from the ignorant and unskilful ; as the subject is the more noble you work on , so strive to perform your office more excellently , intending not only your profit but decency in the dispatch , that you may please the eye both in the time of , and when you have done your work . Thus shall you gain credit to your self , and endear your Patient to submit the more readily to your Rules , which is not the least part of the cure .

The next thing that offers it self for keeping the Lips of the wound together are Sutures , Sutures 3 Sorts . and they are of three Sorts ; the Incarnative , the Restringent , and the third Conserver , Incarnative . the first is that which is in most use amongst us , and is by making so many stitches at a distance .

The Second is the Glovers stitch , Restringent or Glovers Stitch . and much in use among the Spaniards , they stitch almost all wounds by it ; in the Forehead and Face I have seen them bring the wound very close , and the third day they commonly cut the knot off , and draw the Thread out , then with dry stitches keep them so brought together , and so in two or three dayes more the wound is cured .

The Third Stitch is in great wounds to hold them forceably together ; Conserver . it is performed as in Hair-lips .

There are Four sorts of Stitches , mentioned by the Ancients , for the wounds of the Belly , whereof I shall take notice only of one , which I have made use of my self , in the stitching of those wounds ; the manner whereof is thus ,

You are to take up the Peritoneum on one side , and leave it on the other , and then take it up on the other side , and leave it on this ; This is thus made , that the Peritoneum which is a dry Body may be united with the Musculous flesh , otherwise only the fleshy parts would unite , and the Peritoneum not , through which a Hernia succeeds , whereby you put the Patient to the wearing a Truss the rest of his Life , and to other trouble . The Thread , you ought to use for this purpose , is to be a white , strong and round Thread , proportionable to the Needle , and both according to the wound .

You will remember to cleanse the wound of its clotted bloud , if you can ; but however go on with your work , that bloud will find its passage out .

In great fluxes of bloud the Glovers stitch is best , be sure in your stitching , you bring the Artery and Vein to his wounded fellow , so shall you the likelyer secure your self , and make the work more shape-like .

In the Incarnative you are to consider the wound . If the wound be but the length of a fingers breadth or a little more , 't is not worth the stitching , your Medicaments and Bandage will keep the lips of the wound together , and quickly heal .

If the wound be of two fingers breadth , The distance of Stitches . make one stitch in the middle , if three fingers breadth two stitches , if four fingers breadth three stitches , and so go on making a stitch less than the wound is in number of the fingers , ut semper numerus digitorum uno superet numerum punctorum , so as the number of the fingers breadth always exceed by one the number of the Stitches ; sometimes in declining parts we make our stitches at a little more distance .

The time of taking out these Stitches is , Time of taking out these Stitches . when parts are agglutinated , which is sooner or later according to the habit of Body or season of the year ; commonly in great Transvers wounds eight days is required , in less wounds not so deep three or four days , in the Face the next dressing , lest the Stitches make so many Scars . But in this work you must use your Judgment , for sometimes the wound seems to be agglutinated , while the Lips are held together by Suture , which after the Stitches are cut out is not so exactly Cicatrized , Caution . but that you might have done better to have left the Stitches a day longer ; Dry Stitches . but thereto the dry Stitches will help you , which is the next way of keeping these wounds together ; they are made with little bits of strong linnen Cloath , Triangular or Quadrangular , or of such figure as may serve your purpose ; these are most in use in the Face to avoid Stitching , and are of use in other parts to preserve the Stitches ; These are commonly spread with Sang . dracon . Thuris , Aloes , farinae triticae , Gum-Tragacanth , a part . aeq . mixt with the white of an Egg , Gypsum will will do as much being so mixt ; they are to be applyed at such distance as they may be most strong to perform what they are designed for , they will dry presently if you apply any thing to warm them , then draw the lips together as you do in Sutures .

CHAP. III . Of the Fourth and Fifth Intention , and of Compound Wounds , &c.

THE Fourth Intention is in the Preserving the Natural Temperament of the Part , Fourth Intention . so that thereby Agglutination may be obtained , and is divided into Universal and particular Regiment .

THE Fourth Intention is in the preserving the natural Temperament , Fourth Intention preserving natural Temperament . that thereby Agglutination may be obtained , which Agglutination indeed as I have already hinted , is the work of Nature alone , by whose only power all parts wounded , disjoyned and broken are Knit and made one again ; but in regard there is a certaim Medium which Answers in proportion to a Glew , required in this work , Nature taketh what is next hand , even the nourishment of the Part which is hurt to make it of ; Nature the agglutinator of wounds . Healing . ubi morbus Ibi Remedium is here as an Oracle , where the disease is there is the Remedy ; no sooner is the wound made but the Balsame is discovered . Bloud ( at lest the serous part of it ) is the Glew , which she useth both in curing by the First and Second Intention ; the first being performed per Symphisin , 1 per Symphysin . i.e. a re-union of the part without any Medium , by which word I here mean any Callus or flesh , or other body interposed , for in another sense the Balsam of Nature is the Medium , the Instrument of Unity , and Knits the parts together . 2 per Syssarcosin . The Second per Syssarcosin , i.e. with a Medium or Interposition of some flesh or Callous substance , that fills up the space between the Lips of the wound ; great care must therefore be taken that the Bloud offend neither neither in quantity or quality , too much bringeth on carnem luxuriantem ac supercrescentem , proud and loose flesh ; too little doth defraud the part and affordeth not a competency of matter for the work .

If the quality of the Bloud be ill , it cannot produce good flesh , qualis sanguis talis caro , as the bloud is such is the flesh : the means whereby this Intention is performed is a regiment of the Patient , Regiment , 1 Universal . and that is either Universal as to his diet , or particular as to the peculiar management of the part it self . As to the Universal we are to consider ; first , an victus plenus vulneratis an tenuis , whether a full , or slender diet ? This hath been a dispute in former Ages , but I think no man of common sense but knows , that as a full diet is hurtful for those of a full body , and in wounds where there is great Inflammation and like Symptomes ; so when a Body hath been exhausted through loss of bloud or the like , Consideration from their manner of living . it is reason that a greater liberty should be allowed , as Broaths , Cullices , Cordials , &c. Withal I conceive there should be consideration had of their manner of Living ; some people have so accustomed themselves to drinking of strong drink , that without such a proportion they cannot live , I could instance it by many stories if it were necessary ; but one for all , and from abroad , E. B. cured by allowing Wine . Ed. Br. an old servant to a Person of Honour , was bit by a Monkey in the back of his hand : to prevent Inflammation I forbid him Wine ; he next morning complained he had not slept that night , that he was faint and sick , and that his wound was the least of his ailment ; that day he continued faint and ill , and the next morning complained again of his want of rest , and that afternoon he swooned , and complained he could not live without Wine , he had good Broaths , Caudles and such like , and I believe he did drink some Wine ( but he was allowed by his Master a Bottle of a quart every morning for his draught , and was seldom sober ) his wound was Crude , and Inflamed ; I complied with his desire ; he drank again as he pleased , his sickness went off , his wound digested and he cured . This I have seen often in some of our Dunkirkers at Sea , who drank extraordinarily , and were full of drink in our Sea-fights , I could scarce ever cure them without allowing them Wine , and thereby their Spirits were kept up , and I had the liberty to bleed them as I thought fit .

It hath been a common saying , a hair of the same Dog , and that Brandy-wine is the common relief to such ; what then must become of such a one after a hard drinking for many months together , if he chance in heat of drink to be wounded , and from that time his Chirurgion condemn him to Ptisan for a week together , nay two daies ? will he not Faint and languish , his wounds become Indigested and Inflamed ? you may laugh at my pleading for them , but I hope you will consider I am a water-drinker the while .

In other things such diet is to be observed as their strength will permit , we do not use to purge in wounds with Cathartics lest by stirring matter it flow to the weak part , but allow Lenitives , as Cassia , Tamarinds , Manna , Sena , Rhubarb . with Sal . Prunel . also Electuaries as Lenitiv . diaprun . syr . Ros . sol . de cichor . cum Rhubarbaro , also Broaths wherein hath been boyled Lettuce , Succory , Endive , Sorrel , Purslane , Borage , Bugloss , &c. and bleed according to the strength of Body , and as Symptomes Indicate in a direct line of the same side .

Another part of the Regiment of wounded persons will consist in giving of Vulnerary drinks , Of Vulnerary drinks powders and Electuaries . of which we find many mentioned by Authors , and the Materia Medica very large , witness that great tribe of Vulneraries in Perkinson's Herbal .

The most common Simples with us in England are , Comfrey , Bugle , Ladies Mantle , Agrimony , Sanicle , Pauls betony , Fluellin , Periwinkle , Mugwort , Plantain , Horse-tail , Adders-tongue , Avens , Cinkefoil , Wild Tansie , Vervain , Ground-Ivy , Golden-rod , Herb trinity , Centaury , St. Johnswort , Snakeweed , Knot-grass , Mouseare , Yarrow , Scordium , Strawberry leaves and roots , Tormentill , Bistort , Valerian , Red roses , &c.

Some of these are made choice of to be boiled in water with white Wine and Honey , of which sort you have a sufficient example in the decoctum Traumaticum of the Dispensatory .

Their principal use is in wounds of the Thorax and Abdomen , though they be of frequent use in all great wounds . Sometimes also if the disease run out to a length we add Guajacum , Sarsa , and Scorbutical Medicines .

There are likewise Powders made of Crabbs-eyes , Coral , Nutmegg , &c. and Electuaries of the roots and hearbs beaten up with those Powders .

The particular Regiment is in preserving the natural heat and tone of parts , Second Particular . without which we can hope for no union . For the better understanding hereof I must put you in mind that there is not any part of our Body admits of a solution of continuity without pain ; every scratch in the skin and little cut in the finger is painful , much more wounds in the flesh ; This pain stirs up a heat which ferments in the Serous part of the Bloud , which readily makes way to the wound , and if not timely prevented distends and raises the part into a Tumor and Inflames . If this happens in a full Body , or one of an ill habit , where the bloud is Serous and more apt to ferment , the mischief is greater ; and if the wound be in a declining part , as the legs , the Influx of humours are more abounding , and the member through its weakness not able to assimilate , nor yet expell ; whence crudities heap upon the lower parts and makes an oedematous Tumour there .

To make this more plain , A Person prickt with a Thorn in his leg . I shall give you one Instance of the many that happen daily ; A young Gentleman of about 18 years of age , of a good habit of Body , one day sporting in the Country with his Gun and dogs , was prickt with a Thorn on the outside of the Calf of his leg , he takes little notice of it , returning in the evening to his home , he drest his leg with a little Balsam , the next morning it was more painful , Inflames and Terminates in a Phlegmon ; I am sent for after a few days , and find the Tumour large with great Inflammation , and suppurated ; In the lower part , about the foot an oedematous Tumour : I opened the Tumour , and discharged a quantity of Matter , and cured the Patient as is usual in Phlegmons . If this Person had been treated according to the universal Regiment by bleeding and Lenient purgatives , &c Nay if only after this particular Regiment in the preserving the Temperament of the part , which ought in this case to have been by refrigerants and astringents to have prevented the Influx of humours , and applied some maturative to the festered Scratch or prick , Medicaments proper in the beginning of a Phlegmon . as ung . Basilic . upon a Pledgit of Lint to give a Breathing to the part ; this with any of our restrictive Emplasters a compress dipt in Oxycrate with convenient Bandage over all , had preserved the tone of the part , and cured the Patient without further trouble .

To proceed rationally , by this Intention in wounds , you are to apply to the Lips of the wound such Medicaments as have an Agglutinative facultie , as Bolus Armen . Sang . Dracon . Thus , Aloes , Gum . Elemi . Colophon . Terebinth . And outwardly , to prevent influx of humours , such as are Cooling , Drying and Corroborative , as fol. plantag . Equiseti● Millefolii●● . vincae per vincae , ulmi● . flor . Ros . rub . Balaust . nucum cupressi . Gallar . Baccar . Myrtillor . far Hordei . fabar . vinum rubr . posca . Aqua font . & oleum . These are the Simple Medicaments , which are to be proportioned to the habit of Body and wound , as it is greater or less , Parva & superficiaria vulnera natura sua sponte nullius Medicamenti indiga sanare solet : Labia solum à nobis contrahantur & Ligamento circumdentur , ne pilus aut arena aut tale quid illabatur , & ulcus penitus coalescet , Aetius de curatione vulnerum . In small and superficial wounds , as those which are made according to the length of the member , there Nature of her own accord is wont to effect the cure , without the help of any Medicament ; from us only is required that the Lips of the wound be brought close together by bandage , that neither hair , nor dust , nor any other thing fall between them . But in greater wounds that will not so easily be cured by Suture , we keep the Lips together , sprinkling them with this , or some such like Powder , ℞ Bol . Armen . Thuris . Sang . Dracon . part . aquales , and spreading a cloath with some of the same Powder , apply it with a Compress dipt in Oxycrate , and a sutable Bandage over all ; This is generally the way . But lest by the adhaesion of this Emplastick Medicament , The Authors way . the Lips of the wound should be torn and disturb'd in taking it off ; I chuse rather to apply over the sprinkled Powder , a pledgit of Lint spread with Liniment . Arcei , or this following Unguent . ℞ Terebinth . Venet . ℥ iij . Gum . Elemi . ℥ ij . Sang . Dracon . Thuris . Mastich . an . ʒ j . M. f . Unguent . s . a. or this , ℞ Terebinth . ʒ ij . Resin . Pin . Oliban . Colophon . an . ℥ jss . Mastich . ℥ j . Croci ʒ j . Cerae . ℥ ij . Olei . Hyperic . q . s . ut ft. Unguent . Unguentum Aureum in the London Dispensatory is also good in this case ; as likewise are the compound Emplasters , Diapalma , Diachalcit . de Lithargyr . de Bolo . de Betonicâ ; or you may use this following ℞ Terebinth . lb ij . Resin . Pini ℥ iiij . Gum . Elemi ℥ iij . Aristoloch . Long . ℥ j . Sang . Dracon . ℥ iss . pulver . omn . subtilissimè , & f . Empla . s.a. igne lentissimo .

In all Wounds where I propose to Cure by Agglutination , and would preserve my Stitches , I forbear the use of Fomentations and slabby Medicaments : nor will you have occasion for such applications , if you proceed rationally as you ought to do ; I always accounting these simple Wounds cured , when the Lips are well brought together , and dressed as above-said . Indeed in large and deep Wounds , where the Muscles and Tendons are cut through , there the Wound may require to have a space left open in a declining corner for discharge of Matter , lest it be healed outwardly , and some Matter shut in , whereby it becomes an hollow Ulcer . In this case you may use Fomentations and Embrocations . This is to be left to the judgment of the Chirurgeon , who is not to doubt but that Nature will do much towards the Agglutination of the wound ; if influx of humors be kept off by his Art. But if the wound be so great and deep that you cannot bring the Lips close together , then in a declining part you may put in a Tent with a Digestive è Terebinth . & vitel . ovi , Turpentine being one of the most proper Medicaments in all Wounds , especially those of the Nervous parts ; for it preserves Bruises from corrupting and putrifying , strengthens the part , eases pain ; and this it doth by its Digestive Faculty , and is thus commonly used . If you apprehend its acrimony , you may take that off by washing it in Plantain , or other water : where we fear Inflammation we add farin . hordei . Or you may use this Balsam of the Spanish Priests , known by the name of Oleum Aparici , Ol. Aparici . which is thus made , ℞ Ol. olivar . unc . iij . Terebinth . venet . unc . viij . frumenti Integri , unc . j . sem . Hyperici , unc . ij . rad . Cardui Benedict , rad . Valerianae , an . unc . j . Thuris pulveriz . unc . ij . the Seeds and Roots are to be shread and beaten , put them into a pot , cover them over with White-wine , let them stand two days infusing , then add to them the Oyle and Wheat bruised , boil them to the consumption of the Wine , then strain it out hard , and add to it the Terebinth and Thus , then give it a walm or two , and keep it for your use as a very good Balsam , often used by me . This is to be dropt warm into large Wounds , and prest out again , and the wound brought as close together as you can , with a Compress dipt in Red-wine , wherein hath been infused flor . ros . rubr . Balaust , and such like , over this Compress make your Bandage ; these Wounds are to be drest but every third day .

Galen , speaking of Ulcers , says , In Ulcers , although Matter flowed much , he Drest them but every third day , and in Winter every fourth day , yet there may be occasion of opening sooner , for the straightning the Bandage , or putting on dry Stitches , or cutting out the true Stitches , lest upon any accident the Suture should relax and the Wound open again .

Thus far I have proceeded in Simple wounds , Compound Wounds . to the Agglutination of parts , we shall now consider , of Wounds , wherein there is loss of substance by Abcision , or through a redoubling of the blow cutting twice or thrice in one place , or where through the distance , or hardness of the Lips of the Wound , it could not be kept together , but that a Cavity hath remained in the bottom ; and herein we are to regard the habit of body , that there happen no defluxion or inflammation upon the part . This is done by universal Regiment and Digestion , with Mundification , that a new flesh may be made to fill the Cavity , to which purpose this or such like may be used , ℞ Terebinth . unc . iij . farinae Hordei drach . sex . Thuris Drach . j . s . Vitell . ovi j . to these you may add after a day or two , Mel . ros . aut Mel . com . q . s . and if yet there be required more detersion , or flesh grow lax , you may use Mer . praecipitat . at your pleasure : In these cases I have long pieces of Vitriolum , Vitriol and Allom-stones . Roman . & alumen . fitted to Quills , whereby I dry this supercrescency with less disturbance to the Patient . To this purpose you may use this Mundificativum Apii , ℞ Fol. Plantag . & Apii an . M. j . Ros . rubr . P. ij . Vini rubr . unc . viij . decoquant . ad medias in Colat . dissolv . sach . rubr . unc . ij . Terebinth . unc . j . Farin . Lupinor . & orobi an . drach . j . Aloes , Myrrhae an . drach . s . decoq . rursus & addendo Cerae q.s. reducant . ad formam ung . This is Quercetan's . In the use of detergents you must consider the habit of Body , and accordingly add or diminish , making them of a good consistence , and having so disposed the Wound to Incarnation , if what be prescribed do not Incarn , add Pul . Ireos , Colophonia , Mastich , Sang . dracon . Sarcocoll , to make a Sarcotick Ung. and afterwards cicatrize with Ung. Tutiae Vigon . or desiccativum , &c. or with Pledgits dipt in an Aq. Calcis , or Aq. Alumin . simpl . factâ solutione in Aq. Rubi , and dried again . Contus'd Wound . If a Contusion be joyned with a Wound , then you are in the first place to endeavour , that the Contused flesh in the Wound may be suppurated and turn'd into Matter , and that cum vitello ovi & Terebinth . & ol . Ros . or Ung . Basilici malaxt in ol . lilior . warm the parts about to be Embrocated with lenients Ol. Lilior . Chameli , Lumbricor . and that the more circumjacent parts about be Embrocated with Albumine Ovor . Ol. Ros . Ol. Myrtil . and a little Acet . and some of our restrictive Powders , as Bol . Armen . Sang . Dracon . Flor . Ros . Rub . Balaust , mixt with the above-said to the consistence of a Mel . or Emplast . è Bolo applied over all , to prevent the Influx of serous Bloud into the pained part , and a Compress dipt in Posca , with good Bandage to be made over all , to press out the humors already fallen into the part affected , as also to prevent the access of more , which would be apt to flow thither by reason of the pain ; to which purpose you are to let the Patient Bloud , and proceed as is said in preserving the temperament of the part : If that pain increase , you are to have recourse to Anodynes , as is proposed in the Fifth Intention ; but if there be little pain , and the flux of humors restrained in some measure ; then you are to apply Discutients to the parts about : The Wound digested , proceed as abovesaid with Detergents , Sarcotics , and Epulotics .

These great Tranverse Wounds are not so often seen here in times of Peace , Transverse Wounds . but in the Wars are frequent , especially when the Horse-men fall in among the Infantry ; the Enemy cruelly hacking them , the poor Souldier the while sheltring his head with his Arms , sometimes the one , then the other , until they be both most cruelly mangled , and yet the head fareth little the better for their defence ; many of them not scaping with less than two or three Wounds , through the Skull to the Membrains , and often into the Brain , and if he fly and the Enemy pursue , his hinder parts meet with great Transverse wounds , over the Thighs , Back , Shoulders and Neck . Mr. Sanderson , now one of the Chirurgeons of St. Bartholomews Hospital , was once a fellow-labourer with me in the Dressing such : At Sterling Mr. Chace the Kings Apothecary assisted me in the Dressing many such , and one with such a Gash thwart the nape of the Neck , as it was our wonder that he lived : All these wounds inflicted behind were full of Maggots , they having been some days Undrest : These Wounds I stuped with a decoct . Absinth . Centaur . Scord . Lupinor . Myrrhae , Aloes , and softned the stubborn lips with fomentations of Rad . Althae . Consolid . Maj. Sumit . Malvar . Violar . Hyosciam . boil'd in Broath , or with decoct Hordei , or with Milk , or warm-water , we refresht and disposed them to yield to Suture , or Bandage ; we digested them with Terebinth . & Vitell . ovi , with Dossils , Pledgits , or small Tents dipt in a warm Ol. Hyperici , keeping some declining part open . 'T is proper to pour Oyle or Balsam into these Wounds , but then it must run down , or be prest out of them again : the parts about we likewise Embrocated and applied over all Empl. de Lithargyro , with Compress and Bandage : digestion once made , we then deterg'd with Mund . Paracels . and cicatrized , as hath been said elsewhere . Thus I cured all these wounded people , or so disposed them , as with leave they retired to their own home to be cured with more convenience .

Si vero vulnus profundius fuerit , & in superficie , Angustius , scalpello incidatur ut aequalis amplitudo fiat ; Aetius , lest Matter corrupt and putrifie in the bottom , or if it happen that a wound is made so deep , and amongst the Vessels , or that the Unition is hindred by extravasated bloud , lying in the bottom of the wound corrupting and disturbing the Unition of the part ; and that the Matter cannot well discharge this way , you are then to consider , whether you may not pass the Matter by a Perforation In fundo , which if you may ( as I have often done ) then do it either by Knife , or a Caustick , or both : First a Caustick , then a Knife , or by a Seton-needle with a twisted Silk or Thread , or upon keeping this open a few days by a Tent or hollow Canula , you shall easily heal the upper part by leaving out that Tent only ; it healing up , as it were , of it self , or by the help of Bandage , to compress the parts ; and after a few days more , this lower opening will cure by common Applications , your very Roulers with a Compress dipt in Red-wine , or the like will effect it .

Sometimes wounds are made deep , A Wound double in the bottom with Attrition . as in the side glancing to the Spine , and run between the Musculous flesh five or six Inches ; and in some of these , before the Rapier is half out of the Wound , a second thrust is made , by which there is a double Wound , and an attrition of the lower part wounded : the Chirurgeon is to consider well the wound and part wounded , and if this be so made , and is not likely to be cured , by the first Intention , ( as it is not if it be by Attrition in fundo ) or that a tendinous body be wounded , then consider whether it may not presently have a way made out below ; if it may , and that part kept open by digestion with a small Tent , then the upper part will Unite by Agglutination ; but if it may not be opened , then he is to digest this upper Orifice , and keep it open ; and if it be not large enough , he ought presently by Cutting , to inlarge it , while the wound is warm , and dress with your digestive warm , and let him Embrocate the part , the whole length as it is affected , with Ol. Ros . cum Aceto , and apply a good restrictive Emplaster over all , to hinder influx of humors ; to dispose parts to quiet , then bleed , and what else is necessary for conserving the the tone of the part . If after all these endeavours the wound do digest , yet will not Cure , however he ought not presently to open his wound a-thwart the Muscles , nor yet according to the Fibres of them , to such a length , not though it may be done without laming the Patient ; but shall in such a wound , at the first while it is recent , make search with a Probe to the bottom of it , and with his finger without , feel what thickness the skin is from it , and keep this place as a mark in time of need , for to make the Apertion in ; and if he do after digestion apply his Caustick there , the Matter will thereby discharge , and the Patient be happily cured ; whereas the cutting open such a Wound the whole length hazards his Patients life , and makes a long work for himself .

THE Fifth Intention is in preventing of Evil Accidents , and correcting such as are already fallen upon the part ; and these are , Hemorrhagia , Pain , Fever , Intemperies , Convulsions , Syncope , Delirium and Palsie .

We shall begin with Hemorrhagia , Of Hemorrhage , or Bleeding . as being incident to all Wounds more or less , and sometimes the cause of all the other Accidents : wherefore I have treated purposely of the Wounds of Veins and Arteries in a Chapter by it self , so propose here only to speak of it as the stopping of it is made by some Authors the second Intention . The way to stop the flux of Bloud , as it is common in wounds , is by retaining the Lips of the wound together by Suture or Bandage , and by applying such Medicaments to them as have a drying and Agglutinative faculty ; as Galen's Powder , Aloes p. j . Thuris p. ij . with Hares Furre cut , some of these mixt with a white of an Egg , and applied upon a Pledgit on the Lips of the wound , and over that some little Bole and Sang . Draconis , with a little Resina added to the former mixture , and spread upon a double cloath , and laid over the wound and parts about with Compress and Bandage , and the member placed in such a position as is for the ease of the Patient . This is our first and common way of Dressing wounds , to stop the bleeding and prevent Inflammation , and is not taken off until the third day , by which time the bleeding is stopt , and the wound near Agglutinated ; but if the wound be great and deep , so as you cannot bring the Lips of the wound together , then apply those Powders of Galen's upon Dossils upon the bleeding Vessels , and your astringent next , and a Compress wet in Oxicrate , with good Bandage over all , and by the next dressing you may hope that bleeding is stopt by incarnation , if by your Probing you cause not a new flux of Bloud .

You ought to be speedy in the mitigating pain , Of Pain . for that nothing dispiriteth your Patient more , nor makes more disturbance in Wounds , the humors flowing abundantly to the pained part offending in quality or quantity , according as the habit of Body is affected , whence vehement pain ensues , with great Inflammation and Tumor , wherefore you must hasten to succour it ; and in the first place Phlebotomia is proposed as the best Anodyne , for that it takes away the cause of pain . Unguent . Nututum , Refrigerans Galeni , Ung . Alb. Camphurat . populeon . Cataplasmes of Far . Hordei , Fabar . Flor . Ros . Rubr . Sambuci pul . decocted in Red-wine ; Oxycrate or Oxymel , or Fol. Hyosciami m . ij . boil'd in milk and with white-bread crums , a new-laid-Egg , and a little Saffron , and Ol. Ros . applied as a Cataplasme ; Fomentations of the Roots of Althaea Fol. Malvar . Viol . Flor . Chamel . Meliloti boil'd in Broath of a Sheeps-head and feet . If after this it tend to suppuration , then you may proceed that way as in a Phlegmon , but if it yield to none of these , then you may truly conjecture some Nerve is offended , and proceed as is said in the Wounds of the Nerves . But if pain be caused by Matter that wants a passage out , give it one by Knife or Caustick .

If some hot distemper from Choler offend the part , which may be perceived by the pain and vesication , then those Unguents Nutritum , Alb. Camphorat . Refrigerans Galeni , Populeon . are proper , or this following , ℞ Succi Plantag . Solani , Sempervivi an . ℥ j . Boli Armen . ℥ ss . Litharg . loti aq . Plantag . & Tutiae praeparatae an . ℥ j . Ol. Ros . Omphac . & Nymph . an . ℥ ij . Aceti Rosacei & Cerae Tantillum . Ft. Unguentum .

If the distemper be oedematous , as will appear by the laxness ; then Fomentations wherein Flor . Cham . Aneth . Meliloti Sem . Faenug . &c. such like boil'd in Wine with good Bandage will serve your purpose .

Fever accompanies great Wounds , Of Fever . especially where there is Inflammation , it is almost inseparable : therefore you are the less to trouble your self thereat : but if in small Wounds it happen or continues after the pain and Inflammation is removed , and hath Delirium or Syncope with it , then there is great cause to doubt the welfare of your Patient : You are to order in all these distempers a slender and cooling diet , and humecting , and with lenients gently to loosen the Body , and by bleeding and repeating as you see cause , Apozems , Juleps , Emulsions , Epithemes , which by refrigerating and contemperating the heat , are here proper .

For Gangrena , Convulsions and Palsies ; I refer you to their proper places , as more accompanying Gunshot than these Wounds .

CHAP. IV . Wounds of Veins and Arteries .

THE next thing that offers it self to our consideration , is the Wounds of particular parts , and first of the Veins and Arteries , which are subject to great effusion of bloud , whereon the life of your Patient depends . Est enim sanguis Thesaurus vitae : and therefore requires your speedy help . Signes of the Artery wounded . You may distinguish whether the bloud be from an Artery or a Vein , by the flowing of it , and by its colour . From the Artery the bloud rushes impetuously & per saltum , by reason of the dilatation and constriction of the heart , and is of a florid colour . Of the Vein wounded . The Venal bloud flows with a more smooth and even stream , of a gross consistence , and of a darkish colour . Of these Wounds there is no great danger , Prognostick of Vein and cure . Galen's Powder with the white of Egg , with the Suture and the formerly proposed way of dressing and Bandage , will certainly stay the bleeding of Wounds in the greater Veins , and cure the Wound at the same time , or in few days : Prognostick of Artery . But those of the Arteries are most difficultly stopt , for that the bloud is in a most vigorous and strong motion .

If these wounds be not with loss of substance , And cure . and lips bruised , Suture . you are then by Suture to bring the Lips & Artery both together , passing your Needle , with a good strong thred seared through both Artery and Lips , making Guido's suture , which he calls suppressoria or Glovers-stitch . And having thus secured the Vessels for the present , you are then to apply such as this over all . Applicatives . ℞ Boli Armen . ℥ iij . Sang . Drac . Thuris , Aloes , Glutinis sic . an . ℥ j . Gypsi , Farin . Volatilis an . ℥ ss . Hipocystidis , Acatiae Sumach . an . ʒ iij . with the white of Eggs make it to the consistence of Honey , apply this upon a double cloath over the wound and parts about , with a compress squeazed out of Oxicrate or Acetum , and roul up the Member , with the Agglutinative Rouler , beginning on the opposite part , Roulers . bringing both the heads over the wound , and having taken a turn or two there , roul upwards and downwards , so as to press the bloud from below upward , and to hinder the Influx from above . Your Bandage must so be made , as may be to the ease of the Patient , and the position such as may prevent as much as may be all pain , keeping him cool and quiet , Ordering the part and diet . and to a slender diet , and his drink cooling and Incrassating , as Fountain water , with Sal Prunella , or Acetum , or with Gads of Steel quencht in it , sweetned with Syr . of Coral , or Pomegranates , or some of these of Quercitan's , ℞ . Croci Martis , Essentiae Corallor . an . ℈ j . Syr . de Ros . Sic . & Mirtill . an . ℥ j . aq . Papaver . Rhead . ℥ iiij . m . or a Decoct , Hordei cum Sem . Papaver . Alb. & Hiosciami , with Rose-water and a little Sugar , as a draught at night , or at present in any great extremity in bleeding ; also a grain or two of Laudanum , if the Patient bears it well , in these case is commendable . Bleeding , where , You are to let bloud from the contrary part as the strength of the Patient will permit ; only a little at a time for revulsion , as also Cupping , Friction , Binding the remote parts , & the like for derivation .

In such great effusions dress not the Patient again in five or six days ; Qu . if the Stitches break . then if all be well , dress him again after the same manner ; but if you find the bloud hath made its passage through all , and the Stitches broken , then if you can come to the Arterie , you shall do well to take hold of it by a little hook , Deligation and Abcision . and separate the Vessel from its teguments , and with a twisted thread make a deligation upon the upper and lower-most part of the Artery , and divide it in the middle , so the ends will contract ; and as the Artery Incarns , the Ligature will cast off : Then proceed by digestion and Sarcoticks , and cicatrize the wound . But if the Artery lies so deep that you cannot possibly come to make deligation upon it , Escaroticks , &c. proceed by Escaroticks applied to the Vessel , or by an actual Cautery . If by Escaroticks , then you are to cleanse the wound of the clotted bloud , and dip it in some such like Powder , ℞ Thur . Pul . ℥ ij . Aloes , Glutinis Sic . an . ℥ j . Chalcant . Ust . ℥ ijss . Arsenici ʒ vj . Gypsi ℥ ijss . apply this upon the Artery thick , and fill up the rest of the wound with Galen's Powder , with Hares Furre cut into it , and over all your digestive è Terebinth . & ovo integro , and dress up the wound as before ; and at your next dressing , leave the Escarotick sticking , and Incarn as fast as you can , or instead of them , Vitriol powdred and tied in a fine rag , and thrust to the bottom of the wound , and dressings applied over as before .

But if after these former dressings that Artery bleed , Cautery . and you cannot come to divide the Artery , then you must use the actual Cautery . By it the Vessel shrinks up at both ends , the flux is immediately stopt , and the part marvellously strengthned . You are to convey it down by a Canula , and that it may not heat , cover it over with an Emplaster , and wet the outside with the white of an Egg , or mucilage of Quince-seeds . But before you use your Cautery , you should remove the grumeous bloud , or whatsoever else lies in your way , lest it cool your Cautery , and frustrate your endeavours , and pain your Patient to no purpose : Cautim . Once or twice pressing with your actual Cautery to divide and contract the Artery will be sufficient . Oftner may burn it to a coal , which may cause the falling off of the Eschar before it is Incarned , and a new flux of bloud follow ; that done , dress the part with a little of the mucilage of Quince , mixt with the white of an Egg , and Embrocate them about with Ol. Rosar . and apply your Emplaster Diacalcith . malaxt with some of the same Oile over all ; and after you have allay'd the heat of the part , then digest the Wound , and with Sarcoticks Incarn , and by Epuloticks cicatrize the Wound .

A person of a good habit of body , about 35. years of Age , wounded in a Duel on the right side the Aspera Arteria ; Observ . 1. Wound of the internal Jugalar . being run through his neck below the last Vertebra of that side behind : The Wound was small , yet he bled with a full stream , but it stopt by holding a finger upon it while I made dressings ready , which was with a few of our common astringent Powders , with the white of an Egg , and a little Acet . upon a thick Pledgit of Lint , with an Emplaster after of the same , with Compress and such Bandage as it would bear : The Wound behind bled , when that before was drest . I applied the said Medicaments to that , and we held them on with our hands , until they were dried on , then we put him to bed in the same house , and kept him cool and quiet . I used all my endeavours for the contemperating his bloud , as is usual in such cases , and drest him but once in four or five days , unless I were necessitated by the bursting out of the bloud from his wound ; he bled at times about 16. or 17. days ; his wound by the Vertebrae of the neck was cured in few days : and this near the Aspera Arteria was cured by this way of Agglutination the nineteenth or twentieth day .

A man wounded in the Artery under the right Eye , Observ . 2. An Artery wounded . was at that instant drest by Mr. Fawcet Chirurgeon , the next day in the afternoon it burst out impetuously ; I was sent for , and found it bleeding with a strong impulse , the wound very small , not so big as a silver penny , made by a blow with the corner of a Trencher ; I drest the Wound with Pulv . Galeni , and applied an Emplaster over it made up with my common restrictive Powders , cum Albumin . Ovor . and a little Acetum , with good Compress and Bandage bound it up : The next day his Wound bled again , and upon stopping of that little wound with my finger , the bloud was seen to beat all along the Artery under the Eye to the Temporal Muscle , with a greater force than is commonly seen in an Aneurisma ; I then with a crooked Needle peirc'd through both the Lips and Artery , and by Deligation restrained the bleeding , and with Emplastricks drest it up as before , concluding I should have very little more trouble from this wound ; but within two or three days after , it burst out bleeding again ; then I being absent , some other Chirurgeon was call'd in , and after at another bleeding Mr. Fawcet drest him , and at another time Mr. Aris drest him , the wound was now grown large , with the crowding of Dossils , and being in a very inconvenient place for bandage , it bled often , and was drest by such Chirurgions as they could meet with in their necessity ; Escaroticks being thus frequently applyed to stop the flux of bloud , his Eye was very much inflamed , so as it was verily believed by us , that if he did recover of his wound , yet his Eye would be lost , his continual bleeding thus for many dayes had so exhausted his Spirits , that there was small hopes of his surviving .

At the last bursting out of this Vessel , Mr. E. Molins deceased , Mr. Fawcet and my self met together at his Chamber , we found him lying as dead , with his hand out of his bed upon his breast , we felt for his pulse but it did not beat , we concluded him dead , and took the dressings hastily off the wound , it did not bleed though it was open , we supposed the bloud exhausted , the Artery lay in the wound torn by the Escaroticks , we took up the Ends and tyed them , and drest the wound with Liniment Arcei and an Empl. over it , not believing that the man would ever recover , but from this time , the bleeding of the wound ceased , and the wound by very common remedies daily Incarned to my admiration , and he was in less than a month perfectly cured , both of his wound and eye . This Patient was subject to the like bleeding upon every Scratch .

A Butcher was wounded in the Artery between the Thumb and Fore-finger , with a large wound , Observ . 3. Artery wounded . after he had been drest three or four days by some body , the wound continuing still to bleed , he came to me late one night from Westminster bleeding , with dossils crouded in the wound , I threw them out , and with a needle and a thread stitch't up the wound and the Artery with it , sprinkling my agglutinative Powders upon the Suture with my Empl. and Bandage , as in the former wounds is said ; in three or four dressings I cured him , but after there remained some pulsation extraordinary under the Cicatrix , which proceeded from the too lax Incarnation of the wound , wherefore with a pledgit dipt in a dulcified Tincture of Vitriol prest out , and Applied with a good Compress , and rouled over the affected part , it was dried and shriveled so as from that Application there was seen no more pulsation in the skin from the Artery .

One in the New Exchange had an Aneurisma in the palm of his hand , Observ . 4. Aneurisma broken open . lying a-long to the third and and fourth fingers , which at last broke out , and bled at times the space of eight or ten daies , and being at a loss he sent for me , with this Tincture of Vitriol as above-said , I cured him not only by stopping the bloud , but by making a firm Cicatrix , I drest these Eruptions , but seldom once in four or five days .

A Sedentary young Gentleman of an ill habit of Body , Observ . 5. Wound of the Surall Artery . wounded by a puncture in the Inside of the calf of his leg into the Surall Artery , bled much , a Chirurgion is call'd for ; he fills up the wound with his Dossils dipt in albumine ovi , and astringent pouders , wherein was Escarotics calchantum ustum , &c. Applying over this his Emplaster and Bandage , by which he stopt the flux of bloud , and left the Patient to rest : The next day I am cal'd in to dress the Patient . Upon a relation of the wound and this manner of dressing , I propose not to open the wound in four or five daies , unless some Accident happen I visit him daily , he keeps his bed , complains of a disturbance in the wound , as burning , throbbing , and pain at times , not constantly , and is very apprehensive of its bleeding ; looks himself often upon the Bandage , and Alarums me by messages as often . The third morning his Chirurgion and my self meet , we find the Bandage all bloudy ; we propose to dress , The Apparatus being made we take off the dressings , and find the bloud fresh in the Roulers , but upon taking off the Emplaster see the Dossils come out , and with such a foul bloudy sanies , as is usual in such wounds after the filling them with such Powders . I consider with my Brother Chirurgion , whether the putting in a Tent with Escarotics may not stir up flux of Humours , and be attended with Inflammation , &c. and whether that way we may be sure of meeting with the Artery ; and if we do whether our Medicaments will restrain its bleeding ; and if not , then whether by pressing upon that Artery we may not raise a flux of bloud anew ? To avoid all such I resolve to dress the wound with our common digestive , with Tereb . vitell & ovi with pulvere Galeni , and so we apply it upon a thick pledgit of Lint , and Embrocate the parts about with ol . Ros . & Aceto , & Empl. è Bolo over all with good Compress and Bandage ; by this I suppos'd the parts would be at ease , the wound at liberty to discharge the sloughs and sanies which was made and choaked in by the last dressings ; and the Unition of parts within furthered , and the bloud in the Artery restrained . If it did not thus answer expectation , yet I concluded we had done what became good Chirurgions , and that at the next dressing it would be in our power more easily to lay open the wound , and divide the Artery without hurting the nervous or tendinous bodies near it . For a wound so drest up would either unite or dilate its lips , there being a pledgit proportionable to receive a small quantity of matter , such as might be expected from such a wound , well-condition'd , but a greater quantity , or a new flux of bloud that could not get out so , must necessarily distend the lips , we resolving not to dress the wound again in less than 3 or 4 daies : Thus we left the Patient easie ; but the next day I found him unsatisfied how this wound could cure so dress without a Tent , and oft murmuring that it would rancle ; yet he continued pretty easie , and did not bleed all these three dayes . The Fourth day at the opening , we found no bloud but what was mixt with matter , and the wound lookt well ; but by his importunity I complyed with him , and put in a short Tent spread with digestive and dipt in praecipitate , and drest him up again ; and the third day open'd , and upon the dressings there was a fresh bloud again , which was followed by a thick white Matter , as from a Phlegmon , more than might reasonably be expected from a small puncture , not above half an Inch deep ; wherefore fearing a cavous Ulcer , I resolved to dress without a Tent , and by good compress and bandage to press out thit Matter from within , and defend the part from Influx of Humours from above : to which purpose I drest with pledgits as before with my digestive , &c. and open'd the wound once in three dayes , and altered not this method , though I chang'd the ung . upon the pledgit as I thought fit : Thus I kept the part without tumor or Inflammation , and the matter lessened each dressing , but was not well digested nor free from bloud , but his feet swell'd , and himself ill-disposed ; Scorbutic and such like affections , with loss of Appetite , fainting , &c. To relieve him in these Dr. W. was consulted , and after a while I caused a straight stocking to be laced on both legs , and got him out of Bed at least for some little while every day , and when he was able he retired into the Country , but hath not yet got off of the disease he heightned , by keeping within doors with this little wound . Doubtless this cure had been shorter , if immediately in the first dressing he had been bound up with an Agglutinative bandage , and the whole committed to nature .

A Cooper living near Maidenhead in the County of Bucks , Observ . 6. Artery wounded in a Coopers arm at Windsor . accidentally in letting bloud was prickt in an Artery , the Arm swells and is pained , he puts himself into another Barber Chirurgions hands dwelling in Windsor , who by unfit applications , Relaxes the part , then supposing the soft Tumor he had made was a Suppuration of Matter , ( though indeed it was the Arterial bloud ) he with his Incision knife or Lancet cutts into it , at which an impetuous flux of blond rushes out , to the quantity of four flaggons , he fills up the opening with Lint , and makes a hard bandage round it , which somewhat restrains the flux of bloud , but the Arm swells , and threatens a Gangreen : While this poor man lay thus afflicted , We his Majesties and Royal Highness Chirurgeons attending the Court , did visit him , and proposed to make an apparatus for the taking up this Artery , or in case of failing to take off his Arm by Amputation ; We met the next morning , the Patient is taken out of bed and placed in a Chair towards the Light , one of his friends held him in the Chair : Mr. Whittle stood behind his Arm , and held his Elbow with his left hand ; and with the other hand was ready to help me in the operation ; Mr. L. holds the lame hand : In the first place I viewed the Arm , where finding no Gangreen according to the report of the Chirurgeon , but rather ( as I thought ) an Aneurisma , I made a bandage above the wound , to hinder the Influx of bloud into it : Upon this bandage Mr. Pearce made the gripe ; I then untied the Ligature from about the wound , and found that also free from Mortification ; I put my finger into it , and finding the skin made thin by distention from the bloud , I call'd for a Knife , which while I was searching in the wound , Mr. Whittle took into his hand : I prayed him to cut through the length of the hallowness . It being done , I with my finger thrust out the Grumous bloud and an Abscess from the lower part of the Arm. When I had cleared the parts more distant , which would have fallen in and blinded my Work , I then made way to the Artery , removing from about it the clotted bloud ; upon which it immediately burst out , I prayed Mr. Whittle to hold his finger upon it , he did so ; then I separated it from the parts about it , and passed a crooked Needle under it ; and being ready to tye it , I desired Mr. Whittle to hold off his finger , that I might be the more sure it was the Artery , upon the doing of which it spurted out : I tyed it ; but in tying the Thread broke : This caused a murmuring in some of the by-standers , as that the Patient would die under our hands while I was endeavouring deligation , which by a new wounding of the parts would hasten Mortification and Death ; I desired they would continue their places , and Mr. Whittle his finger upon the Artery , that it bled not ; he did so ; in the while I made a strong Ligature of some twisted Threads , seared it , and put it into the eye of one of our common silver searching Probes . Gentlemen , said I , you shall see me pass this probe under the Artery , and thereby you may be assured I shall wound no parts ; I immediately did so and tyed the Artery , Mr. Whittle took off his finger , it bled not ; then Mr. Pearce took off his hands , I then loosened the Bandage , which was all the time before under his hands , It bled no more ; I told them there was more to be done in order to the binding that Artery ; but in continuation of the continual Fainting of the Patient , we would defer it to the next dressing : then calling for dressings , they brought me what was designed for Amputation , which I refused ; and ordered the common digestive è Terebinth . cum Vitell . ovi , which they fetcht .

I cut off the ends of the Ligature , and dipt some of the pledgits spread with the Liniment in Galen's powder , and applyed them next the Artery , and the rest of the pledgits dipt in ol . Ros . warm , and lightly fill'd up the wound , then Embrocated the Arm with the same oyl , and laid a Diacalcitheos Emplaster over the wound and that part of the Arm , and over the hand and Arm below which was Oedematous , a mixture of Diacalcith . & Paracels . Then with bandage began at the hand and rouled up the wound , and taking a turn or two there , I rouled up to the Axilla . This was the Ligatura Expulsiva , by which I proposed the thrusting back the Influx of humors , and to give strength to the inseebled Member ; He being now again in his Bed , I placed his hand upon his breast in much ease to the great joy of the Patient . At the next dressing , only Mr. Whittle and the Countrey Chirurgeons were present with me , we opened the Member , found the tumor allay'd , the wound fresh and tollerably digested , we now passed another Ligature upon the Artery above the first , and in pulling the first to cut it off between the Ligatures , it broke , which was as well : We drest it up with the same digestive , only leaving out the Powders ; Embrocated and applied our Emplaster , rouled up parts as before ; The next time Mr. Whittle and I undrest the member , and found the wound in a very good condition , with assured hopes of curing it in a few weeks , the Lips of the wound being more digested and contracted , we drest it up with Mund . Paracels . And now being Impatiently expected at London , with my diseased Patients , I return , leaving it to Mr. Whittle , who drest it for the space of 10. dayes , it healing up without any return of bloud ; In his absence Mr. L. dresses the Patient ; but whether in wiping off the knot or what else , it burst out again ; Serjeant Knight came in , dresses it with Calcanth . ust . and from that time it bled no more .

The Ancient way of tying this Artery is as I have already said by tying it in two distinct places , and cutting it off between , but here the Patient often fainting interrupted us in that work , and the breaking between saved us the labour .

The cutting in pieces the Arteries hath often been performed by me in Strumous ulcers , where they ride over the Carious bones ; in doing which I never see the Artery break out in bleeding after the day I cut it .

CHAP. V. Wounds of the Nerves , Tendons and Ligaments .

NErves may be many wayes wounded , viz. Caesim or Punctim , Wounds of Nerves and Tendons . the former way they are usually cut through , and then occasion no new consideration in Chirurgery , because they wholly cease from action and are irrecoverable ; but when prickt by a sharp pointed weapon , which is call'd a puncture , they are much to be regarded ; so also Tendons , not the small Fibres of them ( which are in every wound of the fleshy parts , when they are largely cut , whence they become painful ) but the main body of them , which usually make up the tail or head of a Muscle , if you would know whether these are wounded or not , consider the place wounded , viz. whether near the Joint , in the inside the Arm , or Leg , or the end of the Muscle , or if in the Tendinous parts of the hand or foot , whence immediately arise great pains and Inflammation , also a contraction and hardness in the Nerve or Tendon follows . But if the Nerve be quite divided , the pain is little , a kind of Stupor or Numness , and the particular part is Lame .

The most frequent wounds of Nerves , Ill consequences of bleeding not alway from a prick of Nerve or Tendon . and most to be taken care of in Chirurgery being Punctures ; I shall instance in them , and chuse the most common , viz. those which are made accidentally by letting bloud : and here by the way you must take notice , that in letting bloud , sometimes the Apertion happens to be made when the skin , by the Bandage or position of the Arm , lies equal with the Vein , yet afterwards is not so , or the Apertion is made too small in the skin ; so as part of the bloud is choakt , and lies there extravased , whence a Phlegmon is made , or it happens in those that are well Let bloud , yet through the Indisposition and ill habit of Body , the part prickt festers ( as they usually say ) and is a day or two after sore , and if neglected makes a Phlegmon : all these Phlegmons do Inflame and swell the part , and contract the Arm ; if a Boyl in a fleshy part be painful , then much more these in the Joynts , amongst the Nerves and Tendons , and this accident hath happened to all that do use to Let bloud , whether Physicians or Chirurgeons .

This was the reason that some of our old Master Chirurgeons did after Letting bloud , always apply a pledgit of Basilicon upon the Apertion with an Emplaster over it , this breathed the part , and secured it from corrupting . But we by a contrary way , as by a little Compress dipt in water , endeavour to restrain the bloud , and should be laught at if we should continue the old way of Basilicon .

At the time we Let people bloud , they are commonly labouring under some great fermentation , or apprehend it so ; no wonder if it sometimes fall upon the part where it was invited by bandage .

I have been sent for into the Countrey to a Person , that after a Letting bloud , was seized with a great Inflammation the whole length of the Arm , this was an Erysipelas , the Apertion in the Vein might possibly be the cause , but that place was not affected at all ; Dr. R. complained once of a Chirurgeon , who was so unconscionable as he said , to ask five pounds for curing an Arm he had made sore by his Letting bloud ; but I hope no person is so ignorant or malicious , to impute these accidents to a Puncture of the Nerve and Tendon .

But when they are really prickt , their Symptomes , Signs of a Nerve prickt . as you may read in all those that have writ of them , are suddain with vehement pain , faintings , convulsions , and are attended by great defluxions ; they do not terminate presently in a Suppuration with good Matter , until great Endeavours have been used , these yield not to the simple anodyne Cataplasme of white bread and milk .

Here are other considerations ; and in the first place whether they lie open , or the Apertion in the skin over them be small , or that the Nerve or Tendon lie covered under the Membrane Adiposa ; Cure . if it be so , then you are to open the skin that the Medicaments may penetrate to the wounded Nerve or Tendon , and hereto those Medicaments are proper , which are of hot dry and subtil parts to consume that Ichorous water , which first affects the Nerve or Tendon , and will cause putrefaction : ol . Ros . with a little bay-salt dissolved in it and dropt into the part scalding hot , dressing it with a pledget spread with Basilicon dipt in the same oyl , and the part Embrocated about with ol . Lumbric . with an Empl. diasulp . over , and this cataplasma over that , ℞ farinae Hordei , & fabar . an . ℥ iiij . sem . lini & foenugraeci pul . an . ℥ j . flor . ros . rub . flor . cham . Sambuci , & sumit . Absinth . an . ℥ iij . boyl this in red Wine , or the com . lixivium , adding oxymellis ℥ iij . ol . Ros . ℥ j . M. So roul up the part gently ; if there be much pain dress it twice a day , and if the part requires Medicaments of more drying and subtle parts dress with Balsam sulphuris Terebinthinati , or ol . Sabinae & Terebinth . an . ʒij . Misce or ol . Costinum , Ruthae , Sabinae , Aneth . scorpion . &c. These are all proper Medicines to dress the affected part , they having the quality required to dry and consume that matter which lyes corrupting in them , if applyed actually hot , the Application of the former oyl of Roses and Salt hath alway served my purpose .

In your Application of your Medicaments , you are to consider what degree of heat and Siccity is proper for the offended Nerve or Tendon ; if in your use of these Medicaments your Patient feels not the heat of them , Caution . or feels it vehemently , it is then not rightly fitted ; For in the former case it doth not enough dry up that sanies , or in the latter it doth withal inflame the part ; Prognosticks . if the Patient feel the heat moderately , the medicine is good , but if from the use of the Medicine the part Itch and Smart , and the Apertion made by the Puncture gape as at first , then the Medicament is stronger than it should be ; if the hardness go off and the contraction , and the orifice not too open , 't is a good sign : if the Nerve be cut according to its length it is the least dangerous , but if transverse most dangerous , all these wounds are accompanied with gleet and great pain which stirs up fluxion ; if they yield not in their cure to such Medicaments as have been proposed , then you are to divide them , to prevent convulsions , spasma's , and Gangren , after which they cure as other wounds , but do require more care in their position to keep the member steady , if it be in such a Joint where there are Nerves and Tendons , that move contrariwise ; otherwise the member will not yield to that contraction , and become more difficult in their cure , and of less use when cured .

The Ligaments require much one method with the Tendons , Cure of ligaments wounded , the same with Tendons . only your Medicaments are here to be more drying , as Euphorbium , Sulphur vivum , calx lota Tutia , &c. without acrimony .

A Youth about ten years of Age , Wound in the inside of the wrist one day in the Sessions yard leaning over the spiked pails to see the Malefactors , was suddainly frighted down by the Marshals men ; in his falling was catcht by one of these spikes in the inside of his wrist ; it passing between the bone and Tendons , he hung thereby until he was taken down , they carried him home , I was sent for , I found the Tendons stretcht out to a great length , and some of them broken ; others torn , and one of the bones of the carpus lying loose in the wound . In the dressing this wound there was trouble how to place these Tendons ; I began in taking out the loose bone , and cleansing the wound , and placing these shatter'd and overstretcht Tendons within the lips of the wound , and made my first Stitch in the middle of the wound , bringing the lips as close together as I could , then I made two stitches more , one of each side the middle stitch , dressing him up with my digestive è Terebinthina , &c. dipt in this following Balsam , ℞ Terebinth . lb ij olei olivar . lbiij . ol . Laurini ℥ iiij . Cinnam . ℥ iij . Euphorbii Garyophil . Baccar . Juniperi an . ℥ j . Gum hederae , sagapeni , Ammoniac . opoponac . Galbani an . ℥ j ss . Myrrhae , Mastich . Colophoniae pul . an . ʒ iij . distillentur pro usu . Over this I applyed my Empl. è Bolo , with a compress dipt in Oxycrate , and so rouled up the member , and some hours after let him bloud , and gave him that night a draught of Aq. Paralyseos with syr . de meconio . & aq . cardiac . C. iij . that night he rested ill , and in the morning was full of pain . I took off the Bandage , and bathed the affected part with a decoct . radic . Althae , Malvar , violar . cham . verbasci hioscyami , and applied a Cataplasma with farina Hordei , fabar . flor . Ros . rub . Balaust , decocted in Oxymel , with the addition of ol . Lumbric . & rosar . over the former dressing ; the next day his pain was much mitigated , the Tendons all drawn up , and the stitches laxe : I thought to have drawn the Lips close , but found them too painful to admit of it , therefore I cut the stitches out , and brought them as close as they easily would , and drest up the wound as before . After some few days , the wound being tolerably digested , I drest it with this unguent . dipt in the former Balsam , and applyed over the wound the Empl. Diasulphuris Rulandiae , with bandage and compress as before , ℞ Terebinth . Resinae , pini , ol . Hyperici , an . ℥ iiij . sarcocollae , myrrhae , Thuris , an . ʒ iij . Cerae q. sufficit ; dissolve them , and bring it to the form of an unguent : Thus I happily deterg'd and incarn'd , and by ung . Tutiae and my ordinary Epulotics cicatrized the wound , and he some while after was restored to the use of his hand .

A Coach man wounded transverse over the backside of the wrist , deep into the Joynt , Wound on the inside of the wrist into the Joint . so that his hand doubled inward , was carried into the next Inn : I caused a ferula to be placed under his hand the better to support it , and placing the fingers crookt over the ferula , I searcht the wound and pul'd out many fragments of Bones , and after cleansing the wound brought the lipps together by three stitches , leaving a discharge for Matter in the ends of the wounds which were both depending , dressing those ends with a digestive è Terebinthina cum vitel . ovi & far . Hordei with a little crocus . Upon the Suture I sprinkled the powders of myrrhae , Aloes , Thuris , & sang . dracon . and applyed the unguent mentioned in the former Chapter : then taking Bolus Armen . with some of the former Powders , made up with Alb. ovor . Acet . & ol . Ros . mixed to the consistence of a mel . applyed it as a restrictive over the wound and parts about , and placed his hand again upon the ferula , with a soft folded cloath under it , bringing his fingers over the end of the ferula , that they might be in some capacity for future use : Thus having placed his hand I roul'd it upon a good compress dipt in Oxycrate , and afterward Let him bloud , and gave him ʒ vj . syr . de meconio in a draught of Mace-Ale for his Supper , and setled him to rest , but he slept little that night . The next day I ordered him a Clyster and a slender diet ; the day after I opened his hand again , and fomented the wound and parts about with an Anodyne decoction , as in the former Chapter , and drest up his wound as before , Embrocating patts well about with ol . Lumbric , and applyed my Emplast . è Bolo , over the wound and adjacent parts ; it digested in the declining ends a little , but continued painful , yet much more pained in the fingers : the next days dressing I cut out the stitches , and drest the wound with my digestive è Tereb . dipt in my former mentioned Balsam , and applyed a Cataplasme warm over all the wound and hand , as in the former Chapter , and roul'd up the member again : This wound did not digest kindly , nor was it easie during the whole cure , but the Inflammation went off with the Tumor about the wounded Lips ; but in the fingers and back of the hand remained an oedematous Tumor . The day following I took off the dressings , and finding the Lips which I had stitcht lye open , and a white flesh within them , I dropt in some of my Balsam warm into the wound , and fill'd the crude Lips with mer . praecipit . and laid pledgits spread with the above-mentioned unguent , with some succ . Centaur . & Chelidonii , with mel Ros . boyled it gently to a good consistence , and laid the Cataplasma as before over all : Thus I deterg'd and cured this wound , sprinkling the Lips with calx lota , which cicatrized it . After this I put on a Catagmatick Emplaster , and kept the maimd hand still upon the ferula , and afterwards caused a Glove to be made to lace upon his hand and fingers , to take off that pituitous Tumor , which did accordingly answer my expectation . But his pain continued , and so weak , as he kept it upon the ferula a good while after ; since the writing of this I am informed he continues in the same service , his wrist is stiff , but he drives his Coach .

A Person of a good Age and ill habit of Body walking in the street , A finger bit off by a Horse . passing by a Coach one of the Horses snapt off the end of his finger the Glove with it : I drest the stump with the common digestive dipt in a little ol . Ros . warm , and with Emplast . diacalcitheos , malaxt with a little of the same oyl , roul'd up the stump . This Patient kept not his house with this little hurt , but came to me to be drest once in a day or two , and sometimes drest himself , he not thinking it worth the observation of diet , bleeding , or the like : one day when neither of us suspected ill he came to me , the Ulcer was crude , an Ichor dropt from it , and the part about it was blistered , I scarified the part blistered , and dabbled the wound and about with ol . Terebinth . warm , and strewed mer . praecipitate over all , and with pledgits dipt in Basilicon with a little ol . Terebinth . and with Empl. diacalcith . over it , roul'd it up ; and that night came to his Lodging with a fomentation , and other Medicaments prepared for a mortification , but found it better disposed ; so continued the dressing , and afteward Let him bloud , and the next day purg'd him with an infusion of Senn , &c. the wound digesting well from that time , I Incarned and Cicatrized the stump . Thus sometimes great mischiefs attend little wounds , through the contempt some of our Patients have of them .

CHAP. VI . Wounds of the Face .

A Lady was wounded down the whole length of the forehead to the Nose , and then transverse under the left Supercilium towards the Temporal Muscle , her Eye and Face much bruised . This hapned to her travelling in a Hackney Coach , upon the Jetting whereof she was thrown out of the hind-seat , against the forepart of the Coach .

At the first sight of the wound in her forehead , seeing the bone bare and her self so disturb'd , I doubted whether I should stitch it , or keep it open with dossils ; but seeing no fissure or Inequality in that part of the bone that was bare , and considering the deformity in that place would be great , being the whole length and middle of the forehead , I resolved to make one stitch in the middle of the forehead to bring the lips close together ; so as if any Symptome prognosticated ill , I might at pleasure by the cutting off the stitches lay it open again , but if there was no cause , then the next dressing , I proposed by dry stitches to bring the Lips of the wound close together ; the upper Eye-lid hung down upon the Eye , reaching from the Inner Canthus of the Eye more than half an Inch beyond the outward , it was bruised , excoriated , and much swell'd , not capable of the dry stitch , nor in that place of Bandage , it being all along under the Brow , wherefore I made four stitches at such distance as they might be able to keep the Lips close together , and the last stitch towards the Temporal Muscle , I took in the piece of skin that was divided by a wound above it , as in a double Hair-lip ; and over these Sutures and Wounds I sprinkled a little of these powders , Terra . Sigill . Sang . Dracon . Aloes & Thus , and my Pledgits spread with Arceus his Oyntment , and over these my Empl. è Bolo , and with Compress dipt in Oxycrate , and made my Bandage over from the wound , the two heads of the Roulers meeting behind ; this I did to keep the wound in the forehead from uniting too close , I still fearing some Fissure or mischief there , she complaining much of her head ; I having thus drest her wounds , I caused some Aq. Ros . Rubr . cum Alb. ovi to be beaten together , and dropt in her Eye , and little foulded cloaths doubled and wet in the same to be laid over that part , and over the Cheek my Empl. è Bolo , and forbore the bleeding her that night , in consideration that nunc fluebant catamenia , and she bled the space of five miles coming back .

The second day after I drest her again , and finding less suspition in the wound of her forehead , of fracture or fissure , I brought the Lips of that wound together with dry stitches , with a little of the powder forementioned , with the white of an Egg , and strengthened those sutures of the Supercilia by the same Medicament , lest the continual motion of the Lid should relax them , and then drest it up , and brought the Bandage now from behind , with both the heads forward , passing one by another to bring the Lips of the wound in the forehead close together , and drest her Eye with Aq. Pomor . Matur . with a few grains of Vitrioll . Alb. this warm to remove the suffusion upon the Cornea ; and upon her bruised cheek I applied a Cataplasme of the roots of Orpen beaten in a Mortar , with the white of an Egg.

Two days after I drest her again , and finding that the dry stitches kept those Lips of the wound close together , I cut off the other stitches from out the Lips of the wound , and drest her with my Sarcoticks composed of some of those powders forementioned , which supplied the place of Epuloticks , and that morning I let her bloud , taking away about 10. ounces with a rotten Serum upon it .

The next day she was purged , this was done for the carrying off the flux of humor from her Eye and Face ; thus was she Cured and disposed to go out of Town , the same day seven-night she was wounded , she was hurt upon the Munday , and the Saturday afterward she was cured .

A Servant of the L. B. was wounded on the right Cheek , from under the Eye over the Os Zygoma down the Muscles of the Cheeks ; In cleansing of the wound , I felt a piece of the same Bone which was cut off by a slanting blow , and hung only by some fleshy fibres in the wound ; it was cut over the whole breadth of the Bone ; I took it out , & for that the part would not well admit of Bandage , I made two stitches in the wound , bringing the Lips even and close together ; I drest this Patient as the former , and the third day after drest him again , and found his wound agglutinated ; I cut out the stitches , and drest him with the same agglutinatives as before , and the second day after I opened his wound again , and found it perfectly cured .

And so I have cured all the wounds of the Face as happily ; in a Hair-Lip of the Nether-Lip , I cut a little Boy ( who lay in London , and lived at Greenwich ) of about seven or eight years of Age , and cured him in ten or twelve days , though this Lip by reason of slavering , and a childish trick he had of sucking his Lips in his sleep , was the more troublesome to me ; yet he is so well cured , as I believe 't is scarce discernable .

Whilest I served amongst the Dunkirkers , A Dutch Hamburger markt with a Cross on the Right Cheek . where Snick and Snee was , as it were , a fashion , I had much of this kind of work , and for your diversion shall set you down one of them .

Whilest our Squadron rode at Anchor in the Groine , there came in some Hollanders , under the notion of Hamburgers , with three Ships new trim'd up for the King of Spain's service ; a Boatswain of one of these Ships hapned in company a-shore with some of our men , after a little drink the Hollander began to speak of Religion , upbraiding our men for their wearing a Cross , and after a little more drink became quarrelsome ; and that Sacramenta he would not wear a Cross , no the Divil take him , repeating this often , one of our men beat him down and fell with him , kneeling upon his breast , holding his head down , he draws out a knife sticking in his Sash , and cuts him from the Ear down towards the Mouth , then from under the Eye from that Cheek-bone to the nether-Jaw , now said he you shall wear a Cross that the Devil do not carry you away . I was sent for from the next house as a friend to the Cause , and drest him ; I brought the corners of the Wound close together and even by stitches , then a stitch in each of the slits brought the Lips of the wound together , then drest him , sprinkling a little Pul . Galeni finely powdred , which we always had in our Pockets , over this a Pledgit with some Emplastick Unguent , so with a Compress spread with a mixture of the same powders , cum Albumine ovi over the wound , bound him up , he keeping temperate the first three days , feeding only upon Bread and Bear boiled together , with a piece of Butter and a little Sugar in it : The next morning he was let bloud , and the third day after I took off the dressings , and finding the wound as it were agglutinated in the slits , I cut out the stitches , and sprinkled the wound as at first , drest him up with Pledgits and my Empl. è Bolo , with Compress and Bandage ; and the second day after drest him again , and cut out all the stitches , and in a dressing or two more he was cured , the stitches brought close together , any thing of a drying quality without acrimony cicatrizes ; these , your Suture does all it self , if the part be defended from influx of humors : The Patient was well pleased with his cure , though there remained some marks of a Cross .

Some of these kind of people wearing them with much pride in their Faces , as marks of their courage .

CHAP. VII . Wounds of the Limbs .

ONe of our Mariners abroad in Spain fighting a-shore , Observ . 1. Puncture of the arm . was thrust into the outside of the Arm , through the Biceps with a Rapier : A Chirurgeon in the Town seeing him bleed much , stitcht the wound with the Glovers-stitch close , and applied over all his restrictives , and rouled up the part well : After three or four days , the Patient belonging to our Ship , came a-board , and being in pain desired me to dress him , the Arm was swelled and inflamed a little , but did not bleed . I cut the stitches open , their issued out a bloudy Sanies in some quantity , and after followed a digested Matter ; by search with my Probe I found the wound wanted little of passing through ; I Embrocated the wound , and drest it up with a short Tent with my common digestives , to see whether it would by good Bandage and the help of Sarcoticks Incarn , but it would not ; whereupon I passed a Seton-needle through , and that way discharged the Matter , and after that Apertion was digested , I dilated it , and kept a Tent there a few days : In the while , the upper part of the wound healed up , and the wound below digested well with little Matter . I also healed it up . This I insert , not that I approve of stitching Punctures , but this way without stitching wounds , in a good habit of body , by good applications and Bandage , does sometimes agglutinate them in a few days , when drest by Tents they are of longer and difficult cure .

While I was in the King's service in the time of the War in the West-country , Observ . 2. Wound in the Thigh . I was fetcht to Captain M. who in fighting a Duell was run through the Thigh , with a broad sword ; I was also fetcht at the same time to the other , I hastily drest this Officers Thigh , with Pledgits spread with my Agglutinative , and some Astringent powders mixt with the whites of Eggs , applied it over both the orifices , bringing the Lips of them close , and with Compress and Bandage rouled it up , and left him to go to bed ; from whence I went to dress the other , who had many little wounds , as his fingers , hands , and head cut . At my return I visited my Patient , whom I found in his bed with little pain : the second day after I drest him again , and finding all in good temper without pain or swelling , I drest the wounds as before ; well satisfied that his wounds would heal up by agglutination , there being little or no Matter , pain or swelling : If it had appeared inflamed with tumor or pain , I ought then to have kept the Orifice most distempered open ; and if they had both suffered , to have kept them both open with small short Tents , drest with the common digestives , and have let him bloud , and have proceeded as in a body ill-disposed ; but there was no need , there was only required a quiet position of the part which he submitted to . He was happily cured in seven or eight days . This was truly performed by the Balsam of his bloud , I neither bleeding nor purging him in the time of his Cure or after .

A person wounded in the in-side of the Arm , Observ . 3. A Wound in the arm . the sword passing over the joynt , and through the out-side of the Arm , he was first drest by a Chirurgeon near the place where he was hurt ; he bled much . The next day I opened the wound in the presence of Dr. T.C. one of the Kings Physicians , I found the wound Tented at both Orifices , the Arm swelled , and a little disturbed , as wounds in that place are subject to be , when the bloud is shut in by Tents , and not drest rationally by refrigerants and astringents , and good Bandage . The swelling most between the two orifices , and was from bloud choak'd in the part , which was now more straitned from the influx of humors , so not likely to yield to other than suppuration ; yet we foment the wounded parts with discutients and dissolvents , and keep both the orifices open with small Tents dipt in the common digestive , and Embrocated about the wound with Ol. Ros . & Gutt . aliquot Aceti , and over all my Empl. è Bolo , rouled it up : the third dressing there appeared bloud from that orifice in the in-side of the arm , which I fill'd with Precipitate and a dossil upon it , then drest the parts up as before . This time I acquainted the Patient with my thoughts of opening the swelled part , between the two apertions ; there being no likelihood the Matter there could discharge it self by either of these openings , yet it was not safe to heal them up , wherefore I proposed the opening of that tumor by a little Caustick , after a day or two D. C. was acquainted with it , and it was opened as was afore proposed , and a corrupt Serum was discharged : from that time I threw my Tents out of the wound , and healed them up in four or five days after , and as the Escar separated and the Ulcer digested , I cured that in few days . That the bone was bare under the tumor , may I suppose yet be felt from the Adhesion of the musculous flesh to that bone .

A person was wounded in the out-side of the Right Leg , Observ . 4. Wound in the Leg . below the Gartering-place , the wound running upward ; after six weeks dressing by the neighbouring Chirurgeons , the part being much disturbed by a flux of humors , I am call'd in ; I find the wound sinuous ( some two inches ) undigested , and inflamed with a tumor about it upward ; the small of the leg and foot Oedematous , the whole member so weakned by the influx of humors , that it was neither able to assimulate its aliment , nor yet to resist the crudities that fell upon it , so would be difficult to cure ; as all such wounds are where the Patient is ill ordered , as to his diet and dressings in the beginning of the disease : I propose in order to the cure to dissipate this flux about the wound , and to digest the wound by Lenients , to mitigate inflammation , and to discuss and breath out that pituitous tumor on the foot and parts about , and with the help of good Bandage to restore the tone of the parts , and then if this sinuous Ulcer yielded not to agglutination , to lay it open : To which end I proposed a fomentation of Summit . Absinth . Scordii . Flor . Ros . Rubr . Chamom . Sambuci , Bacc . Myrtillor . Balaust . Nuc . Cypress . these boiled in Aq. Font . adding Vini Rubr . lb ij . and some Spir . Vini ; with this I foment the parts , and dress the wound with Ung . Basil . Mag . adding Precipitate to it , and Embrocate the parts about with Ol. Ros . cum Aceto , over this I applied Cerat . Galeni , and over the Oedematous tumor below , Empl. Diacalcith . p. ij . Empl. Stict . Paracels . p. j . and over all these a good Bandage , not opening the Oedematous tumor more than once a week , and then to give a breathing to the part , The wound I continued to dress daily as I had begun , and happily freed the part from inflammation and influx of humors : But the wound would not digest as I desired , wherefore I laid it open a little more than an inch , and drest it up with dossils spread with the same medicament as before , and incarned and cicatrized it in three weeks or a month after , but not without some difficulty , and the help of a strait Stocking . This person had been long kept in his chamber by this wound , and now supposing himself well , he rides to his Country house , unknown to me , seventeen miles off , but that night his Leg swells much , the Cicatrix scarce confirmed breaks out again , with great excoriation and inflamed redness . Thus this Gentleman returns again to his house , and sends for me . To allay this pain and inflammation , I foment the part cum decoct . Malvar . Violar . Plantag . Solan . & Flor . Ros . Rubr . and laying a fine Lawn wet in a solution of Troch . Alb. Rhasis made in some of the same decoction . I also dress'd it with Ung . Alb. Camph . over this Lawn , and spread some of it upon the edges , lest the Matter should be shut in by the Lawns adhesion to the Lips , and the fretted Cuticula raised more up . Thus I dress twice a-day , and keep the Leg upon the bed ; after some few dressings , that the heat and acrimony were allay'd , then in the place of the former Unguent , I apply Ung . Tutiae Mag. Vigon . and dipt the Lawn in a decoction of Fol. Plantag . Summit . Rubi , Equiseti , & Flor . Ros . Rubr . to which I added some Lapis Calaminaris , Tutiae Com . Cervi ust . & Calx lota pul . ostrear . combust . this was set in Balneo , and afterwards strained out , and applied upon Pledgits over the Lawn : Thus with much difficulty I cicatrized this wound and Ulceration , which at first possibly might have been cured by the way of our ancient Masters in few days .

CHAP. VIII . Wounds of the Breast .

WOunds of the Breast are penetrating or not , if they do penetrate , then we are to consider the depth , whether it be only between the Mediastinum in the hollow cavity of that in the lower part of the Breast , or if it pierce into the cavities of the Thorax , or what the parts are that be hurt . How the Breast is circumscribed , with the symptoms of each part when hurt , you may find in the Treatise of Gun-shot .

The signs of the wounds penetration are discovered by the proportion of the searching Candle or Probe , which enters into the Cavity ; Signs of penetrating wounds . you may also when it penetrates the cavities of the Thorax perceive it by laying a Down-feather upon the wound , or by holding a lighted Candle near the wound , the Patient holding his breath the whilest , in this case it will move the feather or flame , if it do not blow away the one , and extinguish the other ; as also the Air makes a noise in its issuing forth ; sometimes it 's discovered by the quantity of bloud discharged by the wound or mouth , or both with difficulty of breathing .

Wounds in the hinder part of the Thorax are reckoned dangerous by reason of the Nerves and Tendons , and if they penetrate that way , Prognostick . there is another danger from the great vessels of bloud which are nearer to the weapon in this case , than in those wounds which are made forward . Yet all wounds in the Breast are dangerous , by reason of the bloud that falls down to the Diaphragma and corrupts .

If the Lungs be wounded deep amongst the great vessels , though they escape the first nine days , yet they commonly terminate in a Pthisis or Fistula .

A Wound in the outer part of the Breast is cured as a simple wound ; if it penetrate , Cure . you are to endeavour first the restraining the bloud , then that the extravased bloud be discharged , and that either by the mouth by expectoration , or by the Wound , or by Urine .

The way by Urine Fab . Aq. Pend . says , is by a branch of the Azygos , which , saith he , passes near the Diaphragma , by the Spine to the Emulgents . Those that own the circulation will hardly allow of his Hypothesis ; however if the matter of fact be true , that there is sometimes a discharge by Urine , which I confess I have not yet observed in my own practice , it will be reasonable to propose as he doth : In this case Diureticks , as the Decoct . Capill . Veneris , Polytrichi , Rad . Petroselini , Beton . Apii , Faenicul . Asparag . To prevent inflammation , Ptisans with Ol. Sulphuris , Vitrioli , Barly-creams , Emulsions , &c. The Ancients gave Acetum with warm water for dissolving the concrete bloud , and restraining the present flux .

The second way is by Expectoration , & thereto our Decoctum pectorale , Lohocs , Syr . Capell . Ven . Jujub . Glycirrhiza , Oxymel . &c. whereof our Pharmacopeia Lond . is full . This I have mentioned for their sakes who cannot have a Physician ; but here I leave this work to them , these cures consisting much in their well ordering and prescribing internal Remedies , and content my self in the dressing of the Wound , Whether the wound is to be kept open or not ? as it appertains to Chirurgery . In the treating these Wounds there is a question , whether the Wound shall be kept open , or agglutinated ; they that are for a speedy agglutination do urge it , lest the external Air corrupt parts within , and the heat expire : they that propose the keeping them open , do design thereby a readier discharge of Matter ; for , says Aq. Pendens , if the Matter be to be discharged by Urine , it must first pass into the substance of the Pleura , then into the Vein Azygos , so into the Emulgents , then to the Kidneys , and through the Ureters and Bladder . If by Expectoration ; then it must also first pass into the substance of the Lungs , then into the Aspera Arteria or Weazond , from thence cought up by the Mouth .

In my practice in these Wounds of the Breast , The Authors judgment . I consider the wound how it is capable of discharging the extravased Bloud and Matter , if it was inflicted so as that the Bloud or Matter may be there discharged , then it is to be kept open , the well-fare of the Patient depending mainly upon the well-dressing and governing it ; but if it do not lye well for evacuation of that extravased bloud , then it may do hurt , so ought to be healed up .

A person of about 23. years of Age , Observ . 1. of a good habit of Body , wounded into the Breast , upon which followed immediately great effusion of bloud , almost to the exhausting of his Spirits . Mr. R. Chirurgeon , and my self , were presently sent for , we find him lodg'd in an Inne near Fox-Hall , we view'd his wound , it was four fingers above the Cartilago ensi-formis a little to the left side ; he laboured under a small pulse , fainting often : Dr. W. & Dr. Wed. came in while we were providing dressings , How to order Tents in penetrating wounds of the Breast . the wound was large and penetrating , we made a foft Tent with a thread fastned to it ; which in these wounds you must be sure to do , lest you lose it in the body : This Tent we dipt in a mixture of a powder composed of Bol . Armen . Sang . Dracon . Thuris , Mastich , &c. with a new-laid Egg and a Pledget spread with the same over all , with Empl. è Bolo , and Compress with convenient Bandage . The Phycisians prescribed such things as restrained the bleeding , and were proper to resolve the concrete bloud , and withall to relieve his fainting spirits : that night he rested ill , the next day when we met , seeing him labour under great difficulty of breathing , with pain above the Diaphragma , his Pulse quick , little Urine , and that high , we agreed he should be let bloud presently , which was done accordingly in the left Arm , the bloud flowed with a quick stream , we took about six or seven ounces , a meer Serum , but the Patient was relieved by it ; we took off our dressings to look upon the wound , whereon we found some bloud and Sanies discharged : we then drest him with Terebinth . Lot . in Succo Lamii adding some of the former powders with Vitell . ovi , this upon a Tent as before , with an Emplaster and Bandage over : Thus we continued to dress him , until we see the bleeding cease . In wounds within the body , I have always endeavoured to preserve the native heat of the part , and further the discharge of Matter from within , by keeping the wound open , until it lessened , and the ill symptoms went off ; but shun the casting in of liquid Medicaments which are not easily to be gotten out again , they commonly proving very destructive . Here the Physician is to act by Internals , we only to assist by keeping a way open , if it may be , for the discharge of what is extravased and corrupted within the cavity , and commit the cure to Nature . In this Person here was a great effusion of bloud upon the receipt of the wound , and the orifice large to discharge the extravased bloud and Matter ; the Physicians careful in restraining accidents , and removing what he laboured under ; through all which our work succeeded prosperously , so as parts within united ; we threw out our Tent , and by Sarcoticks cured this wound without , and the Patient was restored in few weeks to perfect health , and continues so .

Another person was wounded into the Breast below the fourth Rib on the right side , Observ . 2. coughed up much bloud at times ; Sir Fr. Pr. was his Physician , he prescribed him Ptisans , Pectoral decoctions , &c. by which , and by often Phlebotomy the symptoms went off , the wound digested , the Patient rambled abroad , and was cured by such dressings as I left for him at his Chamber , I seeing him no more until he was wounded again .

Another wounded in the right Breast , Observ . 3. coughing up much bloud , with great pain and difficulty of breathing , I took away ten ounces of bloud presently , and ordered him ( it being then night ) some Syrup de Meconio & Jujub . in a draught of Aq. Papaver . with a few drops Sp. Sulphuris , he slept well that night ; against the morning he had the Decoct . Pectorale ( the hotter herbs left out ) and it I sweetned with Syr . de Ros . Sic . & Jujub . with Sp. Sulph . this he drank in the morning , and at other times as he listed ; by his disorder , he cought up bloud at times , and I let him bloud as oft , in the while I kept his wound open and digested : Upon another relapse I began to be sick of him , and perswaded him to send for a Physician , Sir Ed. Graves was call'd in , who see his wound almost cured , we agreed and let him bloud : and from that time he continued well .

A person run through the Body the breadth of three fingers under the right Clavicle , Observ . 4. and out below the Scapula , was first drest by the Chirurgeon near the place where he was wounded : I found him in his bed faint and weak , but without pain or difficulty of breathing , Dr. Bacon his Physician : The next day I met him and Mr. Sh. Chirurgeon to his Highness Pr. Rupert . The patient had rested very ill the preceding night , had bled from his wound in his back through the bed , and fowled many Napkins that night in coughing up bloud , we took off the dressings from the wound in his Breast , from whence there was bloud discharged , and more came out in the dressing : I drest up the wound with a short Tent dipt in a little Terebinth . with Farina Volatilis , a few of our Agglutinative powders cum Vitello ovi , with an Empl. Diacalcith . over it ; the other wound under the Scapula was painful , but so small as it was not reasonable in our judgments to keep it open ; we laid a Pledgit of the same mixture with an Emplaster upon that , and drest it no more ; this method of dressing I continued , and let the Patient bloud : The third day he coughs up bloud , and some little issued from his wound for a few days ; after four or five days I waited upon him to his lodgings in London , by the way he cought some bloud , and so more or less day and night ; but by the care of his Physicians it lessened , his wound digested , and I now kept in it a hollow Tent made of a Sparadrap , which was composed of Resina , pini , Gum . Amoniac . Bdelli . Galb . Terebinth . & Cora , with Pul . Ireos , dipt in a little Mel . Ros . Rubr . This way of dressing I continued until the coughing of bloud diminished from twelve Napkins in a day and night , to ten , eight , seven , four , two , one , and but one Napkin in a week , and after that in a weeks space I see no bloud one way or other , nor any symptom of ill . I then call'd in his Physicians together , and severally , and had all their positive judgments for throwing out the Tent , and healing up the wound : I did so , and in a week more cured him ; five days after , or thereabouts , he sent me his thanks by his servant ; and within few days after I made him a visit , and there met Dr. Willis , who enquiring of me whether his wounds were cured , I desired that person that he would shew the Doctor whether they were or not , he presently stript himself of his shirt , and shewed the Doctor , who both see and felt their scars , and replied they are well .

A young man wounded in the Breast , Observ . 5. labouring under very great pain and difficulty of breathing , with a cough , sent for me late one night , he shewed me some little bloud he had then cought up : he had been wounded the night before by a man standing at a door some steps higher than himself , as it were over him , thrusting his Rapier from within the breadth of two fingers of the right Clavicle downward into the Lungs , the Patient run into that house bleeding much , and was seised with such difficulty of breathing , as he was forced to stretch his arms at length over his head , without which doing he could not breathe ; he had been let bloud twice , and prescribed Ptisans , &c. But for all this he was little relieved , I presently let him bloud about ten ounces , and ordered the Apothecary to give him a draught of Aq. Papaver . with Syr . de Meconio & de Ros . Siccis , with a little Aq. Cordial . frig . Sax . and against the next morning to send for a Physician to meet me , they did so ; when I came in the morning , I found the Patient marvellously relieved , and resolved to remove his lodging , which was now by Scotland-yard to his own in Wildstreet : in the presence of his Physician Dr. St. I took off the dressings , found his wound small and shut up from within , but not skin'd , and if it had not , yet the wound within was so much below this without , as it was not capable of discharging the Matter : So this was not worth my attendance , the wound within was the work of the Physician , however he continued me with his Physician , and we agreed to bleed him again ; we did so , taking away about ℥ viij . of bloud , and the Physician proceeded by Clysters and Internals proper in his case : That afternoon the Patient , unknown to me , pursued his intention of removing to his old lodging in Wild-street , where going up three pair of stairs to his chamber , he relapst into the former difficulties of breathing with pain and coughing bloud , and in the morning after where I met his Physician , the Patient seemed to me quite tired , labouring under great oppression ; and by his pains about the Diaphragma and Back there was suspition of extravased bloud ; to relieve him there was a necessity of taking away a little bloud ; we took away some four or five ounces , and proceeded with Embrocations , Lohocs , Pectoral Decoctions , &c. and got off this difficulty in five or six days , then I left him : But after that , by disorder he relapst again , and was freed again the same way by his Physician , and since holds well , but I never see him since .

Of all these wounded Patients , and many more I have helpt to cure , The Authors observation concerning the discharge of the Sanies of the Breast by Urine . I never see one that I could say passed their disease by Urine , nor many of them that passed their Urine well during the time of their lying under these wounds ; nor have I often seen them who recover , expectorate any such quantity of Matter , as might be thought to proceed from the great quantity of bloud extravasated : They cough fresh bloud most of them , like to what they discharge from their wounds , but more florid .

Those who do cough great quantity of Matter from these wounds made by a sharp Weapon , or avoid it by their wounds , do seldom well : They usually terminate in a Tabes , with or without a Fistula : Yet by the ninth day one may truly predict their present recovery , if all things have been rightly administred .

CHAP. IX . Wounds of the Abdomen .

A Man wounded with a Rapier into the belly , Observ . 1. through the Right Hypocondrium out to the side of the Back , is brought to my house one night to be drest , he had bled much ; I considered the wound , see it had past through , the orifices were small , little advantages to be made by keeping them open , yet I put in two small Tents dipt in a little Digestive è Terebinth . & Vitell . Ovor . and drest up with Empl. è Bolo , and a Bandage over , and advised him to go to his bed and keep quiet . I gave his friend ʒ vj . Syr . de Meconio , mixt with a draught of Aq. Papaver . with a little Cordial-water for the Patient to take in bed : The next morning I found him hot , and his Pulse a little disturbed , but without symptoms of any part of the Viscera wounded within : Signs of the inward Viscera hurt by a wound of the Abdomen . neither Tension of the Belly , Collicke , Vomiting , or ought by Urine or Stool . However I Let him bloud about 10 ounces , and ordered him to keep his bed , and a Clyster of Milk in the afternoon with Sugar , and at night his haust us again . The next day I opened his wounds , and considering here was no Symptome of hurt within by Urine or Stool , nor Tension nor Swelling , only the wound a little heated by the Tents , I threw them out , and drest both the wounds with pledgits spread with the same digestive , Embrocating the parts with ol . Ros . drest him up as before , and desired him to keep his bed six or seven dayes . Two daies after I drest him again and found all well , with Inclination to cure ; from that time I drest him no more , but ordered him to keep a spare diet , and to lie quiet in bed , and if there were occasion I would see him again : my servant drest him afterward , and before the seven days were expired he was well and walkt abroad not complaining more of that wound . So I have happily sometimes cured such wounds through the body ; in this wound here was no considerable part toucht , yet if the wound had been kept tented with long tents , Digression concerning the ill use of Tents . they might have stir'd up inflammation , or so the Air might have altered the parts within , or the Matter offended them , whereby putrefaction , Collicke and Ill accidents would have followed : But what could the Chirurgeon have advantaged the Cure of his Patient , if bloud had extravasated within , by keeping such little wounds open ? Yet if it be not done , he is usually condemned by the common Vogue ; therefore it is , that against their own Judgments they keep them tented often to the ruin of their Patient . If in these wounds of the Belly the small Intestines be wounded , there follows a continual vomiting of Choller with Griping , and death within few daies ; Signs of the gutts wounded . if in the first dressing these wounds a Chirurgeon should propose a cutting open the wound , to seek the wounded Intestine to stitch it , Of opening the belly in wounds of the Intestines . Cure of wounds of great Intestines . the friends would not permit it , nor in truth have we Authority or Example for it , so we have nothing to do but stitch up the wound , and refer the Cure to Internal remedies , yet at last when he is dying , they will wish we had attempted it . In the great Intestines where they are fleshy , if the wound be not great enough , you are to enlarge it and seek the Intestine , and stitch it up with the Glovers stitch , and cleanse the Bowels from the Excrements , and sprinkle the Sutures with some of your Incarnative powders , and reduce them to their places , and stitch up the belly , as you shall see presently : you are in these cases to give your Patient Clysters made with Chicken or Veal-broath , wherein Barly flor . Ros . rubr . Chamom . hath been boyled , adding the yolks of Eggs to it , with Mel . Ros . & sacchar . Ros . an . ℥ j . and Internals such as are glutinative , as decoct . plantag . Equesiti , pimpinellae , pilosellae , Rad . Consolid . ma . these sweetned with Sugar of Roses , spec . diatragacan , cons . Cydon . Cons . Ros . rubr . boli . Terrae , sigill : their diet must be sparing , drying and agglutinative : they must be Let bloud , and after some days their Clysters must be agglutinative and often repeated . After this manner the wounds of the Viscera are to be treated , only in them you are to keep the wound open in some declining part , whereby they may be drest if occasion be , and discharge their Matter . If a flux of bloud happen as in wounds of the Liver and Spleen , the Ancients commonly commend succ . pilosellae , pimpinell . plantag . Pologoni ; with pul . Bol . Terr . sigill . sang . Dracon . Thuris , and such like mixt , and put in by Tents , and after the like mixt with syr . Ros . suc . and parts about Embrocated with ol . Ros . Mirtyl . & Empl. Diacalcith . over all , or a Cataplasme ex farin . Hord . fabar . flor . Ros . Rubr . coct . cum hydromelite and treat them by Internals as I have said , such as are agglutinative , exsiccant and detergent , I refer you to the treatise of wounds made by Gun-shot , where you shall see their various Symptomes and way of Curing .

A Man wounded and brought to Lambeth sent for me one morning early , A wound in the Abdomen . Observ . 2. he was wounded transverse the belly a little below the Navel , on the left side the Omentum , and Intestines thrust out , and kept close with a Hankerchief in his hand , I see parts fresh ; the Omentum or Call much out , but not altered . I caused warm cloaths presently to be held upon them very close , and the Patient to be laid low with his head , his Hips raised up , and by the help of his friends raising them up and shaking his body , I reduced them . Then they leaving his Hips high , and he declining with his body on the Right side , by the help of one pressing with his hand a little above the wound ( by which the Lips of the wound were a little turned upward , and the viscera kept down ; ) I with a strong Needle a little crookt at the point with a strong Thread seared take hold of that lower lip , Manner of sewing the Peritoneum in this case . and near the end past my Needle first through the Peritonaeum , and then on the opposite side through the flesh and skin , leaving the Peritonaeum , and so go along passing the Needle from without Inward , till I sewed up the wound , which cannot be very close , then I pulled the stitches as close together as I could , What to have been done in case the Omentum had changed Colour . and fastened my Thread . If any part of the Omentum had been altered in its Colour , I should have tyed it hard and cut it off , and placed it with the Thread hanging out , and so I would have served a great part of it , if I could not have reduced it , I having done so heretofore often ; but if the Intestines had been so swell'd , What if the Intestines were swel'd . as by no way of fomenting or position I could have reduced them , I ought then to have cut the wound more open , but these were easier reduced , and the wound stitcht , I then sprinkled them with pul . Aloes , Colophoniae , sang . Dracon . Mastic , sarcocolla , Bol . &c. and over them pledgits of my Incarnative , and with some of these powders mixt cum Albo ovor . to strengthen my stitches , I applyed them upon a cloath over all , and with compress and a strong Towel bound all fast , then after a while let him bloud , and ordered him to ly quiet upon the well side , and to a spare diet , and to keep his body soluble by Clysters ; every other day I drest him after the same manner , and after the wound seemed to be Cicatrized , and that my stitches began to fret , I cut them out the Eighth or Ninth day , and after with the continuance of my sarcoticks , I cured him very well . These wounds are not subject to great Inflammation or defluxion , but by reason of the fatness and thickness of the Lips , and manner of sewing , 't is a troublesom work ; and yet if they be not so stitcht as the Peritonaeum and fleshy parts may unite together , a Rupture follows to the great trouble of the Patient , and shame of our profession : the Peritonaeum bears a great stress , therefore you must be sure to take good hold with your stitches , and if you doubt their holding , make dry stitches over them and good Bandage .

CHAP. X. Of Wounds in the Head .

WOunds in the Head according to Hippocrates and our daily experienced are full of danger , how slight soever they may appear to a common eye .

In this discourse I propose to write of them , not only as they are made by cut , stab , or bruise , but also of those made by Gun-shot , and so by Anticipating part of the discourse next ensuing , to give you the full doctrine of wounds of the Head made by what Instrument soever without the necessity of future repetitions , and that you may understand the Basis whereon these cures are wrought , I shall represent the head to you as it is framed .

The Head according to Galen . de usu part . is the noblest Member of our Body , Parts of the head considered . the principal faculties being there seated , for the use of which it was ordained : and is so contrived as to be the fountain of the Animal spirits , and also to contain the principal Organs both of the Internal and External senses .

In the first part , The Hairy Scalp . the hairy scalp presents it self to our eye , and therein is to be considered its Thickness , Sense and Vessels , with the Muscles that lie under it . The Hairy Scalp is thinnest on the top of the Head , nor is there any Muscle between it and the Skull in that part , unless you will call the membrana carnosa a Muscle , ( which some men of late do , and possibly not improperly ; ) and here the rather , because by it many men move the whole Scalp . If you doubt of a fracture there , you may boldly cut into the Hairy Scalp , it is of an obtuse sense and easily healed up again . Forehead . But be cautious how you make your Incision in the forehead , where a transverse Incision may cause the Eye-brows to fall over the Eyes ; therefore if you are forced to make Incision , let it be according to the length of the Fibres , and avoid the vena frontis , lest its bleeding disturb your work . And be careful that you make no Incision upon the Temporal Muscles , Temporal Muscle . for thereby Convulsions and other ill Accidents may happen .

Under the Hairy Scalp lyes the Pericranium , Pericranium . which we are to cut through , in making way to the Cranium ; you are to raise them both together when you lay bare the Cranium for the use of the Terebra ; for if in perforating you tear this Membrane , Inflammation and Fever may follow , the Pericranium arising from the dura mater through the Sutures ; by which continuity that may also partake of the Inflammation .

The Cranium follows , Cranium and Sutures . which is a Bone composed of many joyned together by Sutures , of which there are five concern us Coronalis , Lambdoides , Sagittalis , &c. two false ones . In perforating the Cranium , you are to shun these , ( if you may ) for through them the dura mater passes , being continued unto the Pericranium . The Sutures divide the Bones of the Cranium , by which one part of the Cranium may be preserved entire while the other is broken , which otherwise would be in hazard ; These Sutures are weak in resisting Blows , and upon them also Matter may be easily contracted and make a Caries the sooner , and sooner worke through to the brain than in either parts of the Skull . It is necessary to know them well , lest as Hippocrates well cautions , you take them for Fissures . The way to find the Sutures . The way of finding them is , by passing one string from ear to ear , and another from the Nose to the Crown of the head ; the former of these shews you the Coronal Suture , the second the Sagittal , which usually begins at that point where these lines intersect , being the part where we make Fontanels , and reacheth to the Crown of the head where the Lambdoides begins ; sometimes it beginneth quite at the Nose . The Lambdoides begins at the end of the Sagittal , and goeth forked down the two sides of the occiput : of the Suturae nothae : the two chiefly to be regarded are the Squamosae , which run under the temporal Muscle of each side , round about the outermost verge of the ear .

You are also to take notice that the Cranium is thinnest in the middle part of the head , Thickness of the Cranium . and thickest in the hinder part , and of a middle thickness in the fore part : Hence it is that wounds are most dangerous in the Crown of the head , where the Skull by reason of its Tenuity easily communicates its hurt to the brain , and also for that the upper part of the brain lyes there high , one of the largest Sinus being immediately under the Skull , and many Capillary veins running so close with it , as to make themselves Trenches in the Internal part of the Cranium : Wherefore upon a blow or concussion in this place , the veins may easily be broken , and the bloud extravased between the Cranium and dura mater , and ill Accidents follow .

The dura mater , a strong Membrane , Dura mater . is placed under the Cranium , which being wounded is attended frequently by Palsies , and in progress of the distemper by Convulsions and other ill Symptoms ; and the greater if wounded in the middle part of the head according to its length , there being many Vessels , which if they chance to be cut , will fill the vacant space between the Cranium and dura mater with bloud .

The Pia mater lies upon the body of the Brain so close , Pia mater . that a wound cannot be made into the Pia mater and the Brain escape ; and from its many veins a flux of bloud must follow .

The Brain lies under the Pia mater , Brain . in whose ventricles is lodg'd the Plexus choroides , and under whose Basis ly large numerous branches of Arteries and Veins , which by great blows of the head may be broken .

From the Description of the head we shall proceed to the Description of its wounds , Wounds of Brain . which are strictly so call'd , when any part of the skin , flesh , bones , membranes or brain is either cut or torne , or when more of these are hurt together .

Contusions and Concussions do not truly belong Contusions to this place , yet for the better Information of the young Chirurgeon , I shall say something of those also , and shall treat of all these things by the sollowing degrees .

First , there may happen Contusions , or great and violent Concussions of the Brain from a blow , fall , &c. when there is no visible wound either inward or outward .

Sometimes this Concussion is accompanied by a ruption of the Vessels of the Meninges . Sometimes a fissure of the Skull , or a spill broken off from the inside of it , &c. the skin all this while remaining whole .

Other while the wound begins on the outside being made by Sword , Bill , or Bullet , &c. and either goeth no further , or else penetrates sometimes to the Skull , sometimes into the first Table , sometimes through both , or yet further through the dura or pia mater , or into the brain it self .

Some are meer cuts , others contused wounds , and in Gunshot , the very outward parts of the head , as hair , skin , flesh , bones , &c. are often driven by the violence of the Bullet into the Brain it self .

Of Fissures some are directly under or near the place of the Blow ; some on the quite contrary side , and are called contra fissurae .

Celsus in his 8 lib . & 4 ch . gives you the signs ; Signs . when you are call'd to such a Patient , presently saies he , you shall enquire num vomuerit , &c. whether he vomited , or was stupified at the first receipt of the Blow or Fall , or a Resolution of the Nerves followed , or torpor , or delirium , or raving ; these shew the Membrane of the brain affected , and the Patient in great danger . But if none of these were , you may then dubitare an os fractum , doubt whether the Bone be broken : then it is to be considered , whether it was Stone , Iron , or Lead , that he was hurt withal , and with what force the Blow was given . But if there be a wound , nothing is more sure than the finger or Probe ; if it feel smooth or slippery , the Cranium is safe : But if you feel any Asperity or roughness , if it be not the Suture , then you may be assured of a Fissure or Fracture , the holding a Tread between the Patients Teeth , or biting of a Crust , is mentioned as a sign of a Fracture , but this way is very uncertain : To find hair cut in a wound may be a sign , if you consider , no small force will cut a hair there .

If by your Probe you make no discovery of the fissure , and yet the Symptomes be grievous , then lay it open , and if the Fissure do not then appear , rub the bared Cranium with Ink , and wiping it off again , you will see the Ink remaining only in the Fissure or crack , then Rugine it .

If no breach of skin appear , you must consider the outer side , numquis locus mollior sit , & tument , eumque aperire ; whether any part be softer and swell , which you must open and see whether there be any Fissure , non tam magno negotio , cutis sanescit etiamsi frustra dissecta est , it being no great matter to heal it again , though it should be laid open in vain .

In the Prognostick , Prognosticks . wounds by much how nearer the Brain , are so much the more dangerous ; the solution made by Incision is of less danger than those made by puncture , this of less than those made by Contusion ; and those of Gun-shot worst of all wounds . In the middle of the head most dangerous , the hinder part least dangerous , the fore part of a mediocrity between both , it having passages near for discharge of its bloud and matter : Wounds of the Sutures are dangerous , but those are more or less as they fall into good or bad Chirurgeons hands , and as the Patient submits to the method of cure . A simple wound by a Blow hath been through ill Chirurgeons , &c. the cause of much danger , that in skilful hands would easily have been cured : All wounds save those of the Brain are curable , if the Chirurgeon be timely call'd in , and that it be discovered in such place where he may lay open safely .

We begin with the cure of Contusions of the Calvaria , Contusions of the head . where the outer skin is whole , yet with great attrition of the Musculous flesh and membrane underneath ; which often happens from blows or Falls , and are subject to great pain , tumor , Inflammation , and Apostemation , &c. caused through the Ill habit of body , or untimely applications , therefore it requires your special care in the first place to prevent the afflux of humors and pain , which is performed presently in the beginning by repellents and astringents , which are to be often renewed , lest they heat the part affected . You are in the first place to shave the hair , if there be any , then Embrocate with ol . Ros . & myrtil . cum aceto , and apply this or such like over the contused parts ; ℞ farin . hordei , fabar . an . ℥ vj . pulv . Nucis , Cupressi , balaust , Alum Rochae , Ros . rubr . an . ʒ j . ol . Ros . ℥ iij . Alb. ovor . nu . ij Aceti q. s . ft. Cataplasma . You are to make your Bandage over this , to further the expulsion of the serous humors from the grieved part , therefore your Bandage begins there , and terminates where it may resist the Influx ; then bleed , &c.

The second day you are to foment with Red wine , wherein hath been boyled flor . ros . rubr . Bacc . myrtill . fol. beton . & flor . Chammol . and if much pain Embrocate with ol . Ros . & Chamom , or decoct . beton . ros . rubr . Rad . Althe . sem . Lini , fenugraeci : If after these your endeavours the part affected do tend to Apostemation , you must then use suppuratores , and open it in the declining part , and digest it as in a Pphlegmon ; but if the pain do mitigate , then it will be proper to discuss and breath out the Serosity by such like , ℞ farinae hordei fabar . an . ℥ iij . flor . ros . rubr . Bacc . Mirtill . pulv . an . ℥ j . sumit . Absinthii , fol. beton . slor . sambuci & chamom . pulv . an . ʒ iij . sem . Cumini , pulv . ʒ j . mel . ℥ ij . coq . in vino Austero , ft. Cataplasma , addendo ol . Cham . Ros . an . ℥ j . apply it ; then in the next place comes in the use of Emplastr . Vigonis .

If there happen a Concussion from some great Fall or blow without a wound , Concussions . we cause the head to be shaved , Embrocate with ol . Ros . & myrtill . cum Aceto , all the head , neck and behind the ears , and apply a Cataplasm with farin . hordei . fabar . bacc . Mirtill . flor . ros . rubr . decocted in Red wine or Oxycrate , adding mel . ros . to it or Empl. vigonis , or such as this which is his , and hath been often used by me in such cases , ℞ furfuris Tritici ℥ iiij . far . lentium ℥ ij . flor . ros . rub . Bacc . Myrtillor . Balaust . an . ʒ j . Calami Aromatici ℥ j ss . flor . chamomel . Melilot . pulv . an . ℥ ss . nuc . Cypress . no . 6. pulver . omnia coq . in vino Austero q . s . ad consistent . Cataplasmatis addendo olei Rosati Chamom . an . ℥ iij . or add wax to it , and make it into the form of a Cerott ; you may make fomentations of the like ; you must remember in these Concussions to bleed largely , even to defailancy of spirits , according as the Symptomes do shew to you the greatness of the Malady , and as strength of body will permit , and keep the body soluble by Clysters , also Julips , Emulsions , and what else may allay fermentation of the bloud ,

In the cure of wounds of the head , Cure . if it be a simple wound only to the Pericranium , the lips are to be brought close together ; the stitching these wounds is objected against by some , lest thereby Matter should be pent in , Simple incised wounds . and Inflammation and caries of the Skull follow , but done judiciously ; it is safe , if you can satisfie your self that the wound ought speedily to be healed . Abroad I have seen them as commonly stitcht as other incised wounds , and do my self in great wounds of the Scalp make a few stitches to keep it close ; however you are not to croud those wounds with dossils , but having shaved the hair bring the lips close together , and cure it by the first Intention , vid. Agglutination ; as in simple wounds , by Arceus's Liniment or some incarnative , and keeping the lips close by Empl. è Bolo , or with some of your Astringent powders mixt with album . ovor . Thus in a few days all these simple incised wounds may be cured .

In a wound in the right Temporal Muscle , Observ . 1. Wound in the Temporal Muscle . where the Artery was wounded , I have often stitcht them up without any ill Accident . Smith a Tanner sometimes in Chester , Captain of a Company of Dragoons pickt up in hast to disturb us in our flight from the Battel at Worcester , was bleeding almost to death , by a wound he received from some of our routed Forces ; when I was brought a prisoner to his Quarters , I stitcht up his wound , taking the Artery up with the lips and with a little wheat-meal , and the white of an Egg , laid over all upon a Compress dipt in aceto , bound his head up ; this was upon a necessity , but this served to keep my stitches close ; after two or three days , I dressed him again , and found all quiet , I now sprinkled the lips with pulver . Thuris , sang . dracon . an . p. aeq . and applyed a pledget with Linim . Arcei & Empl. diacalcit . all which I was now supplied with from Warrington ; and the next dressing cut out the stitches , and drest him up again with the same as before , and from that time he was cured : which was before he had recruited his spirits from his loss of bloud .

In wounds of the head where you cannot cure by the first Intention , Contused wounds . as where the wound is contused or some part of the Hairy Scalp torn off , there you are to digest with Terebinth . and the yolk of an Egg , I commonly boyl the Turpentine a little to make it thick , otherwise it is too slabby ; add a little farin . Hordei , After Digestion I add a little Sarcacoll . Myrrhae , Aloes , pul . Ireos , with mel . Ros . by which it serves to deterg , I commonly Incarn with this of vigoes , ℞ ol . Rosat . ℥ vj . ol . mastich , ℥ ij . pinguedinis vitulin . porcin . an . ℥ iiij . fol. plantag . matrisylvae , Beton , pimpinellae , pilosellae , flor . Anthos . an . Mss. vini odorif . cochl . iiij . coq . ad Consumpt . vini in colat . add mastich . Gum . Elemi , Resin . pini , an . ℥ j . litharg . Auri & argent . an . ℥ ij . Minii ʒ x . Terebinth . venet . ℥ iiij . cerae q. s . ft. vng . S. A. or with Lin . Arcei ; touching the lax flesh , as I think fit with either of the stones , and by the help of ung . Tutiae mag . Lint dry or dipt in sp . vini . Aq. calc . Alum , and prest out , I cicatrize these and all such like wounds .

If in a wound of the head by Incision the Pericranium be bared , Pericranium laid bare or cut . if there be no fissure , you are to keep the Air from it by bringing the lips of the wound close together , that the bone may Incarn : But in these wounds Fabr . ab Aq. Pend . says , and by the authority of Galen , that you ought to Exfoliate the bone ; for says he , it is not likely so thin a membrane as the Pericranium , adhering to the bone , can be cut , and the bone not hurt ; and if the Cranium be but a little hurt , there is a necessity of Exfoliation : In my Practice I have often met with wounds in the head , where the Pericranium hath been cut , and the bone only bare ; sometimes also the bone is cut : But if I came into the first dressing , it hath for the most part Incarned without any difficulty , and the better for the little cut made into it . But where the bone hath been bared by a Contusion , the bone is commonly altered by the Air , or Gleet from the contused flesh , and doth for the most part require Exfoliation ; yet in this case I have cured without Exfoliation , but with great difficulty .

If a Contusion be made by a blow or musquet-shot , Cranium laid bare by contused wounds . when the force is spent , or when the head is armed , if there be no wound or symptom of fracture , or the like , you are to shave the hair off , and Embrocate the part well , and apply over all a Cataplasm , è Farin . Hordei , Flor . Ros . Balaust . decocted in Oximell , adding some Ol. Ros . and let your Patient bloud , and if there be a wound joyned with it , and made by shot or blow , you are to digest that wound as in contused or Gun-shot wounds : If there be not a way for discharge of Matter , you are to make one , that it be not shut in , and cause inflammation in Pericranio , and Fever follow . After digestion and separation , you are to proceed to Exfoliation of the bone ; for in such wounds the bone is Altered , both by Air and Matter . In order to Exfoliation you are to consider , that if the bone were not hurt , it is smooth and slippery , as it were polished , and flesh difficultly grows upon it ; wherefore by the Authority of Galen and your own reason , you are with Rugines to make it rough and thin , that you may make way for the Callus to sweat out of it : In this case if you rasp it here and there thin , till you see the bloud ready to come out of it , the bone will thereby be sooner supplied with materials for generation of flesh ; but if your Patient will not admit of Rugines , as in children it will not be allowed , then you are to keep your dossils with Sarcoticks close to the lips of the wound , and make your Exfoliation from the edges , that the sound part may thrust off the rotten bone ; for neither Crabs-eyes , nor any Medicine inwardly prescribed , or wine outwardly with Lint or other medicament applied to the middle of a bone , will signifie any thing to the Exfoliation ; nay the while you are so trifling , the matter from the edges will rot the bone underneath , and in continuance pierce through the first table , and run underneath betwixt the two tables , and do much mischief , and put you upon the use of the Terebra , in the curing of your Patient . If therefore you propose Exfoliation , then according to the Ancients you are to use Rugines to scrape the bone , and after the use of them , the bone requires its proper medicaments , Sarcoticks most drying in potestate & actu , as ℞ Rad . Ireos , Aristoloch . Rot . Thur . an . prt . aeq . in moister bodies Thus alone ; I suppose that bones raspt require digestion , and therefore dress it with liniment Arcei , and such like spread upon Pledgits of Lint , and so commonly Incarn them , then proceed with Ung . Tutiae , &c. to cicatrize .

Hitherto we have written of wounds and contusions of the hairy scalp and Pericranium , Cranium wounded , or fracture . and of the Cranium laid bare , as also of concussion : now follow those wounds of the Cranium it self , whether by cutting or puncture , by sharp or pointed weapons , which cannot be without solution of Continuity of the hairy scalp , but by a musquet-bullet shot at a distance , by a fall or blow the skull may be fissured or fractured , and the hairy scalp whole , and this fracture or fissure under the Contusion , or in some other part : If the symptoms do demonstrate that there is a fracture or fissure , you are then without delay to open the hairy scalp , according as the part will admit , Angular , or in the manner of a Cross , or of the letter T , that the fracture may be discovered by the raising up of the hairy scalp with its Pericranium : For if you shall in doubtful fissures or fractures make a round Incision , Against round incisions upon surmise . and take out the whole piece , then if there chance to be no fissure , you have made your self a long work to little purpose ; and if your fissure run farther than your Incision under the Calvaria , not discovered sufficiently , you are to cut it open that length , by which it will appear you have through mistake laid it open more than was necessary in one place , and too little in another , doing that which neither Hippocrates nor any of the Judicious would ever allow : Whereas if you made it without cutting off a piece , but only raising the scalp , you might , I say , if reasonably judged , have laid it open , so as you might have discovered the fissure or fracture ; and if yet part of the fissure or fracture had lain undiscovered , you might have stretched your Incision to it ; and in case after all , there had been no fracture or fissure which often happens , as in counter-fissure , then you might have laid the hairy scalp down again , and easily cured it , which by an excision of part of the scalp you have made , you cannot do .

Objection . As to what may be objected , that the raised up Lips may be troublesome to the Chirurgeon in his work , and are painful to the Patient ; there is no such thing ; for if the Incision be made the way proposed by the Ancients , and that the fracture or fissure be all in your view , you may order the lips of the wound as you please .

The Cranium laid bare , you are to fill up the place opened with dossills , pressed out of Red Wine or Oxycrate , or a Spunge prest out of either of the same liquors , and apply an Emplaster over all of Diacalcith . malaxt with Ol. Ros . cum Aceto , and bind it up .

The next day you are to consider the fissure , Trial of Fissures . if it be so small , as you doubt whether it be one or not , then wet it with Ink , and wipe it off again , and where the fissure is , the Ink will discover ; but if it do not , then this Emplaster is proposed ; ℞ Cerae novae flavae , Thuris , Laudani , an . unc . ij . Farinae Fabar . Terebinth . Aceti an . ℥ j . Misce ad Ignem : you are to apply it on the suspected part , and the next day where it is found moist , that there you are to Rugine .

Fallopius tell us , that where the Cranium is contused , certain spots will appear red , not unlike those white ones which are seen in the nails of the fingers ; but after the third day the bloud exhales , and that redness ceaseth : If by the former you discover the fissure , or that the bone be contused , you are to Rugine the contused bone , and the whole length of the fissure ; To which purpose and for that use to supply your self with various forms of Rugines : Whilest you are working with them , the lips of the wound are to be covered , that neither you hurt them , nor the Air offend them ; sometimes these very small fissures , how inconsiderable soever they may seem , are the cause of the Patients death , there being often found extravased bloud upon the Dura Mater , the Veins being broken either by the concussion from the blow , or by the rough edges of the inner table next the Membrane : Therefore you are to consider the symptoms , and accordingly lay open either by Rugines or cutting into it , so as the Sanies may be discharged , and the Asperity taken away : But if there be a fracture of the Cranium in one or both tables with a depression of the bone and a fissure also , Depression . which often happens , you are presently to make a way to relieve the Membranes underneath , for they cannot be without great disturbance and inflammation , and a putrifaction will follow , whence those symptoms of Fever , Delirium , Coma , Convulsions , Palsies , and Death ensue , if neglected . In this case you are to consider , whether the fissure do discharge the serous bloud or Sanies , and whether by cutting that fissure open , the deprest and fractured bone may not be raised up ; if it may , then you are to proceed by inlarging that fissure , and there with your Levatory raise up the deprest bone , and remove the fragments , and cleanse the membrane from the Raspings or ought else hath soiled it : But if the fracture doth not penetrate so far into the bone , nor there be any such depression or fear that Sanies is detained underneath , then you ought not to perforate the bone , nor expose the membrane to the Air , or more than is necessary ; in this your eye and symptoms will guide you .

In order to perforation of the Cranium , Perforation . the bone is to be cleared of its Pericranium , least in setting on the Terebra ( or Modiolus , which are two several names for a Trepan ) you tear the membrane , then the lips of the wound to be covered , and the Terebra set on the breadth of a finger distant from the edge of the fissure , on the side which is most depending ; if it may be with convenience , when you have set it on , press upon it with your left hand , and turn it round with your right , you must use a little Ol. Ros . or Milk , to cause it move the easier , and as it fouls brush it , in the doing of which it will cool , or you may dip it in water to cool ; when you come to the second table , which you will know by the bloud that appears , it will be required that you take out the pin & proceed more warily , not listning to the pratling of the standers by , but often lifting up your hand , lest by your compression or haste you unawares fall upon the Dura Mater and wound it . All this while it is fit his ears were stopped , lest the noise disturb him , and the room close . The perforation made in Cranio , and the bones taken out , you are to smooth away the Asperity , which remains in the lower part of the main bone , and this is to be done by the Lenticular instrument made for that purpose .

If after this the membrane be fouled by the saw-dust , from the bone you are to wipe it off with a little Lint upon your Probe ; the part cleansed , you are to dress the membrane : First dressing after perforation . About this first Application Authors differ , Avicen drest the Patient with Lenients , as Ol. Ros . Celsus he dressed the part with Siccantia , as with Aceto acerrimo , you may find him positively for it in these words , His factis , the perforation made , ea Membrana acri aceto , respergenda est , ut sive aliquid sanguinis ex ea profluit cohibeatur , sive intus concretus Cruor remanet discurtiatur ; The Membrane is to be sprinkled with sharp Vinegar , to prevent the flowing of bloud from the part , and that if there should remain any clotted bloud , it may be discust . But the most part of the Ancients and many of the Moderns do propose Lenients , as Ol. Ros . that the crude Sanies descending upon the Dura Mater , in pus convertatur , may be digested into Matter : In this you are to be guided by your eye : If there be Sanies or putrifaction , Mel . Ros . Spir . Vini , and higher detergents are to be used , as the putrifaction is more or less . If there be much bloud extravased , or that you fear bleeding , that of Celsus may be proper ; but if the bloud exceed not in quantity as it seldom doth , and if it be recent , it possibly happened from some scratch of your Terebra or little asperity of the inner bone or Table , or if there be neither of these , but the membrane fresh , and of its natural colour , then you are not to grieve that membrane , new exposed to the Air with detergents , nor by the Acrimony of the Vinegar ; for if you shall by scratching of the membrane make it bloudy , and then dress it with either Acetum or Mel . Ros . & Spir . Vini , you shall then proceed contrary to the common Indications in Chirurgery , which teacheth to digest recent wounds before you deterge : And indeed what would you deterge ?

Therefore I do propose to you Lenients , not only by the Authority of those Ancients and Moderns , but by my own Practice . Galen proposed Sang . Columb . and the bloud of Turtles dropt warm from their wings , Fallop . and Fabric . Aq. Pend . propose , as I said , Ol. Ros . with Resin . Abietis , and afterward they increase the Resina and lessen the Oil ; but if there be putrifaction through the long lying of concrete bloud , then Mel . Ros . & Spir . Vini are proper ; The thinner part . yea Mel . Egyptiac . and higher as occasion shall offer ; otherwise in common cases of recent Terebrations by the Emplastick quality from the Resina ; the concoction is better made , and the part secured from inflammation , &c. It is to be proportioned to the habit of body ; dry bodies require more of the Resina and less of the Oil , and by this simple Medicament , I never failed of good digestion , and afterwards by the tempering this , ( as I have said ) have deterged and incarned , continuing it until the membrane was well incarned , not finding the least prejudice the bare bone had received from it ; but you must take care , you do not too much relax parts ; therefore after digestion , Mel . Ros . with the Resina instead of the Oil will be answerable to your intentions , both to deterge and incarn ; or you may use this to both purposes , its composition will commend it self , ℞ Terebinth . Venet . ℥ j . Ol. Ros . ʒ iiij . Mel . Ros . Colat . ʒ iij . Croci ℈ j . Granor . Kermes ʒ ss . Sem . Hyperici ℈ ij . Vini Hispanici ℥ iij . Coq . ad consumpt . Vini Colat . add Aloes ʒ j . m . In the use of Medicaments , you are to consider the part and habit of body , and add or diminish your simples accordingly , and so they will perform all intentions ; if the wound be made by Gun-shot , then you are to dress the wounds as is said in simple Gun-shot wounds , and take out the Eschar , and afterwards deterge , as I have said , or with this , ℞ Terebinth . Opt. ℥ iij . Mel . Ros . ℥ ij . Succ . Plantag . & Apii an . ℥ ss . Coq . simul ad succor . consumption . add Farin . Hordei ℥ j . Sarcocollae ʒ jss . afterwards add Aloes ℥ ss . Myrrhae ʒ iij . Thuris ʒ ij . and so it will incarn ; and apply this Cataplasma , ℞ Farin . Hordei , Flor . Ros . Rubr . Fol. Beton . cum Ol. Myrtill . decoct it in Red-wine , and apply it over all . The Ancients used to the bone after digestion , Pul . Aristoloch . Rot . Rad . Iridis Pucedani , Myrrhae , as their Sarcoticks to sprinkle on the bone , which are very good , but Pledgits of Lint dipt in Spir . Vini , and prest out hard , will at such a time serve your purpose well ; and an Empl. de Beton . over all , or de minio Mag . or the like ; and where the flesh is luxuriant , touch it with either of the stones , or this Pulv . Balaust . Ros . Rubr . & Alumin . an . prt . aeq . Thus at Worcester , Observ . a day or two before the Battel , a Gentleman attended the Earl of Derby thither , with a large wound cut with a sword to the Dura Mater , he had no other dressings on but a Linnen cap , the membrane covered with the shivers of the bone , it had not been drest , and may be the better for him , for if dossils in haste had been prest in the wound , he would have laboured under some severe symptoms ; but the shivers lay loose upon the membrane , and he felt not his danger . I took these lightly out , cleansed the wound , and drest him up with lenients , the short time we were together . Authors have set us a limited time to dress with this or that Medicament , as to the fourth day so , and from that to the seventh to deterge , and so the fourteenth day Sarcoticks , but herein you must make use of your own judgments , persisting to cherish the native heat of the part .

If the wounds penetrate to the Dura Mater , you must consider the sorce of the Weapon , and make haste to relieve the parts under the Cranium . Gun-shot . But where they are made with Bullets or heavy blunt things , there they are often pasht into one another ; there you are presently to lay open the hairy scalp , & raise it up from the Cranium , and relieve the opprest membrane ; but if the flux of bloud should be so great as it will not permit , fill up the part with dossils dipt in Wine or Vinegar ; accordingly open it again as soon as you may , and in the while dress it up as hath been already said . These bones are to be hastened out with as much speed as may be , and the part afterwards drest with Lenients , as hath been said : If the opening in the fractured Cranium be not sufficient , make one in the most declining part , and raise up the bones , and free the membranes of whatever may offend it , but do not take out more bones than needs must , like some of those Chirurgeons I have met carrying them about , boasting in that which was their shame ; for these bones in recent fractures do unite as those in other parts , therefore having raised them up , dress them lightly with the Catagmatick powders , and they will happily agglutinate and make your cure more facil . In these wounds of the Dura Mater , the lenients of Ol. Ros . or warm Pigeons-bloud are proper , they are Anodyne and digest ; Ol. Hyper . and Mastich are also good mixt with Resina , for the curing these wounds , Fabric . Aq. Pend . cites Galen , and he Archigenes using the Succus Calamenthae dropt into the wound , and sprinkling Pul . Milii over for incarnating them , the Milium moderating the heat of the other , he delivers them to us as siccantia , detergentia , & incarnantia . The unition and incarning of the Lips of the Dura Mater is performed by a fleshy substance that ariseth upon the membrane , which afterwards as it increaseth , doth unite over it , and becomes one body , and grows firm ; mean-while the bones within Exfoliating thrust from the side a Callus , which uniting with the forementioned flesh becomes one body with it , & filling up the place that was perforated , is in time more firm than the bone itself was ; but in the while , you must be careful that your Lenients make not the part too lax by their greasiness , for so a Fungus will thrust out thence which may be vexatious to you ; This in the beginning by desiccants , as Pul . Cort . Granat . Balaust . Ros . Rubr . Alum . ust . with a soft dossil and compression by Bandage , will be taken down , or if it grow very big by ligature it is taken off : But to tell you truly , I never met with any such like disturbance as is represented to us by Authors , nor shall you , if you use your desiccants timely : The Vitriol or Allom-stone insensibly takes this off , and disposes the part to cicatrize if daily used .

The Pia Mater is a most delicate fine membrane , and adheres so close to the brain , that it can scarce be wounded without a wound in the Brain ; and these are most commonly mortal , for that it is full of Veins , and subject to great effusion of bloud ; the Brain wounded and exposed to the Air corrupts by reason of the external cold which soon extinguishes the little heat of this part . And by reason of the fluidity of the Brain , and contraction of the Meninges ( or membranes ) caused by the constant pain and irritation , the brain perpetually ouseth out upon you , till the whole wounded Lobe be spent . You must make way to these wounds by removing the shattered flesh and extraneous bodies and bones : but if they will not come easie away , leave it to nature , lest he die under your hands , and you be thought to hasten his death . Your dressings must be with Galen's powder , with Hares Furre , with the white of an Egg to restrain the bleeding , and retain the brain within its bounds , and over them your dressings , as in the wounds of the Dura Mater , and over the wound digestives ; remembring in all these Gun-shot wounds to cut off the shattered lips of the Calvariae , Note . lest a Gleet drop from them upon the Meninges and brain , and heighten the inflammation : If the brain be retained within its membranes Pia & Dura Mater , and they digest and incarn , then you are to proceed in the rest of the cure as in fractures of the Cranium , as hath already been said .

In all hurts of the head what sort soever they be of , the Body is to be emptied , and the rather , Internal medicines . if there be Plethora or Cacochymia ; for in such habits of body humors are apt to stir up ill symptoms , especially if the wound be great ; therefore you are the first day to open a Vein in the Neck or Arm on the same side , and bleed according to the exigency and strength of body ; also cupping with scarification of the Neck and Shoulders , with Fontanels under the Ears is necessary : Then Lenient medicaments , such as may evacuate the serous bloud , which by reason of its tenuity and heat readily flies to the affected part . These are such as have been proposed in the Fourth Intention of Wounds in General , to which I refer you . In these cases cordial Species and Electuaries , with Juleps and Emulsions may be proper , if they be proportion'd to their temperature , hotter or colder , as there are Fever or other Accidents joyned with the malady . Vulnerary drinks are sometimes in use here , if they be fitted according to the nature of the part , and the ingredients , for these are Beton . Artemis . Caryophilat . primula veris , Lillium convallium , Salvia : Hypericon . Sanicula , Veronica . Plantag . Flor . Ros . Rubr . Nux Moschat . &c. as in the Chapter forementioned : Of these you may make drinks with Wine and Water or small-Ale , as ℞ . Sanic . Beton . Veronic . Artemis . an . ℥ j . Cons . Ros . Rubr . Caryophillat . an . ℥ ss . Torment . ʒ ij . Coquantur in Aq. Pur . & Vini Rhenani an . lb ij . Vase clauso in B. M. colentur per manicam Hippocratis ; give ℥ iiij . of this morning and evening , or take ℥ j . of all these Plants well dried and cut , boil these as you do Thè , sweeten it with Mel . or Saccharum to the palate of your Patient , and give them a dish of it to drink twice or thrice a day , you may Aromatize it with Saunder . Cassia Lig . or Sassafras , &c.

In the External Applications to the part affected , External . you are in the first place to prevent flux of humors , which is performed by refrigerants & exsiccants , which also dries up what is already extravased in the part ; to which purpose Hippocrates proposes Far . Hordei ℥ viij . Ol. Ros . ℥ iiij . Coct . in Acet . or Oxycrat . and made into a Cataplasma ; In Winter he added Flor . Ros . Rubr . Pulv . ℥ ij . and decocted it in Vino , others have since added Bac . Mirt . Balaust . to corroborate the relaxt parts , then they Embrocated the head and about the Jugulars , with Albumin . Ovor . Acet . & Ol. Ros . &c. sometimes only with the latter , but without the Acet . the Ol. Ros . seems to me not to penetrate enough . The want of these Embrocations is sometimes the cause that tumors arise behind the Ears . To contused and great wounds speedy digestion is required , not only in the Calvaria , but Meninges of the brain , and these ought to be humectantia & emollientia ; and herein , as I have elsewhere said , Terebinthina is the most proper medicament , and in these Nervous parts you may use it washt or not ; in dry bodies they add Thus , in humid bodies and recent wounds Vitel . Ovor . & Ol. Ros . also Farin . Hord . Cribrat . others Terebinth . Venet . ℥ jss . Ol. Hyperic . ʒ vj . Thuris ʒ ij . Vitel . Ovi j m . or R. Resinae Abiet . ʒ vj . Vitel . Ovi ; or R. Terebinth . Lot . in aq . Salviae ℥ j . Ol. Ros . ℥ jss . Gum Elemi cum olco super Ignem dissoluti & colat . ℥ ss . Vitel . ovi ʒ j . Croci ℈ j . m . and if there be much pain a Cataplasma ex Radic . Althae , Flor . Meliloti , Farinae Hord . Ol. Ros . Vitel . Ovor . and a little Crocus , but you must have a care by your slabby medicaments you cause not putrifaction ; wherefore Matter thus made , which happens in three or four days , you are then to deterge by adding Mel . Ros . or Mel . Com . or this , R. Terebinth . ℥ ij . Mel . Ros . ℥ j . Pul . Myrrhae , Aloe , Mastich , an . ʒ ss . m . Discutients are now required outwardly by Cataplasmes , Cerots , and Emplasters , as Empl. Vigonis de Beton . Gum Elemi de Matrisilva , Cerat . Isidis , or R. Succi Beton . ℥ ij . Ol. Ros . ℥ iiij . Mastich , Myrtillor . an . ℥ j . Pingued . Hirci ℥ jss . Coq . ad Succ . consumption . Colat . add Gum Elemi , Tacamahaca an . ʒ x . Terebinth . ℥ ijss . Cerae Alb. qs . Iterum Buliiant ad consistent . Cerat . or ℞ Gum Elemi ℥ iij . Opoponac . ℥ ij . Bdellii ℥ ss . Resinae pin . ℥ j . Cerae qs . Ft. Ceratum . In all wounds of the head Gum Elemi is much commended , it mitigates pain , and corrects the evil temper of the part , by a peculiar vertue it hath thereunto . Fab . ab Aq. Pend . commends this Empl. R. Beton . Virid . m . viij . Contund . Contus . addantur Ol. lb iiij . Cerae , Terebinth . an . lb j . coquantur , & exprimantur suc . add Beton . virid . Contus . m . viij . Iterum coquantur & exprimantur pro usu .

The use of Spir . Vin . is much commended in these wounds of the Meninges , Spir . Vini of what use in these cases . as having such a siccant quality , as is requisite for them ; but in recent wounds where there is fear of pain and inflammation , it is not to be admitted , but amongst detersives is of great use and proper for the Bones : Vigo commends this , ℞ Spir . Vini ℥ vj . Myrrhae ℥ ss . Aloes ℥ j . Sarcocol . Thuris an . ʒ ij . or this Balsam . ℞ Spir . Vini lb jss . Vin . Malvatici ℥ xvj . Myrrhae , Thuris an . ʒ x . Pul . Rad . Consolid . ℥ j . Pul . Centaur , Min. ℥ jss . Flor . Hyperici Pul . ℥ ss . Tereb . lb ss . set this in Balneo a month , then reserve it for your use , drop of it warm upon the Meninges , or mix it with your other medicaments for your use . If the Dura Mater have changed his colour , and do not deterge with what is proposed , then this is commended to you , ℞ Tereb . Lot . in Vin . Alb. ℥ iij . Mel . Ros . Spir . Vin . an . ℥ j . Myrrhae , Aloe , Sacchar . Alb. an ʒ ij . m . If there be yet such ill quality in these wounds that they tend to putrifaction , scarifie the Lips of the wound , and apply this or such like , ℞ Mithridatii ʒ vj . Theriac . venet . ʒ ij . mel aegyptiac . ʒ j . pul . scord . myrrhae , an . ℈ j . sp . vin . qs . The putrefaction got off , and the Membrane recovered in its colour , you may then dress with the above mentioned , or you may dress it with this of Johan . Andr. à cruce , ℞ ol . Terebinth . venet . mel Rosar . p. aeq . apply it warm , all these Medicaments are to be applyed upon a Sindon to the Membranes . A Sindon is a piece of Silk , or fine Lining cut round proportionable to the perforation made in the Cranium , and is to be placed in under the edges of the Cranium by the Lenticular Instrument , that the edges of the fractured or perforated Cranium hurt not the Dura mater : A Thread or Silk is to be fastned to it to pull it out at pleasure ; over this you are lightly to place soft dossils of Lint dipt in some convenient Medicament , to fill up the void space in the Bone , this serves to cherish the native heat of the part , and to keep the dura mater from rising above the Bone , whereby your Patients life would be in great hazard : the Tincture of Myrrhae forementioned is proper to dip the dossils in after digestion .

In wounds of the membranes of the Brain , Medicine in wounds of the Meninges . and Brain it self , this is good , ℞ succ . Beton . ℥ iiij . succ . calamenth . ℥ ij . flor . Centaur . min. p. j ss . hyperici , contus . ʒ ij . vini odoriferi lb j . Infuse these three days , then boyl them to the consumption of the Juices , then strain it , and add to it Terebinth . clarae ℥ iij . Gum . Elemi ℥ j . dissol . in sp . vini ℥ ij . ol . Hyperi . ℥ j ss . mel . Ros . ℥ iiij . boyl these a little , then add pul . myrrhae , Aloes , Sang . dracon . Thuris an . ʒ j . and reserve it for your use ; oleum Aparici prescribed in wounds in general is an excellent good Medicament in recent wounds of the Meninges and Brain .

Fabr . ab Aq. pend . proposes this in wounds of the Brain , Qu . whether the dose of ol . chalcanth . be not mistaken , at least if by it he mean ol . vitriol . ℞ farinae milii ℥ ss . olei aparici ℥ j . Mithridati ʒ vj . Bals . pervan . ex Aegypto ℥ iij . sp . vini ʒ v. and if more desiccant be required , he adds olei de chalcanto ʒ j ss . drop this ( saies he ) warm and your digestives over the wound , and to Embrocate the head and parts about with ol . Ros . and lay this Emplaster over all , far . Hordei ℥ viij . pul . chamel . ℥ iiij . pul . spicae Scenanthi an . ʒ iij . pulv . Beton . staechad . an . ʒ ij . ol . Mastich . lb ss . ol . Ros . ℥ iiij . oxy mel . simpl . ℥ v. vini albi medioc . potentis . qs , ft.

If the bones be carious and do not readily exfoliate , you are to Rugine them and dress them with ung . Arcei , and if they do not incarn by that , then ℞ sp . vini ℥ x . Myrrhae ℥ j . Aloes ℥ j ss . rad . pucedan . Aristoloch , cort . Thuris , an . ℥ ss . pulveriz . & misceantur pro usu . It is to be used with Lint ; In dry Bodies this ℞ pul . Aloe pumic . ust . pomphol . an . ʒ ij . Myrrhae . ʒ j . pul . ostre . combust . ℈ ij . this to be mixt with mel . Ros . & sp . vini . And this Emplaster over it , ℞ cerae , Resinae pini , amoniaci , Elemi , an . ʒ vj . Terebinth . ℥ iij . pulv . Myrrhae , mastick , Aristoloch . rot . Ireos , Aloes , opoponac . Euphorb . an . ʒ j . ol . Ros . q . s . ft. Emplastrum , after parts are incarned you may cicatrize with one of these or such like , ℞ plumbi usti cum sulphure & loti Litharg . aur . an . ℥ ij . Antimonii usti & loti cerussae , an . ℥ j . ol . Ros . q . s . ft. ung . or thus , ℞ pulv . Aristoloch . ust . flor . Ros . rub . Balaust . cupress . ustor . ostrearum . an . p. aeq . ft. pul . or thus , ℞ calcis testarum ovor . calcinat . ℥ ss . Alum . usti ʒ j . croci martis ℥ j . ft. pul . Thus I have set you down variety of Medicaments , whereof you may fit your selves according to the exigency , and shall now shew you some of my work , wherein I used but a few .

Observations of the Wounds of the Head .

A Poor woman near Ludgate , coming out of Chamber one Night , A large wound of the Calvaria . pulling the door to her by the Key , it slipt out , and she tumbling down stairs , cut and raised up the Hairy Scalp ; from the beginning of the Lambdoides downwards ; I was sent for , and having caused the hair to be clipt and shaved away from about the wound , I cleansed it from the bloud , and brought the lips close together by three or four stitches , and held them so , then sprinkling them with some of my agglutinative powders , I applyed a pledget over the Suture , and Embrocated the parts about cum Alb. ovi , Aceto with ol . Rosar . and adding some of my agglutinative powders with the foresaid mixture , I applyed it over all and roul'd up her head . I gave her afterwards ℥ iiij . Aq. Papaveris with Syrup . de miconio and a little Aq. Cinamom . hordeat . and left her to rest . The next morning I took off my Bandage and restrictive Emplaster , and Embrocated with ol . Ros . & Aceto . and applyed a Cataplasm of farin . Hordei & fabar , dedocted in Oxycrate , adding ol . Ros . and took away a little bloud by the opening a Vein in her Arm , and prescribed her a Clyster of Milk and Sugar that afternoon : Thus , I continued the Cataplasma and renewed it morn , and night ; but drest not the Sutures till the third day , and by that time the tumor diminished , and the wound inclined to agglutination . I Embrocated the parts about , and drest up the wound again as before , the next dressing I cut out the stitches , and drest up with my Agglutimative and Sarcotic , with my Empl. Beton . over all instead of the Cataplasma , and in a few days cured her of that wound by Agglutination .

Some while after I had a young man my Patient , who by a such like Accident was so wounded on the right Sinciput , whom I cured the same manner as abovesaid . It hath often hapned abroad , that upon a fall from their horse , or blow by a Pole Axe or the like , the Patient hath been stunned and did vomit , by which Symptomes I have suspected a Fracture or Fissure , so have presently laid open the calvaria , very large by cross or the like Incision , and after the raising up the hairy Scalp , seeing all well , I have laid it presently down again , and by Agglutinatives , and sometimes by Suture with two or three Stitches at a distance to keep the lips of the wound close , have by agglutination cured it in few days , applying refrigerants and exsiccants with bleeding , Clysters , &c. and have happily gotten them off in a little while .

A Young fellow a servant to a Horse-courser , was cast off his Horse against some of the Bars in Smithfield , Of the Calvaria torn off . whereby the calvaria or hairy Scalp was torn up from the Coronal Suture to the Temporal Muscle on the left side , the Skull was bared between two and three Inches broad , he was led to the next Barber-Chirurgeons , who cut the piece off , and hang'd it up in his Shop ; the next day the poor fellow was brought to me , I caused the hair to be shaved off from about the wound , and drest the Bone and Lips with Linim . Arcei warm , Embrocated parts about cum ol . Ros . & Chamamel . and applyed Empl●● Rolo over the wound , and with compress and bandage rouled up his head . He had been Let bloud the day before without consideration of the great quantity which he had lost from his wound . I continued the former dressing to the Lips of the wound and Bone , untill they were digested well , in which time the edges of the Bone Incarned round , the middle of the Bone I Rugined . whereby I disposed a callus to put forth . After digestion I deterged with mund . Paracell . and after the callus grew up from the Bone , I drest the part with pledgets dipt in sp . vin . prest them out drie and applied them over the Bone . After detersion I drest the wound with one of my Sarcotics mentioned in the fourth Chapter of wounds in General , and afterwards by Epuloticks as ung . Tutie , &c. cicatrized the Lips of the wound even with the callus , as it rose from the Bone , and as the Bone shel'd off here and there in thin Seales I Cicatrized the wound , and about that time to dispose it the better to do so , he was purged sometimes , Thus he was cured as a wound with loss of Substance , a troublesome and vexations work to the Patient and Chirurgeon , which might at first have been cured by agglutination or with a less Cicatrix and have enjoyed its natural treatment with the hair , whereas now it remain'd Bald & very unseemly .

A Cook-maid , by the fall of a great Jack-weight from its full height without doors upon her head , A great contused wound . was beaten down , and stunned for some while by the blow , she vomited and was carried in doors with great pain , there were three wounds to the Cranium , the flesh pasht , with a great tumor , the bone seemed to me to be deprest all under and to have a fissure , I presently made a Circular Incision , and raised up that part of the hairy Scalp in Order to Terebration , and fill'd up the wound , and the bone with dostils of dry Lint , shaving the hair from about the wound . I applyed pledgets spread with my digestive upon the Lips of the wound , Embrocated parts about with ol . Ros . & Aceto , & Empl. è Bolo over , then with compresses dipt in Oxicrate rouled up her head . Some hours after I caused her to be Let bloud about eight ounces , and that night gave her ʒ vj . syr . de meconio , in a draught of Aq. Papaver . with a little Aq. Cardid●a . The next day I took off dressings , and viewing well the bared bone , I found neither depression or fissure , I was deceived by the shape of her head , viz. double crowned , the tumor great , and the saggittal Suture running underneath , I fomented the parts affected with vin . Rubr . wherein was decocted flor . ros . rubr . Chamom . fol. Beton . scabiosae , sumit . Absinthii , Bacc . Myrtil . &c. drest the bone and Lips , the former with my Unguent è succis , and the latter with my digestive è Terebinth . dipt in ol . Hyperici warm , and having Embrocated her head well with ol . Ros . & chamom . I applyed a Cataplasma , sarir , hordei , pulv . balaust . & ros . rub . decocted in Oxycrate with ol . Ros . over all with convenient Bandage , this method I continued till the wound was digested , and pain mitigated , and the tumor discussed , then I deterged the wound , and continued the former ung . to the Bone , as also to the Lips as a sure Sarcotick , and drest over all with one of Vigo's Cerots instead of the Cataplasma ; by this method the bone Incarned , she returning with Medicaments to be drest by some of her fellow servants at her Masters house a few miles off , sometimes coming to me , the Bone and Lips Incarned , I Cicatrized them as in the former Laceration of the Calvariae , I did not believe so great a blow could be without a Fracture and great Accidents , otherwise I should not so presently have raised off the hairy Scalp .

A Tradesman returning from visiting some of his friends in the Countrey , near Knights-bridge , A Concussion . fell off his horse to the ground bruised and wounded his Forehead and Face , was taken up as dead . After he was a little revived , they put him into a Coach and brought him to his house , they sent for me , I found him in his bed labouring under a Concussion , a Stupor upon his Spirits , not capable of giving any account of his ailment , his Face & Nose much bruis'd with a wound to the Bone upon the os ●ribrosormis , reaching from the upper part of his Nose , to the os frontis : I caused the bloud and gravel to be washt out of his wound , and with my Knife laid open the wound a little higher up the forehead , viewed the bone and see it without Fissure , I then brought the lips close together , and drest the wound with my agglutinative , with an Empl. è Bolo over it and his Face ; I then caused the hair to be shaved from the forepart of the head , from the Coronal Suture down to his Ears forward , and Embrocated the parts shaved with ol . Ros . cum Aceto , and applyed a Cataplasme of farinae Hordei with pulv . flor . Ros . rubr . Balaust . & Bacc . Myrtil . boyled in Oxymell , and by Bandage retained dressings close , then I let him bloud , between Ten and Twelve ounces , a Neighbouring Physician visited him that night , and prescribed him what he thought necessary ; he lay dozing all that night , groaning and troubled , and was not better in the morning ; he spake not willingly to any of us , nor so as we could understand what he said , that day I took off dressings , viewed and felt the parts about , the left eye was Inflamed , the lid swell'd , and the forehead bruised , I was not able to make out any thing , whereby I might take new Indications , I drest him up again as before , ordering a little breast milk to be dropt warm into his eye , and renewed the Embrocation and Cataplasme , that day he was Let bloud again , and a Clyster given him , and what else his Physician thought necessary , the next day he was not better , old Mr. Boune a Chirurgeon was consulted , we took off dressings and considered parts , opened the Lips of the wound again , and viewed the Bone , it was fair without the least Impression , Mr. B. did conclude that the wound should be cured without farther enquiry therein , which accordingly was done in few daies after without exfoliation . Blistering of his Neck and Shoulders , and Cupping with Scarification was resolved by us , and accordingly performed with Fontinells behind his ears , Fomentations and Emplasters were applied as in Concussions ; but the relief was small yet by these , purging , fomentation and Emplasters with otherlike applications , he after a moneth or six weeks was so well as a little to folow his occasions abroad , but was not well : his eye was cured , but after he had followed his affairs some while , of a suddain that eye-lid fell down , and recovered not its strength again , but in some moneths after he lost the sight of that eye , without any outward soreness , which I imputed to the obstruction from within , it being the effect of his Concussion : He was a live at the time of the Fire , and may be so still for ought I know ; if ought was omitted it was further bleeding .

A Gentleman of about 30 years of Age , coming out of Hartfordshire in passing through Totenham , Another Concussion rode upon the Causey near an Inn. One emptying a Chamber-pot out at a window , just as he was passing by , his horse started , and rush'd violently between a Sign-post and a Tree which supported it . The poor Gentleman was beaten off his horse by that Tree , and lay stunned on the ground : The people sent Immediately for Mr. Torner , a Chirurgeon from London ; Sir T. B. upon notice of his friends mishap sent me thither also , where I found the Gentleman lying stunned upon the ground , the people and Chirurgeon gazing upon him . I felt his Pulse much opprest , the right Brow bruised , I inquired whether they had Let him bloud , the Chirurgeon replyed he had opened a Vein in his Arm , but it would not bleed ; I replyed we must make him bleed though it be by slitting his Veins . I turned his head on one side , proposing to open the Jugular Vein on the bruised side . I did so , and he bled freely ; after I had taken about twelve Ounces of bloud , the bloud run down from his Arm , which was opened before ; we bled him till he came to life . Then he raved , beat us from him ; we staid the bleeding by Emplaster and Bandage , and caused the people to carry him into the Inn , and put him into a Bed . All the while they carried him and were making him unready , he roared and was very unruly , especially whilest they were pulling off his Stockings from his right Leg , which inquiring more particularly into , we found broken short in the middle of the Thigh-bone , A great Bony Wen . close by a Bony wen of the bigness of a Tennis-ball ; they put him into Bed , and we prepared dressings for setting and reducing the fracture , he opposed us mainly in the Setting and dressing it up , but some of the people holding him down in his Bed , we set and drest his Leg as is said in the Lecture of simple Fractures ; but he was no sooner at liberty , than he endeavoured to loose the Bandage which we had put on for keeping the Fractured bones together , and would not be quiet until he had done it . We contented our selves in what we had endeavoured , and from that time left his Leg to lye unset or drest , not so much as an Emplaster over it , and prepared the application for his head , shaving the hair from that side of the Temporal Muscle , and Embrocated the part which seemed to us affected , cum oleo & Aceto , and applyed a Cataplasma of Bean-meal which was speediest to be had , and with aceto & mel . & oleo , and four whole Eggs , which he permitted patiently . That bound on , I left my Brother Chirurgeon to stay with him and returned to London : The next day , Sir T. B. sent for Sir Ch. Scarborough , and carried us with him to Totenham where we found the Patient raving as by their report , he had done all night . We understood not one word he spake , his pulse was now intermitting , no Indication for bleeding , what was necessary for him to take the Physician then prescribed , and concluded that there was no Indication to do more at present ; his bruise was upon the Temporal Muscle , a part not to be laid open , upon a bare surmise , nor shall I ever allow the laying it open though a Fissure were under it , but content my self , as Ambr. Par . did in such like cases , to open above it , and make discharge that way , wherefore we renewed our Embrocations and Cataplasmes , and continued to dress his head daily as hath been said in Concussions : Then we left the Chirurgeon to wait upon the Patient ; Sir Ch. Scarborough was going a journey farther into the Countrey , I to London , but with promise to return daily to this Patient while he lived . I did so , and the next day finding the Patient raving as I left him , his pulse troubled and intermitting , I resolved to attempt a doubtfull remedy rather than suffer him so to languish , and that was bleeding him : his distemper proceeding from Inflammation of the Membrains of the Brain , the oppression was certainly there ; to which purpose I let him bloud from the same Jugular about Ten ounces , and so proceeded every day or second day at least . The Patient bare it well , and seemed to be relieved , his pulse rising upon it , and he slumbring sometimes , and taking his nourishment which before he did not ; about the 17 day I coming to him near Totenham met his Chirurgeon going to London , he told me that if he had met me at the Patients Lodging , we might have set his Leg , he being now more sensible of the Fracture . I perswaded him back , much rejoycing to hear that the Patient was so well ; but when I came near his Chamber I heard him hollowing . It troubled me what to do , I knew his bleeding had much relieved him , but the People as also the Chirurgeon disliked my so often Letting him bloud , and did abusively say , Now you shall see this Chirurgeon Let him bloud again , and that I would be the death of the Gentleman ; however I resolved to Let him bloud once more , and no more . This I declared with the necessity of doing it , and accordingly opened the same Vein again , and held a white stone Porringer to receive the bloud , which flowed with a sprightly stream , the Patient lying as quietly the while upon his back , I put the Porringer into Mr. Turners hand , and seeing the bloud flow with much vigour , I catcht up hastily a pewter Porringer , proposing to take a little in that . In bleeding these Veins in the Neck , we usually holding the Poringer close to their Neck it serves us as a Bandage to intercept the descent of the bloud . I put this Porringer into my brother Chirurgeons hands , with pretence to make a dressing to lay upon the Vein , but stood at a little distance , looking my Patient in his Face , with a resolution to bleed him until I saw his Countenance change ; which I did , and then stept to the Patient to stop the Vein : The while the Porringer was taking away , the bloud run out of the Porringer , it having been melted in the side , and the hole so covered by the Sawder as I did not see it before ; in the while he was bleeding I thought him long in bleeding , and wondred to see so little quantity gathered from so full a Stream , and now seeing the bed so bloudy , it was evident that when the melted hole prest not against his Neck , the bloud ran into the bed which deceived me . But the Patient upon the taking a little of his Cordial Julip , refresht his Spirits , I sat a while by him , and left him pretty hearty . The next day I returned sooner than I used to do , being doubtful how I should find him , but to my wonder , he was perfectly well in his Sences , and discoursed soberly of what passages he remembred in the time of his delirium .

We presently prepared now to set this fractured thigh bone , after it had lain 17 daies unset , it was without Inflammation Tumor or pain . The Callus I suppose was thrust out at the ends of the bones , and that had covered the Asperity of the fractured ends of them ; as the large bleeding and disease had made revulsion and evacuation . We by an easie extension brought the ends of the bone together , and drest it up as I usually do in simple fractures , and in less than twenty daies the Callus was dryed , and his Leg so strong as to bear him again , and some weeks after he went abroad about his Affairs .

A Youth about Ten years of Age , was struck down by a blow upon the forehead , A Fracture with a long fissure and depression of the Cranium . his Father fetcht me to him , I found him lying upon a bed deprived of his speech with a loss of the use of his legs : I took off the Emplaster which was upon his forehead , there was no wound , nor considerable swelling , but searching with my fingers I felt a depression of the bone , upon which having advertised the Parents of the danger of the child , and the way of my proceedings , I sent for the Chirurgeon at next dore , who had applyed the first Emplaster , I desiring to retain him for more constant attendance , shewed him the way of making dressings ready in order to dilatation : Then causing the hair to be shaved , I made an Incision so large as to set on the Terebra , if an occasion should be , for the raising up the deprest bone . Upon the raising this Calvaria upwards toward the Coronal Suture , I espied a fissure running up from the fractured Bone beyond my first Incision ; wherefore I followed the fissure laying it open the whole length near to the Coronal Suture , out of which I see a serous bloud flow in a good quantity , by which I promised my self a suddain remission of these Symptomes which the child laboured under . The depression was a piece of bone as broad as a three pence sunk in below the first Table : I fill'd up the opening with dossils of dry Lint , and applyed over all my digestive , è Terebinth . vitel . ovi upon pledgets with Empl. è Bolo , and made a Bandage to keep my dressings on , after I had Embrocated parts about with ol . Myrtill . & Ros . cum Aceto ; The next day in the presence of Dr. Barwick and some Countrey Physicians with Mr. Arris Chirurgeon , I took off the dressings , and set the Terebra above the fractured bone for to avoid the great Scar which must have been , had I made it below the fracture , besides that poriness of the bone below . Here in this wound , I also cut that Vein , which in the former discourse I gave you caution to avoid , which could not be here , the fracture being just under it , and in such cases even the Artery it self is not to be spared . The Terebra set on , the bone taken out , and the inner edges smoothed by the Lenticular Instrument I put in a Levator , and raised up the deprest bone even with the rest : That done I placed in a Syndon with a bit of Thread or Silk fastened to it , first dipt in ol . Ros . with a third part Resinae warmed , then with a round dossil dipt in a little Lin . Arcei , which fill'd up the opening , out of which the bone was Terebrated . Then I opened the fissure with my Rugines , scraping away its edges that no sanies or matter might be detained there to hurt the bone . Then I drest up the bone with Linement Arcei warm , in that long wound which I made to give a breathing to the fissure , keeping it open by a single dossil giving way to the lips to fall in , and digested them with the same Linement : I desiring no more opening than was necessary for discharge of matter from within the Cranium , taking care that the fractured bone should not be intangled with lax flesh , lest it become carious . Over these dressings I applyed Empl. Diacalcith . malaxt with ol . Ros . cum Aceto , and with compress Bandage concluded that second dressing ; and from this time , all our threatning Symptomes vanished : Indeed the first opening and Letting bloud that same night recovered his Speech , and after this second dressing his Legs became well again , yet we kept him in the dark , and to a slender dyet allowing no flesh . What concerned Internals Dr. Barwick took care of , the other Physicians and Chirurgeons coming no more ; I continued the same method in my dressing until digestion , which was made in 4 or 5 days , then I added Mel . Ros . instead of the Oyl , and afterwards incarned by increasing the Resina and lessening the Mel . Ros . The flesh rising in little grains presently after the digestion was compleated , after a few days did more cover up the Dura Mater ; Then I hastened the exfoliation of bones , deterging the wounded lips with Mund . Paracels . from this time the work being rather to keep down the lax flesh , than to seek how to make it grow ; to which purpose I drest the Cranium with pledgets dipt in sp . vini , and the Lips of the wound with ung . Tutiae , sometimes touching them with my Vitr . and Allom-stone , which were of great use , and do hasten the cicatrize with much safety : In less than six weeks the bones were Exfoliated , and the wound ready to cicatrize , at which time I left it to the neighbouring-Chirurgeon ; the Patient was cured , and is now a man .

A person wounded near the Vertex by a blow , sent for a Chirurgeon , A contused wound by a blow on the crown of the head . who drest his wound , the Patient going daily abroad kept ill hours , without any Consideration had of his wound , whether it was drest or not . After seventeen days towards the full moon , coming from abroad home one morning , he felt his legs faulter , and before he was got up stairs into his chamber his tongue failed him , his friends and servants put him into a bed and sent for me . They declared to me how he was wounded so many days since , and how he was seized with a Paralisis of his legs and tongue . I saw a necessity of laying open the hairy scalp , for the setting on a Terebra , I offered to go away that I might send for some of my servants to help me : He apprehending that I was leaving him as deplorable , catcht hold of me , would have spoke but could not : he made signs for pen , ink and paper , he endeavoured to write but could not form one letter , he threw himself down in his bed , breathing out Jes . I pray'd his patience , telling him I would return suddenly : but before I went I let him bloud ten ounces , then hastened away , and returned again within an hour , and found that he had lost the use of his Arms. I considered the wound , and concluding a necessity of setting on a Terebra , and thereto having caused his head to be shaved , I made a circular Incision about the wound , and rais'd up the Calvaria with my Spatula , bringing the Pericranium smooth off . I both saw and felt the bone , but could discover no fault in it , with Spunges dipt in Aceto I dried up the bloud , and raised up with my Spatula the edges round from the bone , and with a fresh Spunge dried up the bloud , and lookt again under them , but could discover nothing ill in the bared Cranium . I fill'd up the wound with dossils of dry Lint with my digestive over the lips , and Embrocated the parts about with Ol. Ros . and an Emplaster over the wound , and a Cataplasme è Farin . Hordei , Flor . Ros . Rubr . Balaust . in Vino Rubro , with Syrup . de Ros . Sic . & Ol. Chamomell . and bound it up . That day Sir Fr. Pr. gave him a Visit , and prescribed him a Clyster , with Cordials , Juleps , and what else he thought necessary . The next day was full Moon , at which time the brain is thought to rise high , and the Vessels turgid ; wherefore I deferred the setting on the Terebra , contenting my self with the letting him bloud again . All this while he was in a Fever , and deprived of speech and limbs ; the next morning about ten or eleven of the clock in the presence of Sir Fr. Pr. Serj . Pyle , Mr. Arris and Mr. R. who thought himself concerned for his servant who had first drest him , I took off dressings and lookt into the wound : we found no fissure , however there was a necessity of the Terebra . Wherefore without delay I proceeded , and in order to it covered the lips of the wound with a fine Lawn dipt in Oil of Roses , & began to work with that Instrument commonly called a Trepan , which I much prefer , it being an Instrument that suffers you to turn lightly , and cut equally or how you please , without shaking or pressing so hard on the head : In the performing this or any operation amongst our brethren the standers-by are very apt to be teaching , one cries not so fast , the other thinks you move too slow , but of these I took no notice but proceeded , and brought out the bone , taking out the pin , when I came to the first table . You shall perceive your self to be entring it , when you see the raspings change , or begin to be bloudish , from that time proceed very gently , and take out the head of the Trepan often , and cleanse it by a brush : The Bone out , I lookt into the part , and see the Dura Mater of its natural colour without Matter or Bloud , I drest it up with a Sindon dipt in Ol. Ros . with a little Resina dissolved and warm ; this way of dressing was objected against by Mr. R. as I expected . I smil'd and drest it up with it , and assured the Person that I would cure this Patient without applying any other remedy to the Dura Mater than these two simple medicaments : But withal was much unsatisfied in my self , that such grievous symptoms as loss of speech and limbs with a Fever should afflict the Patient , and yet no deprest bone or fissure , nor ought of Matter or Sanies appear upon the Dura Matter ; this troubled me much , fearing some other place , or that the bloud lay putrified under the Dura Mater . But I drest up with a soft round dossil dipt in the same medicament , and placed it in next the Sindon lightly , and drest the bone with linement Arcei , and continued the digestion to the lips of the wound , and my Empl. de Beton . Mag . over all , I placed him down in his bed . Going presently out of this close room , where I was crouded up with great lights burning near me , into the fresh Air , I burst out with a violent coughing of bloud , but the next day drest the Patient again , and found his speech and limbs restored , but he was hot , and his pulse quick : I opened his wound and found all well , as I could expect : I drest him up again as before with the same , and after I had bound him up , as is usual in these cases , I let him bloud ten ounces , and gave order to repeat his Clysters , &c. From the first opening there came no more any of the Chirurgeons ; I retained the Chirurgeon that had first drest him in his little wound , he dwelling near the Patient . After three or four days dressings these wounds digested , and all symptoms went off well : I then lessened the quantity of the Ol. Ros . and increased the Resina , and made good my word in curing him with these simple medicaments . I deterg'd and incarned as firm and speedily by this , as any Sarcotick I ever used , and as the bones cast off proceeded to cicatrize , as in the former Patient , dressing the lips of the wound with my Basil . Vigon . adding a little Merc . Precipit . to it ; coming one day after the Exfoliation of the bone my Patient was abroad , so from that time I left him to his neighbour-Chirurgeon to dress , but see him twice or thrice after at times , and drest him then again ; he was well cured , and remained well , and is yet so .

I was call'd to consult with Dr. T. C. one of the Kings Physicians , A Concussion of the Brain . in a Gentlewoman who laboured under a great pain between the Coronal and Sagittal suture , from a blow she had many months before received riding under a Penthouse . The blow stunded her , she was brought to London , was viewed by some Chirurgeons of the City , who cured her wound , it being small , but from that time her pain was excessive , and now we were to consider what to do : Her pain seemed to arise from that blow , and we suppose the extravased and putrified bloud caused this pain , with a Vertigo ; we considered the pained part , as she toucht it with her fingers ( the scalp was swelled thick ) and proposed the laying open that part , which we thought necessary , but she would not consent to it : Other things were then proposed as Fomentations and Cataplasmes discutient , blistering , cupping , bleeding , purging , and such like , all which she submitted to , but without success . She then at last yielded to the making a Fontanel in this part affected by a Caustick , which I did , and by Dr. C. consent I made it to the bone , and so large as that I might afterward set on a Terebra ; upon the cutting out the Escar there was neither fracture nor fissure ; we rubb'd the part with Ink , and rubb'd it out again , no mark remained ; I Rugined the bone , but all was smooth , I put some Pul . Aloes , Myrrhae , and Mastich upon the bone , and drest the Escar with Basilicon . Simpl . cum Ol. Terebinth . to hasten digestion and separation of the Escar , and in few days it separated , but her pain still increased , with other indispositions which threatned her life , if something more were not done . Much unwillingly she heard of the opening this bone , but at last it was referred to old Mr. Arris , he is call'd in and approves of it , the thing is resolved upon , we met , I opened it with a Terebra , and find the Dura Mater of its natural colour , but a scent from within , as in corrupt wounds of the brain ; I drest it up with Lenients as the former , viz. Ol. Ros . and a little Resina : Her pains still increased , she kept her bed , her pulse was all a-long weak and troubled ; I drest her again : Next day I find her wound digest which I wondered at , considering what ill symptoms she laboured under .

The third day I drest her again , and in the opening I find good digestion a beginning to incarn , a little red flesh sprouting up out of the Dura Mater .

The next day it was increased , and so the next : but then when I opened the next dressing after , I find the Calvaria sunk , the lips flat and little Matter , but it was of good colour , the Dura Mater did seem no better , the little ruddy flesh was not increased , began to change the colour and look palish , I then left off the Ol. Ros . and added Mel . Ros . to the Resina , with a little Pulv . Myrrhae , and a little Ol. Terebinth . and drest the lips with my Basilicon . Mag. Vig . with precipitate and Ol. Terebinth . warm , laying over the bared Cranium lint dipt in a tincture of Myrrhae , Aloes , Rad . Aristoloch . Rot . Ireos , mixt with a little Extract . Scordii & Empl. Melilot . with a good compress out of a Lixivium , wherein was boiled some of the greater Cephalicks , as Flor . Anth. Beton . Magoranae , Origani , &c. But that night she was seized with Convulsions and a Sopor , and the day after the lips of the wound were without heat , & the flesh upon the Dura Mater altered , and no hopes left . She dying within a day or two after , we would fain have opened her head , but she had forbid it in her life : I turned her head downward the next day , there did run from her nose a purilent Matter of a brown colour , with the same scent that was when I opened her skull : I do believe this putrifaction was from the corrupt bloud extravased between the Pia and Dura Mater , and at first by large bleeding and proper applications might have been relieved , and if here we had timely opened the Dura Mater , this Matter would have there discharged itself ; But this tender sex does not admit of that part of Chirurgery which consists in opening the skull or cutting their flesh , unless it be too late .

A little Girle was brought to me with a swelling upon the left Sinciput , A large Fissure , the Dura Mater putrified . the breadth of about two fingers off the Temporal Muscle , about the bigness and shape of half a great French Walnut , and behind the Ear a little swelling : This greater swelling hapned from a fall down a pair of Stairs some weeks before , but whether through ignorance or negligence the fracture was not suspected by them , though there was visible symptoms of a fracture or fissure , as vomiting oft , and great indispositions , with pains , &c. The Child even languisht with it : I acquainted the Mother with the deplorable condition of her Child , and that the only way to relieve her was by opening that tumor wide , and afterward I believed there must be as much done to the Skull , that I feared through the not timely doing this , her child would now die . She prayed my help , and submitted to what I should propose ; this tumor was soft , and without doubt replete with a Sanies , and the bones underneath fractured or fissured : The way had been in a stronger body to have cut this tumor round , and raised it off from the Skull , and so have made present way to the bone ; but the Child was so weak , as I feared it might die under my hands , or if it did live , yet if after such a bloudy work , if the Child should not be cured , the Mother would never forget my cruelty , ( as she would call it ) Wherefore in such cases I use to work in a more calm manner with that sex , and do that by an Emplaster , which in others we do with a Knife : To which purpose I applied my Ung. Catheraet . and with an Emplaster over it , the Mother bound up her Childs head , and carried it home : And about two hours after I call'd to see the Child , and found it had been very easie , these parts being of an obtuse sense , and the less sensible for that the skin was distended by the Matter ; I took off the Empl. and found it had workt well , I opened it , and discharged about three or four spoonful of a filthy Sanies ; I took off this Caustick the sooner here , suspecting lest it should by longer lying penetrate through , and by its salts offend the parts within : Upon dividing this Escar the bone was seen bare , and by a Probe I felt it to the whole length ; upon which I cut it open , and afterward a-thwart over , and then by turning the Escar aside , I see a long fissure the whole length of the Tumor , running transverse over from the Temporal Muscle backward , the Skull very thin , yielding to the least pressure of my finger , as a piece of Vellum , so as I might have inlarged it with my Knife if I had thought it necessary . I laid the Childs head upon one side and dropt in a little Mel . Ros . with a little of my Tincture of Myrrhe , Aloes , &c. as prescribed in this Treatise , and with Pledgits dipt in the same , lightly covered up the same bone , and with Pledgits dipt in Basilicon . with a little Ol. Lilior . and a little Ol. Terebinth . drest up the Escar , and laid a Cephalick Emplaster over all , and bound up her head , and thus drest her daily , sprinkling my Cephalick powder upon the bone for the space of many days . I see pieces of the Dura Mater purge out , and hang in the fissure , and for some while a thin Ichor came out of the fissure ; the Escar separated , I drest the lips with Mund . Paracels . and the bone with my linement Arcei , dropping into the fissure the Balsam prescribed for these wounds by Vigo , pag . 105. Thus I proceeded , and happily cured this Child : The Tumor behind the Ear and part about I Embrocated with Ol. Ros . warm daily , by which that Tumor went off , it arising from this of the fissure ; but about a year after this Child grew lame of her left Leg , and was strumeous : How I proceeded in this you may read in the Treatise of that disease , she being the product of a diseased Mother .

A Gentlewoman falls with her little Daughter , a Child of half a year old in her Arms , A Caries through the Cranium , wherein the Pericranium and Dura Mater become one body . the Mother is hurt , and the Child a little scratcht on the left side of her head ; it 's viewed by a pretender to skill in such things , and slighted as inconsiderable ; but from that time the Child grew indisposed and vomited often , especially after the receiving its sustenance , & as it grew able to speak complained of a pain in her head , and through her often vomiting she languisht : After Ten years a small Tumor appeared in that part of the head where it had been hurt by the fall so many years before : They now again consult and bring the Child to me , a very starveling ; I viewed the tumor and felt in it a pulsation , which at first I thought an Aneurisma , but pressing my finger more into it , I felt the brain without any skull , the breadth of an old English shilling : This at first a little amused me , but upon consideration of the fall and symptoms succeeding , it was evident to me , that by the fall the skull was fissured ; and being of a thin Cartilaginous substance at that time of her infancy , had been by length of time mouldred away , and from that Erosion the Dura Mater inflamed , and thrust out from within ; and by adhesion to the Pericranium had become one body ; It is usual for parts inflamed to adhere to the next adjacent part : This I supposed the case : The presage here was a sudden death if the cure was not attempted , and in the attempting it she was in great danger : To begin this by a Circular Incision from the compass of the skull , was not difficult ; but then to separate these two membranes , the Dura Mater from the Pericranium , or this from that ( they being become one body ) was a difficult work even in a dead body , here in a weak Child much more , where the bloud would be apt to blind me , and the impatiency of the Child would make it hazardous ; this work requiring a steadiness : Then I consider'd of a Caustick , and having predicted the danger either in leaving it to die by its malady after a few weeks , which was certain , or in attempting the cure doubtfully ; I referred it to them : They had consulted before , and were not ignorant of the danger the Child was in by its disease ; Therefore they readily put the care of managing this great work to me , and lodged it near me , in Suffolk-buildings : I presently caused the hair to be shaved off from about the grieved part , applied the most gentle Caustick I could propose ; and at such time as I thought it might have made its way in the Superficies of the Calvaria , I took it off , and with a Caustick-stone rubb'd into the Musculous part of it ; then I washt out the salts well with Wine first , then Milk , after that with warm Oil , then with a Knife I cut into the Eschar , and Embrocated the part warm , and drest it up with Ung . Basilic . with Ol. Ros . and applied my Emplaster over all , and roul'd up the part with good Compress and Bandage : that night she was seized with a fit of Convulsions , Vomited , and was very ill ; Dr. Fisher was sent for , he prescribed her a Cordial-Julep , proper in that her case , and relieved her : The next morning I took off dressings to look upon the part , and raised up the hairy scalp round from the skull through my Eschar , which gave the wound a breathing , and discharged a little Ichor ; from this time her vomiting ceased , she had no more Convulsive fits , she began to be more lively than in Ten years before : We kept her in bed warm and close , with a slender diet , allowing her only Spoon-meats : Her Physician took care in what concerned her health by Internals : I proceeded to hasten digestion , and by Fomentation and the like to cherish the native heat of the part , and as the Calvaria separated , so I endeavoured digestion sometime , otherwhile detersion interchangably ; as the one medicine corrupted , so the other deterg'd : It was a nice work to separate the Pericranium from the Dura Mater , but I happily effected it , while the latter slough was separating , the Callus rising up in the mean time : The Patient being free of all the former ill symptoms , and brisk , and in a sure way of recovery . I invited Sir Charles Scarborough and Dr. Walter Needham , who did me the honour to see her . It was a rare case , not mentioned by any Author , nor scarce to be seen again : Since that time the bone Exfoliated , the Dura Mater incarned , and the wound cicatrized and contracted to a very narrow compass . The Child returned to her friends perfectly in health , is a witty Girle , but it 's doubted she will be but a dwarf .

An Additional discourse of Wounds of the Brain .

THE greater symptoms that are usually said to attend the Wounds of the Brain , Uncertainty of symptoms in Wounds of the Brain . do shew themselves more uncertainly than a speculative Chirurgeon would imagine . And in Cuts or Wounds made by sharp weapons , or sudden strong force more uncertainly than in Contusions , Concussions , & Depressions of the Skull . The highest of them , viz. Vomiting , Stupor , loss of speech , with a Paralysis of Legs and Arms arising more suddenly in these latter cases , than in the former . These symptoms have appeared in one of the forementioned Observations , where there was nothing of fissure or extravased bloud seen upon the Dura Mater , after the Terebration or Perforation of the Cranium . Nay , we see many die suddenly from a box of the Ear , and from small blows or wounds : In some upon opening the Cranium there is much bloud extravased , in others none at all , or ought else that may be thought to have kill'd the Patient .

A Young man from a blow with a Cudgil upon the forehead , presently takes his bed , becomes delirous , a Sopor follows , and after some days he dieth . I am sent for to see his head opened ; in laying open the forehead , I see a small hair-like fissure , running from the great Canthus of the eye upward : we took off the skull and Dura Mater , and found but little bloud extravased , the Pia Mater as little altered . Others I have been call'd to see opened , where there had preceded only a contusion of the Calvaria , without fissure or extravased bloud , more than is usually seen in every opening , or taking off the Cranium : yet the Patient lay , as I am informed , under all those symptoms of Delirium , Coma , &c.

Then again I have drest many that have been cut through the skull , the shivers of bones and pasht flesh , and hair lying upon the Dura Mater , yet the Patient without any symptom of such a wound ; some whereof you have read of in this preceding Discourse , Observation . some other I shall instance . At Sterling Mr. John Chace was present , when a poor Servant-maid came to me to be drest of a wound she had received on her head by a Musquet-shot , in the taking of Calander-house by the enemy ; there was a fracture with a depression of the Skull : I set on a Trepan for the elevation of the deprest bone , and for discharge of the Sanies : She had laboured under this fracture at least a week before she came to me ; yet had none of those symptoms afore-mentioned , but after perforation , and raising up this deprest bone , and dressing the wound , she went her way , and came daily thither to be drest , as if it were only a simple Gun-shot wound of the hairy scalp : Mr. Penycuke an eminent Chirurgeon of that Nation did assist me in this work ; I think the Brain itself was wounded : I left it in his hands , who I suppose finished the cure .

At the beating up of some of our out-guards near Truro , the enemy pursuing them , a Trooper wounded between the Right Brow and Ear , on the Sinciput ; espying me amongst the flying croud , importuned me earnestly to dress him ; he would admit of no excuse , we stopt at an Apothecaries house on the right hand , going out of the Town towards Perin . I call'd to the Apothecaries servant to bring somewhat to dress him , Observation . in the while hastily I lifted up the bloudy hair , and see a quantity of the Brain lye among it , I took it up with my fingers , and shewed it him , the sight whereof calmed his passion , whereby I had liberty to fly from the Enemy who was entred the Town . Here the Prognostick was certain , yet none of those cruel Symptoms which accompany Concussions or lesser fissures .

From Battails and Sieges of Towns and Garisons , we meet with many such wounds ; Manner of dressing the Brain . in them we hasten our way to the Extraction of the Extraneous bodies , by cutting off the shattered calvaria first , then pulling out what ever was carried within the Cranium ; if this be well performed , we then dress up the Brain and Membranes with a Sindon of Silk or soft linnen , of a bigness proportionable to the wound ; this is dipt in a warm digestive , such as is proper for the wounded Membranes , for however Chirurgeons have proposed to dress the Brain with one kind of Medicaments , and the Membranes with another , that is not possible to be so done , but that the Membranes or Meninges will be washt with the same Medicaments , and if they be offended by that Acrimony , Inflammation , Fever , Delirium and death will the speedier follow : In the Cure of these wounds of the Brain , I do consider the Brain as an Insensible body , and that their cure consists in keeping it within its Membranes , and dressing them as wounds of the Membranes with Lenients , &c. if this can be done , as in small wounds of the Brain it doth sometimes happen , ( and the better if the fracture of the Skull hath not been very large , ) then the Patient may recover .

But if the fracture in the Skull be large , and the wound in the Brain proportionable , that the Brain cannot be contained within , then it corrupts by the external cold , and gets between the Meninges , and offends them by its putrid Acrimony , whence Convulsions , Palsies , and other ill accidents follow , and death . They sometimes live until that Lobe be consumed , or hath wrought it self forth ; as for Instance ,

At the Siege of Mellcome Regis , a foot-souldier of Lieut. Observation . Coll . Ballards by the grazing of a Canonshot , had the fore-part of his head carried off , and the Skull fractured into many pieces , driving some of it with the hairy Scalp into the Brain : The man fell down as dead , but after a while moved , and an hour or two after his fellow Souldiers seeing him endeavour to rise , fetcht me to him . I pull'd out the pieces of bones , and lacerated flesh from amongst the brain , in which they were intangled , and drest him up with soft folded linnen dipt in a Cephalick Balsam , with Empl. and Bandage bound him up , supposing I should never dress him any more . Yet he lived 17. days ; and the 15. day walkt from that great corner Fort over against Portland to the Bridg , which separates Waymouth from Mellcome Regis , only led by the hand of some one of his fellow Souldiers ; the second day after he fell into a Spasmus and dyed , N. B. howling like a dog , as most of those do who have been so wounded .

About the same time a maid servant was shot into the right side of the Sinciput by a Musket bullet deep into the Brain , she lived as long , viz. until the Lobe of the Brain was wrought out or corrupted .

At the Seige of Taunton one of Coll . John Arundell's men in Storming the Work was shot in the face by Caseshot , he fell down as dead , and in their retreat was carried off amongst the dead , and laid into an empty house by the way until the next day , when in the Morning early the Coll . marching by that house , heard a knocking within against the door , some of the Officers desiring to know who it was , lookt in , and saw this man standing by the door without Eye , Face , Nose or Mouth : The Coll sent to me , ( my quarters being nearest ) to dress the man , I went , but was somewhat troubled where to begin ; The door consisted of two hatches , the uppermost was open , and the man stood leaning upon the other part of the door which was shut , his Face with the Eyes , Nose , Mouth , and forepart of the Jaws , with the Chin was shot away , and the remaining parts of them driven in : one part of the Jaw hung down by his Throat , and the other part pasht into his Throat ; I see the Brain working out from under the lacerated Scalp from both brows , I could not see any advantage he could have by dressing , to have cut away the lacerated parts here , had been to expose the Brain to the Air ; But I helpt him to clear his throat , where was remaining the root of his tongue : he seemed to approve of my Endeavours , and implored my Art by the signs he made with his hands . I askt him if he would drink , and proposed a sign by the holding up a finger , which he presently held up and immediately both his hands expressing his thirst , a Soldier fetcht some milk , & brought a little wooden dish to pour some of it down his throat , but part of it run down on both sides ; he made signs to have the dish in both his hands , they gave it him full of milk , he held the root of his tongue down with the one hand , and with the other poured it down his throat , ( carrying his head backward ) better than I had done , and so poured down more than a quart ; After that I bound his wounds up , the dead were removed from thence to their graves , and fresh straw fetcht for him to lie upon , with an old Blanket to cover him , it was in the Summer ; there we left that deplorable Creature to lodge , and while we continued there which was about 6 or 7 dayes , all that while he was drest by some of the Chirurgeons with a fomentation made with our Vulnerary decoctions , with a little Brandy-wine in it , then with Stupes dipt in our common Suppurative we bound him up .

I could tell you of many wounded into the Brain , but do think these may serve to prove what I would declare of them , viz. that the Brain is of it self insensible , that those Symptomes which accompany these wounds proceed from the pain which the Meninges , Dura and Pia Mater suffer : which if oppressed by extravasated bloud , or a depression of the Skull , do quickly suffer the greatest Symptomes , as Vomiting , Stupor , Paralysis , &c. much more if they be pricked by any spill of a Bone , or other Extraneous sharp body . When the Brain it self ouzeth out between them in the manner already mentioned , it is a mild soft substance and lenient to them , so that the accidents appear not till that begins to corrupt between them , and with it the Membranes themselves putrifie , upon which their follows Convulsions , Howlings , and a suddain dispatch of the Patient . From which very Observation , may be seen the folly of dressing these wounds with powerful desiccatives , which so far as I could observe , did hurt the Membranes , but never either digest or Incarn the Brain . According to Hip . non Coalescet , but as it gets liberty , works it self forth like unto Barme , and as I have said corrupts , and the Meninges suffering from that putrefaction , Spasmus follows , and the Patitient dies ; At Sea these Patients wounded in the Brain died presently , we having no conveniency of lodging them , or dressing them so warm as they require . In the wars my Imployment did not permit me to see the finishing of their Cures , and here in my Practice in and about the City , I never was called unto any such wounds , therefore must leave that to others to treat off : But by what I have seen from them heretofore , their Cure consists in dressing them , as in wounds of the Dura Mater , and in keeping the Brain within its membranes , without which no Incarnation can be made on the Membranes .

OF Gun-shot-wounds . PART II .

CHAP. I. Of Gun-shot in General .

GReat hath been the Contention amongst the Learned about fire and venome in Gun-shot-wounds ; Gun-shot wounds , whether fiery or venomous . some maintaining the one , some the other to be in them ; and others defending , that there is neither . That which I suppose might be the occasion of their suspecting Empyreuma , and a Venefick quality , was the deadly colour of these Wounds ; which in those early dayes , when the Invention of Guns was novel , surprized them ; they being not unlike poysoned and burnt Wounds . Where the Bullet pierceth , it extinguisheth the natural heat , and the lips of the Wound are livid , or blackish , and if not drest rationally , it inflames round about , from the afflux of humours , and hath ulcuscula , with a foetid smell .

In this condition the Wound is the first day , and so to the seventh , and ( if not succoured ) it Gangreens , and so the Patient commonly dyes . If in those dayes the Learned thus deceived by their aspect , drest them as venomous Wounds , it will be no marvel that they should write so of them : I verily believing , that in their way of treating them , they were directly as poysoned Wounds , difficult to digest and cure .

In these our times , although they do not call them venomous , Errors in dressing Gun-shot-wounds . yet it is the hardest thing in the world to disswade many of our Chirurgions from dressing these Wounds with Tinctures of Myrrhe , and Honey of Roses , and thrusting in of great Tents , by which way of dressing , I have seen these Wounds , undigested the tenth day , one whereof was in the Cheek , with dry and flaggy lips . These lesser fleshy wounds , being undigested , at last Gangreen ; and in truth it is not to be wondered at . I will undertake to shew you the Experiment every day ; and that in a Fontanel or Issue , made by a Caustick .

Cut you through this livid or black Escar , and put a Pea in the middle of it , with Tincture of Myrrhe and Honey of Roses , as I have seen some of them dress Gun-shot-wounds , and the next day , or two dayes after , when you dress it again , it will be to your sight not unlike a Gun-shot-wound ; continue your dressing it with a Pea , and with your Tincture of Myrrhe , and if it do not Gangreen , yet it will be Inflamed , and slow in digestion . And this is from the improper application in the dressing it . For if you dress this Escar in the Fontanel , with Emollients and Digestives , as you ought to do the Escars in Fontanels , the Escar will separate with digestion , in the worst habit of Body . And so it will in Gun-shot-wounds , with little distemper or difficulty , if you have timely extracted the extraneous Bodies . But a discontinuance in this kind of Chirurgery , makes us apt to forget our selves .

Thus at our entring into Worcester , Observation . when the King came out of Scotland with an Army of that vallant People , a Townsman was shot . A Pistol fired by the Cheek , shot him through his lower Jaw and Tongue , and out by the contrary Cheek , the Chirurgion of the Town a good Chirurgion , upon sight of it , concluded it Gangreened from the black colour ; and declined the dressing it the way he rationally ought ; upon which the part grows exceedingly painful , and inflames and Gleets with great tumefaction . After two dayes , I am called in , and by lenient Medicaments and good Bandage , keeping up the fractured Jaw , allaid the pain and digested the Wound , leaving it in the same Chirurgeons hands , who cured it . In this person , the Wound was burnt by the flame , the very powder sticking in some parts of the Cheek . This , with the putrefaction from the hot weather , contributed to our Brother Chirurgeons apprehension . It is this ugly aspect that puts the inconsiderate Chirurgeon out of his Method , and so makes Gun-shot more difficult of cure , which otherwise would digest , and heal as easily , as any complicated Wound , as I shall make appear in this following Discourse .

CHAP. II . Cure of Gun-shot-wounds ; and First of Extraction of Bullets , &c.

WOunds made by Gun-shot are , Implicatissimum morbi Genus ; The most complicate sort of Wounds that can be inflicted . For they are not onely a solution of continuity , but have joyned to that contusion , Attrition and Dilaceration in a high and vehement kind . To this we may add all sorts of Fractures and Accidents , as Hemorrhage , Inflamation , Erysipelas , Gangreen and Sphacelus ; besides the extraneous Bodies , which are violently carried into the Wound . And multiply Indications ex compositis , affectibus , non unica elicitur Indicatio , sed plures pro diversitate morborum . The number of the Indications in compound , Compound intentions . affections , must answer to the variety of disturbances , were it a simple Wound , the cure of it would presently be performed ( as you have read in the preceeding Treatise of Simple Wounds ) per Astringentia & exsiccantia , by such Medicaments as are of an astringent and drying quality : The cure of a Wound is the exsiccation of it ; but here is alwayes joyned with these that which Indicateth the use of Emollentia , digerentia , & suppurantia , according to that of Hippocrates , Omne quod contusum est , necesse est ut putrescat , & in pus vertatur ; What is contused must necessarily putrifie , and be turned into matter .

That which is fretted and torn must also be reduced to the whole , or cut off , What is torn is to be reduced to the part , or cut off . before your ordinary intentions of Incarning . Moreover , in these Wounds , not onely the Bullet it self is ordinarily lodged ; but many times other strange Bodies are carried along with it . For extraction of which , judicious care and industry are required in you ; Here in these recent Wounds , we very rarely have a flux of blood , though the Veins and Arteries be wounded ; they commonly lie quasht in the contused flesh , until separation of the Escar , and about that time when you least think on it , they may burst out violently . I have seen it thus often break forth ; Haemorrhagy . but if such Vessels do bleed upon the receipt of the Wound , and interrupt you in drawing out the Extraneous Bodies , you must endeavour to suppress the blood , for thereupon depends the Life of your Patient . But withall so proceed , that you may extract the Bullet first , and then be careful that in the restraining the bleeding , by your crowding in Dossils , and strict Bandage , you bring not on a Mortification . Observation . Such a Hemorrhage happened to a Souldier at the surprize of Weymouth , by the Garrison of Portland ; he was shot through the Heel ; for the restraining of bleeding , I applyed my endeavours . But after all , I was put to the use of the actual Cautery , which I did successfully , and have since seen Botallus authority for it : Tutius enim est ( saith he ) eam Ignito ferro constringere . Anodynes Pains are here to be appeased by Anodynes , but you must well consider the application , least you extinguish that small remainder of heat that is left . How you shall deal with all these Inconveniencies , and not add one evil to another , I shall plainly deliver to you . And first , what must be first put in execution , which is the extracting of Bullets and other Extraneous Bodies .

The Part is at first dressing , Dress presently , during the heat of Battle . with what diligence you can , to be cleared of all such Forraign Bodies , as have made violent Intrusion into it , while the Patient is warm with the heat of Battle , and the Wound fresh , and very little altered , by either Air or Accidents , so that less pain must necessarily follow upon the Extraction .

In the Armada Naval de Dunquerquo , where we Chirurgeons were oft imployed in this Service , we after every fight went together , visiting one anothers wounded men : Amongst us it was thought a great shame if any thing of this work of Extraction were then to be done . For after the first and second day the Wound proveth tumefied , Necessity of it . all the neighbouring parts are inflamed and changed so in their temper , that they conceal from your sight both the Bullet and his Companions , that the place they are coucht in can hardly be known ; or being discovered , you cannot without hazard of your Patient , or great trouble of the Part , make extraction of them .

And yet if the Wound be near a Joynt , or the Shot lodged amongst the Tendons , it is much to be feared the pain will not off , until those strange Bodies be drawn out ; consequently the omission of that extraction , will bring Mortification , which hath been the cause of the death of many a brave Souldier . And is the cause of all the mischief these Wounds are subject to , as Pain , Inflammation , Spasmes , Convulsions , Gangreens , Sphacelus , what not ? Every Battel produces Instances of it to the discredit of our Profession .

But if the Bullet be lodged in a less noble Part , as in Musculous Flesh , you may with more ease content your self , unto the seventh day , or until the fierceness of the Accidents be over , and the Wound digested . But withal , it will require more care , for the Wound will be more painful , and slow in digestion then otherwise it would be ; yet by the confession of those that allow fire and poyson in it , the Bullet may ly long there , and do little harm ; nay , I suppose there are not many , but have heard or seen of Bullets that without grievance to the Patient have continued , lying long in fleshly parts of wounded men . Conceive this spoken of Leaden Bullets , for Iron or Brass cannot ( by reason of their aptness to rust ) remain without doing harm ; however let nothing of this encourage you ; for the Bullet pierceth not any part , without carrying raggs along with it , which corrupts in the Wound , and makes Apostemations and prolongs the Cure , as must needs be observed by all men in their practice .

The Servant of a Noble man , Observation . was wounded and shot in the thigh by High-way men , the Bullet not having been drawn out by his Country Chirurgeon at the first dressing , could not be drawn out by me at the second , but occasioned great pain with Inflamation , great heat and watchings : Although he had many other considerable Wounds upon him , to make a derivation ; yet was his Gun-shot more vexatious then all the rest , until I extracted the Bullet and raggs carried in with it , yet this was but a Pistol Bullet . But after I drew out this Bullet , my digestion became good ; and by equal Bandage , with gentle compression of parts , I united and healed it in ten or twelve dayes , which I doubt would not have otherwise been cured in three moneths .

Nay , while any of the raggs remain in the Wound , it will never cure , but the Extraneous Bodies drawn out , there is little difficulty in the curing these Simple Wounds ; if drest , as I shall here following show , but if handled , as some have lately taught , they are as so many poysoned Gun-shot-wounds .

Now for the taking out of the Bullets , Two methods of extracting Bullets . and other Extraneous Bodies , there are two Methods ; 1. One to extract them by the way they went in ; The other to open them a way , by which they would , if their force had not fail'd them , have passed themselves through .

For to take them out the way they were forced in , you must place the Patient , 1. The way the Bullet went in . Methods of search . as near as he can guess in the posture he was in when shot . And , if by reason of his weakness or other Infirmity , he cannot without prejudice , be so scituated ; let him be laid in a position which may as neerly answer it , as may be ; Least some part of a Muscle , Tendon , or Ligament , obscure what you desire to make manifest . Then make search for it with your finger or probe . The Figure of these Wounds is alwayes round ; the Bullet forces the Flesh in with it , and its entrance presently contracts closer ; but it is going out is more laxe ; you may guess by view of the Wound , the largeness of the Bullet , and comparing the Figure with that , make choice of a fit Instrument for extraction , whereof you ought to be alwayes well furnished . Your main care in this work is to find out the Bullet , which if you fail of by searching into the Wound with your Probe : Then you are to feel the parts about , it being wonderful to consider how these Shots do twirle about , at least seem to do so , when the posture is changed in which the Wound was received .

As for Example ; A man hath been shot in the Cheek , and I have cut out the Bullet behind in the Neck : A man shot in the outside of the small of the Leggs , the whole Member unmeasurably swell'd and inflamed , no possibility of finding it out either way ; at last by chance , I felt it in the inner side of the Thigh above the Knee . And so another being wounded in the outside of the Arme , I have cut out the Bullet below the Scapula ; If the Bullet have not been in so long ( as in some of these cases ) that the parts are extreamly pained with Inflamation and Tumor , the pain where the Bullet lodges discovers it .

A common Souldier shot in the Breast through the Sternon , Observation . lay roaring very grievously , complaining of the pain of his Back . I was fetched to him ; and turning him on his side , I saw the Bullet lye like a small Wen or Scrophul , thrusting out under the Skin , not far from the Spine . I made Incision over it , according to the length of the part , and thrust out the Bullet as easily as I could desire . I dressed it , and the Souldier ceased his crying , and acknowledged before us , his pain was from the Bullet in the Skin . For indeed the Lungs and other internal parts , are seldome sensible of pain , when wounded through ; they discover their hurt by other symptomes . The common Souldier dyed , as most do that are shot through the Lungs .

If in your searching for the Bullet , you light on the part , though there be no Extuberance , or ought to be felt , yet his pain there , will be a good sign for it ; if no accident occasioned that pain . Make your way there by Incision , avoiding the Vessels , and take out the Shot , and what else offers it self ; by this you do both quit the part of its troublesome Lodger , and withal make way commodiously for discharge of matter , which in regard most of these Wounds are Sinuous ; ( the Bullet turning aside , when it is hindered in its journey forward ) for want of discharge might in those places occasion Fistula's and hollow Ulcers , not without ill quality .

In the work of Extraction , Caution . take great care you lay not hold of some Nerve or Tendon , and so pluck them along with the Bullet ; for by so doing you may cause intollerable pain and grievous accidents ; you must therefore neither open nor dilate your Instrument , until you may take hold of the Bullet , without any of the circumjacent parts .

CHAP. III . The first dressing after Extraction .

AS soon as you have made a separation of these Extraneous Bodies , if you judge the Wound to be so well conditioned , that there is neither sear of Putrefaction , nor Mortification , ( as in recent Wounds there is not ; ) First dressing after Extraction . ) Be not discouraged at whatsoever evil aspect it hath at present ; but consider it is Livid colour to be natural in the Wounds , when the Contusion is not simple in the Skin , but through Flesh and all , as far as the Bullet hath entred , depriving parts of their sense , to the very bottom , and hath the colour of a gangreened or poysoned Wound . Therefore I pray disturb not your thoughts ; but having taken out the Bullet , dress it up as a contused Wound , with Ol. Catulor . as hot as the part will bear , not giving credit to any that shall perswade you to the contrary ; And it is thus made .

℞ . Ol. lilior . alb . lb vj . boyl in this two new whelpt Puppies , until the flesh fall from the bones , then add Lumbric . terrest . in vino lotor . lb j . boyl these a while , then strain it by a gentle compression ; to the strained liquor add Terebinth . ℥ iij . sp . vini ℥ j . reserve this for your use . Or this ;

℞ . Ol. lini , Canab . an . ℥ iiij . Ol. lilior . chammeli an . ℥ iij . Terebinth . ℥ j . m . s . A. Or this ;

℞ . Terebinth . opt . ℥ iiij . Thuris Mastish . an . See of Apanci in simple Wounds . ʒ iij . Myrrhae ʒ j . Ol. Aparici ℥ ij . Ol. lumbric . & sambuc . an . ℥ iij . m . ℞ . Ol. olivar . lb j . Terebinth . lb. ss . Gum . Elemi ℥ ij . aeruginis pul . ʒ ij . Or this ;

℞ . sp . vini lb ss . Terebinth . lb j . Ol. Hiperici & lini an . lb ss . sang . dracon . subt . pulveris ℥ j . m . s . A.

With this I cured a servant of A. D. shot into his hand , this digested the Wound , Observation . after separation began , I felt part of a bone bare , which I drest with Extrac . scord . dissolved in Mell . Ros . with which I deterg'd , and feeling no more of the Bone , I incarn'd and cicatrized with ung . Tut . &c. in few dayes without any difficulty , Linement Arcei with any of the above mentioned Oyles is very good , adding a few drops Ol. Terebinth . which by its subtilty penetrates , and by its heat rouzeth parts , and putteth them upon digestion and hastens separation .

Quercitanus proposes this . ℞ . succi herbar . Tussilag . oxalidis an . ℥ iij . Caricas ping . Nxx. Thur . ℥ ij . Resin . laric . ℥ ij . ss . Axungiae Gallin . Anscrin . an . ℥ ij . Butyri recentis lb ss . Olci visis pomorum compost . lb j . put this altogether in a Vessel close stopt , boyl them by a gentle heat the space of six hours , then strain them out hot , and evaporate them to a good consistence : Or this ;

℞ . Cerae novae , Resiuae , picis naval . an . ℥ iiij . seu Hircini , medullae , cruris , vitulini an . ℥ ij . aesypi , ℥ j . Ol. olivar . aut lini , lb j . liquefactis omnibus transcollatis , F. ung . quod reservetur ad usum . He adds a ʒ j . of praecipit . to every ℥ of this . But this in recent Wounds will not be necessary ; for you will find by Experience , that these Wounds will digest and suppurate ( and that frees them from putrefaction . ) Nor will it be alwayes for your Credit , if you consider the quantity of Balsomes we use in such Wounds , and the prejudice some people have to the use of Mercury ; yet praecipitate & Axungiae with a few drops of the Terebinth , was a common Medicament among us . But I refer that to you , it being a good Medicament to hasten separation of the Escars ; you are to dress up these Wounds lightly with a proportionable soft Tent , and Plegdits dipt in some of these digestives very warm , not to scald parts . After that Embrocate the parts about with such like .

℞ . Ol. Lumbricor . Ros . Myrtill . an . ℥ iij . Aceti cochl . ij . mix them ; in the first dressing , your Applications over the Wound and parts circumjacent , should be such as have Vim Astringendi & Intercipiendi , to hinder the flux of humours , and strengthen the part , take farinae hordei & fabar . an . ℥ vj . Ros . rubr . Bacc . myrtill . an ℥ j . s . sem . Cydon . ʒ vj . boyl these in Posca , to the consistence of a Cataplasm , adding at last two new lay'd Eggs , with Oximel ℥ ij . ss . Apply this over the Wound and part ; if you apprehend this too heavy , you may add Ol. Myrtill . & Ros . and Wax as much as is necessary , and make it into the form of a Cerote ; and above the Wound lay one of the defensatives , of which , or the like , you may have alwayes ready by you .

℞ . Bol . Armen . ℥ iiij . Terr . sigill . ℥ iij . sang . dracon . ℥ ij . Corn . Cervi . Ust . or burnt bones ℥ ij . ss . our Juice of Sloes dryed , an . ℥ iij , Cerae ℥ iiij . Ol. Ros . & Myrtill . an . ℥ . vj . Acetis ℥ xij . boyl these to the consistence of a Cerote , add four whites of Eggs. Or this ;

℞ . Pulv . Ros . rubr . Bacc . myrtill . an . ℥ j . Bol . Armen . Terr . sigill . an . ℥ vi . succ . plantagin . solan . an . ℥ ij . Aceti opt . ℥ iiij . Ol. Ros . & myrtill . an . ℥ iiij . cerae q. s . m . Apply your Compress , dipped in Aceto or Oxicrate , let your Bandage be put on equally and gently , to retain your dressings , and hinder the Influx of humours .

Having thus drest the Patient , Bleeding . presently consider of letting of him Blood , to prevent ill accidents , and especially if he lost little or no Blood from the Wound , and that there be a Cachochymia , Revulsio enim quae è directo sit , celerrimam utilitatem adfert . Galen . de sang . Missione .

A Glyster should preceed Phlebotomy , Glysters . made of the decoctions of Mallowes , Violets , Beets , Mercury , Bays and Juniper-berries , with Ol. of Linseeds , honey of Roses , Hyera Picra , or Elect . lenetive . But if you have not this in readiness , make your Glyster with the broath of Flesh , Ol. Chamom . Sugar , and the Yolk of an Egg , and a little Salt , if your broath be not salt , or salt-water , or broath out of the Kettle , with a few flowers of Chamom . boyled in it and strained ; adding a little Butter or Oyl , and red Sugar , is a good Glyster in time of need .

Then you are to prepare some Cordials to resist the putrid vapours , Epithema you may also fortifie the spirits if there be need , by some Epithema of your distilled Waters ; as Balm , Bugloss , Acetum , Ros , with the Powder of the roots of Tormentill , Scordium , Scorzonera , Contrayerva , Treacle , Mithridate , &c.

And with these you may make Cordials also , Cordials . adding Syrupe of Citron , Gilliflowers , confect . Alkermes , and for your Common people , an . ʒ j . of Treatle or Mithridate in Whitewine dissolved ; for the better sort , take Aq. Bugloss . Cinamom . an . ℥ ij . conf . Alkermes ℈ j lapis Bezoad . occid . gr. xxij . syr . Citri cochl . ij . m . for an Epithema .

℞ . Aq. Melessae borage Bugloss . an . ℥ ij . Aceti Rosat . ℥ j . species Diarhodon . ʒ j . Croci ℈ j . As to their manner of Dyet hear Celsus , Lib . 2. Cap. 26. Dyet . Ubi aliquis grave vulnus accipit à cibo tantum abstinere debet , quantum vires patiuntur , adco tenuis esse debet dycta , ut vix sustineatur ; In great Wounds it is necessary to observe a spare Dyet , as Barly Gruels , Panadoes , thin broath , or a poached Egg , this much availing to the preventing of Inflammation . But in this the Patients custome must be considered , also the Air must be temperate , and dress not in the Air , frigidum enim inimicum vulneribus , Cold is an Enemy to Wounds : rest is also required as well to the mind as the body . Therefore having thus drest him , and laid him to rest , with ʒ vj . syr . de Miconio , with cochl . ij . aq . Cardiacae , in ℥ iiij . aq . papaveris .

We are now to proceed to the second days work , The 2d days dressing . and we are here to consider the habit of body , and more particularly what concerns the Wound . And in these Gun-shot-wounds it may be convenient the Body be gently purged by Lenitives only , as is formerly said ; Purgatio enim per alvum plerisque vulneribus prodest , you thereby carrying off the bilous and serous humor , which from their heat and tenuity , are most apt to ferment and slow into these wounds , and cause Pain and Inflamation , and other ill symptoms . In which cases use Cassia , Manna , Tamarinds , Syr . de Cichor . cum Rhabarb . Ros . solut . These are lenitive , and may be taken in Whey or Ptisan , and are fit to prepare the humor .

But as for stronger Purgatives , Purging Hipp . saith well , Cocl a sunt purganda non cruda , which is more especially true when you speak of Scammoniate Medicines .

Having this proposed a general way of purging , you must consider the necessity of your particular case ; we shall now again prepare our dressings , and look into the wound , and apply such Medicaments as may be fit for the quality thereof : And now it is necessary your Fomentation be ready , where-out may be wrung a hot stupe ; to which end ,

℞ . sumitat . Hiperici , Contauri , Scordii , Fomentation . Absinth . an . m . j . Flor . Ros . Rubr . Chamom . Mililot . Sambuci , an . m . ss . Furfuris p. j . coq . in Aq. Fontan . ad lb ij . ss . colat . adde vini Austeri lb j . sp . vini ℥ vj . st . Fotus : These will give a breathing to the parts , and defend the Wound from the Air while you consider it . If all be well , proceed with the same , but if it be accompanied with pain , foment with this ♃ decocti Rad . Althae , malvar . fol. verbas . Chamom . Melilot . sem . lini . faenugraeci . boiled in Sheeps-head-broath , If pain . or other ; and of the faeces of this Fomentation you may make a Cataplasma , adding farinae hordei lb ss . sem . lini . Cydonior . pulv . an . ℥ j . ung . Basilic . & ung . Dialthae . an . ℥ j . aux . porc . vet . qs . Croci ℈ ij . four whole Eggs , and apply it over all , or the former Cataplasma . It cherishes the heat of the part , furthers suppuration and is Anodyne . You are to make the Bandage as before , and continue this way of dressing to the seventh or ninth day , until you have digested the Wound , and the Escar is separated , and that you have laudable pus ( as you are wont to call it ) which is Album , aequale , leve & minimè foetidum , Equal , white , light Matter not soetid or ill scented ; then we must seek for other kind of succour , which may restore the wounded part to its former sanity .

If after separation of the Escar parts be not well digested , or want detersion ; ♃ succ . Agrimon . Centaur . min. plantag . Apii an . ℥ j . Mucilagin . hordei ℥ iiij . boil these together ; adding Terebinth . venet . ℥ iij . Mel . Com . ℥ ij . farinae hord . cribratae ʒ iij . Croci pul . ℈ j . ft. mundificativum : To this you may add Aloes , Myrrhae , Sarcocol . Rad . Aristoloch . Gentian Ireos , for the Incarning these Wounds : If you desire rather Injection , the same Ingredients may serve . But in the use of Injections do not stop the Orifice to keep the Liquor in , for you so distend the Ulcer and make it more sinuous .

CHAP. IV . Of Accidents befalling Gun-shot-wounds , and of Sinuous Ulcers .

BUt from the first to the eleventh day , many Accidents are wont to happen to these Wounds , which not onely impede the Cure , but often , without timely help , destroy the Patient . And these are vehement Pain , Inflamation , Erysipelas , and other deadly Accidents , as Gangreen and Sphacelus , all which take their beginning from Inflamation . Therefore I have elsewhere particularly treated of Inflamation and Erysipelas , that you feeing what it is may in its beginning prevent its increase : It commonly proceedeth from a very ill habit of Body , or from the ill handling of these Wounds in the beginning .

The remedy is to prevent the Influx of more humours , & evacuate that which is already fallen into the part . The first way is by bleeding largly and purging , both which are directed you in the first dayes work , if you omitted that then , you must perform it now .

The second way is by Externals ; and that is by Anodynes , which may mitigate and repress the heat of the part ; as also by Discutients and Concoction of the matter in the part affected ; which is performed by those Medicaments which were proposed in the Cure of the Wound , with observation of dyet , &c.

The Prevention and Cure of these , with the manner of handling them , you may see more particularly in the Treatise of Phlegm and Erysipelas , how in the beginning it is to be done with Refrigerants and Repellents ; and in their state by moderate Calefaction and Discutients : and afterwards by Dissipants and higher Discutients , to which Treatise I refer you .

The next and most cruel symptome , Gangreen is Mortification of the part , which so often attends great Inflamations ; and is shrewdly to be suspected , when they yield not readily to Discutients or Suppuratives . In their Wounds it happens most commonly through a Suffocation of the natural heats of the part ; or through the great concourse of humours , or too refrigerating and repellent applications , in the time of great Inflamations and Erysipelas , which have infeebled and hindered the transitus of Spirits into the part . It is perceived by the change of colour , it begins to look Livid , the lips grow flaggy , the tumor sinks , and it gleets and is blistered , and blew spots after a while appear .

When you see such a change begin , you must presently prepare to withstand a Mortification by Scarification , until the blood come , not onely about the lips of the Wound , but deep into it through the Escar to the quick , and suffer it to bleed freely , and make the party sensibly feel , that by such means you may disburden it of part of what would have choaked it , and make way for the entrance of the force of the Medicine .

Then foment the part with a good Lixivium made of Ashes and Salt , with acet . vin . in which you may boyl scord . Absinth . centaur . and such like ; and after Fomentation wash the scarified parts , and dress the Wound with Aegyptiacum , theriac . venet . dissolved in sp . vini , adding Calcin . vitriol . &c. and a Cataplasm of farine , Hord . fabar . orobj . lupinor . decocted in some of the same Lixivium , adding oxginel to it , applyed over all . But for this I refer you to a particular Chapter of Gangreens and Sphacel . for further directions therein ; as the Gangreen , Separates , you are to deterge ; to which end use mundificat , ex Apio or Paracelsi , to which by adding praecipitat . you may happily effect your Cure .

But in the separating of contused parts , Haemorrhage . as I have often told you , great Fluxes of blood usually burst out upon us . Observation . Thus in a Patient of mine wounded by Shot , through the inside of the Radius , upon separation of the Escar , a great deal of blood broke out with impetuosity . I stopped the Orifice which was nearest the Artery , with some mild aglutinative Powder ; suppose Galens Powder ex thuris part . ij . Aloes p. j . cum pilis , leporinis , &c. The blood then bursting out at the other Orifice , I applyed over that also the same Powder , and rouled up the parts with a good Compress dipt in a Styptick Decoction , laying my common Defensative over all , and not opening it till three or four days after . See Treatise of Wounds . How such Fluxes of Blood from the Arteries are to be restrained , you may see in its proper place .

Gun-shot-wounds , Sinuous Ulcers . the Escar being once fallen out , become Sinuous Ulcers ; especially after great mischievous Accidents , and where Bandage cannot be used to preserve the tone of the parts , as in the upper part of the Thigh and Hipp , &c. these Cavities causing much pain to the Patient , and difficulty and trouble to the Chirurgeon , we shall consider their Cure . Our indication therein , is from the parts affected , the largeness of the Wound , Contusion and Laceration of parts : for contused Wounds , must of course corrupt , and turn into matter .

And if the Bullet or any Extraneous Body be yet remaining in , the parts become more lax , and are accompanied with pain and influx of humours , and the included Body is streightned in its passage out , through generation of flesh , which causeth much difficulty in the Cure ; especially if a Cacochymia , or Lues ven . be joyned with it , you will scarce cure your Patient , without exhibiting Antivenerial and Scorbutick remedies .

To prevent Sinuosities , you are to enlarge the Orifice at first , or keep it so wide open , that the matter that is daily there ingendred , may have free passage out , which if it may not by the way the shot came in ; then you must consider , how in another place the Sinus may discharge it self , this being prudently effected , and the matter thereby discharged , you shall speedily perfect your Cure , and with ease .

But before you make this Apertion , you must consider , whether by altering the Position of the part , or by Compression by Bandage , or by hollow Tents , the matter may not be brought out . And to make the Cure of these Cavities more facile , you must endeavour to place the member in such a figure , as the Wound may be depending , and you must have Stupes , Spunges , Compresses , and the expulsive Bandage ; these prest out of red Wine , wherein is infused Flor . Ros . rubr . myrtillor . Cort . Gran . Balaust . nuc . Cypress . sumach . acacia , and dress it twice a day , and Injections of the same Decoction , with Myrrhae , Aloes , sarcocoll . Rad . Irid . Aristoloch . sp . vini . mel . Ros . Aq. Calcis , Aluminosa , and such like .

Sometimes in a Wound by the upper part of the Biceps diepe , the matter not being likely to discharge it self , I have by a Seton Needle preforated it through , and retaining the twisted Silk , until the parts have been digested , then drawn out the Silk , and by a Tent kept that open a few daies , until the upper part by good Bandage Aglutinated . Then the discharged matter below being little and good , I have left of the use of the Tent , and healed it up .

So I have often in Wounds of the Thigh , where by no Position or Bandage I could otherwise effect it . Observation . And here in the Covent Garden , in an old Sinnous Ulcer , which discharged it self from the right Ilion through under the Inguen , viz. by the inside of the Thigh four fingers breadth below that place . I had great difficulty to make out whither the Sinus tended ; at last I found by my searching Candle , that it wanted a little more then an Inch to pass throughout by the Glutens , and that without any opening that way ; the matter would continue to make its Cavities , upon which I applyed a Caustick there , whither I supposed the end of my Probe tended . Then having taken out that Escar by Incision , I prest with my Probe against my finger which was within the Escar , I there felt the end of my Probe , though at a distance , upon which I passed a long Canula instead of my Probe , and feeling the end of that , I passed then a Needle through this Canula , and so through the Escar , which I take hold of , and the while pull back my Canula , and the Needle being free from incumbrance , I pull'd it forward , with a twisted Silk at the end of it , and cutting off the end of the Silk from the Needle , I continue the Silk as a Seton there : the Needle , Canula and Silk were first anointed with Unguent . Dialihae . or Ol. lilior . or the like .

One shot in the Face betwixt the Nose and Eye on the right side into the Ethmoides by a Pistol Bullet , Observation . after some years that this Wound was cured , was troubled with a fretting Ichor , which discharged by that Nostril , and at his first arising up in a morning out of bed , would discharge half a spoonful of a yellowish colour , and had made a chop or gutter at the lower end of this Nostrel , by its acrimony . After some while , he could feel upon bending of his head backwards or forwards , the Bullet to roul to and fro .

He complained to me of his grievance at the Hague in Holland , a little before His Majesties going into Scotland . I proposed to him , as the onely way to free him from this grievance , speedily to cut through the oss . Palati . he assents to it . I placed him in a clear light , one holding his head steadily , I cut into the roof . The flesh was so close tyed as it would not yield to my Spatula , as I expected ; upon which , by a quick working Escarolick held to the place upon Lint a few minutes , I consumed the soft part to the bone . Then I cut into the bone such a hole , as I , by the moving of his Head , could see the Bullet lodged in the hole , but this was not done at once sitting . Yet by degrees the Bullet was taken out , and he eased of that discharge of matter , which threatned a filthy , carious , fistulous Ulcer . My attendance upon His Majesty into Scotland hindred my prosecution of that Cure . I left him in the hands of a Chirurgeon there ; and since have often seen him at Court : but the Ulcer did not shut up with a Callus as it might , had it been closely attended .

This way by making Incision , Method of cure in Sinuous Ulcers . is the speedy way of curing all these Sinuous Ulcers , if it may be safely done without wounding great Vessels , Nerves , or Tendons . Your Incision is to be made according to the length of the Fibres , and a Probe or Canula must be your guide . Having once made your Apertion , you may enlarge it as you see cause by Incision , Gentian , or Spunge , to discharge the impurities of the Ulcer , then digest it with the Com . digestive ex Terebinth , vittell . ovi , and if there be occasion , you may add a little Mell . to it and Myrrhae Thuris rad . Irios , to make it more exiccant , but commonly the depending part oppened , the Wound is cured by Bandage , and keeping open this last Apertion a few days . If these grow Fistulous , you shall find the Cure of them in another place .

CHAP. V. Gun-shot-wounds with Fracture .

HAving declared unto you the way of curing Gun-shot-wounds in the soft and fleshy part ; I purpose now to proceed to the curing them , as they are complicated with the fracture of the Bones ; whose firmness , driness , stability and solidity cannot defend them from these Inconveniencies . Nay , in the case I am to speak of , they are rather Discomodities . For when the Bullet striketh like lightning , were they softer 't were the better , that the Bullet might pass and not shatter them .

Not any of the five sorts of Fractures mentioned by the Ancients , which these blows will not occasion . Sometimes they will cleave the Bone , assulatim secundum longitudinem , according to the length ; and other times they will per transversum frangere , break the bones athwart . Other times they will divide it ad unguem , like the Scales of a Fish . Nay , if the Bones be dryer then ordinary ( as in elderly men , and in such a Nature or Diseases have made them so ) they will grind the Bone like Meal . Yet I have seen , and drest a Souldier that was shot through the Joynt of the Ancle , without ever breaking the least Cartilage .

The wayes to know when there is a Fracture in the Bone are many ; Hipp . bids us compare the sound part with the parts affected , and observe the Inequality .

Secondly , You shall perceive a Cavity if you touch the parts above and under the Fracture .

Thirdly , If you handle the fractured member , you shall perceive a crashing of Bones , by reason of the mutual attrition of the hard Bodies .

Fourthly , There will be commonly extraordinary pain , in regard of the divulsion of the Nerves , and distortion of the Tendinous Bodies ; or the pricking some sensible part , by the shivers of some Bone .

Fifthly , There will be an Impotency of the broken Member , so that the Patient cannot lean upon it .

Sixthly , The antecedent cause will teach much in this case ( Gunshot ) then which there never was ( or ever will be , I believe ) invented a more powerful one .

Seventhly and lastly , The Asperity and Inequality , or roughness of the Bone manifested to you , but the search will give you no small assurance .

In Fractures made secundum longitudinem , all Authors agree that the Member which is hurt must needs shew thicker then the other . Concerning Prognosticks , Prognosticks . you shall understand ,

First , That Fractures are more easily cured in young people then in old , for the greater distance there is à pueritia , the more the humidum primo-genium is exhausted . Wherefore in Youth , Bones will be again Consolidated by the first Intention , in others only by the second , Interveniente materia ( aliena ) quae non est ejusdem naturae cum osse .

Secondly , Bones receive a quicker Agglutination in Sanguine , then in Chollerick Bodies , by reason of the benignity of the Serum which sendeth out better matter for a Callus .

Thirdly , Bones are broke with less danger in the middle , then near to the Joynt ; they are both more hard to be restored , and to be kept so restored . And because of the multitude of Symptomes ( which in such Wounds cannot but Supervene ) are not without great difficulties to be cured .

Fourthly , Those Fractures are dangerous which are made so deep in the fleshy parts , as our hands cannot well come at them , to place them right .

Fifthly , A great Fracture is of more danger then a small . I term that a great Fracture where the solution of continuety is large , the accidents suddain , many and terrible .

Sixthly , Fractures made by Gun-shot , are of far more danger then any other , in regard of their multiplicity of Complicacie .

Seventhly , Among all Fractures the most tolerable is the Transverse , if it be oblique 't is worse ; still worse if the Bone be much shivered ; but worst of all if the Shivers be sharp and pungent . Amongst the Cruisers in particular Frigots from Dunkirk , it was complained that their Chirurgeons were too active in Amputating those fractured Members , as in truth there are such silly Brothers , who will brag of the many they have dismembered , and think that way to ly themselves into credit : but they that truly understand Amputations and their Trade well , know how villanous a thing it is to glory in such a work .

In the Roman History you will find it was not allowed at all . Livy tells you their reward among them . But later Experience judgeth it commendable , if it be necessary , and done in its proper time , that is to say , suddenly ; whereas Amputations the next day are worse then death to them .

Not so in proper time ; Observation . for in the heat of Fight I cut of a mans Arm , and after he was laid down , the Fight growing hotter and hotter , he ran up and helpt to traverse a Gun , and a Walloon , while I was cutting of his Legg , cryed ; Depechae vous con nous vendrone a terre nous bivron , Haste ye , haste ye , when we come a shore we will so drink : But amongst us aboard in that Service , it were a great shame to the Chirurgeon , if that the Operation were to be done the next day , when symptomes were upon the Patient , and he spent with watchings , &c. Therefore you are to consider well the Member , and if you have no probable hope of Sanation , cut it off quickly while the Souldier is heated and in mettle . But if there be hopes of Cure , proceed rationally to a right and methodical Cure of such Wounds . This following Method is best .

Cleanse the Wound first from all strange Bodies , Cure . as Bullet , Armour , Apparel , Shivers of Bones . If the Fracture be near a Joynt , the violence of the blow will many times add a Dislocation also to it . If that happen , restore the Joynt first to its place , before you meddle with the Fracture ; these dislocations are made by great Shot , or pieces of great Wood , whose force shatters the Limbs in pieces , or carrying it quite away : but this later I never see so done , but that when the Member is shattered it hangs by the side , by some little part of the Musculous Flesh and Skin .

Here your work is with a good Razor or Knife presently to plain the Stump , Smooth the stump . and pull up the Flesh , that you may saw off the end of the Bone as even as may be .

In one of these , Observation . whose Arm was shot off above the Elbow , in haste we drest him up , his shoulder proved out of joynt : The next day we could not set it by reason of the Anguish of the stump , it was a greater pain then his Wound , and pained him for some months after , but it happens often and in short stumps is remediless . One of our Captains Reformadoes had been served so formerly with his stump .

If you will endeavour the remedying it , you must do it by help of a Bandage , made above the stump , but if it be above the Elbow , how will you fasten it ? yet in some Bodies they will be restored easily , therefore attempt it before you dress the member .

In another that had his Leg shot off in the place of Amputation below the Knee ; Observation . some two months after , when I wondred the Bone would not scale , I put my Forceps to feel whether any part of the Bone was loose , and feeling it very loose , I took hold of it gently , and found it willing to come away , it was the Apophisis , or head of the great Bone which makes the Knee . I was surprized at it , but considering what is loose must away , I pull'd it out to the amazement of the lookers on , this was relaxt from its ligament , by the force of the blow .

In these fractured Wounds made by Gun-shot , the Chirurgeon ought to propose two things to himself , first the Fracture , and then the Wound . To proceed orderly you begin with the Fracture , viz. by Extension and Coaptation , that thereby the Fracture may be reduced to its proper seat ; which in all these cases must be performed with much steadiness and discretion , not with such force as in them without a wound , lest the Musculous or Nervous parts being torn , bruised or crushed , should cause extreme Pain , Convulsions , and Mortification ( and that which in special we seek to prevent ) death may unaware ensue .

And therefore this Operation would , Dislocations when to be reduced . if it possibly might , be dispatched presently after the receipt of the Wound , before Inflamation come on ; but if the part be accompanied with a Flux of Humour and Inflamation , before the Patient be brought unto you , then you must forbear the Extension until the third , seventh , or eleventh day , according to Hipp .

And if it should so happen , that through such Inflamation the Operation be delayed longer ; it is then to be feared , Putrefaction , and other ill Accidents will happen , and your Patient run great hazards of his life , or a continual lameness of that Member .

The Extension made moderately ; fit the Bones into their former place , with what gentle dexterity and lenity you can possibly . If the Wound be narrow , dilate it by Incision at the first , for these Wounds require more dilatation than any other , that not only the bruised and vitiated bloud and other excrements ; may have a free passage ; but that also by this means the shivers of Bones , of which these Wounds use to be very full , may with less trouble be discharged by nature , or extracted by your selves .

If you make not this dilatation in the beginning , Dressing . you may afterwards perhaps be forced to do it , when the part is accompanied with great defluxion and pain , and the bones altered by the retention of matter , and not only to cut and open the Wound to the vexation of your Patient , but to keep it so dilated .

Now consider whether the Bone be bare or not ; which you may satisfie your self in by your Eye , or your Finger , and the slipping of your Probe . If it be , you must apply next to the Bone some dry or exsiccant Medicine , sicca , siccis Gaudent , dry to dry . Of this sort are dry Lint , Dressing of Gun-shot with Fractures , Powders of the roots of Iris , Myrrh , Aloes , Thus , Spirit of Wine ; take heed of Oyl , for it makes the Bones apt to foul , and hindereth Callus . This done , proceed to the Wound , which is alwayes with loss of substance , and commonly with lacerated Flesh , what of it cannot be restored to good purpose cut away , and dress up the Wound with your Suppuratives warm , as hath been proposed in simple Gun-shot , with an Emplaister of two parts Diachalchith , and a third Paracels . with Ol. Ros . or Empl. de minio malaxt . with Ol. lumbric . over the Wound , and over the whole fractured Member , this Empl. Diachalcit . with the addition of Colophoniae , pul . Rad . consolide . Mai . Bol . Armen . cort . Granator . Succo plantag . Ol. myrtill . Lumbricor . & cerae , qs . as a Cerote over all , or double cloaths dipt in a red Wine warm , wherein hath been infused Flo . rosar . Rubr . Balaust . sumach . Baccar . Myrtill . sumit . Absinthii , &c. Ol. Ros . &c.

The third Intention which is required in these fractured Wounds , is Deligation ; Deligation . for unless they be rightly fitted , none of these Fractures , of what sort soever , can hope for perfect Unition and Cure . In Simple Fractures without a Wound , all kind of Bandage may be admitted , Bandage to be daily loosened in Gun-shot-wounds with Fracture . whereof you may see in my Lecture of those Fractures various sorts , with many circumvolutions about the Member . And once in seven dayes opening will serve your turn . But in these another method of binding is required , for here the Bandage is to be loosned daily , the Wounds lookt into and drest : They being here to be long kept open , for discharge of Excrementitious and Purulent matter made in them , which otherwise wound corrupt the Bones .

Therefore in these like Wounds , you must use such a Bandage as may least shake the fractured Member , Manner of Bandage in Gun-shot with Fractures . for these Wounds being every day to be drest , the so often rouling up the Member would cause grievous pains , and hinder union . Therefore it is that Authors have invented so many kinds of Bandage , to answer the intentions of dressing the Wound , and yet keep the Member immoveable . And your Bandage in this case , is to be made of softer and broader linnen clothes , then that we use in Simple Fractures , that it may comprehend both the Fracture and the Wounds , keeping the lips down , yet not hurt them , by its too hard compression , Minus astringendae sunt fasciae quam si vulnus non adesset , saith Celsus .

Therefore we make choice of a piece of Cloath soulded three or four times double , to give them the more strength , and of such breadth to incompass the lips of the Wound and fractured parts ; and of that length as to come once about the Fracture . It is to be cut into three pieces from the ends to the middle , which middle lyes undivided underneath , to bear more equally the fractured Member ; and these ends to come over one another , with a Compress between , over the Wound , to press the lips of the Wound equally down , which would otherwise become crude , and put out great lips . The Compress also serves to receive the matter , and fills up the inequality : These are so to be fastened , as that you may dress and undress the Wound without disturbing the Member .

But for that it happens , that in these Gun-shot-wounds the Bones are shrewdly shattered , and the Wound lacerated ; and by reason of the largeness , the Wound is most painful , and the part so weakned by its Fracture , as it cannot be kept steady by this Bandage : therefore we make use of Ferulae or Splints ; Splints . whereof I have made mention in my Lecture of Fractures in General , with the Judgment of the Ancients , who have been very Industrious in contriving wayes to make equal compression , and leave a way for the dressing of these compound Fractures .

Their use is not to be until the Inflamation and flux of Humours be off , When to be used . which is not until after the seventh day ; Mean while I propose Splenia , which are linnen clothes foulded four times double , and cut in length and breadth like the Ferulae , so as it may encompass the whole Fracture : these are to be spread with Galen's Cerote , or any Oyntment , so thin as they may adhere to the part only until you have put that Bandage over it ; and this is that I propose where there is pain and fear of Inflamation .

These will handsomely strengthen the part , and make such equal compression , as the Bones ; may be kept in their place , the serous humours prest out of the Cavernulae , and the fractured Member lye soft , which is a great help in these Wounds ; the whole welfare of the Patient depending upon the easie Bandage and Position of the Member . The Pain and Inflamation gone off , and the Wound digested , ( or if you think the Member not so subject to Inflamation , and that it require a greater strengh to support it ) you may use Pastboard cut into pieces proportionable to lay over those Splenia , Pastboard . or having fastned those Splenia by the broad Bandage with three heads , cut a peice of Pastboard fit to receive the lower part of the Member , wet it to make it more pliant , cutting a place commodiously to dress the Wound at . Under this Pastboard three Ligatures are to come , which , after you have placed another Pastboard above to answer that underneath , you are then to firm close by these Ligatures in the most convenient place , for the ease of the Patient : or if the Splenia be wet in whites of Eggs and applyed , they will strengthen the Member , and keep it steady , without those of Past-bord . To this purpose we also use Laminae , Laminae or Plates . Copper or Tin Plates with soft linings to receive the fractured Member , with cuts in the out-side to receive three Ligatures answerable to the first underneath . These are to fasten and loose at pleasure , without disturbance to the daily dressing of the Wound . These Laminae , or what ever else you use , must have a large cut in them , for the Wound to be drest through .

But I have alwayes observed inconvenience in these Plates , that there being not so good Compression made upon the lips of the Wound through those holes , as to hinder the lips from thrusting . There arises a laxity and indigesture in the Wound ; and besides the matter that so discharges ; heats the parts , and in hot weather corrupts and breeds Maggots .

Therefore I make the Pastboard or Laminae over my first to incompass so much of the lower parts as may support the Fracture , and come within an Inch of the Wound . And over the Wound it self I fasten a Splenium of Cloath , folded four times double , or a Ferula of Tin , Copper or Pastboard lined , and this according as I judge , the part can bear .

The first Bandage next to my Cerote , makes an equal Compression by its three heads meeting over one another ; the lowermost presseth the Influx from below , and with the help of its next fellow keeps the Bones together , and presseth the matter out of the Wound ; and ( by the help this middle hath of the uppermost ) the matter is also prest out of the upper part of the Fracture and Wound to the Orifice , which also hinders the Influx from above , strengthened by a defensative lying under it . In the dressing these Wounds , you are onely to undo the middle Binder to come to the Wound , having a special care that this Bandage be neither too hard or slack , but indifferent , to the ease of the Patient .

Having thus proposed to you the way of deligation , I shall now proceed to the last Operation performed in these Fractures of a Wound , Position of the part . which is a commodious Position or placing of the Member ; which as I have told you in the Lecture of Simple Fractures , ought to have three Conditions .

1. Soft , least the Compression offend the hurt parts , and cause Pain and Inflamation .

2. Equal , for if the Member be placed otherwise , it becomes distorted , and the Operation succeeds ill .

3. Lastly , It must ly higher then the parts next the Body , especially the first three or four dayes , for if it incline downwards , the humours by their own weight , will easily flow to the part afflicted . How this Position is performed , I have set down in the Lecture of Simple Fractures , to which I refer you .

The fractured Bones of the wounded part thus restored to their natural places , and the Wound digested , and Inflamation and other Accidents gone off ; you shall now unloose the Bandages , and take of your restrictive Medicaments , and apply the Emplaster Cattagmat . in our London Dispensatory , or of these underwritten over the fractured Member , which may add strength to the part , and further the Generation of Callus .

℞ Resinae , abietis , cerae an . lb j . pulv . cort . Tiliae ℥ iij . succ . Geran . ℥ iiij . coq . ad Cerot . consist . Or this ;

℞ Mucilag . radic . consolid . ma . visci pomor . & populi an . ℥ iiij . succ . Geranii ℥ vj . lap . osteocollae ℥ iij . pul . cortic . Tiliae ℥ ij . Vittel . ovor . No xx . Terebinth . lb j . s . ol . Lumbricor . ℥ iij . coq . omnia bene permixta ad ceroti consistentiam , pro usu . But if you conserve the temper of the part , you need not doubt of Callus . I commonly in these cases make use of Emp. stict . Paracels . p. ij . Empl. Diacalcith . p. j . over these a double Cloath dipt in red Wine , wherein hath been boyled some of the above mentioned Plants .

And now place the former Bandage again , and over those Laminae of Copper , or Tin lined ; or in the place of these , you may add those Splenia of double Clothes dipt in whites of Eggs , and wrung out hard , they will sit close to the part , and after they are dry , will support the fractured Member well .

But if it be in the Thighs , the Plates are best , that part requiring such as are of great strength and length , and such compass , as may take in half the Member , you are now to forbear the use of Suppuratives , and use such Medicines as are detergent , as the Mundif . Paracels . Or if you please

℞ Vincae pervincae , Paeti , persicariae Beton . an . m . j . slor . Hyperici verbasci , an . P. j . rad . Aristoloch . utriusque an . ℥ ss . Thuris ; myrrhe , sarcocoll . Iridis an . ʒ ij . coq . in vino Albo addendo colaturae mellis rosacei , q . s . This may be cast in with a Syringe , it will deterge and incarn ; or by the addition of Terebinth . Wax and Oyl of Hypericon , you may form it to an Unguent .

If there be Caries you may make a Decoction of Scordium , vinca pervinca , pucedanum gentian . cortic . Guaci Rad . Ireos myrrhae in Wine , and adding sp . Vini or the Extract . scordii . If the Caries yield not to this , touch it now and then with some of the following Medicines by a Probe armed with Lint .

℞ Ol. myrrhae distillat . per discentum & purisicat . cum sp . Vini ℥ ss . olei cariophil . ʒ ij . ol . sulphuris ʒ j . ss . m . This will in a short time remove the Cariosity , afterward proceed by Epuloticks .

Vulnerary Potions are here of great use : as this , ℞ Aristoloch . rot . ℥ ij . fol. serpentariae , consolidae utriusque Geranii Columb . saniculae an . m . j . make them into gross Powder , & boyl them in Wine in a Vessel close stopt to a Gallon , give the Patient this , morning and evening ℥ iiij . at a time : you may give in this of Osteocollae ʒ j . poudred , or in a draught of the Decoction of vinca pervinca made with Wine , for confirming and hastening the Callus ; in the rest proceed as in the latter end of Simple Fractures .

A Souldier being shot by a Musket Bullet into the forepart of the Arm , near the Biceps , and out behind , the Bone fractured : I endeavoured by Extension to place the fractured Bone even together , but could not ; upon which I dilated the lower Orifice by a large Incision , according to the rectitude of the Member , to pull out those fragments of Bones which hindred their right Coaptation ; and putting my finger into the Wound to that purpose , I pull'd out a ragged piece of a Bullet , whether it was part of that which had passed through was the question ; some of the By-standers thought he was shot with a brace of Bullets ; but I rather think the Bullet was torn by the Bone , and that the other part was it which had made its way thorow : however by this extraction the main Bone was rightly placed , and the Shivers , with the Extraneous Bodies removed , and the matter happily discharged by this depending Orifice , and the Patient as happily cured by the common Intensions of curing these fractured Gun-shot-wounds .

Whereas if I had taken it for granted , that the Bullet was passed through , and contented my self in having endeavoured the reducing of the fractured Bones , and so drest him up , it had certainly Inflamed and Gangren'd : This confirms that doctrine in setting of Bones , that if any Bone will not be placed equally amongst his fellows , you ought to cut upon him , and take him out .

CHAP. VI . A Fracture made by a Splinter .

IN heat of fight at Sea , amongst the many wounded men that were put down into the Hold to me ; Observation . one of them had his Arm extremely shatter'd , it was about two fingers breadth on the out-side above the Elbow , by a great Splinter .

This mans Arm I ought to have cut off presently , but a sudden cry that our ship was on fire , put me in such disorder , that I rather thought of saving my self , than dressing my Patients . I hastily clapt a dressing upon his Wound , and rouled it up , leaving his Arm in his other hand to support it , and endeavoured to get up out of the Hold , as the others did ; I verily believing I should never dress him , or any of them more .

But our men bravely quitted themselves of the Fire-ship , by cutting the Sprizil Tackle off with their short Hatchets ( which they wore during fight sticking in their Shashes ) we were freed of the Fire , and by our hoisting up the top Sails got free of our Enemy .

Now I was at a loss what to do with this man , who lay not far off complaining of his Arm. I would have cut off his Arm presently with a Razor ( the Bone being shattered there needed no Saw ) but the man would not suffer me to dress his Arm ; he cryed , it was already drest .

The Fight over , we got into the next Port ; I caused presently the Mariners Bed to be set up ( which was four pieces of Wood nailed together and corded , and a Bears skin laid upon it , this was fastned between two Guns to the Carriages : ) Upon this I see him placed , he was a lean man , above thirty years of age , of a good habit of Body ; it was the right Arm , which I caused to be laid outermost , that I might the better come to dress it .

I having my dressings ready , I laid them orderly upon a small Pillow well stuft , and quilted in the middle . Upon this Pillow I first laid a soft double linnen cloath , then next I laid three Ligatures , then a Past-board wet in Vinegar , to make it more soft and plyant ; upon that I laid a double cloath of such length and breadth , as might serve to encompass the fractured Member , this cut from each end to the middle into three Binders . Over the middle of this I placed a Splenium of cloath four double , four fingers breadth , and of such length as to give strength to the Fracture : Over this lay my Defensative , spread upon a thick Cloath of such breadth and length as to take in the whole Arm. Dressings thus laid upon the Pillow , I cut off the dressings from his fractured Arm , and placed the Pillow with these dressings close by his side , so as I see his Arm laid as I designed upon my Restrictive , and his hand upon his Breast . Then I put my fingers into his Wound , and pull'd out a piece of a Splinter an Inch thick , or thereabouts , more or less , then Rags and Bones great and small ; I left not the least shiver .

When I had so cleared the Wound of all the extraneous Bodies and loose Bones ; I was amazed to feel what a distance or void space there was between the two ends of the Bones : But I proceeded and cut off the lacerated lips , which were of no use , and drest up the ends of the Bones with a couple of Dossils dipt in sp . vin . & Mel . Ros . warm , and the rest of the Wound I drest as warm with Axung . porcin . Mir . praecepitat . with some little Ol. Terebinth . mixt upon Dossils lightly within the Wound , and upon Pledgits without , and an Emplaster Diacalcit . malanc . with Ol. myrtil . over all the Wound .

Then I embrocated the fractured Arm with Ol. myrt . & olivar . Immatur , and a little Acet . and brought my Emplaster Defensative , which lay under the Arm , over the whole Arm , from the Axilla to the Elbow , and round the Arm close , only leaving a space to dress the Wound .

This gave a strength to the weak Member , and hindred the Influx from above . Just under this Emplaster there lay a Splenium , to answer that I applyed three more , one on each side , and another above , which four were of such a size , as they lying a little off from one another , encompassed the Arm ; they were spread lightly with a little Cerote , Axungiae and Wax , to make them adhere where I placed them .

Then I brought the Bandage which lay under the Splenium , with three heads at each end , the lowermost of these took in the lower part of the Arm from the Elbow upward , with part of the Fracture , and was fastned on the outer part of the Arm ; this prest the Sanies from below to the Wound , and hindred the lapse of matter that way . The middlemost was made to press the matter out of the Wound , and keep parts close for unition . The uppermost served for restraining the Influx , and press that out which was already in the part : this Bandage was made with great moderation , and so fastned , as they might be loosened without trouble to the Patient .

Then I brought the wet Pastboard close to the sides , and cut another piece to answer it , which I wet in Acet . and by the three Ligatures under , made them fast , but without disturbance to the Patient . If it could not have been so put on , I should have forbore the use of them : the Cure of these consists in the easie dressing and quiet position , without that you will not cure one of these compound Fractures ; the Pastboard as it dryed , received a shape fit for preserving the Fracture in the position I left it , and that with a very slack Bandage .

Thus I finisht the first dressing , leaving my Patient in much case , he slept pretty well that night , and was the next day as well as I could expect ; he was let blood the second day , and kept to a spare Diet , but we allowed a little Wine as a Cordial to all our Patients .

The third day I drest again , took off the upper paste-board , and loosened the Heads of the main Bandage , took off that Splenium which was over the Wound ; raised up the emplaister from the wound , took out many dossils , found it warm and well-disposed ; drest it up quick with my Suppuratives hot , and an emplaster as before , not stirring the restrictive ; made now a compress more particularly for the wound , purposing not to remove the two outer heads of the main Bandage , unless it were sometime to give a little breathing to the member ; but the middle I open'd as often as I thought fit to dress the wound , the other two had short Splenia to make the Bandage equal , but I was not then satisfied how this Arm would be supplied with Bone , yet my Patient was easier then any of my Patients with fractured wounds .

When it came to my turn to be visited by my Brother Chirurgeons of our Squadron , they did not dislike the wound nor my way of dressing , ( for we being used to see one anothers Patients , had all much one way of dressing ) but they laught at the excuse I made for not cutting off his Arm , and doubted I should yet be forced to do it . But I kept my Patient flat on his back , and that after a while was his greatest pain , for the Wound digested and the tumor was never considerable .

After the wound digested and a separation made of the contused flesh ; I then renewed the dressings , taking all off and fomented the member with warm water , to give a breathing to it , and applyed a catagmatic Emplaster , and drest the Wound with a mundificative Parac . or such like , and bound up the Member as at first , and so continued my way of dressing as I see cause , putting into the Wound only a Dossil or Tent made upon a skewer soft and hollow to give way to the Wound to incarn , I scare ever using Injections , but by gentle compression assisting Nature , who seldome fails in supplying the lost substance in Wounds , if we disturb her not by improper applications .

The next opening and dressing of this fractured Member was occasioned some sixteen or seventeen days after , by a troublesome Itching of the patt ; which was I suppose partly from his liberty in diet , the heat of the weather , and want of perspiration : I then took off the Dressings , and bathed with Sea-water , and drest him up with Emplaster de lithargiro ; the Wound was about this time well incarned within , and the Lips beginning to cicatrize from their edges , I dressing them with Epuloticks , as ung . Tutiae , &c. yet I kept my Patient still upon his back , and renewed not the whole dressing until I was necessitated , which was about the fift or sixt week .

One day coming from the Shore ( where those of our wounded had liberty to lodge if they desired it , and were drest by us there ) I found this Patient with a heat all over his body like an Erysipilas , he was much frighted at it , he had it seemed drank Wine a little too liberally with his mates , ( as they would most of them do if they were any thing well ) unless it rather proceeded from a generation of Callus , Erysipelas upon the generation of Callus . in which case it usually happens . I let him blood , and at next dressing finding his Arm pretty strong , and his Wound healed within , and in a fair way of cicatrizing . I raised him up , after he had laine about eight weeks . All which while I believe he never stirr'd his Arm from the time I placed it , but in the time of renewing the dressing , he being the most patient man in that respect I ever attended ; and in truth without that submission , he could scarce have been cured .

There was in this Patient a strong Callus , filling up the void place of the lost Bone at least two Inches , with little or no shortning of the Arm ; but the Joynt of the Elbow was so stiff from the position it lay so long in , that he could not stretch that Joynt whilst I knew him , which was until that Ship was cast away .

My memory will be much cryed up for remembring so many particulars in a Patient , so many years since cured by me : But if you consider how remarkable a case it was , and in my Trade , there will be the less wondering at the possibility of it . You may enquire what was done by me in the Cure of Capt . Reade , where the loss of his Jaw was supplyed by a strong Callus , and that Cheek uniform with the other , and will be long remembred by the then standers by , though not of the Profession .

In our Sea Fights often times a Buttock , the Brawn of the Thigh , the Calf of the Leg are torn off by Chain shot and Splinters ; all these are contused Wounds and look black , and do too often deceive the unexperienced Chirurgeon , he taking them by their aspect to be gangreen'd , and by dressing them as Gangrena , with Aegyptiacum and Spirit of Wine , hath either gangreen'd them , or drawn the other Symptomes upon them of Pain , Fever , Delirium , Convulsions and Death .

Whereas if they be considered rightly , though they look as flesh long hanged in the air , of a dry blackish colour , yet they have warmth , and will by Lenients , as is prescribed in Simple Gun-shot-wounds , digest , and as Separation is made they will deterge and incarn , but they are slow in digestion , and require good Fomentations and Embrocations to cherish the native heat , which is much weakned by so great a loss of substance .

These require Oleum Terebinth . to be mixt with your digestives , but you must have a care you do not inflame and cause Pain , by adding too much of it . A spoonful to six Ounces of your Suppurative is enough in the dryest habits ; your Judgment will best direct you , and your Patients complaint : it being unreasonable to hope that Wounds can digest , while they are accompanied with much Pain .

In the former Sea-fights with the Dutch , Capt . H. had his Hand shattered , and his Fingers torn off ; Mr. L. was his Chirurgeon ; who entreats me , being call'd into counsel , not to think of cutting of his Hand ; I told him it will be of small use to him , and the Shivers of the Bone within hurting the Nervous parts , occasioned those convulsive twitches and pain he was subject to and often felt ; notwithstanding I promised to comply with him , if he would follow such Methods as I would propose , which he agrees to , but does not perform accordingly .

I came two dayes one after another , but finding nothing of it done , at the next meeting he pretends an Excuse , not to dress the Patient . I then discover his craft , and that he had used me onely to defend his Credit , which was questioned for the not taking off the Hand at first , as he ought to have done , of which he now saith I was the cause , having craftily drawn me in to be of his Opinion , though conditionally only ; viz. that he should have laid open the Hand , and taken out the Shivers , which if he had done , he might have cured it , as I have done some others , as appears by this Treatise . Of the truth of this Mr. H. is Witness , who also was over-witted by him . The Chirurgeon of the Ship committed the first error , he ought at the first dressing , while the Wound was recent , to have pull'd out the Shivers of Bones , or to have extirpated the hand , that being the proper time .

CHAP. VII . Gun-shot-wounds in the Joynts with Fracture .

THE Wounds of the Joynts are subject to more grievous Accidents , then those I have heretofore mentioned , therefore they require your more particular care . The Tendons and Ligaments being inserted near the Joynts for the motion thereof ; as also the Membrains , and consequently the parts of a most exquisite sence . The trunk of Nerves also in every great Joynt passeth through for the use of the Member that is beyond it . To which I add , that the part being exanguious , the natural Balsome of the Body is here more sparingly supplyed for the help of the Cure .

What the pains are may be judged by the Wounds in the lesser Joynts . Capt . F. in Musselbrough fight , was shot in one of his Fingers , and the next day so grievously tormented , as he walkt up and down like a mad-man , could take no rest until his wounded finger was digested , yet his pain was not so great in his Wound , as in his well fingers . The greater Wounds are attended with much more vehement Pain , Inflamation , Dilirium , Convulsions , Gangreen , and are commonly deadly . Therefore the shot is presently to be extracted , and dressed with such Medicaments as may defend them from putrefaction , and these are to be moderately hot and dry of subtle parts and Anodyne ; as Ol. Terebinth . de Castoreo scorpion . vulpin . lumbricor . ovor . & pul . scord . Thyris myrrhae , Ter . leminae pul . euphorbi .

And in these Gun-shot-wounds the Orifices of the Wound must be kept open , that your Medicaments may penetrate to the bottom : But if the Wound be on the inside of the Joynts , they are commonly attended with great Haemorrhage : For prevention of which , I refer you to its proper Chapter : And in the first place propose this digestive .

℞ . Tereb . lot . in sp . vini ℥ iiij Thuris , myrrhae mastich . an . ʒ j . olei Hyperici ℥ iij . vitell . ovor . N ij . croci ℈ ij . Or ,

℞ Terebinth . ℥ ij . myrrhae , Thuris , corn . cervi usti . à ℈ iiij . Ol. scorp . de Castorco lumbricor . sambuci an . ℥ ss . vitell . ovor . N ij . Apply either of these warm . If stronger be required ,

℞ . Ol. Terebinth . ℥ j Ol. hyper . cum gumum . ℥ ij . euphorb . pul . ʒ j . drop this very hot , and apply the first mentioned Digestive over all Embrocate parts about well with Ol. lumbricor . & hyperici , and apply this following Cataplasma .

℞ Farinae , Hordei & fabar . an . lb j . flor . cham . Meliloti ros . rub . scordii Absinthii pulver . an . ʒ vj . Decoct it in the Broath of Offal or in Oxymel . adding Ol. Ros . & chamelaemel . Or this ,

℞ . Mucilag . Radic . Althaeae consolid . ma . an . ℥ iiij . flor . Ros . rub . beton . cham . subtil . pul . an . ℥ ss . farinae lini . fenug . an . ℥ iij . farinae , hord . & fabar . an . ℥ vj coq . in vino , adde Ol. Ros . & Lumbric . an . ℥ j . ss . Mel . ℥ ij . vitel . ovor . N iij . The Wound digested , you may deterge with this :

℞ . Farinae Orobi ℥ j s . Thuris rad . Ireos . an . ʒ vj . succi Apii ℥ iij . Mel . com . & Terebinth . an . ℥ ij . m . F. ungu . The Wound deterged , you may dress with this Sarcotic .

℞ . Sumitat . Hyperici equiseti plant . Beton . an . p. j . rad . consolid . ma . Tormentillae an . ʒ iij . sevi Hircini ℥ iiij . lambric . terrest . lot . ℥ ij . Ol. mastichinae ℥ ij . vini odonf . qs . coquantur ad consumptionem vini postea colentur , cum forti expressione , dein . adde Resinae pini ℥ j . Thuris , Myrrhae , Mastich . Aloes , an . ℥ ss . cerae ℥ iiij . m . F. s. A. Ol. Aparici is excellent in these Wounds alone , or heightned by any of the former Prescriptions ; so is the Balsome in the Chapter of the wounded Nerves .

If the Bone be bare , you must be careful that you do not foul it by your greasie or slabby Medicaments ; you must here also consider of Phlebotomy and Universal Regiment . If Pain be violent , and yield not to Anodynes , cut off the affected Tendon , and whatsoever corrupts , least it taint the rest .

But in these great Wounds , you are at first to consider how curable they are , and endeavour to preserve the life of your Patient , by a timely extirpation , before his Spirits be too much exhausted : Of which this following story will give you warning .

A Page of Lieutenant Gen. D. L. was shot through the Knee , A shot through the Knee the Bullet entring in by the lower and outer side of the Rotula , passing through the Joynt out in the hollow of the Ham , tearing the Ligaments and Nervous parts , fracturing the Joynt as it passed , and rending the Artery in going out . This Wound was mortal the very minute it was inflicted , and ought then to have been dismembred : But such Proposals will not usually be admitted of in the first Dressings , whilst there is hopes : Yet the Accidents in these great Joynts thus made are sudden , from the vehement pain . And while Fever , Delirium , &c. are upon the Patient , then to make such an Amputation , most commonly hastens his death .

Wherefore I proposed my first dressing by digestion upon a Pledgit , applyed warm to the Wound upon the Rotula , there being no place for a Tent ; and to inlarge the Wound amongst the Tendons and Ligaments , were to adde one mischief to another . I also embrocated the parts about with Ol. Ros . cum Aceto , applying my Restrictive over all .

In the depending Orifice , there was a throbing of the Arterial blood , as in an Aneurisma , the blood being choakt in by the contused flesh , it therefore was not there to be tented , for fear of making a Flux of blood , nor yet could we endeavor to stop the bleeding by Cautery , Actual or Potential , least thereby new pains should be stir'd up , that part being full of Ligaments and Tendons .

Wherefore I drest that Wound with the same Digestive mixt with pul . Galeni upon a thick Plegdit , and some of the same Restrictive over that , with such Bandage as that Joynt was capable of , hoping this way to hinder the Influx of humour , and that by such dressings the Wound would digest , but the pain continued vehement , and yielded to no Application , nor was there any possibility of conveying any Instrument into it whereby I might pull out the shivers of Bone .

Mr. Penicuke formerly General Chirurgeon to the Scottish Army , was with me at the dressing this Patient , but proposed no alteration of what I had done , the pains increasing , a Fever was made and attended by Dilirium and Spasme , Death followed , as commonly it doth in all such Wounds of the great Joynts . I could instance it in many , but the late case of Sir J. L. may serve for all ; his Wound , as I have heard , was of the Rotula , he had many of our most ancient Chirurgeons , with the most eminent Physicians to help them , Persons who were well experienced in Chirurgery , yet they had no better success . Therefore at Sea while they are warm with heat of Fight , we dismember them , and by actual Cautery stop the Flux of blood .

CHAP. VIII . Wounds of the Belly .

I Have now briefly run through the Parts not principal ; and purpose to say somewhat of the principal Parts , as the Belly and Breast . And that you may more certainly know the part wounded , I shall give you a short Description of them ; and then shew how they are to be handled in order to their Cure .

The Belly is called Abdomen , or Inferior venter , it begins from the bastard Ribs , and extends it self to the Groins , and is divided into three regions by our Anatomists : The upper , middle , and lowermost . The uppermost is called Epigastrum ; the middle Regio Umbilicalis ; Abdomen described . the Inferior Hypogastrium : The sides of the uppermost are the Hypochondria ; the right Hypochondrium possesseth all the Liver ; in the left is the Spleen , between these is placed the Ventriculus or Stomach . In the middle part of the Abdomen is the Navel , round about which ly the Guts , and behind those , on each side the Kidneys . In the sides of the Inferior part are the Ilia , the Pecten or Pubis in the middle , under which lyes the Bladder . Thus much to the Internal Delineation .

The Abdomen consists moreover of parts containing and contained .

Parts containing or teguments of the Abdomen , are either the common , which reach all over the Body , as the Cuticula , Cutis , Pinguedo , Membrana Carnosa , or the particular and proper to this place , which are the Muscles of the Belly the Peritoneum , and in respect of the Guts , the Omentum . The parts contained are some of them designed for the nutrition of the whole Body : others for Expurgation ; and others for Generation .

The Stomack , small Intestines , Mesenterium , vena porta , Cava , Arteria magna , & Celiaca , magna , the Liver and Spleen serve for Nutrition : The Bladder , Gall , all the Intestines , but especially the great ones , Kidneys , Ureters for Expurgation ; and for Procreation Vasa praeparantia & differentia prostatae & uterus in Women . Which parts containing and contained are subject to this Gun-shot , whence various Species arise of these Wounds , sometimes the containing parts ; as Cutis , Pinguedo , Caro musculosa onely are wounded , so as neither the Peritoneum , nor the other Internal parts suffer any hurt .

And this hapned to many in Service , Wounds not penetrating . who have been brought to me as mortally wounded ; whereas I upon search have found the Impression only upon a greazy Leather Jerkin , or their Bellies black or a little scratcht by the Bullet : In others the skin and flesh wounded and no further , these latter are call'd Wounds of the Belly , not penetrating , and are cured as Gun-shot-wounds in fleshy parts ; in which cases all those things are approved of , which have been delivered in simple Gun-shot-wounds .

But this I must take notice of to you , as having often observed , not onely in Gun-shot-wounds , but in abscesses of the Belly , that from the laxity of the parts , they are subject to great defluxion , especially in the circumjacent Muscles : to my late vexation , whilst I was writing a rude draught of this Chapter , the matter flowed out upon us , Dr. S. Physician , Mr. Gin . and my self Chir . from various Sinuses raising up the Muscles , insomuch that the more we laid them open , the less hopes we had to effect our Cure . The particular whereof I shall give you in another place , with more of that kind , enough to shew you the laxness of these parts , which is the greater , because we cannot make such Bandage here as elsewhere , by reason of their figure , scite , and perpetual motion .

These thus briefly considered , we pass to the other Species , for the Bullet is for the most part carried with such force , as it not onely wounds the fleshy parts , but also pierces the Peritonaeum , hurting most an end the Internals . Wounds penetrating . It being indeed impossible that the Bullet piercing the parts containing , should miss the contained which are soft and tender .

I have seen sometimes in the Wars , a Souldier shot scarce to the Peritonaeum , yet the contusion hath been so great that the Peritonaeum hath come of upon digestion , and the Bowels in these commonly labour under Cholicks , and the Patient is troubled with difficulty of breathing .

If the Bullet penetrates through though no further , yet the Contusion makes foul work and requires speedy relief . But if it hath wounded the Internal Viscera , then you are to consider what the parts are that are wounded , whither the Liver , Stomach , or which of the Intestines , which you may apprehend from the scite of the part , and the accidents accompanying such Wounds , and by the proper symptomes of each part .

According to Celsus , Lib . 5. Cap. 26. The Liver being hurt , Signs of the Wounds of Internal parts of the Abdomen . there follows an Effusion of a gross blood ; if the Porta or Vena Cava be hurt , the right Hypochondrium is opprest : If the Artery be wounded , the blood is florid , and with Impetuosity leaps forth , and death follows . But if the Stomack , Singultus or Hiccup , with Vomiting and Nausea , and his sustenance comes out of his Wound , with the Chyle , cold Sweats , and the extream parts cold : Of the Intestines , if the lesser be wounded , poraceous Vomiting , what he eats or drinks , will pass out of his Wound in less then half an hour .

If the great Intestines be wounded , the Excrements and filthy smell will demonstrate it : If the Wound be of the lest Hipochondrium under the short Ribs , you may conclude the Spleen wounded , and the blood floweth forth with great Tension of the Hypocondrium . If the Kidneys , the Wound is in the region of the Loins , near the Vertibra , under the Diaphragma , and the more certain sign is , if the pains reach to the Groins and Testicle , with difficulty of Urine mixt with blood , or pure blood voided by the bladder : If the Uriters be wounded , the Urine comes out of the Wound : If the Bladder be wounded , that part of the Belly is tense , pains are stirr'd up in the Groins , and the Urine is discharged by the Wound , and the Stomach suffers by consent , and the part wounded demonstrates it : If the Womb be wounded , vehement pains reaches to the Groins , and the Coxa and the Blood not only flows by the Wound , but per Vulvam they are troubled in mind , with other shrewd symptoms of death ,

For what concerns the Presage of these Gun-shot-wounds , Prognosticks . if they be only in the region of the Belly , they are not without peril , and much loss in the middle , where the Linea Alba is ; but if they penetrate , ( as you may know by the signs forementioned ) there is great hazard , seldome parts so shattered recover . What I have here seen from a man discharging his Excrements from the Colon on the left side , and heard of other like of the Stomach , are rather Miracles , then the work of the Chirurgeons ; but he was happy that had the managing that Cure .

If Celsus in his time determined these Wounds mortal by cutting Weapons , how much more must they be such that are made in our age by Gun-shot ; Yet Nature , as one saith , in his Vulneribus , Saepe miracula facere solet , is often as merciful and miraculous in the Cure , as the blow was cruel .

In order to the Cure , Cure . we must begin with the Extraction of the Bullet , least it sink into the most inward parts , and by its hardness offend the Bowels , as also the rags carried in with it , least it beget Putrefaction . Then we are to reduce the Omentum and Intestines least they be Inflated and altered by the outward Air : but in these Wounds they do not often fall out , unless it be by Splinter , or great Shot . Then Hemorrhagia is to be staid , and Inflamation allay'd , and we are to resist Putrefaction , by bringing these contused and lacerated Wounds to digestion .

The Intestines and Omentum are disposed to reduction by warm discutient Fomentations ; but if there be not an opening large enough , you must enlarge the Wound . If the Omentum be corrupted , make a Ligature below that corrupt part to cut it off , leaving the Ligature upon the rest to fall of by digestion .

If there be Haemorrhagia , you must inject such Medicaments as have a Refrigerant and Astringent quality , and those may be Aq. urtic . plant . spermatis Ranar . with Syr . de Ros . sicc . with pul . Bol . Armen . ter . sigil . sang . dracon . Aloes , Thure , making a mixture of some of the same Pouders , with a new laid Egg , with Ol. Mastich . & Lumbricor , and apply it upon a Tent fastned to a thread , Wounds of the Stomach and Guts . as is before described , and apply the rest upon a Stupe over all . But if there be no Flux of Blood , digest as fast as you can .

Fallopius hath recommended to our use this , by the use whereof he cured a Wound in the Stomach and Intestines .

℞ . Fol. Pilosellae plantag . rad . Tormentillae consolid . maj. flor . hypericii , these were decocted in red Wine ; in the latter end of the dressing adde a little Manna , Thuris , ol . Mastich . resin . Abiet . Terebinth . Cypriae , croci & verm . terrest . the Wound within to be drest with this .

If there be Putrefaction , you may use such Medicaments as are fit in that case , but those dye in great pain : In all these Wounds of the Belly , to stop fluxes of Blood , I use such like Medicaments as I have proposed , and apply to the Wound it self Digestives , as in simple Gunshot , and by good Fomentations , Embrocations and Cataplasma's , cherish the native warmth of parts .

In Wounds of the Kidneys , Wounds of the Kidneys . you are to inject such Medicaments as have an Abstersive and drying quality as Radices , consolidae , Iridis , Aristoloch . rot . and maj. myrtil . caudae equin . plantag . Balaust these decocted in aq . chalybeat . adding after some Wine , and Mel . Ros . digestivum Terebinth . & Integ . ovum with a little Terra sigil . Thus & mastic . & ol . Hyperici , with Emp. diacalcith . malaxt . with ol . Ros . and a Cataplas . of far . Hordei . fabar . & orobi decocted in Oxymell . adding a new laid Egg to it , with Ol. Ros . to be applyed over all .

If the Liver or Spleen be wounded , Wounds of the Liver , Spleen , &c. there will be great Flux of Blood , in which case I offer this to you .

℞ . Plantag . pentaphyl . polygoni Mille-follii , myrtil . Ros . rub . to these you may adde Thuris , sang . dracon . Bol . Armen . Acaciae , boyled in water chalibeated , adding a little red Wine , and syr . de Ros . succ . This may serve for an Injection : if the extravasated blood fall down into the Cavity of the Belly , you must leave it to Nature .

Thus you are to dress all the Wounds in particular parts of the Belly .

The Wounds of the Womb are accounted deadly , the very least of them : and so are all these made by Gun-shot , yet you are to proceed in the universal regiment with Glysters and Bleeding , and by good Vulneraries : there Diet here is to be medicated , and all endeavors to dispose parts to sanity , if it were possible .

CHAP. IX . Gun-shot-wounds of the Thorax .

AMongst the principal parts which are subject to this divelish Invention Gunshot , the middle Venter or Thorax is numbred with the parts contained in it , viz. the Heart , Lungs , great Artery and Vessels , with the Mediastinum . The difference of these Wounds is as in those of the Inferior Venter ; sometimes it doth not penetrate into the Cavity , so as the plura is not hurt : Other times it doth penetrate through the Membranae and Costae , in which case the principal Viscera are wounded or not wounded .

If the Wound do not penetrate into the Cavity of the Breast , Not penetrating . but be only in the musculous flesh , it shall be cured as Wounds in the fleshy parts .

But if the Bullet hath penetrated into the Cavity , Penetrating . it may be easily discerned by the Laceration of the musculous flesh , and commonly by the Fracture or Perforation amongst the Ribs , Signs . whereby the Wound is left open , and the Spirits and Air pass out with noise ; and if the contained parts be wounded , there will follow a Flux of blood by the Wound or Mouth , or by both , unless the blood fall down upon the Diaphragma , and then the Symptomes of the difficulty of breathing and such like Accidents , will more demonstrate its Penetration . And if the Lungs be wounded , a Cough , with difficulty of breathing , and flux of blood , and sighing often , and a ratling in the Aspera Arteria , the Patient inclining to ly much upon the Wound . If the Heart be hurt , the blood flows with impetuosity and reeking hot , their Pulse languishes , cold sweats follow , and they dye .

The Diaphragma hurt , draws upwards , the Spine is grieved , very difficult breathing , and unequal and painful , with a hoarse Cough , and great pains about the false Ribs .

If the great Vein or Artery be hurt , a terrible Flux of blood follows ; if it flow from the right side , it is the Cava is hurt ; but if from the left side , we suppose it the Artery , you will discover it by its saltation and florid colour . The Aorta wounded , that Patient dies at the instant .

If the Spinalis medulla be wounded , the Nerves are resolved , and a Palsey follows , more immediately in the part under the Wound . Almost all these Wounds are mortal , they generally dye . But it is not consisting with Religion or Humanity , to leave them without help . And for that I have happily prolonged the life of some , and have known others that have recovered of some of these wounds , in the Lungs and less noble parts thereabouts . I shall therefore proceed to deliver you what concerns their Cure , Cure . both as to the Internal concerning the wound it self , and to that which relates to the Contusion and Inflamation Externally , to prevent flux of humors , and facilitate the discharge of Bloud and Matter contained in the Cavity of the Thorax . You are in the first place to draw out the Bullets and Extraneous bodies , amongst which sometimes a part of the Ribs are carried in : All these are to be removed , and the place cleared of shivers , lest they prick the membranes , and thereby hasten ill accidents which attend these wounds . You are then to dress the wound with a Tent dipt in this or such like , ℞ . Bol . Armen . Corn . Cerv . ust . Ol. Ros . & Sambuci , Farinae , Volatilis , and with ovo Integ . Misce ; spread a compress with some of the same , and apply it over the wound : If the bloud stop not by this dressing , then it may be proper for you to Inject some astringent decoction , which is otherwise than was advised in wounds made by puncture : For in Gun-shot-wounds the orifice is wide enough for the Injection to return out again ; insomuch that not only the Astrictive intentions ought to be pursued , but also the Detersive ; here being loss of substance and putrifaction . Therefore boil in Aq. Ger . querc . Fol. Plantag . Ulmi , Urticae , Vincae , Pervincae , Ros . Rubr . fol. Myrtil . & Balaust . adding a little Bol . Armen . & Mastich . Syr . de Symphyto qs . and if more astringent be required , boil it in Aq. Fabr . Having thus quieted the bleeding , you are to dress with this digestive , ℞ . Terebinth . Lot . in decoct . Hordei ℥ ij . Pul . Thuris , Myrrhae , an . ℈ ij . Sem . Faenug . p. ʒ j . Ol. Hyperic . qs . dress with a Tent dipt in this , then apply over it a Pledgit , with some of the same , or with some of your Suppuratives , as in simple Gun-shot-wounds is prescribed , and Embrocate the breast and parts about with Ol. Amygdul . & Lumbric . with Ung . Dialth . m . and an Empl. Diach . simpl . cum . ol . Lumbric . dissol . and after digestion you are to Inject such medicaments as have power to deterge , and are more resolvent , whereby the Matter is disposed to be discharged by the wound ; and to this purpose extract . Scordii dissolved in Wine , with the addition of Mel . Ros . is proper , or decoct . Pilosellae , Caude Equinae , Plantag . Tormentillae , Consolidae , Aristoloch . Rot . Rad . Iridis , & Sarcocollae , these boil'd in Aq. Font . adding Wine to it , with Mel . Ros . qs . and then you may dress the wound with this Mund . ℞ . Terebinth . ℥ ij . Farin . Hord . Cribrat . ʒ j . Thuris , Sarcocol . Rad . Iridis , an . ʒ iij . Mellis Ros . ℥ iiij . Misce S. A. You may dip your Canula or Tent in this , and dress the wound in the fleshy parts with the same . The wound deterg'd incarn and cicatrize , as is said in other wounds , but keep a Canula in it , until it cease to run . Celsus proposes , that in all these Internal wounds the outer parts be vesicated , to draw off humors more powerfully from within , and the medicament he proposes thereto is , Sal bene contritus cum cerato mixtus , quia leviter cutim erodit , eoque impetum materiae quo pulmo vexatur evocat . This his proposal may be proper in wounds made by sharp weapons , as by Arrows , &c. But here in these wounds there is vexation enough outwardly to make a revulsion , if that signified any thing . In the dressing these wounds you must be careful to cut off the sloughs without , lest from them a stinking Gleet distil upon the Viscera within : And in order to the cure there is required Phlebotomy according as the Patient lost bloud by his wound : Here are also Clysters required to keep the body open , and the more temperate : Pectoral decoctions are here proper ; such as is in the London dispensatory , omitting the hotter Plants ; to them may be added Syr . violar . de cichor . de liqueritia , Jujub . Capil . Ven . de symphyto , & Lohochs , and such as may take off the harshness which the Aspera Arteria , and Bronchia are subject to . Their diet is to be slender , and medicated . Hydromel is a proper drink in all these wounds , and may be medicacated with agglutinatives and pectorals added to it , and after Fever and such like accidents are diminished , Asses and Goats milk is necessary , yea a diet of Cows milk alone , or mixt with distill'd milks , and sweetned with conserve of Roses ; but this will be a work for the Physician a-shore .

From the defeat of the Scotch-army near Dunbar , Observation . there came many of the wounded to St. Johnstons , and amongst them there was several wounded into the Breast ; they who were so shot as to have the Ribs broken , were in extream pain from the shivers , whereas those whose Bones were not hurt had scarce any pain at all , but what proceeded from difficulty of breathing and coughing : A stinking Sanies issuing out both before and after the separation of the sloughs in great quantity ; in one a very great proportion daily , of a brown thin Matter , of a rank smell ; none but this died under my hands ; they after some while retiring to their homes , where ( as I have often heard them say ) their Leeches performed great Cures , by vertue of their Plants which they gave Internally , and with Fats they made Balsams of ; yet I believe most of these died Tabid .

CHAP. X. Of Symptomes of Gun-shot , omitted in the Fourth Chapter .

THe Symptomes attending Gun-shot , as you have read already elsewhere , are Pain , Fever , Delirium , Syncope , Phlegmon , Erisipilas , Gangrene , Convulsion & Palsie . The Pain proceeds from Inflamation or Phlegmon or Erisipilas , which I have elsewhere purposely treated off , as also of Gangrene ; The Fever is Symptomatical , so is the Delirium , & will go off with the Pain , but may with the forementioned be relieved , by bleeding and Lenient purgatives , such as I have mentioned , and to fortifie the Spirits against fainting , which proceeds from putrid Vapours and Pain which may affect the part , there are Cordials and Epithemata already taught , so that there remains only Convulsion and Palsie .

Convulsion is an involuntary contraction of the Nerves to their Original , Convulsion . by which contraction the Member is also drawn up , and is said to be caused of Repletion and Inanition ; In this our case it ariseth from putrid Vapours or Acrid matter offending the Nerves , which is often found in these wounds ; The part affected is the Brain , which being thus provoked causeth an involuntary contraction and rigidity of the Members . In parts dismembred , as near the Knee or Shoulder , there the Contraction cannot be discerned but by a trembling , which trembling is usually attended by a Convulsion of the Jaws : It likewise follows great Inflamations , especially in the Nervous parts ; The Prognostick here is always Fatal , they being the forerunners of death . Observation . In the Wars I was called to see a poor Souldier who had his Arm shot off , near the Shoulder , his Chirurgeon drest him with Egyptiac . as for a Gangrene , from which sharp dressings great Pain followed , with shivering of the Stump , Inflamations and Gleets , but no change of Colour in the skin , he had roared some days , through the vehement pain ; I drest him up with Anodynes , as Linement Arcei cum vitel . ovi , fomented the part with fol. malvar . violar . caps . barbat . decocted in lacte , and with Lenients Embrocated , as with ol . Lumbricor . & exped . Bovinis , and applyed Empl. Diapalma cum succis over all , and anointed parts about , as Neck and Spine with ung . Nervin . and blistered the Legs and Thighs , but it was too late ; he died howling .

Paralysis or resolutio Nervorum is generally defined a privation of Sence or motion or both , Palsie . in some part or parts , and affects the Brain & spinalis medulla ; But in Palsies which arise from wounds , the parts immediately affected are the Nerves of that part only , this doth not take away the life of the Patient , though it may sometimes threaten a Mortification through the resolution of the part . In a Sea-fight an Irish Mariner having discharged his Gun which was hony-combed , Observation . and loaded it suddainly again , whilst he was ramming in a Carthage , the powder took fire , and shot the Rammer out of his hand , it did tear the Palm of his hand , and some of his Thumb and Fingers : The wound was not considerable , but it extinguished both Sence and Motion of the Member . I drest him up with our common digestive , of which at such a time we had great quantity ready , and over all a common Restrictive , so rouled him up , there being then no time for bleeding ; But after the fight I let him bloud , and the next day or two Purg'd him , and Fomented and Embrocated him , with ol . Lumbricor . Cham . Aneth . lilior . ung . Nervinum , and such like I suppose , and did all that we Chirurgeons of the Squadron thought fitting , but without success ; one night lying a-sleep in his Hamock , he was awakened by the wet he felt , and got up to a Candle , and found the dressing upon his hand all bloudy , as also his belly whereon it lay : I was called , taking off his dressings , found the palm of his hand and fingers gnawed by Ratts , they had eaten through his oyl'd clothes , and had knaw'd his hand more if he had not wakened from the trickling of his bloud . I drest his wound with my digestive , purposing not to hasten its cure . I supposing it might be a help to his recovery . I after the cure of this made him a Fontanell in that Arm , and bathed the Member , Cupt and Scarified it , and afterwards used Emplasters of Pitch , to stir up a heat in the part ; but he was a young man and otherwise of a strong Constitution , and out of hopes of reward for his lost Arm , he hastened away to Madrid , and at his return had more use of it : These Paralyses do often happen in great Contusions , and after dislocations in the Shoulders , I could instance it in several . Dr. T. C. and Dr. T. W. did both see it in a Lady who had dislocated her Shoulder . I was sent for , and by the help of her Servants set it presently , and she so well the next morning , as Sir W. G. then present scarce believed it had been out ; I was dismist , but within a month after she was so Lame , as it was doubted , whether the Bone was Set or not . A Bone Setter was sent for , who at a time in another person pretended he had set so many Bones , where none were dislocated or broken . This man , I being present , acknowledged that the Bone was well Set ; but had I been absent , he would have delivered otherwise , and by new Extension have rendred the part Incurable .

AN APPENDIX TO The Treatise of GUN-SHOT-WOUNDS .

To the Reader .

HAving thus finished the Discourse of Wounds , I considered with my self that my design was to help the Sea-Chirurgeons , who seldom trouble their Cabins with many Books . I therefore thought it convenient to make this little Treatise as comprehensive for their use as I could , by making it contain all those things which may easily be foreseen to be of use to them . Now besides Wounds , we know by our experience that Burnings by Gun-powder and other materials do too frequently happen at Sea : and also by Ill dressing of Wounds Gangrenes and Fistulae arise , and withal much the sooner , if broken Bones , especially those with Wounds , be not well brought together and so held : The ease and life of the Patient consisting in the well handling and ordering of them . All which matter we occasionally handled in the foregoing work , yet not so much , but that for their fuller Instruction I thought it requisite to anticipate something of other Discourses , I intend for the Press , by the following Appendix , which if well perused may perfect the Chirurgeon in what remains to be known concerning Wounds , and save him the labour of reading many Authors .

AN APPENDIX TO The Treatise of GUN-SHOT WOUNDS .

CHAP. I. De Ambustis , or Burning .

FOrasmuch as it often happens , that in close fights at Sea men are sometimes burnt by Gun-powder by their Enemies , and by various accidents amongst themselves : I shall therefore deliver to you the most plain way of curing them . For however people cry 't is nothing to cure a Burn , yet by what I have seen of these Cures from Country or City , they are often very ill performed . Whether they are Burnt by Gun-powder , or any other way , their Cure is much alike ; they only differing , secundùm magis & minus , only if they be burnt with Gun-powder , they must pick out the powder first , else they will carry the same blew mark in their faces , which some of our people use to do in their hands and arms , which I have often been employed to take out , when done wantonly in their youth ; but could never remove this mark , otherwise than by taking off the skin .

If the Burn be superficial , it raises the Cuticula up in Blisters . If it go deeper into the skin , it causes an Eschar : If it burn deeper into the flesh , the force of the fire makes a hard crust with a contraction : In all these the pain is excessive . Once dressing a Gangrened Leg with warm Spirits of Terebinth . &c. Mr. Arris and Mr. Hollyer Chirurgeons , and others being close about me , and I upon my knees ; the candle being too near the hot Spirits , catcht the flame , burnt my thumb and fingers , with that part of my hand before I could get free from those behind me to throw it into the chimny , which was some distance off . I felt much more pain for the while in the superficial scalding , than where it was burnt to an Eschar . The pain is vehement , & makes great fluxion . Cure of a Burn . The Indications of Cure are of two kinds , either by refrigerants and Emollients to bath or anoint the part , until the heat be off , and the Eschar removed , and then to deterge and cicatrize ; or by hot medicaments to relax the skin and open , to resolve and dissipate ; and so by accident allay the heat and burning . By Refrigerants . The Refrigerants are Aq. Solani , Plantag . Hyosciami , lac Ebutyratum , and all the cooling Juices and Unguents ; as Album . Nutritum , Populeon . Rosat . &c. These must be used warm , until the heat and pain cease , or the fire be taken out , ( as the common expression is ) else they will rather cause pain . The other is by Rarefaction to ally the fiery heat and pain , which in the first place is done , By Rarefaction . by the holding a burning-hot Iron or fire to the part ; so whilest the fire calls forth that fire it made , it becomes its Alexiterium . But the common remedy is to apply salt and an Onyon beaten together upon the Burn . But this is not to be done after the Blisters be out ; for so you exasperate the pain and increase the inflammation . There are many other things do the like , Fimus Equinus doth the like fried in Ol. Nucum , uvae immaturae , Sambucus & Ebulus , in oleo Coct . Calx viva extinct . & cum Ung . Rosaceo mixta , ad consist . Ung . These are to be renewed often , until the pain and heat be off , which they in few days effect ; if there be Cacochymia , it is another kind of work : If these applications do not prevent the arising of Pustulae , you must cut them as they arise , lest by their Erosion they make hollow Ulcers , and inflame with sharp pains , Fever , &c. But where they are burnt to a crust or Eschar , you must hasten its fall with Emollients ; deterge , then incarn and cicatrize .

Here is required bleeding and evacuation by lenients and spare diet , Regiment in Burns . with all other regulation proportionable , as the Burn is greater or less . I could present you many cases of this , but shall give you one for all .

A Scholar of about ten years of age , Observation . at a School a few miles off , the evening before the Fifth of November , having fill'd his right pocket full of Squibs and Crackers , would before he went to bed , throw one of them in the Embers , it took fire : Whether it scattered the fire , or some spark , or that it was the Cracker , but those in his pocket took fire also , and his cloaths were on fire ; his little chamber-fellow ran for help , a little boy from some other Apartment takes the alarum , first comes in , sees his School-fellow in fire , catches up a bason of water , throws it upon him , runs out , cries help , they come in and help him out of his burnt cloaths : A neighbour-Chirurgeon is sent for , who dresses him , and the next day the burnt child is brought to Town , and lodged by me . I find him burnt into the flesh , from a hands-breadth below the Axilla , down the side , and part of the belly , within two inches of the knee ; in breadth from the belly , over the Os Ileon to the Gluteus , and scorcht about the edges ; and by endeavouring to free his pockets of the Crackers , which was burning there , he burnt his hands from the fingers end , all the in-side of his arm to his elbow joynt ; where the parts were burnt to a crust , these I anointed with Mel cum Succo Caepar . & Pul . Iridis mixt ; and all the parts about I fomented with a decoction of Hyosciam . Malvar . Solan . Violar . & Sem . Cydon . & Psillii , adding to it a third part of lac Ebutyratum ; and then Embrocate the parts with Ung . Stramon . Then he should have been let bloud , but would not : Clysters were admitted , and pearl Juleps , his Fever was very great with the pains ; as any Blisters arose we snipt them . As they became raw , I finding that Cerots or ought else of Pledgits were apt to shut in Matter , and bring off the skin with it ; dipt a fine Lawn in the decoction , and laid it over the parts , and with a feather dipt in Ung . de Stramon . mixt with Ol. Amygdul . anointed the Lawns , through which the Matter passed , and the parts lightly burnt healed ; The parts deeper burnt , as they threw off their Eschars , I digested , with the yolk of an Egg , a little Tereb . lot . in aq . Solani , adding a little Farina Hordei finely searsed cum . Ol. Amygdalar . with a little Saffron . Upon the sides I laid of this Ung . Stramonii , with a little Calx Lot . and on other parts Ung . Album , adding a new-laid Egg to it . Thus each part is to be considered , and especial care that Matter be no where pent in .

In these large Burnings there are variety of intentions at the same time : Some require anodynes , Several Indications in a large Burn . Others detergents ; digestion some , and others desiccants : Some the parts drest twice a-day , Others but once : Some I drest with this Ung . ℞ Ol. Sambuci . lb j . Cerae ℥ iij . These I melt , then taking it off the fire , I add Lithargar . Cerussae , Calcis lot . Thuris & Sarcocol . Upon some of these Lawns I laid Pledgits dip'd in a solution of Troch . Alb. Rhaz . made in a decoct . of Equiset . Ros . Rubr . and Summit . Rubi to cicatrize the part : And as the part bears , I make it more drying . Thus I happily cicatrized this young Gentleman , even and smooth , without the least unequal Cicatrix ; nothing but the red colour to make it discernable ; and that was gone off his hand when I see him last : And I must tell you , in these great Ulcers it will require your care , that an Hypersarcosis be kept from growing upon you ; for so your Cicatrizes will be deformed . I have had some persons of good quality come to me , so deformed with these , as they have suspected them to be wenny ; and where they have hapned upon womens Breasts , they have suspected them Cancerous : These were much to the credit of the Female-Chirurgery . In others from ill Chirurgery the lax flesh hath grown so high and callous , as when one of them came into my hands , he required to be burnt again in order to his Cure ; but I performed it easier . In the face there is a special care to be had , as also in the neck and breasts of the Female sex . Medicines for Eyes burned . A great care must be had likewise of the Eyes , that they be drest with no greasie medicines , and that the Lids be not drest with too drying , lest they contract and make a Lippitudo ; in the cure of the Eyes you have Pigeons bloud , Breast milk , Aq. Solani , Plantag . Ros . Pomor . Sem . Cydon . Faenug . Troch . Alb. Rhas . Tutiae , Lap . Calam . Thus , Sarcocol . washt or nor washt . The Ears , for want of care , I have seen adhering to the scalp , and the fingers one to another ; and in others close contracted , with hard Callus ; one of which I cut : It was a Boy from Cheshire the Lady B. commended to me . Observation . I cut the cicatrix of each finger , and caused a roul to be placed under his crookt fingers , which carried with bars to the inward part of his wrist , which had by skrew there fastened gently , thrust forward the bar , till it had born all the fingers before it , and by a compleat extension restored them to their former liberty . The wrists and other joynts are subject to the same inconveniences , which are prevented by the knowing Artist , by the well ordering them , without which the best Medicaments signifie little .

CHAP. II . De Gangraena & Sphacelo .

THE most cruel Symptomes that attend great wounds , and especially Gun-shot , with broken bones , are Gangraena & Sphacelus ; Gangrene is the beginning of a Sphacelus ; It is the disposition of fleshy , and Spermatick parts to a mortification : Sphacelus is a perfect Mortification , with the extinction of the native heat , and privation of Sense and motion of the part . They differ only as the Mortification is more or less .

The Signs of Gangrene , and Sphacelus are much alike , the last more intense ; Signs . it is of a deadly Livid Colour , Fetid , the lips Flaccid , without heat or sence of Knife or Fire ; if there be yet sence in it , 't is there Gangrena ; If no sence then Sphacelus .

That Brother was grosly ignorant , that told me aloud , there was no need of inlarging the wound , he could turn his finger in it , and pull out the rags , &c. As I came out I met Dr. W. who askt me how the Patient did ; I replyed the Chirurgeon within hath given me unwittingly the certain sign of his death , which I had some two or three days before prognosticated , and advised his wound to be laid open for perspiration , and the taking out of Extraneous Bodies : The Chirurgeon tells me there is no need , he hath easily put his fingers into the wound and pulled out some rags , by which I conclude the Patient will dye in few hours : The Doctor replyed , yea , without doubt , and the Patient did die the next day . In magnis vulneribus & pravis si tumores non appareant , ingens malum . This was a great wound , and not being digested , it should have been accompanied with flux of humor , and Inflammation . The lips of the wound full , and rather with a narrow contracted Orifice , but the heat was decayed , the tumor sunk , and the lips flaccid .

The causes of Gangreen are various in Gun-shot wounds , Causes of Gangrene . it commonly happens from errour in the first applications , and not making timely extraction of the Extraneous Bodies , and shivers of bones ; which prick the nervous and fleshy parts , by which great flux of humors falls into them , which debilitates and choaks their natural heat ; Cold hard winters , by intercepting the spirits , cause mortification ; hard Bandage is a caused deficiency of heat in old age ; And the Scorbute is often a cause .

The Prognosticks of these are sad : Prognosticks . The Sphacelus incurable ; The Gangreen is curable , if the habit of the body be good and timely succoured ; otherwise it terminates in Sphacelus , and the Patient dies miserably ; whensoever you see the Inflammation will not discuss nor suppurate , or that you perceive the bottom of the wound doth not matter , but feels deeper , soft and more foul , you may suspect ; but if the matter be changed to worse , you may assure your self the heat is decaying , and the outer Symptomes in the change of Colour and sinking of the Tumor will follow . Therefore hast to prevent it , there being great danger in delay ; Cure . If it change colour , and Blisters arise with certain Livid spots , and they but in the superficies of the skin , Scarifie them to the Quick , and let them bleed freely , by your Patient's sensible feeling them , and by the fresh trickling down of bloud , you may judge of the mortification : But if the Gangreen have crept deeper , or arise from the bottome of the wound , then Scarifie deeper into the fleshy parts to the Quick ; and if there be any abscess deep under the muscles or lips of the wound , let it out ; So shall you give a breathing to the parts : If in making your deep Scarifications , you chance to cut some Vessel , whereby a flux of bloud happens , have a care of Choaking the part with your Astringents and Dossils ; for so the Gangreen will be increased : In this Case , I propose the Actual cautery , which will not only secure you from a flux of bloud , but dry up the putrefaction : Then you are to apply such things , as may remove the Escar ; as honey , powder of Ireos and juice of an Onyon : And afterward deterge , Incarn and Cicatrize as in other wounds . If in your Scarifications you wound a Nerve or Tendon , you add to the Gangreen ; So you do if you burn but in part , or apply sharp Medicaments upon them newly hurt ; or it may be it was at first , as I said , some Nerve opprest by hard bodies , or prickt by shivers . Consider well , and if such lie in your way , ( as in Nervous parts they may ) you had better cut them off , or burn them through , than Scorch them : The hurting and burning of these is often a cause that the pain and fluxion is kept up . I see it daily in my practice in Sinewy parts , and while I was a writing of this , I cut off some of them to quiet the part , which otherwise upon every touch was grievously pained and inflamed ; that so I might with more ease come at the carious bone that lay under it : But if you meet with none of these accidents , then after Scarification , consider how far the Gangrene hath proceeded , and accordingly cleanse the wound , by washing out the clotted bloud , either with a Tincture of Myrrhae and Aloes ; with extract Scordii or Theriac . Aristoloch . Gentian , or ( if you will ) add Calcantum ; or that common Medicine of the Ancients , Salt in water , or a good Lixivium , or dissolving some Aegyptiacum , and afterwards it is in your choice whether you will dress it warm , with these or some Chymical oyles , as Terebinth . Caryophyl , &c. In a Gangrene coming in a Phlegmon elsewhere mention'd , I Scarified the parts , and washed out the Bloud , with a little ung . Aegyptiac . disolved in sp . of wine , and fill'd the Scarification round , between the Gangren'd lips and sound parts , by Sir Alex . Frasier's , Observation . chief Phys . to the King , order with a precipitate ; And applyed over such a like Cataplas . ℞ farinae fabar . Lupinor . pisor . an . lib . coq . in Aceto optimo & melle , with the addition of Succ . Apii & Absinthii : The part where we sprinkled the precipitate separated with a perfect good matter , as much as was of it , and I have since often used it with good success . Observation . I have sometimes when the Gangrene hath been coming on , washt and drest the Patient , with a little ol . Tereb . hot with an Arm'd Probe , and dipt a Dossil , first in the same oyl , and then in precipitate , and put into the wound ; And a Pledget of Basilicon dipt in the same oyl of Terebinth . hot over that ; and in hast mixt the Crums of a wheaten Loaf , with good Brandy ; and stirring it over the fire , with the yoalk of an Egg , and some Safron to the form of a Cataplasma , and applied it over the part afflicted , and roul'd it gently on : The first time I ever used it , was upon a contused wound , on a person of a full body , his pain was great , his wound gleeting , and the parts changed in their colour : Against the next morning I was better provided , but there was no need , his pain was mitigated , the colour of the lips was returned , and the wound dry : I suppose my precipitate with the oyl had made some little Escar , therefore let it alone to fall off of it self , and applied a fresh pledget as before , over the Dossils , and after I had a while fomented the part affected , I laid over it the remainder of the former Cataplasma : The next dayes dressing the Dossils came out with good digestion , and the wound afterward was Cured . But in these according to the increase , you must fit your Applications , farinae , hordei , fabar . orobi , Lupini , lentium , pisorum , sumit . Centauri , Min. Absinth . Scordii , Cardui Benedicti : Rutae , rad . Ireos Aristoloch . Gentian , vincetox . Sal . com . Lixivium . oximel . Myrrhae & Aloes sp . vini ; These are the common remedies , of which Fomentations and Cataplasmes are to be made , to corroborate and resist putrefaction .

Then you have the common Aegyptiac . which you may heighten by the addition of Sal . com . Armoniac . nitri , Theriacae , Mithridati , Camphorae , &c. and a good defensative above the part , of Bole Terrae sigil . sang . dracon . Acetum succ . solani , ol . Ros . Myrr . Cerae , Alb. ovor . &c.

In these dressings you are to cut away the mortified parts ; and each time cleanse it of its putrefaction , Note , otherwise it may be feared , it may be corrupted again under the Escar .

If after all these Endeavours , the Gangrene penetrate more inwardly , Actual Cautery . you must then attempt it , by the actual Cautery according to Hypp . Illi affectus qui Medicamentis non sanantur ferro sanantur , qui ferro non sanantur Igne sanantur , qui Igne non Curantur hos existimare oportet insanabiles ; Those diseases which will not cure with Medicaments , are cured by a Knife , and those which yield not to that , are cured by Fire , and those which will not by either , are counted incurable .

By the actual Cautery you shall resist all the degrees of putrefaction , except a confirmed Sphacelus , it not only corrects putrefaction , but corroberates the part .

But if after all our vigilancy and industry in contriving remedies to resist the Gangrene , it does yet delude us , and terminate in Sphacelo , there is then no more need of taking Indication from antecedent causes or changing of Medicines , according to the variety of the Causes that introduced it : whether a Gangrene arise from an hot Intemperies or cold , moist or dry ; Sphacelus is alway the same extinction of the native heat and destruction of the Member : The mortification creepeth on , and not only incompasseth the Member , but infecteth the Spirit to the very heart with its corrupt vapours , mortifying the Vessels all along the sound parts , leaving the Member immoveable without sense or heat , rotten , black and cadaverous ; wherefore there is nothing now to be thought of in this case , but Amputation or cutting off , quia curatio syderationis non consistet in medio , the cure of this disease not consisting , as I said , in outward applications , but manual operation ; and what success may be therefrom expected is much to be doubted . Extirpation . At satius erit , with Celsus , Anceps auxilium experiri quam nullum . It is a miserable kind of help , yet it is the determination of all Authors , that in Sphacelus , Membrum corruptum abscindendum est , In this case it becomes the Chirurgeon to acquaint the friends with this last woful kind of remedy , and withal to make his prognostick accordingly , and then provide all things in readiness : But before we undertake this last Remedy , we must consider how to proceed in the operation ; In those places where Amputation cannot be made , as in the Buttock , Shoulder , Back , &c. Fab . Hild . proposeth the use of potential Cauteries applyed to the mortified part , and often renewed , till the last Escar reached to the live flesh ; yet he condemneth Arsnick as being venemous , and producing many dangerous Symptomes : It is true , that I my self have often used that method of Cure in Sarcomata with good success , but in a mortification there appears to me many greater Inconveniences that attend it ; first from the caustick it self , as he proposeth it of Salts , it will melt in the working , and is more disposed to spread in the skin than penetrate deep into the flesh : This every young Chirurgeon knows in his making of Fontinels , that he cannot apply a bit so little with all his Art in defending it , but that it will have spread much farther than he designed it ; then the separation of such Escars is too slow to effect your purpose , and in an ill habit of body , such medicaments are apt of themselves to procure a mortification rather than Cure : Whereas on the contrary , an actual Cautery answers all Intentions ; it not only consumeth the mortification , but dryeth up the venemous humour , thereby preventing its farther progress , and also communicateth warmth to the languishing parts ; by vertue of which the separation is much farthered , and by working upon the Gangren'd sloughs performed more easie , as I shall shew you in my practice elsewhere . But where Amputation it self is feisable , nay altogether necessary , as in the Limbs , there ariseth a new question ; Whether it ought to be done in the sound part or in the dead : Fabr . ab Aq. Pend . adviseth the dead part within a fingers breadth of the live , ( as also do many others ) then with a Cautery burns up all the remaining mortification . Others do perform the Operation with a hot Knife , the figure of which you may see in Hildanus . Aq. Pend . speaks so confidently of his success in the practice of this way , that utterly to deny the thing were to give him the lie . I shall only make this objection , that the Sphacelus doth seldom affect the Member so equally round , as that an operation in the dead part is feisable ; nay which is worse when once the mortification seizeth on the great Vessels , it runneth up so fast under the skin , that before any considerable part of the Member is outwardly Gangren'd , on the one side beyond the Knee or Elbow ; The other side will have reached to the Inguen or Axilla . This I confess frustrates all manner of Amputating , whether in the sound or mortified part : yet generally speaking the Gangrene doth not grow so fast , but that if you make Amputation two fingers breadth more or less , within the live flesh , you may prevent it , and that far better than it is possible to be done by the other way of operating ; for if you work there by actual Cautery with an hot Knife , your Knife will stick fast in the flesh till the moisture be wholly dryed up , and then you must repeat many Knives and Cauteries , in every one of which you will meet with the same inconvenience ; Yea before you can cut through with your hot Knife , it is very probable that you will near the Bone meet with some parts that are alive and sensible , especially when you come to the Periostium ; for the Bone doth not usually corrupt at the same rate of swiftness with the other flesh , and then all your pains and trouble will be as great or greater than if you did it in the sound part . As to other Inconveniences , I shall refer you to Hildanus , who hath taken pains in confuting this opinion .

The greatest motives to the Ancients for the use of this and that other way of Amputating in the Joynts , I presume was the easiness of preventing fluxes of bloud this way , which they found more difficult than the other .

But modern Chirurgeons have answered this objection by good Bandages and deligation of the Vessels , and when we cut above the Knee by clapping Cauteries to the Vessels only , which sufficiently answers that Intention : Thus have I seen in my first Sea voyages , Amputations made above Knee , and afterwards practised them with great ease and safety :

Now since not only in this Chapter of Gangrene , but frequently in this Book , we have mentioned Amputation , I think it necessary to take this occasion of shewing the manner of performing it , the rather because the operation is much the same , whether it be done upon the account of Gangrene , or for other reasons . I shall therefore in general terms insert the whole doctrine of Amputation though briefly , not mattering whether the examples instanced be Sphacell or not ; all instances being alike instructive , viz. If in heat of fight at Sea , a Leg or Arm be shattered by Splinter or Great Shot , What is to be considered in heat of Fight . you are to consider the loss of Substance , whether the principal Muscles and Vessels are torn off ; or if the wound was inflicted by Musket-shot in the bending of the Arm , in the inside of the Elbow , or in any of the Joints of the Leg or Arm ; if you cannot extract it , or if the Bullet did pass through , yet if the fracture be great , or the shivers of Bones so lodg'd within the Joint , as you cannot pull them out , and if the Artery be wounded by the same shot , and that you cannot come to dress or stop it otherwise than by crowding dossils into the wound ; you shall then presently make extirpation of them , cutting the Arm in the place where it is so shattered , and saw off the end of the Bone even ; your assistant the while pulling up the musculous skin and flesh . If it were the Ankle thus maimed , you shall then cut off the Leg within three or four fingers breadth under the Knee , for that so long a stump would be troublesome : But if it were shattered in the calf of the Leg , do not put your Patient to the pain of Amputation , for the gaining a hands breadth or higher : If the Toes with part of the foot was shot off , cut off the lacerated parts smooth , but with care to save as much of the foot with the heel as you can ; it being much better than a wooden Leg : But if the Arm or Leg be not so shattered , though the wound be large on one side , and hang gaping down with great fracture of Bones , yet be not discourag'd , the largeness of the wound will make for your better pulling out those extraneous bodies , shivers , splinters , rags , or ought else ; and for the easier discharge of matter , dress it as a wound by a splinter .

If the great Joynt be so shot by Musquet-bullet , that you think it not reasonable to cut off the member , be sure you make extraction of the Bullet , and free it of all extraneous bodies ; leaving not the least shiver to prick the Nerves or Tendons , and make such way presently , that you may be able to dress the wounded Nerves , Tendons , &c. without after-openings , when the part is inflamed and unfit for it .

If after some days the wound do not digest but inflame and Gangrene , and the Gangrene do not yield to your Applications , as hath been proposed in Gangrene , then as in Sphacelus you are to proceed with the extirpation of that rotten member , while the Patient is free from Delirium , and hath strength to bear the operation .

Seat him so as it may be for your conveniency . At Sea they sit or lye ; I never took much notice , nor do I remember I had ever any body to hold them ; with the help of my Mates , and some one or two that belonged to the Hold , I went on with my work . At Sterling I made an Amputation above the knee , and had as little help ; besides my servants , there was only a Sea-Chirurgeons assisting me , we stopt the flux of bloud by actual Cautery , the wound digested and cured without any ill accident ; but where we have convenience to proceed more formally , there we place the Patient in a Chair , where he may be held firm , and in a clear light , and your assistance come better about you ; the member is to be supported by some one of the servants , then one of your assistants should draw up the skin and musculous flesh above the part you propose to extirpate , then make a Ligature two fingers-breadth or there-about in the sound part ; so as if you Amputate in case of Gangrene , you may be sure to quit your self of the mortification . This Ligature is omitted by many of our Chirurgeons here in the City , they only making a turn with a Tape , pinning it on as a mark to circumcise by ; and instead of the Ligature I. propose they make a Gripe , which Gripe is commonly made by some Assistant who is strong in Griping : Indeed this is good where a shattered member is to be cut off to smooth the stump , where there is no great fear of bleeding ; but in Amputation it seems to me to be very inconvenient , for I never see any man so gripe , but that the Artery bled with a greater force than was allowable ; yea when Mr. Wodall grip'd , who was so applauded , and in truth made for the work ; it being so , in what a huddle is the stump then drest : But suppose the uneasie posture , and the long griping tires him , or that his hand be crampt the while , what is then the condition of the Patient ? Whereas by this ancient way of Ligature which I propose , the Vessels are secured from bleeding , the member benum'd , and the flesh held steady , ready to receive the impression of your crooked Knife , ( or Razor which I have often Amputated with ) the Amputation made , the drawn-up skin and musculous flesh falls down to cover the stump , and the Chirurgeon hath time to take up the Artery or cauterize the mouths of the Vessels , and afterward to bring the lips over the stump by a cross stitch . This Ligature made , the Assistant strengthens it , whilest he draws up the musculous flesh ; the mean time the Operator with a sharp crooked Knife by a turn cuts round to the bone , then with the back of his knife he scrapes the Periostium from the bone ; if there be two bones , he with the Divider separates the fleshy membrane there , while the Assistant pulls up the divided parts more powerfully ; during which the Operator with a few motions saws off the bones or bone : If there remain any Asperity on the end of the bone , it must be smoothed . There is to be a boul with Bran or sifted Ashes to be under the member , while this work is doing , to receive the bloud : When you make this circumcision , begin in the upper part on the out-side of the Leg or Arm , cut down close to the bone , bringing your Knife round to the inside , where the great Vessels are ; so shall you have the less effusion of bloud : That done , and the bones freed of the Periostium , Guido proposes a linning , and Hildanus a kind of a purse to be brought over the upper-divided flesh , to pull it upward , to make more way for the Saw ; but I think that needless . The flesh divided , the parts separate enough of themselves , besides the Assistants pulling up the musculous flesh and skin is sufficient , the bone is to be sawed off close by the flesh above : that done , you are at liberty , whether you will cauterize the Vessels by a Button-Cautery , or by Ligature stop the bleeding , or by agglutination . The use of Calcanthum I do not approve , to apply Escaroticks to the ends of the Nerves and Tendons , new incised , causes great pain , weakens the part , and makes way for Gangrene : It not being likely you can so apply them to the Artery , but that you must burn the parts about , which are , as I said , the Nerves , &c. The way Hildanus proposes by drawing the Vessels out by a pair of Forceps , is not a work to be done in heat of fight , nor without a clear day-light ; if you attempt it on Land his Arm would be bowed , and his Leg stretcht out , that the Vessels may be elonged after extirpation , that you may the better take hold of them . Ambr. Par . proposes a more easie and sure way of deligation , that is , by passing the Needle with a good strong Thread through the skin , about half an inch above from the lips , your Needle to come out just by the side of the great Vessels , then pass your Needle from the other side over the Vessels within , through the Raw-flesh out through the skin ; there putting a fold of a rag or of Emplaster spread , and tye the two ends of the thread over this straight ; thus you bind the Artery and Vein with inconsiderable pain : But at Sea , I suppose , your actual Cauteries are always at such times in readiness by you : Therefore in such cases use them , they will secure your Patient from the present danger , and fortifie the part against future putrifaction , they requiring no such strict Bandage , as that thereby you shall fear interception of Spirits ; when we Cauterize the Artery , we do then touch the end of the bone , it hastening the Exfoliation : The next thing is the loosening the Ligature , and bringing the lips close over the stump , then whether you should with a cross stitch hold them so , or content your self by Bandage as well as you can , is by some controverted ; they that object against it say , it causes pain and inflamation , so doth Bandage , if it be made too straight ; Therefore they should object against that also . The most that I have seen without cross stitch have the next dressing been broad stumps , some of them with lips turned outward by the Bandage : In the least of them the whole stump hath been bare , whereas those where I have brought the lips over the stump , have been the next dressing close , covering the great Vessels , and a third or half part of the stump hath been well digested , and by the second dressing hath been near agglutinated , so far as it lay under that skin , & without inflammation happily cured : Whereas the broad stump is a certain sign of a long Cure , and commonly death . The exposing those incised parts too much to the Air , causes pain , and the want of native heat makes them gleet ; or if they do digest , the discharge of so great a quantity of Matter commonly exhausts the Spirits of the Patient .

If the musculous flesh and skin was well pull'd up in time of Amputation , and brought over by a moderate extension , as far as they will easily admit , you will find it not painful ; you are to pass the Needle with a strong brown-thread seared , you are to pass it about half an inch from the edges of the lips , having made them cross from side to side equally , tye them with a moderate astriction , then apply a Pledgit on the Cauterized Vessels with Pul . Irid . Suc . Cepar . & Mel . But if no Cautery was used , then Buttons of Tow spread with your Restrictive , and dipt in Pulv . Galeni are to be applied to the mouthes of the Vessels ; afterward sprinkle the stump thick with this powder , ℞ . Bol . Armen . Farin . Volatil . Picis , Naval . an ℥ iiij . Aloe , Thuris , Mastich , Sang , Dracon , an . ℥ j . Gypsi ℥ jss . Pil . Lepor . Corii raspat . an . ʒ ij . Pul . Subt . m . Mix some of the same cum Albumine ovor . and apply it upon a round thick Stupa , which hath first been wet in Oxycrate , and dried ; over that another Stupa spread with the same so broad as to come over the first , & up a pretty height above the stump this is to be snipt deep in the edges , that it may lye smooth about the member ; an Oxe-bladder ready cut & wet is to be turn'd over this , & a cross cloth next the bladder to hold the dressings steady ; then with a Rouler with two heads , begin upon the stump , & roul up to the next joynt , and so again about the member to retain your dressings firm ; then fasten it , so as that it may not be capable of falling off . But before you make this Bandage , you ought to apply your defensative over the parts above the stump : Some apply it before they begin the Amputation , but then it is found full of wrinkles , and sits uneasie . In the dressing of these stumps , you are to apply your medicaments , as you may without much bungle roul up the member , and place it to the ease of the Patient , one holding his hand somewhile upon the stump : Your defensative may be of the same which is proposed in Gun-shot-wounds , or this ; ℞ . Far . Hord . Bol . Armen . an . ℥ iij . Sang . Dracon . ℥ jss . Flor . Ros . Rubr . Balaust . Nuc . Cupressi , Pul . an . ʒ vj . Acet . ℥ x . Album . Ovor . n . viij . Ol. Ros . & Myrtil . an . ℥ j . Cerae qs . Boil the powders in the Acet . then add the rest to it , to make it of the consistence of a Cerot . The third day take off the dressings , and then you may cut the cross stitches , and sprinkle the wound with Pul . Galeni , and dress with this Digestive ; ℞ . Terebinth . Lot . in decoct . Hordei ℥ iij . Ol. Lumbric . ℥ j . Gum Elemi dissolut . in praedict . Oleo ℥ ss . Far . Hordei Cribrat . ʒ ij . Vitel . unius Ovi , Croci Pul . ℈ j . m . Apply to the bone a Pledgit of Lint wet in Spir . Vin . and dried ; after the wound is digested , you are to deterge with Mundificat . Paracels . or Apii , or this , ℞ . Terebinth . Venet . Lot . in Spir . Vin . ℥ iij . Pul . Rad . Iridis , Aristoloch . Rot . Sarcocoll . Thuris , an . ʒ j . Mel . Ros . ℥ j . Then incarn and cicatrize , as hath been said in Compound Wounds .

Whilest I was a prisoner at Chester , after the Battel of Worcester , I was carried by Coll . Duckenfield's order to a substantial man , that out of too much zeal to the cause pursuing our scattered forces , Observation , the ill consequences of wounds in the Joynts . was shot through the joynt of the Elbow , from the lower and outer-part of the Os Humeri , out below , between the Ulna and Radius ; he had laboured six weeks under great pain , the wound was crude , the lips turgid , with lax white flesh , the Bones not likely to unite , many shivers lying within the wound and joynt , without hopes of getting out , the bones within carious , and the member oedematous from the wound down-wards to the fingers-ends , full as it could hold ; and the more , for that the Patient could not suffer his Elbow to be bowed as to bring his hand to his breast , the upper part of the wound from above the joynt to the Axilla above the shoulder inflamed , a perfect Phlegmon formed . The Patient thus tired with pain desired to be cured , or have his Arm cut off : To which purpose he had procured the Governors leave for my staying with him . But while that Phlegmon was upon the upper parts , there was no hopes of a prosperous Amputation , nor of cure while those shivers of bones lay pricking the Nervous parts within the joynt : The Phlegmon was too forward for repercussion , and yet not likely to suppurate in less than a weeks time ; therefore I endeavoured by Emollients and somewhat discutients , to succour the grieved shoulder and parts thereabout , by hindring the increase of the Phlegmon , and give some perspiration to the part , then with good fomentations to corroborate the weak and oedematous member below , and by detergents , fomentation , and bandage to dispose the wound and fractured part to a better condition , and made way for discharge of Matter , and the shivers of bones , also to remove the Caries ; to which end I had brought his hand nearer his breast : A few days after I opened the Abscess above , and below under the Axilla ; A while after , the Matter discharged from above , the tumor flatted and agglutinated within , and the Ulcer cured : But the continual pains stirr'd up in the fractured joynt , kept that opening in the Axilla from healing : The Patient growing weaker , and without hopes of cure , I was necessitated to proceed to the Amputation : To which purpose I sent to Chester for Mr. Morrey a knowing Chirurgeon , Amputation . ( since Mayor of that City ) to come with Instruments and other necessaries whereby I might the better do the work . Mr. M. came , we prepared dressings ready , which were Stupa or Pledgits of fine short Tow well workt , some like the Splenia , others round bigger or less , these wet in Oxycrate and dried ; also some buttons of Tow , then compresses of Linnen-cloath dipt in Oxycrate , three or four Roulers with one or two heads , Needles threaded and seared for making the cross stitch , and lesser Needles threaded for common use , with Filletting for Ligature , and Bladders ready cut and wet in Oxycrate . A defensative of the above-mentioned prescription , spread upon a soft Linnen-cloth , to apply upon the parts above more distant , and a mixture of the Astringent powders with whites of Eggs to spread upon the Splenia and buttons , which buttons were also dipt in some of the same powder : Then for the round Pledgits which were designed to be applied next to the stump ; Mr. M. proposed that they might be spread with a mixture of Umber and Calx viva , with whites of Eggs , according to Dr. Read in his observation upon an Amputation he performed upon a servant of the Lord Gerrards at Gerrards-Bromley , whose fame yet lives in that Country , and amongst us Chirurgeons , while his painful Lectures have a being .

The Apparatus thus made , and the Patient some while before refresht with a draught of a good Caudle , his friends take him out of his bed , and place him in a Chair towards the light , one of his servants held his Arm , another of his friends his other hand , then Mr. Morrey drew up the skin and musculous flesh of the Arm towards his shoulder , whilest I made a strong Bandage some three or four fingers breadth above the affected part : Then with a good Knife I cut off the flesh by a quick turn of my hand , Mr. Morrey pulling up the flesh , whilest I bared the bone ; then with a few motions of my Saw , I separated the bone , the Patient not whimpering the while . After this Mr. Morrey thrusting his hands down-wards , with the musculous flesh and skin which he had drawn upwards , I with a strong Needle and Thread passed through the middle of the fleshy skin on both sides , within half an inch of the edges , and brought the skin close within a narrow compass , and having tied that fast , and cut off the string , I passed the Needle again through the two contrary sides , and this I tied as close ; this is called the Cross-stitch , and is of so great use , as without the performance of this , the Patient is long in Curing ; and sometimes through the great discharge of Matter the Spirits are wasted , Spasmaes and the like follow : Or if he do recover , 't is a long work and much pains ; whereas by this cross stitch the stump is covered to the breadth of a five shillings or half-crown piece , the flux of bloud in a good measure choakt , the heat of the part kept up , and the wound soon cured , and the Patient grows fat and strong : The while , having made this cross stitch , I untied the Ligature , and applied little round Stupes of Tow , which had been first dipt in Oxycrate , then dried , and spread with a Restrictive , wherein was a quantity of Galens powder , mixt with Alb. Ovi . From these round ones I laid long Pledgits , spread with the powder of Umber , &c. mentioned by Dr. Reade in his Lectures ; this and the long Pledgits were Mr. M's . proposal , and sat very close from the middle of the stump each way upwards along the Arm ; then I put on a Bladder , a cross-cloath , and rouled up the stump , and made a Bandage from under his other Arm , and over his Neck to this Bandage , ( which prevented an accident which hath since happened to a Patient here in London , where many of the best Chirurgeons were concerned . ) Then I put him into his bed , and three days after opening him , the wound was well digested , but the binding occasioned a new eruption of the Ulcer , which formerly came from the Phlegmon in the Axilla : Our stitches brought the skin so close to the stump , as here was no place for buttons with Escaroticks , which are so constantly used in these Operations , which lying commonly upon the new incised flesh , Nerves , and Tendons , do much disturb the quiet of the part .

The second dressing was made by a digestive of a little Terebinth . washt in decoct . Malvar . with the yolk of an Egg , and Ol. Rosar . and with a large Stupe of Tow , with some of the same digestive , and a proportion of Galens powder upon it , and having Embrocated the parts with Ol. Rosar . and a little Acet . I applied my Empl. de Bol . over all , and rouled up as formerly , but very easie ; and afterwards mundified with that of Paracels . and with Sarcoticks and Epuloticks incarned and cicatrized , and the bone Exfoliated : Then having procured a pass to come to London , I hastened away , leaving his stump cured .

At the Siege of Weymouth I was called at break of day to an Irish-man of Lieutenant Coll . Ballard's Regiment , who in shooting off his musquet , brake and tore his hand to pieces after a strange manner : I purposed to cut off his hand ; Observat . I sent presently to my quarters to one of my Servants to bring a Saw , and Knife , and dressings , of which at those times we had always store , which being brought , I took a red ribbon from off my Case of Lancets , and bound about his Arm some four fingers above the Carpus , and cutting the flesh , bared the bones of their membrane ; I divided the flesh between the bones , and setting the Saw close to the flesh above , I sawed it off , and untied my Ligature above , and bringing down the musculous flesh and skin over the end of the bone , not making any cross-stitch , here drest up that stump with my Restrictives , and rouled him up , and returned again to my quarters : I had not been one hour gone , but I was sent for again to this Irish-souldier , he being as the messenger said grievously full of pain ; I wondered at it , and hastened away , before I came to his hut , I heard him crying , I asked him what he ailed to roar so , it was a while before he would answer me , at last he told me he was not able to indure that red Ribbon that I tied his Arm with ; I was at first herein surprized , to think I should leave the Ligature upon his Arm , that being a sure way to bring a mortification upon the part : I put my hand in my pocket , and shewed him the red Ribbon on the Case of Lancets , he seemed at first to doubt it , but after he see it was so , he laught ; and was from that time in ease : Two days after our men were surprized , and chased out of the Town and Chappel-fort ; I was at the same time , it being about twelve a clock , dressing the wounded in a house for that purpose in the Town , almost under the Chappel and Fort , I heard a woman cry , fly , fly , the Fort is taken : I turned aside a little amazed , towards the Line , not knowing what had been done ; when I got upon the Line , I see our people running away , and those of the Fort shooting at them , I slipt down this Work into the ditch , and got out of the Trench ; and as I began to run , I heard one call Chirurgeon , I turned back , and seeing a man hold up his stump and his hand , I thought it was the Irish-man , whom I had so lately dismembred ; I returned , and helpt him up , and we ran together , it was within half musquet-shot of the enemies Fort , he out-ran me quite .

CHAP. III . Of Fistulae .

A Fistula according to the Vulgar denomination is every sinuous Ulcer , if it have been but of two months continuance ; but strictly saying those only are Fistulae which are narrow , sinuous , and have contracted a hard Callus , they are usually some years in making : The worst sort of these , at least that ever I see , was from Gun-shot-wounds with fracture ; especially where there hath been loss of bones , or through long continuance the Caries hath chambered the bone , the lips of the wound and wound become Callus by keeping long open in order to Exfoliation , and sometimes through former sinuosities which have prolonged the cure , there the lips grow hard , and do become inverted thick , and are more or fewer in number as the Abscess or wound was more or less sinuous : This Callus of the Fistula is hastened by the perspiration and resolution of the thin and subtil humors , and Incrassation of the more pituitous , by the congestion of which a long pipe of skin is made , which brancheth itself inwards from the orifice quite through all the Cavities of the Ulcers , from whence it hath its name .

The differences of these Fistulae are made not only from the parts affected , Difference . as some in fleshy , others in Tendonous , or in the bones , or joynts , or the breast , belly , &c. But also from the figure , magnitude and number of the Sinus , as sometimes only one , then again two or three crooked or winding , till they enter the bones themselves .

They are known by the Veiw , and by the touching of the parts , Signs . or by searching with a Probe , and from the discharge of a thin serous Foetid Matter , and have an Arched hollowness : If by your searching the parts are pained , or a drop of bloud follows your Probe , the Fistula is not confirmed , but if neither succeed , the Fistula is confirmed .

All Fistulaes are hard to cure , Prognostick . and those of long continuance with great discharge of depraved humors in sinuous parts amongst the bones and joynts are worst , because their Sinus are narrow , and have contracted a hard Callus , and without that be removed they can admit of no cure .

The way of Cure is performed by manual operation or by Medicaments ; But before you proceed in either , you are to consider that these Fistula's are subject to pain and defluxion ; wherefore you are in the first place to proceed by evacuating of those humors which may disturb you in your work , and that is done by purging and bleeding , good Traumatic decoction and observation of dyet , as is said in universal regiment .

To proceed to the Cure by manual operation , Cure . you are to consider the part affected , whether the Callus be only in the lips , or in some part of the Fistula , or that the Callus be throughout the whole length of the Sinus , and this is discovered as I have aforesaid by the Probe , &c.

If there be neither pain nor matter , the Fistula tending only down directly to the bone , then do you let it alone accounting it an imperfect cicatrix , and if undisturbed will in time grow more close ; But if it be the former , then you must remove the Callus if you propose to cure it .

If the Sinus may conveniently be laid open , divide it with Knife or Scissers the whole length ; if after the laying it open , the Sinus be not Callus , or not a confirmed Fistula , then deterge the Ulcer and Incarn and cicatrize it : But if the orifice of the Fistula be streight and narrow , that you cannot lay it open , you must then dilate it with Tents of Spunge , gentian , Aristolochia , Elder-pith , &c. until the Sinus be large enough for your purpose ; and to further this work it may be proper , that you outwardly apply such Medicaments , as may by their Emollient and digestive quality resolve and dissipate the matter , impacted in the parts about , and these are Rad . Altheae . lilior . Enulae campan . Sigill . Solomonis , cucumeris agrest . sem . lini , fenugraec . Medullae ossium , Axung . Porcinae , Axungiae Humanae , Anseris , Gallinae , dialthae . Gum . Galban . Amoniac . &c. Of these you may make fomentations , Cataplasma's or Cerots : You have also to this purpose Empl. de ranis cum aut sine Mercurio , Empl. de Musilag . diacal . cum Gum . The Fistula thus disposed for laying open , you are to consider whether you may not remove the Callus by Catheretics : to which purpose Celsus proposes , lachrama papaver , cadmia , attramentum , sutoneam , Erugo , sandarach Alum , we commonly use our Lap . Caustic . Vigo's Troch . de minio Arsenicum ol . calcanth . or thus , ℞ Cerae resinae an . ℥ j . sublimati ℈ ij . mix this upon the fire , and dip a Spunge in it , but not to hot , lest you burn your Spunge ; then press it out , and cut it into what length and thickness may serve your purpose ; Guido commends Aq. fortis as the most Excellent for destroying the Callus of all these Fistula's : But if you had rather have an Injection , you may make this or such like , ℞ ung . Aegyptiac . ℥ ss . sublimat . ʒ ss . Arsenic . ℈ j . Lixiv . ℥ j . Aq. ros . ℥ ij . aq . plantaginis ℥ iiij . boyl this ad tertiae partis consumptionem , casting a little of this in with a Syringe three days together , shutting the orifice up with Cerae or some Emplaster ; so shall you consume all the Callus : But you must consider the parts underneath that Fistula , that by its too far penetrating it hurt not the bone , or parts underneath . If these answer not your Expectation , then having dilated the Sinus , lay it open by Knife or Actual Cautery ; after the application of these stronger Medicaments , or Actual Cauteries , you must by Lenients mittigate the pain , and defend the part from defluxion which will follow such appliplications , and these are by decoctions to Syringe , as fol. Malvae , bismalvae , violar . verbasci , Hyosciami sem . Cydonior . hordei , or ol . vittel . Byturum . Axungiae , ung . Basilic . cum ol . lileor . dealthae , &c. and over the parts refrigerants ; as Empl. è Bolo Oxelium , Diapalma cum succis , or some of the defensatives mentioned in this Treatise : When Inflamation is off , deterge with this , ℞ Terebinth . in aq . vitae lot . ℥ iij . succ . Apii Cinaglossi an . ʒ vj . Mel . Ros . Colat . ℥ j ss . decoq . ad succ . consumptionem , dein adde Aristoloch . rot . pul . ʒ ij . farin . lupinor . ℥ ss . you may add to it pulv . Ireos , myrrhae , sarcocoll . Thuris , and thereby Incarn , and afterwards cicatrize : If the Bone be caries , you are to consider how far the caries hath entred into it , and proceed in the removal of it , either by Actual Cautery or Rugines scraping the rottenness off , then by cattagmatics hasten Exfoliation , and proceed in the rest with Sarcoticks and Epuloticks .

But if these Fistula's be near , or over some noble part , or that there be Nerve , Tendon , Artery , or in such bones where it reaches to the Medulla , or Joints where you may not safely proceed by Actual Cautery , or potential , and that it will not yield to milder Medicaments ; you shall do better to palliate by some Emplasters and Unguents , as may dispose the part to quiet , purging the Patient sometimes , and observing the Universal Regiment in dyet , &c.

And old Officer of our Army labouring long under an Ulcer on the outside his Thigh , A Fistula in the fleshy parts by the vastus externus from an old Gun-shot-wound , implored my help ; the Ulcer appeared with a small contracted orifice , scarce admitting my least Probe , it ran towards the Bone about an Inch deep , then running downwards with a Sinus more lax , discharging a thin Sanies it was outwardly accompanied with a pituitous Tumor , but nearer about the Ulcer was hard , and of a darkish red colour , not unlike an Imperfect Schirrus : In order to his cure , I proposed to him temperance and quiet , purging and bleeding to carry off the Plethora ; to the part affected I proposed discutients and resolvents , Fomentations , Embrocations and Emplasters , as is abovesaid in the general Chapter , with Bandage to resist the Influx of humour : That done I applied a Caustic upon the orifice of the Fistula , and after separation of the Eschar , I dilate the Sinus by Tents made of Gentian , dipt in ung . Dealthae . This Sinus inlarged , I make way to the other by the same means , and having dilated that Sinus , I cut it open the whole length , and fill that with dossils spread with Basilicon and Turbith mineral filling the said Sinus , by which I proposed the Eradicating the Callus ; To the recent parts cut I applyed dossils with my digestive , and over all a Cerot composed of ung . pupuleon & cerae , and with a compress dipt in Oxycrate make my Bandage over all : The next day I take off my Bandage and Emplaster , Embrocate the part with ung . Pupuleon , and apply my Cerot and Bandage over all again . This I did to allay the heat of the part , and prevent Influx of humor , nor medling with the Escarotick till it came off of it self with the slough ; then where I found any part of the Callus remaining , I rub'd it off with my Lapis Caustic . The Callus thus removed , I deterged with the Mundificative above proposed , and hastily Incarned , lest parts should again contract a Cicatrize , as they are apt quickly to do , whereby my former Endeavours would have been rendred vain .

An old Officer had long laboured under a Fistula , A Fistula with Caries in the Os Tibia . from Gun-shot in the upper part of the os Tibia , near the Knee upon the Shin bone , where that Bone had been grievously Fractured , and from thence had been long Carous ; he was my Patient in France , but here I finisht what I there attempted and had not time to do . I here after general Evacuation applyed a Caustick the whole length of the Sinus , whereby I took off that Callus , and gave way to the discharge of that Faetid Ichor made in the Bone , and took out several pieces of the rotten bone which was shut in there : This done , I Rugin'd away that rottenness , and drest the Bone with my Cattagmatick powders , &c. By which means after some time a Callus thrust forth , and United with the Musculous flesh , and after which by Sarcoticks Incarned , and was afterward cicatrized by Epiloticks , as is said in Ulcers of the Legs .

It often hapneth , that in the time of Exfoliation of Caries in the bones , where there hath been loss of bones , as in Gun-shot-wounds is too often seen , there while we are attending Exfoliation , the lips grow Callus , so as the Cicatrix is deep , and the lips at some distance .

In this case heretofore I have taken much pains to better the Cicatrize , but since by often experience have found , that in time the Lips flat , and the Callus rises up to them of it self , and the Cicatrize becomes firm and seemly .

CHAP. IV . Of Fractures in General .

A Bone is a Similar part of the Body , and the hardest , and dryest of all , the General 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 Skeliton considered joyntly may be looked upon , as performing that office to the little world , that Atlas hath been fabulously reported to do 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 desection they appear to be , Nam si ossa abessent non flecteremus manus non nervos & fibras ; nay if the least bone be but a little maimed , the use of the part is hindred , but they are not only fulcimenta , as Galen sayes de usu partium , sed etiam defensio but also a defence . The Cranium veluti Galea , as a helmet defends the Brain from external Injuries ; So Pectus ossibus clauditur , the Heart , Lungs , and great vessel of the Thorax are guarded by a wall of Ribs ; the Spina is a bulwark to the Marrow included in it , and such a defence is the os pubis and the os coxa & Ilion to the Womb and bladder ; others otherwise serve the uses of Nature , as the three little Bones in meatu Auditorio by firming the Timpanum , are a great help to the hearing ; the os hyodes 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 Scituation , of the Connection of them , the wise Creator as much shunning Superfluity as deficiency . Indeed the whole Fabrick is so full of Excellency that it would take up much time to express them ; But that is not my business : 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 my present Discourse , and that only in General , it being sufficient for my design .

To proceed Methodically , I shall begin with their definition , which according to Galen , de methodo medendi , Is unitionis sine continuitatis solutio quaecunque in osse , but this being too general , and taking 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 rupturia à causa violenter irruente : But this likewise seems to me to be lyable to many exceptions , I shall name only this , viz. That a cut made into a Bone by a sword or a sharp Instrument , seems to be rather a wound than a Fracture : And for this Reason Guido de Cautiaco makes it to be continuitatis solutio in osse non à re qualibet facta , sed ab ea qua contundit ; yet 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 contusion 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 Battail excepted ) the most frequent of all Fractures , yet not without some violence to be reduced to any of these later definitions . I shall therefore chuse to define a Fracture in the following words , The Authors definition of Fractures . It is a solution of continuity in a Bone suddainly 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 immediately upon the Fracture , but in the places where the blow is given : In Flexure there is seldom 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 , that in his time non desunt ex Medicis Junioribus qui ambitiosè omnes fracturarum differentias propriis nominibus interpretantur , there wanted not ( saith he ) young Physicians who affected to give proper names to all the several 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 , Differences . 1. à figura . 2. à magnitudine . 3. ab ossium fractorum varietate : First from their Figure , it 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 lesser . 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 internal there are none , Causes . unless it be ab humoribus corporis erodentibus , and of that sort you may read many in Skenkius , 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 external there are many , as the too violent assaults or strokes of all external 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 evident ; Signs . the first and most certain is , when in our handling it we feel the pieces of Bones sever'd a sunder , and hear them crackle : Secondly , the Impotency of the Member : Thirdly , vehement pain : Fourthly , a distortion of the part ; also by comparing the one with the other , the Fractured Member being shorter . But if there be a wound joined to the Fracture , then if the Bones thrust themselves not forth , yet you may easily know it to be Fractured , if you search with your finger or Probe . There is also a curvedness which may be reduced to 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-fryars , and others : It is as it were when you break a green stick , it breaks but separates not , so is cured by a due Extention with little trouble to the Chirurgeon , or pain to the Patient after the Extension is made .

If the Fractures be secundùm longitudinem , it will appear first by the unnatural thickness of the Member , then by the pain and inequality of the part .

In Prognostick or presage , Prognosticks . 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 , the wound is 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 than in a small , and the greater if the bones be broken , as the two Focills in the Leg or in the Arm , where the radius and ulna are ; yet if in the middle of the bones , it is the less dangerous : Those in or near the Joint are more painful and difficultly cured , and if any shivers press upon the Nervous parts , ill accidents commonly follow . A Fracture with a wound is the most dangerous of all . As to the time of Cure , the lesser bones are perfected in 14 , 18 , or 25 daies ; the bigger in 40 , or 50 , according to Guido : yet let me advise you not to be too hasty in taking them out of their Beds , for in some Bodies the generation of Callus is very slow , and a new distortion may happen , and ill accidents follow . I have been call'd in to consultation upon such an Accident , the Patient did recover , but by lying so 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 , unless pain and Inflamation be prevented ; For a Fracture of the Bones is not made without an Internal wounding of the Periostium and parts next to it , whence grievous pain arises , which stirs up defluxion , and is attended often with great Inflamation , and from the weakness of the Member many Excrements are made and received , which it is neither capable to assimilate , nor yet expel ; and the mischief is the greater , by how much the Bones lye deeper within 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 , unless it be in little children , but by the second , viz. an intervening of Callus .

The Method I thereto propose , Intentions of Cure . is first to joyn the fractured parts together ; Secondly , to keep them so joyned ; Thirdly , to preserve the Tone of the part ; Fourthly , to generate Callus ; Fifthly , to correct Accidents .

That parts may be rightly joyned together , 1 Intention . there is need of Extension and Coaptation ; for in fractures , especially transverse ones , the bones are commonly distorted , the rectitude of the Member lost , some parts are prominent , and others hollow , the Fractured bones lying one upon another , and so the Member made short , quia musculi perpetuo membrum trahunt versus suum principium : for which cause extension is necessary , Extension . that the parts which are indirect may be brought right , and the parts that stick out be reduced 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 Fractured bones do not lye one over another , nevertheless you ought to make due extension in all Fractures , because they never lye exactly equal , and most frequently they ride one over another ; The want of which Extension is one reason , why the Fractured Thigh bones hap to be so often shorter than they should be , as Celsus hath it in these words , Si femur perfractum fuerit brevius erit ; his reason is , Quia nunquam in antiquum statum revertitur : And I find in Galen , that Hipocrates saies the same of the Leg and Arm , and withal tells us it is nisi ante confirmationem extensio debita adhibeatur & comodâ deligatione ossium coaptatio servetur ; by which you may observe the fault is want of good Extension , and keeping the part in its right seat , else you shall hazard the starting again of the Bones , and thereby their Fractured ends may hap to be broken off , by mutual Attrition in the Act of joining together ; and if they do chance to fall in again , between the Fractured bones , they will then hinder their uniting , and if those shivers slide outwardly towards the Membranes , they will cause extream pain ; This Inconvenience is therefore to be shun'd by the help of Extension , but again in Extension , there must be observed a mean , as Vigo notes to us , ad magnam quidem Extensionem futurus spasmus valde suspectus est . Yea sometime the very Muscles are torne a sunder , as Galen tells us , and Albucasius cries out cave extensionem vehementem & compressionem fortem sicut faciunt multi stolidorum , multoties enim faciunt Apostema calidum & contractionem in membro ; by which it seems in his time there was such a people , who thereby drew sad accidents , as Convulsions and Inflamations upon their Patients : But yet if the Extension be less than 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 forceably to their original , do require the stronger Extension , and such are the Thighs , Legs and Arms ; and if both the Focills be broken , the more Extension the Radius requires , lest because it hath no Muscles to draw it upwards , its motion being only secundum pronum & supinum : In Extension it behoves us to observe debitam figunationem , 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 habit of body do best suffer Extension , elderly and dry bodies the contrary .

In the next place is to be considered the most reasonable time to reduce the Fractures , When to be made . and herein we all agree , the sooner the better , and that to avoid the Inflamation according to Celsus , Si in primis diebus non restauratur , Inflamatio oritur , sub qua difficile & periculosa vis Nervis adhibetur : If at the first or second day the Fracture be not reduced , it is in danger of Inflamation and Mortification , for indeed after the second day it is supposed , the Fracture is accompanied with great defluxion , so yields not to Extension , without hazard of drawing such ill accidents upon it self .

Therefore Fallop . in his exposition upon Hipocrates de Capitis vulneribus , and by his Authority tells us what we shall do in such a case , Si os non fuerit in suo loco , saies he , Ideo ad septimam , qui est primus Terminus Inflamationis , vel usque ad nonam , qui est secundus , debemus bene advertere , & oportet Impedire Inflamationem , if the bone was not restored before the time of Inflamation , then we ought to attend till the seventh day , which is the first period of the Inflamation , or until 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 , oleosis quae habent vim refrigerandi , per deligationem pluribus fasciis , either by lenient Medicines , or by deligation : We lenifie with soft cooling oyls , we make our deligation or Bandage by many turns of the roulers , these are to be done until the Seventh or Ninth day ; Inflamation abating there is opportunity for reducing the Fracture : The Instruments for Extension are threefold . First , the Chirurgeons hand for gentle Extension ; Instruments of 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 are funes and habenae , a sort of Bandage fit to pluck at in order to Extension . Thirdly ; are organa & machinamenta Engins 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 than one . An old Gentleman came out of the Countrey , by a fall going down Ludgate-hill , breaks his Right Arm a little above the wrist transverse , and near the bending of the Arm a second Fracture oblique , this double Fracture hath hapned to others in the Leg , it requires your circumspection , lest the one escape your sight , and the Member left deformed and weakned in its Action .

The Extension made ; 2 Coaptation . the Extenders are to be loosed gently , and the Operator shall with his hand endeavour as gently to press 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 his fellows , cut upon it , and take it out , you shall know the perfect Coaptation of parts by these Signs ; First , Signs of good Coaptation . 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 , 2 Intention that the parts brought together may so be preserved , and that is performed by Bandage , which ought to be so made , as not only to keep the parts so joyned together , but to defend them from Inflamation ; and to this purpose I commend to you that of Hip . and from my own practice . It consists of 3 Roulers made of Linnen Cloath , not too coarse , lest by its hardness it offend the part affected , nor yet too soft and fine , lest it break ; 1 Rouler . with the first Rouler you are to begin upon the fracture , and take three turns , then roule upward to the sound part , and so at the upper-part end this Rouler ; it will steady the fracture a little , until the other Bandage be made , and restrain the influx of humors which might cause inflamation .

And the second Rouler as long again as the first , must be rouled contrary to the first ; Second Rouler . so as if the first was made to the right hand , then 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 Rouler begins upon the fracture , and after a turn there is carried downwards , that so you may press the influx of humor from the fractured part , and so having made three or four turns downward upon the sound part , you may roul upward again by the fracture , and making a circumvolution upon the fracture itself , pass upwards , until you come to the end of the first Rouler . And there Hippocrates terminates this second Bandage , because there is fear of the descent of humours à parte superiori , and these two Bandages do more defend the part from inflamation , than strengthen the fracture ; but they being made . Hippocrates puts over them ( about the fracture ) compresses of Linnen-cloath three or four times doubled , of such length as to reach over the fracture , Splenia . but so narrow , as that five or six might be placed over about the fracture , the distance of a finger one from another , and are to spread with a little Cerot , only to make them stick ; these are called Plagulae and Splenia from their figure , and do supply the absence of agglutinative Medicaments , and lessen pain by hindring the compression of the Bandage .

The third Rouler of Hippocrates fastens the said Compresses ; Third Rouler . and its first turn is made upon the fracture , the one head is carried upwards , and the other downwards : And you are to take notice , that the Bandages are to be drawn more straight upon the fractured parts than elsewhere , that the fractured part being more weak may be kept from defluxions .

Celsus in his Eighth Book and Tenth Chapter , Celsus's way of rouling . proposes another way of Bandage , first he dips a cloath in red Wine and Oyle , and applied it over and about the fracture , and after he brings six Roulers , his two first are those of Hippocrates , and so rouled , over them , he brings a broad Linnen-cloath , spread with Cerot , to keep them close down , and because the fractured bone hath always a propensity that way , whither it tended when fractured ; therefore saith he , You are always to put a Compress of Linnen-cloath dipt in Wine and Oyle , Ei parti quae contraria est parti in quam membrum inclinat , and over this he brings the four remaining roulers ; so as the following rouler be rouled 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 authority 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 inflamation : But then in your Binding you must observe such a mean , as consists with the ease of the member bound . Sign of good Bandage . A small and lax tumor appearing at the extremity of the member a day after , is a sign of good Bandage ; but if there appear no tumor , or if the swelling be great and hard , then the Bandage is nought ; the first shewing the Bandage not to be straight enough , and the last too straight , therefore you should often visit your Patient , to inform your self how the Bandage is .

But if no accident happen , you shall not unbind the fracture until the seventh day ; Bandage , when to loosen . and then if all be well , the Bandage will begin to slack of it self , and that is one reason , why fractures should be opened about that time ; another cause may be , for that often in fractures there is an intolerable itching through the detension of humors , which are made sharp by deligation , perspiration being thereby hindred , and is wont to terminate in a most painful excoriation and inflamed redness : And in this 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 now at this time you are to put Ferulae or Splints instead of the Splenia or Compresses , but in fractures with great contusion , or in and near the Joynts , there I have continued the use of Compresses wet in white of Eggs ; during the whole cure , with good success : And lately a youth about ten years of Age , labouring under a Carious Ulcer in his foot , the last great frost brake his Thigh-bone , according to the length of the member : This fracture was drest by my Emplast , è Bolo with Splenia , moistened with Albumin . ovor . this with Bandage , &c. as is proposed in this Treatise , confirmed the Callus ; Mr. Yowell , 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 only keep the member steady , but straight , and of these some are made of Tin , others of Scabboard , Pastboard , and of wood sowed up in Linnen-cloaths ; those of Tin do very well by reason of their lightness ; those of Scabboards are apt to bow , and so is 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 Artists care they may be all used with good success , yea from the first day of the fracture : As in the case of a Reverend Divine , who brake both the Focils of his left Leg , within a few fingers breadth of the Ankle : This person laboured under an Astma , which grievously shaked the fractured member , wherefore I was necessitated to put on Ferulae the very first dressing , and continued the use of them 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 Emplaster , which is more than ten years since . But Hippocrates used them not until the seventh day , for before that day there was more need of hindring the inflamation , than of strengthening the fracture , post septimam contra , but afterward the contrary is required .

The third Intention in curing of fractures is in preserving the tone of the part ; Third Intention . Natura enim os unire nequit nisi pars sit sana , Nature cannot knit the bones while the parts are distempered , and that cannot presently be removed ; for though fractured parts be very well set , yet there will remain some Cavernulae , which will be apt to fill with Sanies , and the part through its weakness can neither well assimilate nor expel , so is like to be burdened with Excrementitious humors : Therefore Phlebotomy may be here of especial use , and the keeping of the belly soluble by Clysters , or otherwise , and a slender diet prescribed ; but this is the work of a Physician . Yet they not being alway 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 repel inflamation : And these in a word are Astringentia , of which we have choice . Hippocrates he used Cerot , then red Wine ; Celsus , you have heard , he used Wine and Oile ; others used Oile of Mirtils , Roses , red Wine , and whites of Eggs together ; others again used whites of Eggs alone ; and others added oils of Myrtill . Balaust . Ros . Rubr . Sang . Dracon . Bol . Armen . with a little Oil and Wine made up to the consistence of a linement , and applied upon cloaths over the fracture . By the use of this latter medicament , I cured a man whose Arm was sore 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 the Splenia of double soft Lining with Bandage , as in Compound Fractures , and happily cured him . If the inflamation be not great , I then take off the Empl. Diapalma , and some of the forementioned powders , with a little oile of Myrtles and Vinegar , made up to the consistence of an Emplaster . This I call my Empl. de Bolo , Empl. de Bolo . which I spread upon cloath pretty thick , and apply over the fracture , and this not only restrains the defluxions , but strengthens the fracture : They are all very good , if they be proportioned to the malady , and excellently preserve the tone of the part .

There is yet farther requisite to the performance of this Intention , Position of the member . position of the member , and that according to Gallen , debet esse mollis , the hurt part ought to lye soft , for that hard lying presses and causes pain and inflamation , debet esse aequalis ne distorqueat , it must lye smooth or equal , because an uneven scite distorts or draws a-wry the part ; Sursum versus ne humores descendant , it should lye somewhat high , lest a painful defluxion fall upon it ; Oportet congruam membri sigurationem considerare , It behoves , saith Hildanus , to consider the convenient figure of the member , that the Muscles be kept in their right scite , 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 possibly may guess , but no tongue can express , 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 Towel , or the like : But if it be the Leg that is fractured , we then place it in a bed , and in a Cradle , or upon a Pillow quilted in the midst with Juncks to support it , having a special care , that the hollow of the Ham and Heel be fill'd up , lest the weight of the Foot hurt the Heel , from whence grievous pain doth ensue , and sad accidents may , as some of us have seen , or at large may read in Fabr . Hildanus .

The fourth Intention is Callum Generare , Fourth Intention . to make Callus , which is to be endeavoured after the fear of inflamation 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 is to be set , possunt diversa & mala accidentia generari , saith Vigo , yet after the seventeenth day of the fracture , I have set the Thigh-bone , and cured the Patient , who is living without any ill accidents .

How the Callus is made , you may read at large in Fallopius , in his exposition on Hippocrates ; and though it be not bone it is so hard , saith he , that if the member hap again to be broke , potius in alia parte frangitur quam ubi Callus est Genitus , it breaks any where rather than in the Callus .

Two things are therefore required : First , that it 's to be supplied with fit matter . Secondly , That that matter be not wasted from the edges of the fractured bones , aut foras evocetur , saith Galen ; as for the matter to make Callus , most Authors do agree , Diet for the ingendring of Callus . that there be a greater liberty in diet ; At quo tempore ( saith Galen ) Callus gignitur , nutriendum corpus est cibis boni succi , & qui multum nutriant , and that viscuous , his reason is , Quia ossis alimentum crassum , and thenceforth they commend at this time offall of flesh , and broaths of Kid and Veal , and the like which are 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 here , where our Patients are inclinable to feed plentifully ; therefore in such fractures , where the Patient is constrained to keep his bed , I propose a slender diet , and of such things as are of easie digestion , for without that liberty surely we cannot fail to compleat our cure ; the bones having naturally a poriness in them , in which is always contained a matter fit for their nourishment , and ex illo ipso nutrimento in fracturis Generatur Callus , of that nourishment Callus is made : So if you be careful to prevent inflamation , 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 they 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 : Therefore 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 , as it would quite diminish it , and frustrate our cure : In children Albucasius commends to us whites of Eggs alone , or with a little Farina Volatilis ; In those of more years , Pul . Myrrhae , Aloes , Acatiae , Gum Tragacant Thuris , Labdani , &c. the Emplasters of Paracels . Diapalmae , Oxycroceum , severally or mixt : But this latter Vigo is very angry with , and says 't is a Diabolical Emplaster , too hot for the Summer , and not very proper for Winter ; Vigoes Emplaster , ad ossium fracturas is excellent , and so is our Catagmaticum in the London-Dispensatory . As to Internal medicines there are many , but I shall only recommend to you Ostrecolla , and that by the authority of Fabr . Hildanus , who often experienc'd it , it is Dose ʒ j . in Aq. Rad . Simplyti , 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 materials for the generation of Callus ; now lest that the matter of which it is to be generated should be hindred from thrusting forth , it behoveth you to alter the Bandage , the member not to be rouled now so straight ; by which means the nutritious juices will have liberty to flow in , and there by gradual digestion to thicken into a Callus : In the opening it , you are to consider whether the Callus generated be such as is required , how the fault of the Callus is to be remedied , if it be less or greater than it should be , you shall hear presently .

Thus I have done with Fractures in General , which if they be Simple , whether transverse , or secundum longitudinem , are cured by the same methods , only those which are secundum longitudinem require a more strict Bandage , otherwise the bones will be apt to gape : I hasten to the fifth Intention :

Which is correcting of those accidents , which happening in Fractures retard their cure , Fifth Intention . and they are many ; as Pain , Inflamation , Aposthumation , Gangrene , Itching , Excoriaton , Callus more or less than should be , weakness of the member and depraved figure : If Pain invade the place , then Lenients are proper , and such as restrain defluxion , and hinder inflamation , and of which sort I have mentioned some , and for more variety , refer you to those who have written of a Phlegonon . If Gangrene appear , slacken your Bandage , and foment the part with a Lixivium , in which hath been boiled Scordium Absinth . Centaur . and the like , and you may apply over all a Cataplasma with Barley-meal , Lupines , with the tops of the forementioned Herbs , and the like powdered , adding Oxymell to it : But if Itching affect the part , then foment the part with warm water , which will give a breathing to it by the pores , or with salt-water , Quae propter salem expurgat & poros aperit ; the Itching neglected , is wont to terminate in excoriationem dolorosam , a very painful excoriation , cui occurrendum est exsiccantibus & refrigerantibus , such are Ung . Album , Camph . Nutritum , Populeon , &c.

As to the Callus , it is sometime just , sometimes greater or lesser than just ; if it be too great , Callus to lessen . you will perceive it by its bunching out ; as also it will be painful to the touch or pressure , and besides it renders the part unapt for motion ; in this case abate his diet , and make your Bandage more strict , and foment with discutients , and apply Emp. de Cicutâ , de Ranis cum Mercurio , &c.

But if the Callus be less , the signs are quod ad motum redditur debilis , 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 : Callus to encrease . But I think it rather proceeded from improper applications , or too straight Bandage ; yet if the Patient be in years , and of a spare body , you may both increase and incrassate his diet , but withal slacken your Bandage , and invite forth the humors by warm water , not too hot ; donec pars rubescat & in tumorem attollitur , untill the parts a little swell tunc enim desistendum : But if the member be extenuated , it 's either from the too straight Bandage , or over-much bathing with warm water ; therefore you must now bath with fresh broaths , and good Embrocations , also a Pitch-plaster applied , and presently pulled off again , will by its adhesion to the hair and skin cause pain , and also an attraction of aliment to the part , and so the member is nourished .

Also after the fracture is cured , the member is too oft found to be of a depraved figure , by reason the bones were not well set , or through ill Bandage , or some inordinate motion , aut propter inscitiam Chirurgi . To help this , if the Patient be young and lusty , and the Callus but six months old ; There is , saith Celsus , yet one refuge , that is , fracturam de novo rumpere ; and in order thereunto , you are to foment the part with decoctions , ex Althaeâ , Cicuta , and then rursus os frangitur manibus vel digitis , impellendo seu comprimendo .

But if the Callus be yet so hard , as it yields not , then says Fab . ab Aq. Pend . Frango eum instrumento attrahente in diversas partes : But this Albucasius a Chirurgeon , as bold as any , and one that had seen the effects of such rash undertakings , utterly condemns ; says it is operatio valde vituperabilis perducens ad mortem : So advises the Patient , not to give ear to such vain people , but content themselves with such help as Emollients , Decoctions , Linements , and Emplasters may effect , which in truth is safer , if you consider that after the Callus is so confirmed , as it yields not to extension , than I say if you should break it anew , or any other way separate it ; yet it would no more yield to a right coaptation , than a Hare-lip or my two fingers will to agglutination , without separating their dry body , which is not possible to be done in Bones .

I could here insert many of my Cures in Fractures of particular parts , Observation . but it would signifie little more than I have already written , their cure consisting in the very same extension and coaptation , and are subject to no other Accidents : 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 tell you , that in Bridewell some years before the Fire , I was sent for to a poor Widow inhabiting there , 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 , striking the Ethmoides 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 beaten in , and the lower Jaw sticking out , nor did I presently know how to help him ; by what Art to make my extension ; But after a while , he a little recovering his senses , was perswaded to open his mouth . There I see the os Palati and Uvula carried so close back , that it was not possible for me to get my finger behind , 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 Uvula , then raising it a little upward , pull'd it forward with the Ethmoides into its former place very easily ; but I no sooner let go my extender , than the Body returned back again : Upon which I contented my self in dressing up the face with a restrictive Cerot to prevent influx of humors , and let him bloud , and within few hours after caused an Instrument to be made , whereby the great fractured Body was more easily brought into its natural 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 restored to a good shape , better than could have been hoped from such a distortion in that place . The Patient is yet alive and well .

Thus have I done with that which concerns Simple Fractures . Compound Fractures . 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 together , as was proposed in the first and second Intention 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 methods being to be altered upon that occasion , for the reasons there alledged . Then endeavour as in our third Intention , to keep the fractured and wounded parts together by dressings , which may as well mittigate the pain , as keep off apostemation , by repelling the matter flowing to the part , and denying that already flown , Qualia sunt Astringentia , Glutinantia , of which sort I have sufficiently offered unto you , in the Discourse of Simple Fracture . Galen , by the authority of Hippocrates , recommends Cerot of Roses , but if their be no pain , you are to endeavour the strengthening of the fracture , and preventing defluxions by cloaths spread , 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 Linnen than we use in fractures without a wound , that it may comprehend both the lips of the wound , and keep them down , yet not hurt them by its too hard compression , Minus Astringendae sunt fasciae quam si vulnus non adesset , says Celsus , and therefore it is that Hippocrates and Celsus make so many Circumvolutions : cum melius sit saepe circumire quam astringere , ( saith Celsus again ) The third day they loose the Bandage , then ferulae vel non apponendae ne vulnus comprimant , saith Albucasis ; or if they be put on , super vulnus apponi non debent ; rather in these fractures do we use deligation , pluribus fasciis with many Roulers , saith Albucasis ; and so all along he goes in his Sermons of Fractures , as if he had been rather bred under Hippocrates or Celsus in Greece or Italy , than where he was ; But in truth this way of deligation is not only 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 without a Fever , if his wound be every day to be so roul'd and unroul'd : Therefore in these Compound Fractures we chuse rather to follow the method of some of the Moderns , who instead of these many long Roulers , make choice of two or three short cloaths , folded three or four times to give them the more strength , and of such breadth as to encompass the lips of the wound and 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 only keep the lips of the wound down , but fill up the inequality , 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 in rouling and unrouling so many long Roulers as the Ancients proposed ; and with this method I have cured Arms and Legs , so shattered by Splinters from Cannon shot , and with such loss of substance , as I even despaired of their Cure . But in some of these I have made use of Hippocrate'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 compression was gentle and equal , 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 only 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 , and yet is again restored to its place , then let the wound be stitcht and drest , as I proposed to you even now in the Compound Fracture .

A Commander at Sea valiantly fighting in the midst of the enemies Fleet , Observation . his Leg was fractured by the fall of his Mizon-Top-Mast , it breaking his Leg transverse near the Ankle , the edge of the bone thrusting out through the skin . He not suffering the bone then presently to be set while it was warm , afterwards being swell'd and stiff , it did not yield to extension , but became painful and inflamed : After some few days he was brought to London , I was sent to him , he was of an ill habit of Body , subject to the Gout and dysenteries , and the Fracture accompanied with great defluxion , not in a condition to admit of Extension ; therefore according to Falopius upon Hippocrates cited by me in this Treatise , I proposed to his Chirurgeon to proceed by Lenients , to mitigate pain , Inflamation , and by Bandage to hinder defluxion , which we did , and his Chirurgeon continued that method a few days : The Accidents gone off , Mr. Arris , Mr. Hollyer , and my self , met Mr. Pearce his Royal Highness's Chirurgeon at the Patients Lodging , with the Chirurgeon of the Ship , we find the Patient in ease , taking off the dressings we see the Member in good temper , we agree to make Extension and reduce the Fracture , the Patient was of a dry tough Body , the Member yielding difficultly to Extension , we satisfied our selves with what we had done , doubting that upon a more forcible Extension , ill Accidents might follow ( as an Inflamation presently did ) we drest it up as a Compound Fracture , so as the wound was daily drest , and after some while a Callus thrust forth and united the Bones . That Callus confirmed and dried , we hastned the Exfoliation of the bare Bone , by a little Aegyptiacum & pul myrrhae disolved in sp . vini applyed hot upon an Armed Probe : Thus the Bone was Exfoliated and the Ulcer cured by the ordinary Intentions required in them . Yet that inward leaning of the Bone , continued a weakness a long-time , as is usual where the Fracture hath not been timely reduced . To supply this , I cause a Bar to be fixed in his Shooe with Joints , this by a Bandage strengthned his Leg , whether he hath yet left it off I know not : But if the end of the bared Bone have thrust it self so our , as that without great force it cannot be restored to its place , Tunc è duobus malis minus est eligengendum , 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 seazed upon the parte it may be performed with good success .

In St. Clements parish behind the Church , some years since one Evening while I was preparing my dressings for the Setting a Fractured Thigh bone in a little Child , I was presently fetcht to assist one Mr. P. a Barber-Chirurgeon in the Setting a Fracture of both the Focils of the Leg in a man of about Sixty years of Age , of a Tough dry body . Observation . There I met Mr. Tatham an endustrious knowing Chirurgeon , the Fracture was oblique almost secundum longitudinem , and the os Tibiae or greater Focil had shot it self out by the inside of the Ankle a great length ; we endeavoured by a strong Extension to Reduce this Fractured Bone into its place , but the bone yielded very difficultly to our Extension : Yet we reduced it , then cleansed the wound of what we met of the Shivers or pieces of Bones , and brought the Lips of the wound together by Suture , hoping thus to keep the Fractued Bone the closer . Then we drest the wound with our digestive warm , and with an Emplaster of diacalc . malaxt with ol . Ros . over it a mixture of flor . Ros . rub . Balaust . Baccar . myrt . Bol . Armen . sang . drac . pulverizat . cum albumine ovor . ol . Ros . & acet . m . ad consist . mellis : This spread upon a double cloath , and applyed over the Fractured Member and fastned by Bandage as hath been proposed in compound Fractures ; but for the more strengthening the Fractured Member , we put on Ferulae with soft compresses between them and the first Bandage , and having fastned 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 the middle with Juncks to keep it steddy ; 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 was sore bruised , and stretcht by the great Extension , so was not likely to be attended with less mischief than 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 pains continuing with much disturbance ; a fever followed , and within two or three daies he became delirous , and in the absence of his attendance got out of Bed , 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 , we took off the dressings and see the Bone distorted , the lower Stitches broken , and the wound of an ill Aspect , it tending to mortification without hopes of being any more reduced by a new Extension . Upon which consideration we resolved to Saw the end of it off , and to that purpose having prepared 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 Tendinous flesh underneath from being wounded by the Saw : That done we cleansed the wound from the Saw-dust and Shivers of little Bones , which we had not discovered in our first dressing , they lying under between the distorted Bone and Membranes , by which those sad Accidents had been hastened : The wound thus cleansed we turned the foot right in to its natural place , there being no need of Extension : The great work was now , how to support the foot and keep it even with the Leg , there being so great a distance between them without any whole Bone , we scarified the Lips of the wound and washt them with Spi . vin . with a little aegyptiac . dissolved in it , and dressing the ends of the Bones with Pledgets dipt in it , and prest out , we drest the rest of the Bone with ung . Basilic . with a little ol . Terebinth . warm , with an Empl. of Paracels . & diacalcith mixt , and applyed it over the wound and parts about with a Compress and Bandage over that , as in compound Fractures , and placing the Leg as before upon a Pillow , he was again put in to his Bed , we committing him now to the care of his friends to keep him still , and ordered him Cordial Julips , &c. and after some hours Let him bloud again . From that time his pains lessened , and his Fever and other ill Symptomes went off as the wound digested . But after some daies , the heel became very painful and was discovered to us Inflamed with an Ulceration to the very Bone . The Patient not permitting to have his foot stir'd , 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 because the Patient grew soon weary of this position , which also was inconvenient for our dressing the great wound , we therefore designed an Instrument of Tin to receive his foot and leg , his heel to lye hollow in a place cut for the purpose , whereby we could daily dress it without disturbing the Patient , only placing him down lower toward the Beds feet , as the heel might lye over it ; the side of this Instrument that came up by the wound , was to be taken off at time of dressing his wound , and afterward placed close again , whereby he was drest without disturbing the weak Member . It lay also soft by the folds of Linnen we placed under , and between the Leg and Instrument , and was kept straight in hopes it might be supplied with Callus , but the wound became Sinuous , the Matter fowling the Bones , hindred the growth of Callus , and while we waited for Exfoliation , the Lips of the Ulcer became callous , which prolong'd the Cure : The Ulcer in the heel we digested , and after we found the Bone would not Incarn , we drest it with aegyptiac . with a little Merc . Subl . dissolved in it , by which dressing we hastened the Exfoliation of the Bones , and cured the Ulcer : The wound above was after the generation of Callus cured , as a Fistula with a carious Bone . The Patient 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 than to leave the Bone distorted until digestion , as in a such like case I have seen it .

But if the Bone be not so much distorted , as that you may come to Saw off the end of it , nor yet cannot reduce the Bone after the ordinary way , then you may with a Chizil-like Instrument , thrust between the Fractured ends of the Bone , and use it after the manner of a leaver for the reduction of the prominencies ; But then it 's supposed these fractured ends of them are within the wound , and not much over-shot one another , and the Fracture is transverse or oblique , otherwise this way will do little good ; Nay possibly Rive up the piece of bone , and make another kind of Fracture , and grievously pain your Patient ; and that you may do if the ends break off upon your hard and unsteddy Extension : Therefore it becomes us to be very wary in making this extension , else I say , we may grievously pain our Patient , and do 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 Inflamation and all other accidents , by dressing up the Patient with such Medicines as hath been proposed in compound Fractures , and make your Bandage so as you may come to dress the wound , as occasion shall offer , with as little molestation to the Fractured Member as is possible , having a care you grieve not the tender parts with Splints , until the Inflamation be over , and the wound well digested .

Then afterwards 't is to be endeavoured , that the bones rob'd of their periostium may again be Incarnated or Exfoliated , which is the work of Nature , yet ought to be helpt by Medicines , which have a manifest hot quality and a peculiar faculty thereto , of which there are are enough in the Treatise of Gun-shot-wounds .

The Bones Exfoliated , the rest will do it self , or may be performed by Epuloticks , of which you may have choice in this Book .

ERRATA's of Wounds in General .

PAge 106. line 5. for pervan . read peruvian . p. 36. l. 21. r . dip a pledgit : p. 55. l. 12. r . dabled about : p. 82. l. 12. for either r . other : p. 126. l. 15. r . until : p. 43. l. 4. r . indisposed .

ERRATA's of Gun-shot-wounds .

Page 59. line 8. read Ureters : l. 23. for loss r . less : p. 61. l. 24. for digestium r . digest cum : p. 106. l. 8. for sub . ℥ ij . r . ʒ ij . p. 14. l. 2. for the Terebinth . r . Ol. Terebinth . p. 16. l. 31. for and laid r . lay : p. 20. l. 19. for their r . these wounds .

There are other Literal faults occasioned by the hasty Printing this Treatise .

Imprimatur ,

Guliel . Wigan . Ap. 4. 1672. THE END .