The head may show a lightly bruised scalp, which has no open wounds. At other times, there may be an injury without any visible contusion, and occasionally, there might be both bruising and open wounds present. Skull fractures can vary in severity; some are superficial, while others can extend down to the diploe (the spongy bone layer between the inner and outer tables). In some cases, the fracture may penetrate both tables of the skull and reach the meninges, potentially affecting the brain itself. It is not uncommon for the brain to be jostled or shaken, leading to the rupturing of internal veins, and various symptoms can arise even in the absence of any visible injury on the head.
In Hippocrates’s treatise on head injuries, he categorizes four or five types of skull fractures. The initial type is termed a fissure or fracture, followed by what he calls a contusion or collision. The third type is referred to as ‘effractura’, the fourth goes by ‘Sedes’ or a seat; and should there be a need for a fifth classification, it might be named a Counter-fissure, or as termed by Paulus’s interpreter, a ‘Resonitus’, which occurs when the bone splits on the side opposite to where the impact was received.
The variations among these five types of skull fractures are significant. Fractures may be large, small, or of moderate size; they can extend widely or remain narrow; some are limited to the surface while others might reach into the diploe or penetrate both tables of the skull; they may run straight, obliquely, or even in a circular pattern. Some fractures are intertwined, with a fissure invariably linked to a contusion; others coincide with different complications like pain, warmth, swelling, and bleeding. Occasionally, the fracture results in bone fragments pressing against the underlying membrane as sharply as needles, though in other cases, none of the bone may be displaced. All these distinctions are crucial for they dictate the necessary treatment variations. To aid in memory retention, I will delineate these differences in the table that follows.
The causes of a skull fracture are typically external, including falls, blows from various objects whether they be sharp, blunt, heavy, or hard, and animal bites, among others. The indicators that a skull has been fractured can be identified in two main ways: some through cognitive inference and others through direct sensory observation, such as visible and palpable signs present in the wound.
Rational indicators can help us determine whether a skull fracture has occurred and its nature. You may suspect a fracture if the patient collapses following a blow, or if they fall from a height onto a hard surface. If, after the impact, the individual remains unresponsive—showing no speech, sight, or hearing—and experiences such intense pain that they frequently touch the injury, these are significant concerns.
It’s essential to account for the weapon involved—whether it is heavy, blunt, pointed, or sharp—as well as the force with which the blow was delivered, the level of aggression behind it, and the distance from which it struck. Additionally, consider if the patient was struck while their head was unprotected, whether they lost consciousness immediately after the impact, and their mental state upon regaining awareness.
Observe for signs such as blurring of vision, dizziness, or bleeding from the nose, mouth, ears, or eyes, and whether the patient has vomited. Hippocrates noted that individuals with brain injuries often develop a fever and experience vomit that is yellowish in color, a point supported by Galen in his commentary, who stated that similar symptoms could arise when a wound penetrates the membranes surrounding the brain.
A subtle sound, resembling that which comes from a cracked vessel, may be heard from the skull when the hair and pericranium are removed and it is gently tapped with an iron probe. This phenomenon is noted by Paulus Aegineta as a reliable indication of a fracture. These various signs collectively lead to a strong presumption, or even certainty, that the skull has sustained damage and the brain could be affected, a situation that generally implies a fracture of the bone, as Celsus documented.
However, there have been cases where individuals experienced a skull fracture without these immediate signs, though such instances are rare. Of the numerous indicators, it’s important not to overlook a particular method described by Guido. To pinpoint the location of a fracture, he suggests having the patient bite down on one end of a lute string or thread while the surgeon holds the other end. By tapping lightly on the string, the patient should sense vibration at the fracture site and instinctively react to touch the affected area, although my own attempts to verify this technique through practical application have yet to yield conclusive results.
Further assessments involve methods mentioned by Hippocrates in the Coan Prenotions. For patients suspected of having a skull fracture, they should chew on an asphodel stalk with both sides of their jaws. During this action, they should pay attention to any cracking noises or sensations within their head, as such sounds might indicate the presence of a fracture.
In summary, recognizing a skull fracture involves noting both classical signs and innovative diagnostic techniques, though not all methods are confirmed by modern standards and require further validation.
These indicators are said to be perceptible to the senses, clearly revealing a fracture when the bone is exposed, visible to our eyes, and assessable by touch and probing instruments. When hairs in the wound appear disheveled and stand on end, it is an indication that the bone beneath is likely fractured. This is because hair, which gives way under the force of the blow, cannot be sheared off like this if the underlying bone, which resists the impact, remains intact. This observation by Hippocrates allows us to suspect, from just this sign alone and before any detailed examination of the wound itself, that the skull may be fractured, convincing onlookers of the severity of the injury.
Furthermore, even before we make any incisions to expose the bone, we can estimate by touch whether the skull is fractured. By pressing our fingers around the area of the wound, if we feel the bone abnormally elevated or depressed, we can deduce that the skull’s natural structure has been disrupted.
Once the skin has been incised and the bone exposed, if the fracture is not readily apparent to the eye, it becomes necessary to investigate using a probe. This probe should neither be too thin nor excessively sharp—using a probe that is too thin may lead it to slip into natural crevices, causing unfounded suspicion of a fracture, while a probe that is too thick may overlook subtle fissures. Upon contacting the bone, if the probe encounters a surface that is smooth and slippery, it indicates that the bone remains intact.
Conversely, if you detect any roughness, particularly in areas devoid of sutures, this suggests that a fracture may be present. The surgeon must remain mindful that fractures can often occur along the sutures, and that these sutures do not consistently occupy the same position. Moreover, it is not uncommon for a fracture, whether cleft or broken, to be undetectable through either visual inspection or instrumentation. Thus, if you suspect the existence of such an injury based on the aforementioned signs, you may apply a mixture of ink and oil to the area. This method will help reveal any cracks or fissures, which will be discussed further in the subsequent sections.
Once a fracture has been positively identified, it is crucial to promptly assess the severity of the injury and swiftly administer the appropriate treatments. Indeed, when a fracture occurs along a suture line, diagnosing the issue becomes particularly challenging, unless the fracture is distinctly severe. This difficulty arises because the inherent splits and roughness of sutures can mimic the characteristics of fractures, a phenomenon that even Hippocrates admits led to misdiagnoses in his practice.
Having succinctly discussed the distinguishing features and indicators of a fractured skull, we can now proceed to explore the various types of fractures, including those with a fissure.
If the surgeon, through the signs previously noted, recognizes that the skull is fractured or cracked, and the injury to the muscular skin is insufficient for examining the fissure, then he must shave the hair and use a razor or incision knife to cut through the muscular skin and the underlying pericranium. This should be done in either a triangular or square shape, appropriately sized, taking care to avoid the sutures and temples as much as possible. There should be no apprehension about potential harm from this procedure; it is far preferable to expose the bone by cutting the skin than to leave the type and nature of the fracture obscured by overly cautious preservation of the skin. Indeed, the skin can be healed quite straightforwardly, even if it is removed unnecessarily.
According to Hippocrates, it is far more prudent to treat illnesses safely and effectively, even if the process takes longer, rather than hastily with the risk of relapse and additional complications. When performing this dissection, a razor or sharp knife should be used, and if the instrument causes any cuts in the skin, one of your incisions should be made in line with that injury.
A razor, or incision knife
Now you must carefully section and slice through the muscular skin along with the pericranium using a sharp razor. Ensure that the razor is firmly and steadily handled. The skin and pericranium should then be entirely peeled away from the underlying skull so that no remnants adhere to the bone; failing to do so could lead to severe fevers and inflammation if it becomes snagged or torn during the trepanning process. Start peeling back from the corners where the incisions intersect at right angles, using the chisel depicted here.
A chisel, or instrument to pull back or separate the pericranium from the skull
Next, you should fill the entire wound with soft, fine lint bolsters to ensure that the edges remain separated. Additionally, appropriate medications should be applied to help stem the bleeding. However, if the bleeding persists vehemently and cannot be controlled by any means, you will need to directly ligate the vessel as follows:
First, pierce the muscular skin on the exterior with a needle and thread, then thread the needle back through. Secure the thread with a knot on the outside, but first place a roll of lint approximately the size of a goose quill between the thread and the hair-covered scalp on both sides. This precaution prevents the tight twisting of the thread, which is intended to stem the bleeding, from cutting or tearing the skin or causing pain. Then, you should elevate the patient’s head slightly.
Recently, I treated a coachman who had sustained a severe bruise to the back of his skull after being thrown from his coach onto a stone pavement. Given the circumstances, it was necessary to make a cross incision in the muscular skin to allow for the release of congealed blood and to assess any potential fractures. However, during the procedure, an artery was inadvertently severed, and the surgeon present was unable to control the profuse bleeding. The coachman had already lost a significant amount of blood, leaving him weak and barely able to speak or move in his bed. When summoned, I demonstrated that, despite prior attempts to employ astringent medications proving futile, the most effective course of action was to ligate the vessel to stop the bleeding rather than risking the patient’s life simply out of a childish fear of causing him further discomfort.
Let us return to our previous discussion. The day after initial treatment, the surgeon should assess the type of fracture, if any, affecting the bone. If no physical evidence of a fracture is apparent to the eye, or detectable by touch or probing, one might still suspect a break based on other signs. In such cases, as previously advised, the exposed bone should be coated with writing ink mixed with a small amount of rose oil. This mixture will stain any cracks or fissures, making them visible. During the next dressing, the bone should be dried with a linen cloth and the ink and oil mixture scraped away using specialized instruments. If any ink has penetrated into the bone, indicating a crack, scraping should continue until no trace of the fissure remains or until reaching the dura mater.
To further confirm whether the fissure extends through both tables of the skull, instruct the patient to hold their nose and mouth closed and attempt to breathe forcefully. This action causes the chest to pressurize, pushing up the brain and its membranes, and may cause bloody fluid or pus to exude through any fissure, visible as a frothy discharge.
If a fissure is confirmed, the surgeon should carefully excise the bone down to the dura mater using a radula and other suitable scraping instruments, being mindful not to injure the membrane. However, in cases where the fissure is extensive, it may not be advisable to trace it to its full extent, as nature often facilitates healing through the formation of a callus in certain parts. In accordance with the teachings of Celsus, the surgeon ought to minimize the removal of bone, given that the skull serves as a vital protection for the brain.
Thus, it suffices to create a passage for the escape of blood and any purulent material, preventing the risk of these substances being trapped, which could lead to bone corruption and subsequent inflammation of the brain. If possible, the excision of the broken bone should occur within three days, particularly in summer, to mitigate the risk of inflammation. However, I have, on numerous occasions, successfully removed sections of the skull using a trepan and scrapers even after the seventeenth day, regardless of the season. I emphasize this practice to ensure that no one is left without treatment, as it is often better to attempt a remedy, even if uncertain, than to undertake no action at all.
That said, it is crucial to inform those present of the associated risks, as statistics show that far more individuals perish when fractured skull bones are left unaddressed compared to those who undergo intervention.
The tools used to excise wounded or split bones are known as scalpels or radulae. I have provided illustrations of various types here, allowing each practitioner to select according to their preference and the specific requirements of their task. All these tools can be fitted into a single handle, a design of which is also presented here.
Radulae or Scalpri, shavers or scrapers
Radulae of a different design, intended for more effective cutting of larger bones.
In summary, when dealing with a skull that is merely cracked or exhibits a simple fracture, the surgeon should consider their intervention sufficient for the patient. Practically speaking, if they apply the recommended instruments to divide the bone and enlarge the fissure—without employing a trepan—even if the fissure extends through both layers of the skull, their approach is warranted. However, if the fissure does not penetrate beyond the outer layer, it is wise to halt the use of scrapers upon reaching the inner layer, in accordance with Paulus’s advice. Conversely, in cases where the bone is shattered into several fragments, these should be carefully removed using the correct instruments, and a trepan may be employed as needed, which we will elaborate on in the following sections.
Such contusions occur more frequently in children, primarily due to the softness and swelling of the affected area, which make them readily apparent. In my experience, when I have incised these contusions with a scalpel, I have often observed the release of serous, clotted, and dark blood. The healing process is typically completed through moderate compression of the area and the application of drying medications.
Moreover, a significant contusion can cause the skull of a child to be pressed inward, similar to the deformation observed in thin metal vessels made of brass, lead, or pewter. Often, when pressure is applied with a finger, these materials become dented, leaving an impression behind; however, they can sometimes return to their original shape and smoothness. This phenomenon is also seen in the bones of children, women, and individuals with soft, humid, and phlegmatic constitutions.
If the bones do not naturally spring back into position, it is advisable to apply a cupping glass heated with a strong flame. Instruct the patient to exert a powerful breath while keeping their mouth and nose tightly shut; this technique may create sufficient pressure to restore the depressed bone to its original position, as the spirits are forced upwards towards the brain and skull by the suction of the cupping glass.
Should these methods prove ineffective, an incision must be made in the skin to securely attach a trepan—such as the one illustrated here—directly onto the depressed portion of the bone, allowing it to be lifted upward in a manner akin to how coopers raise the staves of their casks when they have sunk too low.
If the bone is especially strong, thick, and dense, which makes the extraction instrument ineffective, one must drill into the center of the depressed area in the skull. Use a three-pronged instrument, known as a levator, by inserting it into the drilled hole to elevate and reposition the bone to its original placement; this tool is sufficiently robust for such a task. Its design includes three legs, enabling it to adapt to any rounded area of the head. Moreover, this instrument can be fitted with various heads tailored to the specific needs of the procedure, as depicted in the accompanying illustration.
However, if the bone is not completely broken or depressed, but merely displaced on one side, it will be suitable to lift it up and create an opening for the drainage of any debris. In such cases, you can use small saws, similar to those depicted here, to carefully divide the skull. This technique allows for the removal of only as much bone as necessary without causing compression, thus minimizing the risk of injuring the brain or surrounding membranes with any fractured bone fragments.
However, if the signs observed indicate that the contusion affects only the second table, or possibly does not reach that far, the removal of the bone should be limited to the extent of the contusion. This approach will be sufficient to prevent inflammation and a variety of other symptoms. This procedure can be performed using a scaling or desquamatory trepan, which allows you to easily excise precisely the amount of bone you deem necessary. A diagram of this instrument is provided here for reference.
A A. shows the point or tongue of the levatory, which must be somewhat dull, so that it may be the more gently and easily put between the dura Mater and the skull, and this part thereof may be lifted up so much by the head or handle taken in your hand, as the necessity of the present operation shall require.
The use thereof is, thus; put the point or tongue under the broken or depressed bone, then lift the handle up with your hand, so that the depressed bone may be elevated.
Before addressing the topic of effraction, I believe it is important to request the understanding and forgiveness of the courteous reader. This is particularly pertinent because, in the previous chapter, while I intended to discuss contusions, I inadvertently included many references to depressions. Similarly, in this chapter on effraction, I will also intersperse discussions of contusions. This overlap is not due to ignorance of the terms; we recognize that a contusion occurs when the bone is depressed and crushed but remains intact, whereas an effraction involves a bone that is both fractured and displaced due to a severe impact.
It is almost inevitable that these conditions will be conflated in both occurrence and description, meaning one will rarely observe a contusion without some degree of effraction, or vice versa. Bones are frequently broken and displaced by strong, forceful impacts from weapons, whether round or square, or from falls from significant heights, with the extent of the damage varying according to the intensity of the blow, the nature of the weapon, and the condition of the affected area.
Consequently, one must be equipped with a variety of remedies and tools to address these injuries. If a bone is compressed and shattered into multiple fragments, it may be unnecessary to extract these splinters using a trepan. Instead, one can effectively treat such cases with specially designed levatories, which I will detail further here.
A levatory
But we must have special care, lest that in pulling and taking out of these scales and splinters, we hurt the membranes. These scales are sometimes very rough and prickly, so that they cannot touch the meninges without offense; but somewhiles the business is so intricate, that they cannot be taken out unless by enlarging the fracture. Wherefore in this case, if there is a space so large, as that the ends of these mullets may enter, you may easily shear off so much of the bone, as is necessary and requisite for the taking away of these scales, without any assistance of the trepan, which I have done very often and with good success; for the operation performed by these mullets is far more speedy and safe, than that with the trepan; and in the performance of every operation, the chief commendation is given to safeness and celerity.
Cutting mullets, commonly called Rostra Psittaci, or Parrot’s beaks
Moreover I have thought good here to give you the figures of chisels, scrapers, and pincers, together with a leaden mallet, because such instruments are not only very necessary to take forth the scales of bones which are broken, but also to plain and smooth those which remain whole.
The truth of this matter was recently revealed in the case of Master Grolo’s servant, who sustained a fracture of the coronal bone from a severe blow inflicted by a mule’s hoof. I made a triangular incision in the overlying skin with the intention of applying a trepan in that area. The following day, after boring into the bone, I attempted to extract it and exerted force to pull it out, as it had already been divided with the trepan. However, I observed a troubling displacement of the fracture; the bone was notably loose beneath my hand, extending from the center of the forehead to the inner corner of the eye. Therefore, I abandoned both my original intent and the effort to remove the bone, deciding instead that it would be sufficient for the patient if I merely elevated the depressed section of bone. This approach ensured that the bone did not press on the dura mater, allowing any accumulated matter and debris to be drained through an opening created with a saw. Ultimately, the patient made a full recovery, though he did lose the eye adjacent to the fracture.
Hippocrates calls a seat that kind of fracture of the skull, when the weapon so falls upon the skull, that the fracture retaining the print thereof is neither stretched forth any further, nor contracted to any less space.
And seeing there are many forms hereof, they all whether they are superficiary, or shall pierce even to the diploe, or else pass through both the tables, whether it is with any loss of the bony substance, whether it run long ways, or else is but short, or otherwise are dilated to some breadth, or else is but narrow; whether they shall be done with a cut, or with a prick with a dagger, stiletto, lance or other kind of weapon, whether they shall have this or that accident joined with them, I say all of them, how many and various soever they are, ought and must be cured by some of the formerly described instruments and means. Yet this must be noted, which as yet we have not remembered, that if it happens by a violent stroke, and great wound, that a portion of the bone is wholly cut off, that it is clean severed from the rest of the skull, and hang only by the pericranium and musculous skin; yet you must not pluck it from the pericranium, and cast it away as unprofitable, but restore it to its proper seat and place, so by the force of nature, to be glued by a callus, as Celsus has observed.
I recently put this experiment to the test on Captain Hydron. He suffered a severe injury to the midsection of his coronal bone, measuring approximately the width and length of three fingers, which had been cleanly severed by a sharp sword. The fragment was barely attached to the remaining bone, clinging only weakly to the periosteum and overlying skin, and was displaced downwards over his face, exposing the dura mater beneath. Initially, I intended to remove the fractured piece and discard it; however, I recalled Hippocrates’ admonition against stripping the brain of its protective covering.
Thus, I first cleaned the blood that had accumulated on the dura mater, from which its pulsation was clearly visible. Next, I repositioned the bone fragment and secured it in place with three sutures. To facilitate drainage of any residual matter, I packed the spaces between the stitches with lint. By these methods, and with the mercy of God, he made a remarkable recovery despite having sustained several other extensive wounds on his body. This experience reinforces the principle that we should not discard any parts of the skull, periosteum, or overlying skin unless absolutely necessary; indeed, it is crucial to avoid leaving the brain exposed and unprotected.
Sometimes the fracture is made in the part opposite to that which received the blow; as if the right side be struck, the left is cloven; this kind of fracture is very dangerous, because we cannot find it out by any certain sign, as it is written by Hippocrates Lib. de vulu. Capitis. Wherefore if at any time the patient dies of such a fracture, the surgeon must be pardoned.
And although Paulus Aegineta laughed at this kind of fracture and thinks that it cannot happen to a man’s head, as that which is hard and full, as it happens in empty glass bottles, yet I have sometimes seen and observed it.
Neither is their reason of any validity, who thinks nature therefore to have framed the head of many bones knit together by sutures, left the fracture of the one side, should be stretched to the other. For peradventure this may take place, in such as have express sutures, seated and framed according to nature. But it takes no place in such as either want them, or have them not seated according to nature, or have them very close and so defaced that it may seem one bone grown together of many; This is made manifest by recital of the following history.
A servant of Massus, the Postmaster, sustained a serious blow to the right bregma from a stone. While the injury resulted in only a small wound, it caused significant contusion and swelling. To ascertain whether the bone had been affected and to facilitate the drainage of congealed blood, the wound was enlarged by the skilled and reputable surgeon, Theodore Hereus. He meticulously performed his duties, leaving no aspect of the treatment unaddressed.
Upon opening the skin, the bone appeared intact, although there was considerable concern that it might be fractured, as the patient had collapsed immediately after the impact, vomited, and exhibited other symptoms indicative of skull fracture. Unfortunately, he succumbed to his injuries on the twenty-first day of his illness. After being summoned to investigate the cause of death, I used a saw to divide the skull and discovered a substantial accumulation of bloody fluid (sanies) on the side opposite to the blow, along with an abscess in the dura mater and within the brain itself. Notably, there were no sutures present aside from the two scaly types.
This case underscores an important principle supported by both Hippocrates’ authority as well as reason and empirical evidence: a blow to one side of the skull can lead to a fracture on the opposite side, particularly in cases where the sutures are either absent or so tightly fused that they are barely distinguishable.
First, when the fracture is in the same surface of the smitten bone, as if that part of one of the bones of the Bregma, which is next to the lambdoid suture be smitten, and the other part next to the coronal suture be cloven. Secondly, when as not the same superficies and table which receives the blow, but that which lies under it is cleft, which kind of fracture I observed in a certain gentleman, a Horseman of Captain Stempan’s troop. He, in defending the breach of the wall of the Castle of Hesdin, was struck with a musket bullet upon the Bregma, but had his helmet on his head. The bullet dented in the helmet but did not break it, no nor the musculous skin, nor skull, for as much as could be discerned, yet notwithstanding he died apoplectic upon the sixth day after.
I, being very desirous to know what might be the true cause of his death, divided his skull and observed that the second table was broken and cast off scales and splinters, wherewith as with needles the substance of the brain was continually pricked, the first and upper table being whole, for all this: I afterwards showed the like example to Capellanus and Castellanus, the King and Queen’s chief physicians in the expedition of Roane.
Hippocrates prescribes no method of curing this fifth kind of fracture, because he thinks it cannot be found out by any circumstance whence it happens that it is for the most part deadly. Yet we must endeavor to have some knowledge and conjecture of such a fracture if it shall at any time happen. Wherefore having first diligently shaved away the hair, we must apply an emplaister of pitch, tar, wax, turpentine, the powder of iris, or floure deluce roots, and mastich. Iif any place of the head shall appear more moist, soft and swollen, it is somewhat likely that the bone is cleft in that place, so that the patient, though thinking of no such thing, is now and then forced to put his hand to that part of the skull. Confirmed with these and other signs formerly mentioned, let him call a counsel of learned physicians and foretell the danger to the patient’s friends, which are there present, that there may no occasion of calumny remain, then let him boldly perforate the skull, for that is far better than to forsake the patient ready to yield to the greatness of the hidden disease, and so consequently to die within a short while after. There are four sorts, or conditions, of fractures, by which the surgeon may be so deceived, that when the skull is broken indeed, yet he may think there is no fracture. The first is when the bone is so depressed that it presently rises up into its true place and native equability. The second is when the fissure is only capillary. The third is when the bone is shaken on the inside, the utter surface nevertheless remaining whole, for as much as can be discerned. The fourth is when the bone is stricken on the one side and cleft on the other.
We must not neglect any wounds in the head, no not these which cut or bruise but only the hairy scalp; but certainly much less, these which are accompanied by a fracture in the skull; for oft times all horrid symptoms follow upon them, and consequently death itself, especially in bodies full of ill humors, or of an ill habit, such as are these which are affected with the Lues venerea, leprosy, dropsy, Pthisick and consumption; for in these, simple wounds are hardly or never cured; for union in the cure of wounds, but this is not performed, unless by strength of nature, and sufficient store of laudable blood: but those which are sick of hectic fevers and consumptions, want store of blood and those bodies which are replete with ill humors, and of an ill habit have no afflux or plenty of laudable blood: but all of them want the strength of nature; the reason is almost the same in those also which are lately recovered of some disease.
Those wounds which are bruised are more difficult to cure than those which are cut. When the skull is broken, than the continuity of the flesh lying over it must necessarily be hurt and broken, unless it is in a resonitus. The bones of children are more soft, thin and replenished with a sanguine humidity than those of old men, and therefore more subject to putrefaction. Wherefore the wounds which happen to the bones of children, though of themselves, and their own nature they may be more easily healed, (because they are more soft, whereby it comes to pass, that they may be more easily agglutinated, neither is there fit matter wanting for their agglutination due to the plenty of blood laudable both in consistency and quality) than in old men, whose bones are dryer and harder, and so resist union, which comes by mixture, and their blood is serous, and consequently a more unfit bond of unity and agglutination; yet oft times through occasion of the symptoms which follow upon them, that is putrefaction and corruption, which sooner arise in a hot and moist body, and are more speedily increased in a soft and tender, they usually are more suspected and difficult to heal.
The patient lives longer of a deadly fracture in the skull, in winter than in summer, for that the native heat is more vigorous in that time than in this; besides, also the humors putrify sooner in summer, because unnatural heat is then easily inflamed and more predominant, as many have observed out of Hippocrates.
The wounds of the brain and of the meninges or membranes thereof are most commonly deadly, because the action of the muscles of the chest, and others serving for respiration, is many times disturbed and intercepted, whence death insues. If a swelling happening upon a wound of the head presently vanish away, it is an ill sign, unless there is some good reason therefore, as blood-letting, purging, or the use of resolving local medicines, as may be gathered by Hippocrates in his Aphorismes. If a fever ensue presently after the beginning of a wound of the head, that is, upon the fourth or seventh day, which usually happens, you must judge it to be occasioned by the generating of pus or matter, as it is recited by Hippocrates. Neither is such a fever so much to be feared, as that which happens after the seventh day, in which time it ought to be determinated; but if it happens upon the tenth or fourteenth day with cold or shaking, it is dangerous, because it makes us conjecture that there is putrefaction in the brain, the meninges, or skull, through which occasion it may arise, chiefly if other signs shall also concur, which may show any putrefaction, as if the wound is pallid and of a faint yellowish color, as flesh looks after it is washed.
As it is in Hippocrates Aphoris. 2. sect. 7, It is an ill sign if the flesh looks livid, when the bone is affected; for that color portends the extinction of the heat, through which occasion, the lively, or indifferently red color of the part, faints and dies, and the flesh there abouts is dissolved into a viscous pus or filth.
Commonly, another worse effect follows hereon, wherein the wound becoming withered and dry, looks like salted flesh, sends forth no matter, is livid and black, whence you may conjecture, that the bone is corrupted, especially if it becomes rough, whereas it was formerly smooth and plain; for it is made rough when caries or corruption invades it; but as the caries increases, it becomes livid and black, sanious matter withall sweating out of the diploe, as I have observed in many: all which are signs that the native heat is decayed, and therefore death at hand; but if such a fever be occasioned from an Erysipelos which is either present or at hand, it is usually less terrible. But you shall know by these signs, that the fever is caused by an Erysipelas and conflux of choleric matter; if it keep the form of a Tertian, if the fit take them with coldness and end in a sweat; if it is not terminated before the choleric matter is either converted into pus or else resolved; if the lips of the wound are somewhat swollen, as also all the face; if the eyes are red and fiery; if the neck and chaps are so stiff, that he can scarce bend the one, or open the other; if there is great excess of biting and pricking pain, and heat, and that far greater than in a phlegmon. For such an Erysipelous disposition generated of thin and hot blood, chiefly assails the face, and that for two causes.
The first is, due to the natural levity of the choleric humor; the other because of the rarity of the skin of these parts.
The cure of such an affect must be performed by two means, that is, evacuation, and cooling with humectation. If choler alone caused this tumor, we must easily be induced to let blood, but we must purge him with medicines evacuating choler. If it is an Erisipelas phlegmonodes, you must draw blood from the cephalic vein of that side, which is most affected, always using advise of a physician. Having used these general means, you must apply refrigerating and humecting things, such as are the juice of night-shade, house-leek, purslane, lettuce, navel wort, water lentil, or ducks-meat, gourdes; a liniment made of two handfuls of sorrel boiled in fair water, then beaten and drawn through a sieve with ointment of roses or some unguent. Populeon added thereto will be very commodious. Such and the like remedies must be often and so long renewed until the unnatural heat is extinguished. But we must be careful to abstain from all unctuous and oily thing, because they may easily be enflamed, and so increase the disease. Next we must come to resolving medicines; but it is good when anything comes from within, to without; but on the contrary it is ill, when it returns from without inwards, as experience and the Authority of Hippocrates testify: If when the bone becomes purulent, pustules shall break out on the tongue, by the dropping down of the acrid filth or matter by the holes of the palate upon the tongue, which lies under. Now when this symptom appears, few escape. Also it is deadly when one becomes dumb and stupid, that is, apoplectic by a stroke or wound on the head; for it is a sign that not only the bone, but also the brain itself is hurt. But oft times the hurt of the brain proceeds so far, that from corruption it turns to a sphacel, in which case, they all have not only pustules on their tongues, but some of them die stupid and mute, othersome with a convulsion of the opposite part; neither as yet have I observed any which have died with either of these symptoms, due to a wound in the head, who have not had the substance of their brain tainted with a sphacel, as it has appeared when their skulls have been opened after their death.
Many have to this day inquired, but as yet as far as I know it has not been sufficiently explained, why a convulsion in wounds of the head seizes on the part opposite to the blow. Therefore I have thought good to end that controversy in this place. My reason is this, that kind of symptom happens in the sound part due to emptiness and dryness; but there is a twofold cause, and that wholly in the wounded part, of this emptiness and dryness of the sound or opposite part; to wit, pain; and the concourse of the spirits and humors thither by the occasion of the wound, and due to the pains drawing and natures violently sending help to the afflicted part.
The sound part exhausted by these means both of the spirits and humors, easily falls into a convulsion.
For thus Galen writes; God the creator of nature, has so knit together, the triple spirituous substance of our bodies, with that tie, and league of concord, by the productions of the passages; to wit of nerves, veins, and arteries, that if one of these forsake any part, the rest presently neglects it, whereby it languishes, and by little, and little dies, through defect of nourishment. But if any object that nature has made the body double, for this purpose, that when one part is hurt, the other remaining safe and sound, might suffice for life and necessity: but I say, this axiom has no truth in the vessels and passages of the body. It has not everywhere doubled the vessels, for there is but one only vein, appointed for the nourishment of the brain, and the membranes thereof, which is that they call the Torcular, by which when the left part is wounded, it may exhaust the nourishment of the right and sound part, and though that occasion cause it to have a convulsion, by too much dryness; Verily it is true, that when in the opposite parts, the muscles of one kind are equal in magnitude, strength, and number, the resolution of one part, makes the convulsion of the other by accident; but it is not so in the brain.
For the two parts of the brain, the right and left, each by itself performs that which belongs thereto, without the consent, conspiration, or commerce of the opposite part; for otherwise it should follow, that the palsy properly so called, that is of half the body, which happens by resolution, caused either by mollification or obstruction residing in either part of the brain, should infer together with it a convulsion of the opposite part. Which notwithstanding daily experience convinces as false. Wherefore we must certainly think, that in wounds of the head wherein the brain is hurt, that inanition and want of nourishment are the causes, that the sound and opposite part suffers a convulsion.
Francis Dalechampius, in his French Surgery, renders another reason of this question; That, (says he) the truth of this proposition may stand firm and ratified, we must suppose, that the convulsion of the opposite part mentioned by Hippocrates, does then only happen, when due to the greatness of the inflammation in the hurt part of the brain, which has already inferred corruption; and a gangrene to the brain and membranes thereof, and within a short time is ready to cause a sphacel in the skull, so that the disease must be terminated by death; for in this defined state of the disease, and these conditions, the sense and motion must necessarily perish in the affected part, as we see it happens in other gangrenes, through the extinction of the native heat. Besides, the passages of the animal spirit must necessarily be so obstructed by the greatness of such an inflammation or phlegmon, that it cannot flow from thence to the parts of the same side lying there under, and to the neighboring parts of the brain; and if it should flow thither, it will be unprofitable to carry the strength and faculty of sense and motion, as that which is infected and changed by admixture of putrid and gangrenous vapors. Whereby it comes to pass, that the wounded part destitute of sense, is not stirred up to expel that which would be troublesome to it, if it had sense; wherefore neither are the nerves thence arising seized upon, or contracted by a convulsion.
It furthermore comes to pass, that because these same nerves are deprived of the presence and comfort of the animal spirit, and in like manner the parts of the same side, drawing from thence their sense and motion are possessed with a palsy; for a palsy is caused either by cutting or obstruction of a nerve, or the madefaction, or mollification thereof by a thin and watery humor, or so affected by some vehement distemper, that it cannot receive the animal spirit.
But for the opposite part and the convulsion thereof, it is known and granted by all, that a convulsion is caused either by repletion, which shortens the nerves by distending them into breadth, or by inanition, when as the native and primitive heat of the nerves being wasted, their proper substance becoming dry is wrinkled up and contracted; or else it proceeds from the vellication, and acrimony of some vapor, or sanious and biting humor, or from vehemence of pain. So we have known the falling sickness caused by a venenate exhalation carried from the foot to the brain. Also we know that a convulsion is caused in the puncture of the nerves, when as any acrid and sanious humor is shut up therein, the orifice thereof being closed; but in wounds of the nerves when any nerve is half cut, there happens a convulsion by the bitterness of the pain.
But verily in the opposite part, there are manifestly two of these causes of a convulsion; that is to say, a putrid and carion-like vapor exhaling from the hurt, and gangrenate part of the brain; and also a virulent acrid and biting sanies, or filth, sweating into the opposite sound part, from the affected and gangrenous; the malignitie of which sanies, Hippocrates desirous to decipher, in reckoning up the deadly signs of a wounded head, has expressed it by the word Ichor; and in his book of fractures he has called this humor Dacryodes et non Pyon. [that is, weeping and not digested.] Therefore it is no marvel if the opposite and sound part endued with exquisite and perfect sense, and offended by the flowing thereto of both the vapors and sanious matter, using its own force, contend and labor as much as it can, for the expulsion of that which is troublesome thereto. This laboring or concussion is followed (as we see in the falling sickness) by a convulsion, as that which is undertaken in vain, death being now at hand; and nature over-ruled by the disease. Thus (says Dalechampius) we must in my judgment determine of that proposition of Hippocrates and Avicenne.
But, he adds further, in wounds of the head which are not deadly, practitioners observe that sometimes the hurt part is taken with the palsy, and the sound with a convulsion; otherwhiles on the contrary, the wounded part is seized by a convulsion and the sound by a palsy; otherwhiles both of them by a convulsion or palsy; and somewhiles the one of them by a convulsion or palsy, the other being free from both affects; the causes of all which belong not to this place to explain. Thus much Dalechampius.
Now that we may return to our former discourse; you may certainly foretell the patient will die; when his reason and judgment being perverted, he shall talk idly, when his memory fails him; when he cannot govern his tongue, when his sight grows dark and dim, his ears deaf, when he would cast himself headlong from his bed, or else lies therein without any motion; when he has a continual fever with a delirium, when the tongue breaks out in pustules, when it is chapped, and become black due to too much dryness; when the wound grows dry, and casts forth little or no matter, when as the color of the wound which was formerly fresh, is now like salted flesh yellow and pale; when the urine and other excrements are suppressed; when the palsy, convulsion, apoplexy; and lastly often swooning, with a small and unequal pulse, invade him. All such signs sometimes appear presently after the wound, otherwhiles some few days after; therefore when as the brain is hurt and wounded by the violence of the incision, or fissure, of the contusion, compression, puncture, concussion or any other fracture, the aforementioned signs appear presently in the first days; but when they do not appear till many days after the blow, you may know that they rise and appear, due to an inflammation and phlegmon in the brain, occasioned by the putrefaction of the blood poured forth upon it.
But we must observe this by the way, which also belongs to the prognostics, that flesh is easily regenerated, and restored in all parts of the head, except in that part of the forehead, which is a little above that which lies between the eyebrows, so that it will be ulcerated ever after, and must be covered with a plaster. I believe that, in that place there is an internal cavity in the bone, full of air which goes to the sive-like bones of the nose, by which the growth of flesh may be hindered; or else that the bone is very dense or compact in that place, so that there can scarce sufficient juice sweat forth, which may suffice for the regeneration of flesh; add hereunto a great conflux of excrements flowing to this ulcer, which should otherwise be evacuated by the eyes and nose, which hinder by that means the dryness of the ulcer, and consequently the healing thereof.
Hence certainly it comes to pass, that if you desire the patient thus affected to breathe, shutting his mouth and nose, the air or breath will come forth of the ulcer with such force, as it will easily blow forth a lighted candle of an indifferent size held thereto. Which thing I protest, I observed in a certain man, whom I was forced to trepan in that place, by reason the bone of the forehead was broken and depressed.
But on the contrary these are salutary signs, when the patient has no fever, is in his right mind, is well at the application or taking of any thing, sleeps well, has his belly soluble, the wound looks with a fresh and lively color, casts forth digested and laudable matter, the Crassa Meniux has its motion free and no way hindered.
Yet we must note, which also is observed by the ancients and confirmed by experience; that we must think none past danger, and free from all chance, until the hundredth day has past. Wherefore the physician ought so long to have a care of his patient, that is, to consider how he behaves and governs himself in meat, drink, sleep, venery and other things.
But let the patient diligently avoid and shun cold. Many, when they have been cured of wounds of the head, by careless taking cold have been brought into danger of their lives. Also you must know that the callus, whereby the bones of the skull are knit together, requires almost the space of forty or fifty days to its perfect coagmentation and concretion. Though in very deed one cannot set down a certain number of days, due to the variety of bodies, or tempers. It is sooner finished in young men, and more slowly in old; And thus much may serve for prognostics. Now will we treat as briefly and perspicuously as we can of the cure both in general and particular; wherefore beginning with the general we will first prescribe a convenient diet by the moderate use of the six things not natural.
The first cure must be to keep the patient in a temperate air; and if so be, that it is not such of itself and its own proper nature, it must be corrected by art. As in winter he must have a clear fire made in his chamber, lest the smoke cause sneezing and other accidents; and the windows and doors must be kept shut to hinder the approach of the cold air and wind. All the time the wound is kept open to be dressed, somebody standing by shall hold a chefandish full of coals or a heated iron bar over the wound, at such a distance, that a moderate heat may pass thence to the wound; and the frigidity of the encompassing air may be corrected by the breathing of the diffused heat. For cold, according to the opinion of Hippocrates, is an enemy to the brain, bones, nerves, and spinal marrow; it is also hurtful to ulcers, by suppressing their excrements, which suppressed do not only hinder suppuration, but also by corrosion makes them sinuous. Therefore Galen rightly admonishes us, to keep cold from the brain, not only in the time of trepaning, but also afterwards. For there can be no greater, nor more certain harm befall the fractured skull, than by admitting the air, by such as are unskillful. If the air is hotter than the brain, then it could not thence be refrigerated; but if the brain is laid open to the air, in the midst of summer, when it is at the hottest, yet would it be refrigerated, and unless it were relieved with hot things, take harm: this is the opinion of Galen, whereby you may understand that many who have their skulls broken, die more through default of skill in the curing, than by the greatness of the fracture.
But (when the wound is bound up with the pledgets, clothes, and rollers as is fit) if the air chance to be more hot, than the patient can well endure, let it be amended by sprinkling, and strawing the chamber with cold water, oxycrate, the branches of willows and vine. Neither is it sufficient to shun the too cold air, unless also you take heed of the over light, chiefly until such time as the most feared and malign symptoms are past.
For a too great light dissipates the spirits, increases pain, strengthens the fever and symptoms. Hippocrates wholly forbids wine, therefore the patient instead thereof must drink barley water, fair water boiled and tempered with julep of roses, syrup of violets, vinegar and the like: water wherein bread crumbs have been steeped, water and sugar, with a little juice of lemons, or pomecitron added thereto, and such as the ability and taste of the patient shall require. Let him continue such drinks until he is free from malign symptoms, which usually happen within 14 days.
His meat shall be pap, ptisan, shunning almond milks; (for almonds are said to fill the head with vapors and cause pain) stewed damaske prunes, raisins and currants, seasoned with sugar, and a little cinnamon (which has a wonderful power to comfort the stomach and revive and exhilarate the spirits) chickens, pigeons, veal, kid, leverets, birds of the fields, Pheasons, black-birds, turtles, partridges, thrushes, larks and such meats of good digestion, boiled with lettuce, purslane, sorrel, borage, bugloss, succory, endive and the like, are thought very convenient in this case. If he desire at any time to feed on these meats roasted, he may, only dipping them in verjuice, in the acid juices of oranges, citrons, lemons, or pomegranates, sometimes in one, and sometimes in another, according to his taste and ability. If any has a desire to eat fish, he must make choice of trouts, gudgeons, pikes and the like, which live in running and clear waters, and not in muddy; he shall eschew all cold sallets and pulse, because they fly up and trouble the head: it will be convenient after meat to use common dridg powder; or aniseed, fennel-seed or coriander comfits, also conserve of roses, or marmilate of quinces to shut up the orifice of the ventricle, lest the head should be offended with vapors arising from thence.
Children must eat often, but sparingly; for children cannot fast so long as those which are elder, because their natural heat is more strong, wherefore they stand in need of more nourishment; so also in winter all sorts of people require more plentiful nourishment, for that then their stomachs are more hot than in summer.
When the fourteenth day is past, if neither a fever, nor anything else forbid, he may drink wine moderately, and little by little, increase his diet, but that respectively to each one’s nature, strength and custom. He shall shun, as much as in him lies, sleep in the day time, unless it happen that a phlegmon seize upon the brain or meninges. In this case it will be expedient to sleep in the day time, especially from morning till noon, for in this season of the day, as also in the spring, blood is predominant in the body, according to Hippocrates. It is so vulgarly known, that it need not be spoken, that the blood when we are awake is carried into the habit and surface of the body; but on the contrary by sleep it is called into the noble parts, the heart and liver. Wherefore if that the blood by the force of the sun casting his beams upon the earth, at his rising is carried into the habit of the body, should again be more and more diffused by the strength and motion of watching, the inflammation in the brain and meninges would be much increased. Wherefore it will be better, especially then to stay by sleep the violence of the blood running into the habit of the body, when it shall seem to rage and more violently to affect that way. Watching must in like manner be moderate; for too much depraves the temper of the brain and of the habit of the whole body; it causes crudities, pains and heaviness of the head, and makes the wounds dry and malign.
But if the patient cannot sleep due to the vehemence of the inflammation of the brain and meninges, Galen wishes, to wash, besmear and anoint the head, nose, temples and ears with refrigerating and humecting things, for these stupify, and make drowsy the brain and membranes thereof, being more hot than they ought to be. Wherefore for this purpose, let the temples be anointed with unguentum populeon, or unguentum Rosatum with a little rose vinegar, or oxycrate; Let a sponge moistened in the decoction of white or black poppy seed, of the rinds of the roots of Mandrages, of the seeds of Henbane, lettuce, purslane, plantain, night-shade and the like. He may also have a broth or barley cream, into which you may put an emulsion made of the seeds of white poppy, or let him have a potion made with ℥j. or ℥iss. of the syrup of poppy, with ℥ij. of lettuce water; Let the patient use these things 4 hours after meat to procure sleep. For sleep does much help concoction, it repairs the efflux of the triple substance caused by watching, assuages pain, refreshes the weary, mitigates anger and sorrow, restores the depraved reason, so that for these respects it is absolutely necessary that the patient take his natural rest.
If the patient is plethoric, let the plenitude be lessened by blood-letting, purging and a slender diet, according to the discretion of the physician who shall oversee the cure.
But we must take heed of strong purgations, in these kinds of wounds, especially at the beginning, lest the fever, inflammation, pain, and other such symptoms be increased by stirring up the humors.
Phlebotomy, according to Galen, must not only be made respective to the plenty of blood, but also agreeable to the greatness of the present disease, or that which is to come, to divert, and draw back that humor which flows down, by a way contrary to that which is impact in the part; and which must be there evacuated, or drawn to the next. Wherefore for example, if the right side of the head is wounded, the cephalic vein of the right arm shall be opened, unless a great plethora or plenitude cause us to open the basilica, or median, yet if neither of them can be fitly opened, the basilica may be opened, although the body is not plethoric.
The like course must be observed in wounds of the left side of the head; for that is far better due to the straightness of the fibers, than to draw blood on the opposite side; in performance whereof you must have diligent care of the strength of the patient, still feeling his pulse, unless a physician be present, to whose judgment you must then commit all that business. For the pulse is, in Galen’s opinion, the most certain shower of the strength. Wherefore we must consider the changes and inequalities thereof, for as soon as we find it to become lesser and more slow, when the fore-head begins to sweat a little, when he feels a pain at his heart, when he is taken with a desire to vomit, or go to stool, or with yawning, and when he changes his color and his lips look pale, then you must stop the blood as speedily as you can; otherwise there will be danger lest he pour forth his life together with his blood. Then he must be refreshed with bread steeped in wine, and put into his mouth, and by rubbing his temples and nostril with strong vinegar, and by lying upon his back.
But the part shall be eased and freed from some portion of the impact and conjunct humor by gently scarifying the lips of the wound, or applying of leeches. But it is diverted, by opening these veins which are nighest to the wounded part, as the Vena Puppis, or that in the middle of the forehead, or of the temples, or these which are under the tongue; besides also cupping-glasses shall be applied to the shoulders sometimes with scarification, sometimes without; neither must strong, and long frictions with course clothes, of all the whole body, the head excepted, be omitted during the whole time of the cure, for these will be available, though but for this, that is; to draw back and dissipate by insensible transpiration the vapors which otherwise would ascend into the head, which matters certainly in a body that lies still and wants both the use and benefit of accustomed exercise, are much increased.
But it is made manifest by this following and notable example, how powerful blood-letting is, to lessen and mitigate the inflammation of the brain, or the membranes thereof in wounds of the head.
I was lately called into the suburbs of Saint German, there to visit a young man twenty eight years old, who lodged there in the house of John Martial, at the sign of Saint Michael. This young man was one of the household servants of Master Doucador, the steward of the Lady Admiral of Brion. He fell down headlong upon the left bregma, upon a marble pavement, whence he received a contused wound, without any fracture of the skull, and being he was of a sanguine temperature, by occasion of this wound, a fever took him on the seventh day with a continual delirium and inflammation of phlegmonous tumor of the wounded pericranium. This same tumor possessing his whole head and neck by continuation and sympathy of the parts, was grown to such a size, that his visage was so much altered, that his friends knew him not; neither could he speak, hear, or swallow any thing but what was very liquid. Which I observing, although I knew, that the day past, which was the eighth day of his disease, he had four saucers of blood taken from him by Germaine Agace Barber-surgeon of the same suburbs; yet considering the integrity and constancy of the strength of the patient, I thought good to bleed him again; wherefore I drew from him 14 saucers at that one time; when I came to him the day after, and saw that neither the fever, nor any of the forementioned symptoms were any whit remitted, or assuaged, I forthwith took from him four saucers more, which in all made two and twenty; the day following when I had observed, that the symptoms were no whit lessened, I durst not presume by my own only advice, to let him the fourth time blood as I desired. Wherefore I brought unto him, that most famous physician Doctor Violene, who as soon as he felt his pulse, knowing by the vehemence thereof, the strength of the patient, and moreover considering the greatness of the inflammation and tumor which offered itself to his sight, he bid me presently take out my lancet and open a vein. But I lingered on set purpose, and told him, that he had already twenty two saucers of blood taken from him: Then said he, Grant it be so, and though more have been drawn, yet we must not therefore desist from our enterprise, especially seeing the two chief indications of blood-letting yet remain, that is, the greatness of the disease, and the constant strength of the patient. I being glad of this, took three saucers more of blood, he standing by, and was ready to take more but that he wished me to differ it until the afternoon; wherefore returning after dinner I filled two saucers more, so that in all, this young man to his great benefit, lost twenty seven saucers of blood at five times, within the space of four days. Now the ensuing night was very pleasing to him, the fever left him about noon, the tumor grew much less, the heat of the inflammation was assuaged in all parts, except in his eyelids, and the laps of his ears, which, being ulcerated, cast forth a great quantity of pus or matter. I have recited this history purposely, to take away the childish fear which many have to draw blood in the constant strength of the patient, and that it might appear how speedy and certain a remedy it is in inflammations of the head and brain.
Now to return from whence we digressed, you must note that nothing is so hurtful in factures and wounds of the head, as venery; not only at that time the disease is present, but also long after the cure thereof. For great plenty of spirits are contained in a small quantity of seed, and the greatest part thereof flows from the brain; hence therefore all the faculties, but chiefly the animal, are resolved, whence I have many times observed death to ensue in small wounds of the head, yea when they have been agglutinated and united.
All passions of the mind must in like sort be avoided, because they by contraction and dissipation of the spirits cause great trouble in the body and mind. Let a place be chosen for the patient as far from noise as can be, as from the ringing of bells, beatings and knockings of smiths, coopers, and carpenters, and from high-ways through which they use to drive coaches; for noise increases pain, causes a fever, and brings many other symptoms.
I remember when I was at Hesdin at the time that it was besieged by the forces of Charles the Fifth, that when the wall beaten with the cannon, the noise of the ordinance caused grievous torment to all those which were sick, but especially those that were wounded on their heads, so that they would say, that they thought at the discharging of every cannon that they were cruelly struck with staves on that part which was wounded; and verily their wounds were so angered herewith, that they bled much, and by their pain and fevers increased, were forced with much sighing to breathe their last.
Thus much may serve to be spoken of the cure in general, now we will out of the monuments of the ancients, treat of the particular.
Let us start with a straightforward wound, the treatment of which has a singular goal: union. Typically, unless the wound extends to the skull, it is treated similarly to other wounds affecting the fleshy parts of the body. However, if the wound is compound, its complexity presents multiple challenges, each requiring its own specific approach. In such cases, priority must be given to addressing the most pressing issues and underlying causes.
If the wound is simple and superficial, the first step involves shaving the hair from the area, followed by the application of a plaster made from egg white, bole armenic, and aloes. On the subsequent day, apply either Emplastrum de Ianua or Emplastrum de gratia Dei, continuing this treatment until the wound completely heals. However, if the wound is deeper, reaching the pericranium, the surgeon would be advised to use a digestive ointment at the second dressing. This ointment can be prepared from Venice turpentine, egg yolks, oil of roses, and a touch of saffron, and should be applied until the wound matures. At this stage, add honey of roses and barley flour to the digestive mixture. We then move to other medicines that do not include oily or greasy substances in their composition, such as the one previously described.
Prescription: Terebinth (venetian turpentine) 2 ounces, syrup of rose 1 ounce, powdered aloes, myrrh, and mastic, each 1 drachm.
Let them all be incorporated and made into an unguent, which is perfectly regenerated; then it must be cicatrised with this following powder:
Prescription: Burnt alum, burnt pomegranate peel, each 1 drachm. Mix them together to make a powder.
If the wound is large enough to require suturing, the number of stitches shall be determined by what seems necessary.
While I was at Hesdin, I treated a soldier who had suffered a severe injury when the earth collapsed on him while he was digging. His scalp was pressed down to the pericranium and was completely detached from the back of his head to his forehead, leaving it hanging over his face.
To treat this injury, I began by washing the entire wound with slightly warmed wine to cleanse it of the congealed blood and earth. After drying it gently with a soft linen cloth, I applied Venice Turpentine mixed with a bit of Aqua Vitae, into which I had dissolved some Dragon’s Blood, Mastic, and Aloe.
I then carefully repositioned the hanging skin and secured it with stitches, making sure they were not too tight or too close together, so as to avoid causing pain and inflammation—issues that frequently occur when the wound begins to drain. The stitches were placed just tightly enough to hold the skin in place and prevent air from entering, as this can be detrimental to the healing process. I also filled the lower edges of the wound with somewhat long and broad tents to allow any fluid to drain out. Finally, I applied the following poultice to the entire head:
Prescription: Take six ounces of wheat and bean flour and three drachms of rose oil; add enough vinegar to form a poultice.
This remedy has the ability to dry up excess moisture, cool the affected area, alleviate pain and inflammation, and help staunch bleeding. I refrained from drawing blood, as he had already lost a significant amount, particularly from some severed arteries near his temples. After being treated in this manner, he recovered quite quickly.
However, if the wound is inflicted by the bite of a wild animal, it requires a different approach, as illustrated by the following account. Once, a crowd was watching King Henry II’s lions, housed in the tilt-yard in Paris for his amusement. During this event, one of the most ferocious lions broke free from its restraints and leaped among the spectators. It knocked down a twelve-year-old girl, clasped her head in its jaws, and repeatedly bit her scalp, causing multiple injuries to the muscular skin, though fortunately not harming the skull. Eventually, the Lion Master saved her from near death, and she was entrusted to the care of surgeon Rowland Claret, who happened to be present. A few days later, I was summoned to examine her; she was feverish, and her head, shoulders, and chest—everywhere the lion had bitten or clawed her—were swollen. The edges of the wounds were discolored and exuded a watery, acrid, virulent, and foul-smelling dark green substance, making it almost unbearable to be near her. She also suffered from severe pricking, biting pain. Observing this, I recalled the old adage that wounds from animal or human bites are somewhat poisonous. It is critical, therefore, to address the venomous contamination left by the animal’s teeth and claws. I treated her by making multiple small cuts around the wound edges and applying leeches to draw out the poisoned blood and reduce inflammation. I then prepared a wash using a mixture of aegyptiacum, theriac, and mithridate.
Prescription:
Take 1 ounce of Mithridate, 1.5 ounces of theriac, and 0.5 ounces of Egyptian remedy. Dissolve all in aqua vitae (water of life) and carduus.
(Note: “Mithridate” refers to a historical antidote for poison, “theriac” is an ancient medicinal mixture, and “carduus” likely refers to a type of thistle used for its medicinal properties.)
Let the wounds be fomented and washed with it warm; besides also treacle and mithridate were put in all the medicines which were either applied or put into the wound; and also of the same with the conserves of roses and bugloss dissolved in the water of sorrel and carduus benedictus, potions were made to strengthen the heart and vindicate it from malign vapors.
For which purpose also this following epithema was applied to the region of her heart.
℞. Take 4 ounces each of rose water and nenuphar water, 1 ounce of squill vinegar, and 1 ounce each of coral, white and red sandalwood, and red rose powder. Also take 1 ounce each of spodium powder, Mithridate, and theriac, along with 2 drams of ground cordial flowers and 1 dram of saffron.”**
(Note: “Spodium” refers to bone ash or burnt hartshorn, typically used in historic medicinal concoctions. “Nenuphar” refers to water lily components.)
Dissolve them altogether, make an epitheme and apply it to the heart with a scarlet cloth or sponge, and renew it often. Verily she dressed after this manner, and the former remedies but once used, pain, inflammation and all the malign symptoms were much lessened; to conclude she recovered, but lingered and was lean some two years after, yet at length she was perfectly restored to her health and former nature. By which you may understand, that simple wounds must be handled after another manner, than these which have any touch of poison.
But now that we may prosecute the other affects of the hairy scalp; say that it is contused with a blow without a wound, that which must be first and alway done, (so that the affect may better appear, and the remedies which are applied may take more effect) the hair must be shaven away, and at the first dressing a repelling medicine applied, such as is this following Oxyrhodinum.
℞. Take 3 ounces of rose oil, 2 nut eggs, and 2 drams each of powdered cypress nuts, balanced alum, and red rose powder.”**
(Note: The term “nut eggs” likely refers to an ingredient derived from nuts used in historical remedies.)
Let them be all incorporated, and make a medicine for the former use, or instead thereof, you may apply the cataplasm prescribed before consisting of farina hordei, sabarum, aceto & oleo rosaceo.
But such medicines must be often renewed. When the pain and defluxion are appeased, we must use discussing medicines for the dissipation of that humor which remains impacted in the part;
℞ Take 2 drams of mucilage plaster, 1 ounce each of oxycroceum plaster and melilot plaster, and 1/2 ounce each of chamomile oil and dill oil. Mix them together and prepare a plaster for the named use.
Such a fomentation will also be good.
℞ Take 4 lib. of red wine, 2 lib. of lixivium (or alkali), 10 nuts of cypress, 1 oz. of myrtle powder, 1 M. (or 1 ounce) of red rose, wormwood, sage leaves, marjoram, stacte, and flowers of chamomile and melilot, each 1 M. (or 1 ounce) of rock alum, root of calamus aromaticus, and cypress root, each 1/2 ounce.
(Note: “lib.” is short for “libra,” a Roman unit of weight equivalent to about 327 grams; “M.” can refer to a measure of weight equivalent to an ounce.)
bulliant omnia simul, and make a decoction to foment the grieved part. After somewhat a long fomenting it, whereby it may the better discuss, dry and exhaust the concrete humor; the head must be dried & more discussing things applied such as the Cerate described by Vigo called de minio, which has an emollient and digestive faculty in this form.
℞
Take 10 oz. of chamomile oil and the same of lily oil, 2 oz. of mastic oil, 1 libra of sheep fat, 8 oz. of litharge of gold, 2 oz. of minium, and one cup of good wine. Boil all these together while stirring with a stick, initially over a slow fire, but then over a brighter flame, until the whole mass takes on a black or very dark color;
at the end of the cooking process, add 1/2 libra of turpentine, 2 oz. of mastic powder, 1 oz. of gum elemi, and enough beeswax, then boil again for one more bubbling and let it become a soft plaster.”
(Note: “lib.” is short for “libra,” a measure of weight; “℥” stands for “uncia” or ounce; “cyathum” is a measure of liquid, roughly equivalent to a cup.)
But if the humor is not thus discussed, but only grow soft, then the tumor must be quickly opened, for when the flesh is inflamed and putrified through occasion of the contained humor, the bone under it putrifies also by the contagion of the inflammation and the actimony of the matter falling upon the bone. When you have opened it, wash away the filth of the ulcer with this following detersive medicine.
℞ Take 1 oz. each of rose syrup and absinthe, 1.5 oz. of turpentine, and 1.5 drams each of powdered orris root, aloes, mastic, myrrh, and barley flour.
(Note: “℥” represents “uncia” or ounce, and “ʒ” represents a dram.)
Instead here of if there is great putrefaction Aegyptia. either by itself, or mixed with an equal quantity of unguentum apostolorum may be put into the ulcer. When the ulcer is cleansed it will be time to use scarcotic and cicatrizing medicines.
Original
If the skull is broken, so that it is necessary to trepan it, or to elevate and lift it up, or scrape it away, the musculous skin being cut as we formerly noted, the pericranium shall be plucked from the skull, as we said before; which because it can hardly be done without great pain, due to its exquisite sense and connection with the membranes of the brain, we must labor to mitigate the pain for fear of inflammation and other accidents. Therefore the first dressing ended and the corners of the wound drawn each from other; at the second dressing put to the wound, a digestive (as they term it) made of the yolk of an egg, and oil of roses, but you must apply no humid thing to the bone, because we desire to keep it sound and whole. For Galen’s opinion is, that bared bones must not be touched with unctuous things, but rather on the contrary, all dry things must be applied to them, which may consume the superfluous humidity. Therefore we must lay some lint and the cephalic powders, which we shall hereafter describe, upon the bone we intend to preserve, and must have diligent care that it is not offended either by the the air, or touch of humid medicines. You must in trepaning have a special care of the Crassa Meniux. I have often observed a great quantity of blood to have flowed from some broken vessel which adhered to the second Table: neither must we presently and forthwith stay such bleeding, but suffer it to flow according to the plenitude and strength of the patient; for thus the fever, and together therewith the rest of the symptoms are diminished.
In the opinion of Hippocrates, in every green wound it is good to cause often bleeding, except in the bellies; for thus the vehemence of pain, inflammation and other accidents will be less troublesome; also it is not amiss too for old ulcers to bleed much, for so they are freed from the burden of the impact humors. When you think it has bled sufficiently, it may be stanched with this following medicine described by Galen:
Modernized
If the skull is fractured and requires trepanning, elevation, or scraping, we must first cut through the muscular skin, as previously noted. Next, the pericranium— the membrane covering the skull—should be carefully removed. This procedure can be quite painful due to its sensitivity and its close connection to the brain’s membranes, so it is important to take measures to alleviate the pain in order to prevent inflammation and other complications.
After the first dressing is complete and the edges of the wound are pulled apart, you should apply a second dressing. This dressing should include a digestive mixture made from egg yolk and rose oil. However, it is crucial to avoid moist substances touching the exposed bone, as we want to keep it healthy and intact. Galen advises against applying oily substances to bare bones; instead, he recommends using dry materials to absorb excess moisture.
We will apply lint and specific cephalic powders, which I will describe later, directly onto the bone we aim to protect. It is vital to ensure that the bone does not come into contact with humid air or moist treatments. During the trepanation process, careful attention must be paid to the Crassameninx. I’ve observed that significant bleeding can occur from vessels attached to the inner layer of the skull. Rather than immediately trying to stop this bleeding, it is preferable to allow it to continue according to the patient’s overall condition. This approach can help reduce fever and other associated symptoms.
According to Hippocrates, it is beneficial to induce frequent bleeding in all fresh wounds, except those in the abdominal area. This practice helps reduce the severity of pain, inflammation, and other complications. Additionally, it is also advantageous for old ulcers to bleed significantly, as this rids them of the burden of accumulated humors. Once you determine that sufficient bleeding has occurred, you can stop it using the following remedy described by Galen:
℞ Take 2 drams of powdered aloes, and 1.5 drams each of frankincense and mastic. Mix them together with the finely cut hairs of two hares’ eggs. Let a medicine be made.
When the bleeding is stayed, you shall, for the assuaging of pain, drop upon the Meniux some pigeon’s blood, yet warm by opening a vein under the wing, then it shall be strewed over with this following powder:
Prescription:
2 drams of powdered aloes
1.5 drams each of frankincense and mastic.
Combine these ingredients with the finely cut hairs from two hare’s eggs to create a medicine.
Once the bleeding has stopped, to alleviate pain, apply warm pigeon’s blood to the affected area by drawing it from a vein under the wing of the bird. Afterward, sprinkle the following powder over the area:
℞ 2 drams of aloes, frankincense, myrrh, and dragon’s blood. Mix together to make a fine powder
Also you may make an irrigation with roses vinegar, or some repelling medicine; such as is a cataplasm ex farinis, & oleo rosacco. Which may be applied until the fourth day to assuage and mitigate pain.
Vigoes Cerate will be of good use in this case, as that which in my opinion is most fit for fractures of the skull, because it draws powerfully, resolves and dries moderately, and due to the smell, refreshes the animal spirits, and strengthens the brain and membranes thereof, as you may easily perceive by things which enter into the composition thereof.
Prescription:
2 drams aloes
2 drams frankincense
2 drams myrrh
2 drams dragon’s blood
Combine all ingredients and form a fine powder.
Additionally, you could prepare an irrigation using rose vinegar or create a repelling remedy such as a cataplasm made from flours and rose oil. This can be applied to the affected area until the fourth day to help alleviate and reduce pain.
In cases of skull fractures, Vigoes Cerate proves highly beneficial. In my view, it’s particularly suitable because it powerfully extracts, resolves inflamed tissues and moderately dries them. The aroma also revitalizes the animal spirits and fortifies the brain and its membranes, which is evident from the constituents used in its makeup.
℞ Take 2 ounces each of pine resin and gum elemi. 1 and a half ounces of mastic, 2 and a half ounces of fat from a castrated ram. 1 handful each of betony leaves and honeysuckle flowers. Half a dram of ammoniacum, 10 grains of dyer’s grains. Grind these ingredients together, initially without liquid, and then liquify the ammoniacum at the same time with scillitic vinegar; thereafter, let all ingredients boil together in 2 pounds of good wine on a gentle fire until the wine has evaporated. Then, press out the mixture. With the expressed substance, add 4 ounces of turpentine and as much white wax as necessary to make a soft cerate for the aforementioned use.
Also let the neck and all the spine of the back be anointed with a liniment, which has force of mollifying the nerves, lest they should suffer convulsion; such is this:
Prescription:
2oz pine resin
2oz gum elemi
1.5oz mastic
2.5oz fat from a castrated ram.
betony leaves, 1 handful
honeysuckle flowers, 1 handful
0.5 dram ammoniacum
10 grains of dyer’s grains
Grind these ingredients together without the addition of any liquid.
Scillitic vinegar
good wine, 2lbs
4oz turpentine
white wax
Dissolve the ammoniacum using scillitic vinegar.
Combine all the ingredients and allow them to simmer together in the good wine over a gentle flame until the wine has evaporated.
Press the mixture to extract the essence.
To the extracted substance, incorporate the turpentine and sufficient white wax to achieve a soft cerate suitable for the prescribed application.
Additionally, it is advisable to anoint the neck and entire spine with a liniment designed to relax the nerves, thus preventing any risk of convulsions. The formulation for this is as follows:
℞ Take equal parts of rue, horehound, rosemary, elderberry, sage, paralysis herb,
1 drachm each of iris root, sweet flag, and laurel berries.
1 ounce of chamomile flowers,
1 drachm of St. John’s wort.
Grind and macerate all these ingredients in white wine overnight; then boil them in a double boiler with 2 ounces each of worm oil, lily oil, turpentine oil, goose fat, and honey until the wine has evaporated.
Afterward, strain the mixture, and to the strained liquid add 3 ounces of Venetian turpentine and half an ounce of aqua vitae, along with enough wax to create a liniment according to art.
But when the pain is assuaged, we must abstain from all such unctuous things, lest they make the wound become sordid and malign, and putrify the adjacent parts, and, consequently, the Crassa Meninx and skull; for the integrity of all parts may be preserved by their like, and such are dry things in a fracture of the skull. Wherefore all humid and oily things must be shunned in the cure thereof, unless peradventure there is some need to mitigate pain and bring the humor to suppuration.
Prescription:
Take equal parts of:
rue
horehound
rosemary
elderberry
sage
paralysis herb
Add 1 drachm each of:
iris root
sweet flag
laurel berries
along with 1 ounce of chamomile flowers and 1 drachm of St. John’s wort.
Crush and soak all these ingredients in white wine overnight.
The next day, heat them in a double boiler along with 2 ounces each of worm oil, lily oil, turpentine oil, goose fat, and honey.
Continue heating until the wine has fully evaporated.
Following this, strain the mixture.
To the strained liquid, add 3 ounces of Venetian turpentine and half an ounce of aqua vitae.
Incorporate enough wax to form a liniment, prepared according to the traditional method.
However, once the pain has subsided, it is crucial to refrain from applying such oily substances. These can cause the wound to become dirty and malignant, potentially leading to putrefaction of the surrounding tissues and, subsequently, affecting the Crassa Meninx and the skull.
For the preservation of all parts in cases of skull fractures, dry treatments are recommended. It is essential to avoid humid and oily substances in the treatment unless necessary to alleviate pain or promote suppuration.
According to Galen, we are oft forced for a time to omit the proper cure of the disease, so to resist the symptoms. Furthermore, Hippocrates would have us not to foment the skull, no not with wine, but if we do, to let it be but with very little. Vidius interprets that little to be, when there is fear of inflammation; for wine if it is red, tart and astringent, has a repressing, refrigerating and drying faculty: for otherwise all wine although it heats and dries by its faculty, yet it actually humects and cools, both which are very hurtful in wounds of the head, or a fractured skull, especially when the bone is bare; for from too much cooling of the brain there is fear of a convulsion, or some other evil symptom.
Wherefore let this be ratified, that is, we must not use humid and unctuous medicines in wounds of the head, except for curing of an inflammation, or the mitigation of pain caused thereby. Therefore let the bared skull be strewed with catagmatic and cephalic powders, (being so called by the ancients, for that they are convenient and good in fractures of the skull & the rest of the bones) for by their dryness they consume the superfluous humidity, and by that means help nature in the separating of the broken bones, and the regenerating of flesh. Such powders usually consist of such things as these ensuing.
According to Galen, we often find it necessary to temporarily forgo the proper treatment of a disease in order to manage its symptoms. Additionally, Hippocrates advises against applying any compresses to the skull, even with wine; and if one must use it, it should be in very small amounts. Vidius interprets this caution to apply especially when there is a fear of inflammation. While red, tart, and astringent wines possess qualities that can suppress, cool, and dry, most wines, despite their heating and drying effects, can actually moisten and cool the body. This is particularly dangerous for head wounds or fractured skulls, especially when the bone is exposed, since excessive cooling of the brain may lead to convulsions or other serious complications.
Therefore, let it be firmly established that humid and oily applications should be avoided in head wounds, except when addressing inflammation or to relieve pain associated with it. Instead, the exposed skull should be treated with drying and healing powders, known as catagmatic and cephalic powders in ancient texts, which are specifically beneficial for skull fractures and other bone injuries. These powders, by virtue of their drying properties, absorb excess moisture, thus assisting the body in the separation of broken bones and the regeneration of tissue. The composition of such powders typically includes a variety of medicinal ingredients as follows.
Thus, root of Florentine iris, barley flour, and vetch, powder of hepatic aloes, dragon’s blood, mastic, myrrh, root of birthwort, gentian and generally all such simples as have a drying and an abstergent faculty without biting; but you must not use these things before the pain, inflammation and apostumation is past; that is then, when the membranes must be cleansed, the bones scaled, and the flesh generated.
For the skull by how much it is the dryer, by so much it requires and more easily endures more powerful and dryer medicines, than the dura Mater or pericranium, as that which in quickness of sense comes far short of these two. Wherefore when you would apply the aforementioned Cephalic powders to the Meninges, they must be associated and mixed with honey, syrup of roses or of wormwood and such other like, so that their too violently drying faculty may be alayed and tempered.
Thus, ingredients such as the root of Florentine iris, barley flour, vetch, powdered hepatic aloes, dragon’s blood, mastic, myrrh, root of birthwort, and gentian, among other simples, possess drying and cleansing properties that are effective without being harsh. However, it is crucial not to use these substances until the pain, inflammation, and swelling have subsided. At that point, when the membranes need to be cleansed, the bones scraped, and new flesh formed, these ingredients become appropriate for use.
The skull, being drier, can tolerate and sometimes requires more potent and drying remedies compared to the dura mater or the pericranium, which are more sensitive. Therefore, when applying the aforementioned cephalic powders to the meninges, they should be combined with substances like honey, syrup of roses, or syrup of wormwood. Such mixtures help to moderate the potentially overly drying effects of the powders.
There are four causes of this remedy. The first is to raise up the depressed bones, and take forth their fragments, which press upon the meninges, or also upon the substance of the brain. The second is, that the sanies or matter may be evacuated, cleansed, wasted, and dried up, which by the breaking of any vessel is poured forth upon the membranes, whereby they are, and not they only, but the brain also is in great danger of corruption. The third is, for the fitter application of medicines, convenient for the wound and fracture. The fourth is, so that we may have something whereby we may supply the defect of a repelling ligature, and such an one as may hinder defluxions; for such a ligature cannot take place here as it may in the other parts of the body, due to the spherical or round figure of the head, which does not easily admit binding; and then the density and hardness of the interposed skull is a means that the vessels lying under it (by which usually the defluxion comes) cannot easily be bound with a roller sufficiently to repel the running blood. And the external vessels, (to whom the force of the ligature may come) cannot be bound without great pain, and danger of inflammation.
By such a compression the pulsation of the arteries would be intercepted, and the efflux of the fuliginous excrements which uses to pass through the sutures of the skull, would be suppressed, due to the constriction of these sutures.
Besides also, the blood would thus be forced from the wounded part without, to within into the membranes and brain; whence pain, inflammation, a fever, abscess, convulsion, palsy, apoplexy, and lastly death itself would ensue.
And these are the chief causes, that trepaning is necessary in fractures of the skull, and not so in the fractures of other bones.
But before you apply or put to your trepan, the patient must be fitly placed or seated, and a double cloth must be many times wrapped about his head, and then his head must be so laid, or pressed upon a cushion or pillow, that when you come to your operation, it may not sink down any further, but remain firm and steady.
Then you must stop the patients ears with cotton-wool, so that he may not hear the noise made by the trepan, or any other instrument.
But before you put to your trepan the bone must be pierced with an instrument, having a three square point, so that it may be the more speedily and certainly perforate. The point thereof must be no bigger than the pin of the trepan, so that the trepan which is forthwith to be applied may stand the more firmer, and not play to and again in too wide a hole.
The shape of this instrument is not much different from a gimblet, but that the point is three-square, and not twined like a screw; as you may perceive, by this following figure.
There are four principal reasons for this remedy. First, it aims to elevate any depressed bones and remove any fragments that may be pressing on the meninges or the brain itself. Second, it seeks to evacuate, cleanse, and dry up any unhealthy fluid—referred to as sanies—that may seep into the membranes due to the rupture of a vessel, which poses a significant risk of corruption not only to the membranes but also to the brain.
The third reason is to facilitate the appropriate application of treatments suitable for addressing the wound and fracture. Lastly, this procedure provides a means to compensate for the lack of effective ligatures, which would typically prevent fluid from accumulating. Unlike other body parts, the spherical shape of the head makes it difficult to apply binding effectively; the dense and hard skull impedes the binding of the underlying vessels through which fluids might flow, making it challenging to control bleeding with a bandage.
Moreover, if compression were to be applied, it could disrupt the arterial pulse and prevent the passage of harmful excretions that typically move through the sutures of the skull. This constriction could lead to grave consequences, forcing blood from the injured area back into the membranes and the brain, resulting in pain, inflammation, fever, abscess, convulsions, paralysis, apoplexy, and ultimately, death.
These are the primary reasons why trepanation is deemed necessary for skull fractures, unlike fractures of other bones.
Before you perform trepanation, however, it is essential to prepare the patient properly: they should be seated comfortably, and a double cloth should be securely wrapped around their head. Their head must then rest on a cushion or pillow in such a way that it will remain stable and not sink further during the procedure.
You must also block the patient’s ears with cotton wool to shield them from the noise generated by the trepan and any other instruments. Before applying the trepan, the bone should be punctured with an instrument featuring a three-sided point. This allows for a quicker and more precise perforation. The point must be no larger than the pin of the trepan, ensuring that the tool fits snugly and does not wobble in an excessively large hole.
The design of this instrument resembles a gimlet, except that its tip is three-sided rather than twisted like a screw, which can be illustrated by the figure that follows.
[image]
A Gimblet or piercer to perforate the skull, before the setting too of the trepan.
[image]
A gimlet or piercer used to create holes in the skull prior to the application of the trepan.
Trepans are round saws, which cut the bone circularly more or less according to their greatness; they must have a pin standing in the middle a little further out than their teeth, so to stay and hold fast the trepan that it stir neither to this side nor that, until it is entered and you have cut through the first table at the least: then you must take forth the pin, lest going quite through the bone, it may prick or hurt the Crassa Meninx.
Wherefore when you have taken forth the pin, you may safely turn it about until you have cut through both the tables; Your trepans must also have a cap, or something to engirt or encompass them, lest no way hindered they cut more of the bone than we would, and in conclusion run into the meninx.
They must also be anointed with oil, so that they may cut the more readily and gently; for thus carpenters use to grease their saws. But you must, during the time of the operation, often dip them in cold water, lest the bone by attrition become too hot: for all hard solid bodies by quick and often turning about, become hot; but the bone made more hot and dry, is altered and changes its nature, so that after it is cut, more of it scales and falls away.
Trepans are circular saws designed to cut bone in a round shape, varying in size according to their dimensions. They should have a pin positioned centrally, extended slightly beyond the teeth, which serves to stabilize the trepan and prevent any lateral movement until it has penetrated the outer layer of bone. Once you have cut through the first layer, it is important to remove the pin to avoid injuring the tough outer meningeal layer.
After removing the pin, you can safely rotate the trepan until you have cut through both layers of bone. Additionally, the trepans should have a cap or some form of enclosure to prevent them from cutting more bone than intended, which could result in damage to the meninges.
To facilitate smoother cutting, the trepans should be lubricated with oil, much like carpenters do with their saws. However, during the procedure, it is advisable to frequently dip them in cold water to prevent overheating, as rapid and repetitive motion tends to generate heat. Excessive heat can change the properties of the bone, leading to increased scaling and fragmentation after cutting.
Now you must know that the bone, which is touched with the trepan, or the air, always casts off scales, for the speedier helping forwards whereof, you must strew upon it powders made of rocket, briony, wild cucumber and aristolochia roots. When the bone is sufficiently scaled let this following powder be put upon it, which has a faculty to cover the bone with flesh, and to harden it with dryness convenient to its kind.
℞ Pulver, Ireos Illyrica, Aloes, Manna thuris, Myrrha, aristolochia an. ʒj.
Flesh being by these means generated, let it be cicatrized by strewing upon it the rinds of pomegranates and alum burnt.
It is important to understand that when the trepan comes into contact with the bone or the surrounding air, it tends to shed scales. To facilitate this natural process, you should apply powders made from rocket, briony, wild cucumber, and aristolochia roots onto the area.
Once the bone has adequately scaled, you can apply the following powder, which possesses the ability to promote the development of flesh and to firm it through proper desiccation:
**Recipe:** –
Powdered Ilyrian iris
– Aloes
– Manna
– Frankincense
– Myrrh
– Aristolochia
Each ingredient should be used in equal parts (approximately 24 grams each).
After this flesh has formed, you should promote healing by dusting the area with powdered pomegranate peels and burnt alum.
Neither shall the surgeon forcibly take away these scales, but commit that whole work to nature, which uses not to cast them off before that it has generated flesh under them. For otherwise if he do anything rashly, he brings new corruption to the bone; as we shall more at large declare, when we come to treat of the caries or rottenness of bones.
He which uses the trepan, must consider this, that the head is of a round figure, and also the trepan cuts circularly, and therefore it is impossible to cut the bone so equally on every side, as if it were performed upon a plane body. Furthermore the thickness of the skull is not alike in all places; wherefore you must look, and mark whether the trepan goes no more deep on one side than on the other, which you may do by measuring it now and then with a pin or needle; and if you find that it is cut deeper on one side than on the other, you must press down the trepan more powerfully upon the opposite part.
The surgeon should refrain from forcibly removing the scales; instead, he must allow nature to take its course, as she typically does not shed these scales until new flesh has formed beneath them. Acting impulsively in this matter could introduce further complications to the bone, an issue we will elaborate on later when discussing caries or bone rot.
When employing the trepan, the surgeon must keep in mind that the head is round and the trepan operates in a circular manner. As a result, it’s challenging to achieve an even cut throughout the bone, unlike procedures performed on a flat surface. Additionally, the thickness of the skull varies at different points; thus, it is essential to monitor the depth of the trepan’s incision on each side. This can be done periodically by measuring with a pin or needle. If you notice that one side is being cut deeper than the other, you should apply additional pressure to the trepan on the opposite side to ensure an even incision.
But seeing there are many sorts of trepans invented and expressed by many men, yet if you weigh and rightly consider them all, you shall find none more safe, than that I invented, and have here delineated. It cannot pierce one jot further into the skull than he pleases that uses it, and therefore it cannot hurt either the meninges or the brain. An iron head or cover stays it as a bar, that it can penetrate no further than you shall think it requisite.
This head, or cover, is to be drawn up and down, and set higher and lower, as he which uses it shall think good, and so it will stay the trepan that it shall not go a hairs breadth beyond your intended depth. So that hence forwards there is no surgeon, howsoever ignorant in the performance of his art, which by the benefit of such a trepan may not perform this operation without any danger or fear of danger of touching the dura Mater; the hurting whereof, puts the life in jeopardy.
[image]
The figure of our trepan opened and taken in pieces.
A. shows the whole handle or brace of the trepan.
B. The Cover or Cap of the trepan.
C. The ferule.
D. The screw pins which hold and stay the ferule and trepan.
E. The trepan without his pin.
F. The trepan furnished with its pin.
The figure of the same trepan fitted and put together
A. shows the Brace and trepan fitted in every point.
B. The place into which the trepan is put and fitted.
C. C. C. The upper end of the trepan which is to be fitted and put into the brain.
D. The trepan with its cover or cap upon it.
E. The ferule.
F. A screw pin by the twining whereof the trepan is fastened in the Brace.
G. Another screw pin which fastens the ferule closer to the trepan.
H. The Three square point.
While there are numerous types of trepans devised by various individuals, upon careful examination and consideration, you will find none safer than the one I have designed and illustrated here. This trepan allows the operator to control its penetration into the skull precisely, ensuring that it cannot inadvertently harm the meninges or the brain itself.
The trepan features an iron cap that serves as a stop, preventing it from penetrating further than desired. This cap can be adjusted up or down according to the user’s judgment, providing the necessary control to maintain the desired depth of cut. Consequently, no surgeon, regardless of their level of experience, will find it beyond their capability to perform this procedure safely, thanks to the design of this trepan. The risk of damaging the dura mater, which poses a significant threat to life, is considerably reduced with this tool.
[image]
The illustration of our trepan, disassembled and presented in its individual components.
Instead of the other trepan set forth by the author, I have thought fit to give you the figure of that trepan that is here most in use, and the fittest therefore, as it is set forth by Mr. Doctor Crook.
All these particulars of the trepan taken in sunder, you may see united and fitted together in the other figure. But when you cannot bring out the bone which you have cut off with your trepan; then you may take it forth with the Terebellum or Gimblet here expressed, that is, screwing the point thereof into the hole made by the three square pin; the handle of this instrument may also serve instead of a levatory.
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A Terebellum or Gimblet consisting of three branches and A Lentil-like cutting scraper.
Rather than presenting the trepan described by the author, I have chosen to provide you with an illustration of the trepan that is currently most widely used and deemed the most suitable, as outlined by Mr. Doctor Crook.
All the details of the trepan, as they are depicted when separated, can be observed when they are assembled in the other illustration. However, if you find yourself unable to remove the bone that you have cut with your trepan, you may utilize the Terebellum or Gimblet shown here, which operates by screwing the pointed end into the hole created by the three-square pin. Additionally, the handle of this instrument can also function as a lever.
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A Terebellum or Gimblet featuring three prongs, accompanied by a lentil-shaped cutting scraper.
When with the gimblet you have drawn or taken forth that part of the skull which was cut away by the trepan; if there are any sharp splinters in the second table, which may hurt and prick the meninx, when it is heaved up by the motion of the brain, they must be shaved away and planed with this lentil fashioned scraper, being so called, because it has the head thereof fashioned and smooth like a lentil, lest being sharp it should hurt and breadth the membrane in the smoothing thereof.
But if due to the thickness, the skull cannot be cut with this lentil-like scraper, you may use the cutting scrapers and a mallet. The mallet must be of lead, so that it may shake the brain as little as may be. But you must diligently with your mullets take forth the sharp splinters, and pieces of the bone. But if the fractured part of the skull be such, that it will not admit that section which is requisite for the bared bone, as when the fracture is upon the temporal muscle, or at the sutures; then instead of one trepan, two or three must be applied, if the necessity of the present case so require, and that within a very small compass; but they must not be applied to the fractured part, but nigh thereto, as we shall show more at large in the following chapter.
After using the gimblet to remove the portion of the skull that was excised by the trepan, it is essential to check for any sharp splinters remaining in the inner layer of the skull. These splinters could potentially injure the meninges as the brain is elevated by its natural movements. To address this, the lentil-shaped scraper should be employed to carefully shave away and smooth any protruding pieces. This tool is aptly named for its head, which is shaped and polished like a lentil, ensuring that it does not cause damage to the membrane during the smoothing process.
However, if the thickness of the skull prevents effective use of the lentil-shaped scraper, you may resort to using cutting scrapers along with a mallet. It is important to use a lead mallet to minimize any jarring motion to the brain. With your scrapers, diligently remove any sharp splinters or bone fragments.
In cases where the fractured area of the skull cannot accommodate the necessary section for access to the exposed bone—such as fractures affecting the temporal muscle or located at the sutures—multiple trepanning instruments may be needed. Two or three may be applied if the situation demands it, but they should be positioned carefully within a small area, ensuring they are not placed directly on the fractured site. Further details regarding this procedure will be provided in the subsequent chapter.
But the trepans shall be applied so near to each other, that the ring of the second may be joined with the ring of the first and third. But if a fracture shall happen to light upon a suture, then you must not apply a trepan to it, but use two thereto on each side; he that shall do otherwise, shall tear in sunder the nervous and membranous fibers, and also the veins and arteries by which the dura Mater is fastened to the skull, and yields matter to the pericranium. He which shall apply one trepan, that is, but upon one side of the suture, he shall not be able to get forth all the sanies which is fallen down on both sides due to the partition of the Crassa Meninx which lies between, and rises up by the sutures of the skull.
To conclude, when for what cause soever we cannot make use of a trepan, we may employ this instrument, if so be as much of the bone is bared as is needful. It is made in form of a pair of compasses, and by means of a screw may be opened more or less as you please. You as need shall require may change the points, and put other in their places, for they may be fitted to one side of the compass with a screw.
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A pair of cutting compasses to cut forth the skull.
A. shows the one leg of the cutting compasses, which as you carry it about cuts the skull.
B. The screw which fastens the point to the leg of the compasses.
C. Two different points which may be screwed to the leg of the compasses, as need shall require.
A great screw which fastens upon an iron string, along which the one of the legs of the compass running, may be widened and straightened as you please.
Moreover it is fit that the one leg of such cutting compasses should stand firm and steady, whilst the other is drawn circularly to cut. Wherefore it is fit you have an iron plate made full of little holes, wherein you may firmly stay that leg of the compass, lest it waver against your will; it is requisite that this plate be crooked, (because the head is round) so that it may be fitted to any part thereof.
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The trepans should be positioned closely together, ensuring that the ring of the second trepan overlaps with the rings of the first and third. If a fracture occurs along a suture, it is crucial not to place a trepan directly on that suture. Instead, two trepans should be utilized on either side of the suture. Failing to do so may result in the tearing of the delicate nerve and membrane fibers, as well as damaging the veins and arteries that anchor the dura mater to the skull, thus allowing for proper drainage to the pericranium. When only a single trepan is applied on one side of the suture, it will not effectively remove all the sanies that has accumulated on both sides due to the partition of the crassa meninx that lies in between and extends along the sutures of the skull.
In summary, if circumstances prevent the use of a trepan, one may employ an alternative instrument. This tool, shaped similarly to a pair of compasses, features a screw mechanism that allows for precise adjustment in opening width to meet your needs. The points of the instrument can be changed as necessary, as they are designed to be attached to one side of the compass with a screw, making it adaptable for various applications.
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A pair of cutting compasses designed for excising sections of the skull.
A. illustrates one leg of the cutting compasses, which functions to cut through the skull as you maneuver it.
B. This is the screw that secures the point to the leg of the compasses.
C. Here are two interchangeable points that can be attached to the leg of the compasses, depending on your requirements.
D. This is a large screw that clamps onto an iron rod, allowing the leg of the compass to be adjusted wider or straighter as needed.
Furthermore, it is essential for one leg of these cutting compasses to remain stable and secure while the other is moved in a circular motion to achieve the cut. To aid this, an iron plate with numerous small holes should be used to firmly hold the stationary leg of the compasses, preventing any unintended movement. It is advisable for this plate to have a curved shape to accommodate the rounded nature of the skull, ensuring it fits snugly against any desired area.
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First of all, you shall not apply a trepan to a bone that is so broken that it is wholly, or in the greater part thereof divided from the skull by the violence of the stroke, lest by your weight and pressing of the trepan, you force it down upon membrane.
Secondly, you must not apply one to the fractured sutures, for the reasons mentioned in the former chapter.
Thirdly, nor to that part of the forehead which is a little above the eyebrows, for these reasons we gave you before in the twelfth chapter. For there is in that place under the first table of the skull itself, a large cavity replenished with a certain white and tough humor, as also with a certain spirituous and airy substance, placed there by nature, to prepare the air which ascends to the brain by the nostrils: unless the surgeon observe and be mindful hereof, he may be deceived, supposing this cavity to be an effracture of the bone and a depression thereof.
Fourthly, neither in the lowest parts of the skull, lest the marrowy substance of the brain, due to its weight, should slide through the hole made by the trepan.
Fifthly, neither to the bregma bones of children, as those which as yet have not acquired just solidity, to endure the impression of a trepan.
Sixthly, nor to the temples due to the temporal muscle, the cutting whereof in the opinion of Hippocrates causes convulsion of the opposite part. Being cut athwart it loses its proper action, that is, to move and lift up the lower jaw; but then the opposite temporal muscle being whole and perfect, using its strength, (his antagonist suffering it, and not resisting or laboring any thing at all to the contrary) it draws the same jaw to it, whereupon the mouth and all the parts of the face are drawn awry, and suffer a convulsion towards the sound part, the other being resolved according to Hippocrates his rule.
As often as the muscles of one kind are equal in number, magnitude and strength on each side, the resolution of the one part, causes the convulsion of the other.
Neither does this danger alone arise from the cutting of the temporal muscle, but also another, which is, that this muscle when we eat and speak, is in perpetual motion, whereby it comes to pass, that being once cut, it is scarce ever united again, besides also the commissure or joining together of the stony bones lie under it.
But by the second caution we are forbid to trepan upon the sutures; moreover also many veins, arteries and nerves are spread over the substance thereof, so that by cutting of them, there is danger of many and malign symptoms, as pain, inflammation, a fever, a convulsion not only of the part itself, but also of the whole body, whence lastly death ensues.
Wherefore let no surgeon be so fool hardy as to attempt the cutting of this muscle, so to trepan the bone which lies under it; rather let him apply his trepan above it, or on the side thereof, or as near to the affected part as he can, as I did in a Gentleman called Monsieur de la Bretesche.
He in the triumphant entrance of King Henry the Second, into the city of Paris; was so hurt with a stone, that the Os Petrosum or scaly bone, was broken with the violence of the blow, and the temporal muscle was vehemently contused, yet without any wound. I being called the next day (viewing the manner of the hurt, and the condition of the wounded part) thought good to bring some physicians and surgeons with me to consult hereof, of whom when some thought it expedient presently to divide the temporal muscle, that baring the bone we might apply a trepan, and so take forth the broken bones: I on the contrary begun earnestly to withstand that opinion, citing that saying of Hippocrates, ex libro de vulneribus Capitis, wherein surgeons are forbidden to cut such muscles, for fear of the aforementioned symptoms; also I cited experience, how that I had often observed all those which had this muscle cut, died with a convulsion; but that it should be far better, that near above the fracture the bone should be trepaned, not touching the temporal muscle at all if he could. When all of them at the last had inclined to my opinion, I presently divided the musculous skin which was over the upper part of the fracture with a three cornered section: the day following which was the third of his disease I trepaned him, and after I had done, some few days after, I took out some four splinters of the broken bone; and I put in a plain leaden pipe, by which (I wishing the patient ever when I dressed him to hold down his head, to stop his mouth and his nose, and then strive as much as in him lay to put forth his breath) much sanious matter came forth, which was gathered between the skull and Crassa Meniux. Other filth which stuck more fast, I washed out with a detergent decoction, injected with such a syringe as is here expressed; And I did so much, God blessing my endeavors, that at length he recovered.
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A plain leaden pipe to carry forth the sanies gathered under the skull.
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A little syringe fit to make injections withall.
First and foremost, you should refrain from applying a trepan to a bone that is severely fractured, such that it is either completely detached or largely separated from the skull due to the impact. Doing so might cause your weight and pressure on the trepan to force it down onto the membrane beneath.
Secondly, you should not use a trepan on fractured sutures for the reasons outlined in the previous chapter.
Thirdly, avoid applying it to the area of the forehead just above the eyebrows. As explained in the twelfth chapter, there exists a significant cavity beneath the outer layer of the skull in this region. This cavity contains a thick, white substance, along with a spirituous and airy substance created by nature, which helps to prepare the air that ascends to the brain through the nostrils. If the surgeon is not vigilant and aware of this, he may mistakenly think that this cavity is an actual fracture or depression of the bone.
Fourthly, do not apply a trepan to the lower regions of the skull, as the weight of the brain’s marrow-like substance could cause it to slip through any opening made by the trepan.
Fifthly, refrain from trepanning the bregma bones of children, as they have not yet developed the strength required to withstand the pressure of the trepan.
Sixthly, you should avoid trepanning the temples, as this area houses the temporal muscle. According to Hippocrates, cutting this muscle can result in convulsions on the opposite side of the face. If the temporal muscle is severed, it loses its ability to function properly—specifically, to move and elevate the lower jaw. Consequently, if the opposite temporal muscle remains intact and strong, it will pull the jaw toward itself, causing the mouth and facial features to distort and leading to convulsions directed toward the unaffected side, in accordance with Hippocratic teachings.
Whenever the muscles on either side are equal in number, size, and strength, the failure of one side leads to the convulsion of the other. This risk is not solely the result of cutting the temporal muscle; there is an additional concern. The temporal muscle is constantly engaged during eating and speaking, which means that once it is cut, it rarely heals properly. Moreover, the junction of the bones in the skull lies beneath this muscle.
Secondly, we must refrain from trepanning at the sutures. Additionally, numerous veins, arteries, and nerves run through this area, and cutting into them poses significant risks, including severe pain, inflammation, fever, and convulsions not only localized to the affected area but potentially impacting the entire body—consequently leading to death.
Therefore, no surgeon should be so reckless as to attempt cutting this muscle in order to trepan the bone beneath it. Instead, it is advisable to position the trepan above or to the side of the muscle, or as close to the affected area as possible, as I did in my care of a gentleman named Monsieur de la Bretesche.
During the triumphant entry of King Henry II into the city of Paris, a stone struck him with such force that it fractured the os petrosum, or petrous bone, and caused significant bruising to the temporal muscle, albeit without any visible wound. The following day, upon receiving a call to assess the injury and condition of the affected area, I deemed it prudent to consult with several physicians and surgeons. While some of the medical professionals suggested it would be wise to divide the temporal muscle to expose the bone for the application of a trepan, I strongly opposed this viewpoint. I referenced Hippocrates’ text on head wounds, which cautions against incising such muscles due to the risks of severe complications. I further cited my own observations, noting that patients who had their temporal muscle cut often succumbed to convulsions. I argued instead for the approach of trepanning the bone just above the fracture, avoiding any contact with the temporal muscle. Ultimately, my colleagues agreed with my perspective. I proceeded to make a triangular incision in the skin overlying the upper portion of the fracture. On the third day following the injury, I trepaned the patient, subsequently extracting four splinters of the fractured bone. I then inserted a plain leaden tube, instructing the patient to keep his head down, close his mouth and nose, and attempt to exhale as much as possible during dressing changes. This resulted in the expulsion of a considerable amount of purulent matter that had accumulated between the skull and the dura mater. For the more stubborn debris, I used a cleansing solution, which I administered with a syringe as detailed in my notes. Through these efforts, and by the grace of Providence, the patient eventually made a full recovery.
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The like chance and fortune befell Monsieur de Pienne at the siege of Mets. As he fought at the breach of the wall, he had the bone of his temples broken with a stone struck out of the adjacent wall, by a piece of ordinance shot from the Emperor’s camp; he presently fell down with the blow, and cast blood out of his mouth, nose and ears, with much vomiting, and remained dumb & senseless almost 14 days, so that he knew none of the bystanders. He had often palpitations, and convulsive twitchings, and his face was swollen. His forehead bone was trepaned at the side of the temporal muscle by the hand of Peter Aubert, the King’s surgeon: and although on the 25th day, soft flesh, endued with exquisite sense grew out of the hole made with the trepan, whose growth could not be hindered by cathaeretic powders, yet at length he recovered.
The ancients called this kind of growing flesh a Fungus [i. a mushroom] for that it is soft, and grows with a small root and broad top like a mushroom: but it increases and decreases, according to the plenty of the flowing matter, and industry of the surgeon hindering by art the growth thereof.
This flesh stinks exceedingly, they commonly call it Ficus sancti Fiacrii [i. The fig of S. Fiacrye.] This disease commonly has its origin after this manner. Even as in the bodies of trees from the excrements of nourishment, a certain half putrid gross and viscous humor sweats through the bark, and gathered together little by little grows into a mushroom, so blood melancholy both in temper and consistency, springs from the broken vessels of the skull and Crassa Meninx, which also is sent sometimes by nature for the necessary repairing of the flesh in these parts, whereupon a certain fungus breeds, which in Galen’s opinion, savors or partakes of the nature and condition of the parts to which it grows; though in general it is of the nature of malign warts, or excrescences. But for to take away such fungi, you must apply medicines which have a specific faculty to waste superfluous flesh; such are these which strongly dry, and gently waste and eat, such as this which follows.
A similar misfortune befell Monsieur de Pienne during the siege of Metz. While he was engaged at the breach of the wall, a stone, dislodged from the adjacent wall by a cannon shot from the Emperor’s camp, struck him violently on the temple, resulting in a fracture of the bone. He collapsed immediately from the impact, bleeding profusely from his mouth, nose, and ears, and he experienced intense vomiting. For nearly 14 days, he remained unresponsive and senseless, failing to recognize any of those around him. He suffered recurrent palpitations and convulsive twitching, and his face became markedly swollen.
The King’s surgeon, Peter Aubert, trepanned the forehead bone near the temporal muscle. Remarkably, on the 25th day following the injury, soft tissue rich in sensation began to grow from the trepanation site. Despite the application of cauterizing powders to inhibit its growth, this new tissue persisted, and he ultimately made a recovery.
The ancient medical texts referred to this type of regenerative tissue as “fungus,” drawing a comparison to a mushroom due to its soft nature, small root, and broad cap. Its growth varied in accordance with the abundance of fluid present and the surgeon’s efforts to manage it. This tissue is known to have a particularly foul odor, commonly referred to as the “fig of Saint Fiacrius.”
Such conditions typically arise in a manner reminiscent of trees, where a thick, viscous humor oozes from the bark, gradually forming a mushroom. Similarly, the melancholy blood, altered in both temperament and consistency, emanates from broken vessels in the skull and the dura mater, sometimes produced by the body’s own efforts to mend the affected area. Galen posited that this fungus possesses characteristics reflective of the tissues from which it arises, although it generally bears resemblance to malignant warts or excrescences.
To effectively remove such fungi, one must employ remedies specifically designed to reduce excess tissue; these remedies should have the capacity to dry and dissolve this superfluous flesh gently. Here follow some such treatments.
℞ Sabinae ʒij. ocrae ʒj. pulverisentur simul, aspergatur caro excrescens.
or else.
℞ Hermodsctylorum combustorum ℥ss. make a powder for the same use.
But if this fungus flesh come to such growth, (as it often happens) as to equal the size of an egg, it must be tied and straightly twitched close to the root with a silken thread; and when it shall fall away due to this binding, the place must be strewed with the fore-mentioned powders, for so it will be more certainly cured, than with more acrid cathaeretics.
Prescription:
Take 2 drams of Sabina and 2 drams of oak, and grind them together into a powder.
Apply this to the excrescent flesh.
Alternatively: Take 1½ ounces of burnt hermodactylus and prepare a powder for the same purpose.
If this fungoid tissue grows to an extent that it is comparable to the size of an egg— as can frequently occur—it should be tightly bound at the root using a silk thread. Once it detaches due to this binding, the site should be dusted with the previously mentioned powders. This method will likely lead to a more certain healing than using more caustic cauterizing agents.
There sometimes follows a corruption and sphacel of the fractured bones of the skull after a wound to the head; which happens either because they are touched by the air, which they are not sensible of; or for that the sanies putrifying and detained under them, has infected them with like putrefaction; or by the cure unskillfully handled, they by the rash application of suppurating and oily medicines becoming more moist, and so undergoing an unnatural change of their proper complexion and native temper, as we shall show more at large when we shall treat of the reason of the caries in the Lues venera. We shall know this unnatural change and corruption, partly by sight, that is, when from white they become yellowish, livid and black; partly also by putting down a probe; when as it meets with nothing smooth and slippery, but feels rough in many places, and besides also when it enters and easily penetrates with a small thrusting down into their substance, as if it were fungus. Yet this last sign may often deceive you, for I have several times observed rotten bones, which being bare had long suffered the injury of the air, to become so hard that a trepan would scarce pierce them; for it is putrid humidity which makes the bones soft and fungus; but the air by drying them exhausts this humidity and lastly dries it, whence follows such contumacious hardness. This sign will be far more certain, if the flesh which is grown upon the bone is more soft than is fit, loose and have little or no sense or feeling. You may correct and amend this corruption of the bone with cauteries as well actual, as potential, or with the powders of Aloes, Gentian, Aristolochia, centaury, cortex pini, as,
℞ radic. Ireos, Flor. aristolochiae an. ʒj. centaur. ʒij. corticis pi•i ʒss. Misce & fiat pulvis subtilissimus ossi inspergendus.
Following a head injury, it is sometimes observed that the fractured skull bones may experience corruption and necrosis. This can occur for several reasons: they may be exposed to air, which they cannot feel; or the stagnant, putrid fluid beneath them could infect them, leading to similar decay. Additionally, if the treatment is poorly managed, the indiscriminate use of suppurative and oily medications may increase moisture levels, causing an unnatural alteration in their original state and qualities. We will discuss this further in our exploration of caries associated with syphilis.
Such unnatural changes and degradation can be identified through both visual examination and tactile assessment. Visually, the bones may shift from a white hue to shades of yellow, livid, and black. Tactile examination with a probe can also reveal abnormalities; when it encounters roughness instead of a smooth surface, and penetrates easily into the substance of the bone, akin to a fungoid texture. However, this latter observation can sometimes be misleading. I have frequently seen exposed, necrotic bones that have endured prolonged exposure to air become so hard that a trepan would struggle to pierce them. This is because the putrid moisture softens bones into a more fungoid state, but air dehydration can strip away this humidity, resulting in a stubborn hardness.
A more reliable indicator of corruption is the condition of the flesh surrounding the bone; if it is excessively soft, loose, and exhibits little to no sensation, this is a concerning sign.
To address this corruption of the bone effectively, one could employ cauterization—both actual and potential—as well as utilize the following powder mixture:
**Recipe:**
Take 1 dram each of Iris root and Aristolochia flower, 2 drams of Centaury, and ½ ounce of Pine bark. Mix these thoroughly to create a very fine powder that can be applied to the affected bone.
But if it is much corrupted, it must be scraped forth with your scalpra. And you must expect the falling or scaling of the corrupt bone from the sound, and not forcibly procure it; for otherwise the sound bone, which lies under it, being as yet covered with no flesh growing over it, would be corrupted by the appulse, or touch of the air. Yet you shall little by little gently move and shake rotten bones with your probe, so that they may more easily scale and with less trouble to nature. But note by the way, that the scaling of the bone which has environed the trepan, is commonly performed in the space of forty or fifty days. So long also will that caused by the unusual appulse or touch of the air, or application of a cautery, or the aspersion of cephalic powders; besides also in the same number of days broken bones may be united and joined together by a callus, which is to them as a scar, yet sometimes sooner, somewhiles later according to the variety of the ages, tempers and habits of various men.
But if the caries or rottenness can neither by these fore mentioned remedies be overcome and amended, neither the loosed continuity agglutinated nor united, you must give the patient a vulnerary potion, for hence I have found happy success in many. But sometimes not only a certain portion of the bone is taken with a caries, but also the whole is often seized upon with sphacel, and all falls out. In Hippocrates’s opinion, Lib. de vulneribus capitis, the bone of the skull being broken falls from the sound more or less, according to the violence of the blow; which also is confirmed by experience.
If the bone is significantly decayed, it must be carefully scraped away with your scalpel. It is important to allow any unhealthy bone to fall away naturally from the healthy bone underneath, rather than attempting to forcibly remove it; to do otherwise risks exposing the sound bone to the air, which could lead to its corruption due to lack of protective tissue. You should gently manipulate and shake the decayed bones with your probe to facilitate their removal, thus easing the process for the patient.
It is worth noting that the separation of the bone surrounding the trepan typically occurs over a period of about forty to fifty days. This timeframe also applies to decay caused by exposure to air, cautery, or the application of certain powders. Broken bones can likewise begin to unite through the formation of a callus within a similar range of days, functioning as a scar. However, the duration can vary based on the age, constitution, and overall health of the individual.
If the decay or necrosis cannot be resolved with the remedies mentioned, and if the continuity of the bone cannot be restored, it may be necessary to administer a vulnerary potion to the patient, as I have observed positive outcomes using this approach on numerous occasions. Sometimes, rather than just a portion of the bone suffering from decay, the entire bone may be affected, leading to complete necrosis. According to Hippocrates in his work on head wounds, the degree to which a fractured skull bone separates from the healthy area depends largely on the severity of the impact, a notion supported by empirical evidence.
For which purpose I think good in this place to recite a history, whereof I was an eye witness, whilst I served as surgeon in Piemont under the Marshal de Montejan (who was the King’s Lieutenant there). It happened that a Lackey of Monsieur de Goulaines came to me to be cured; he had the bregma bone of the left side broken with a sword, neither yet did the fracture come to the second Table; a few days after his recovery the bone being agglutinated and united, it came to pass that a company of Gascoine soldiers, his countrymen, came to Turin, with whom one morning he ate plentifully tripe fried with onions and spices, & drank a great quantity of strong wine. Whereupon he presently fell into a continual fever, and lost his speech and understanding; his head swelled, his eyes looked red and fiery and as though they would have started out of his head. Which things being considered, I let him blood, having first (by the physician’s advice) given him a glister, and applied to his head such things as were fit, and also I labored with frictions and ligatures of the extreme parts to draw the humors downwards; yet for all this the part of the head which was formerly affected begun to impostumate; which being opened, there came forth a great quantity of matter, and at length the musculous skin and pericranium sinking down, both the Tables of the skull became putrified and rotten, as you might know by their blackness and stench. Now to take away this corruption, I applied at certain times actual cauteries, both to amend the corruption and separate that which was altered: but mark, after some month’s space, a great number of worms came forth by the holes of the rot, ten bones from underneath the putrified skull; which moved me to hasten the separation and falling away of the putrid bones. Which being done, upon the very Crassa Meniux, which is more strange, in that place which nature had covered with flesh, I observed three cavities of the largeness of one’s thumb filled with worms about the size of a points tag, with black heads, diversely wrapped amongst themselves. The bone which nature separated was of the size of the palm of one’s hand, so that it was strange so that large a portion of the skull should be cast off by nature, and yet the patient not die thereof; for he recovered yet beyond all men’s expectations, but after the agglutination of the wound the scar remained very hollow according to the decree of Hippocrates. Flesh does not easily grow upon a callus, because it is a thing strange and supposititious by nature; besides, as a scar is a thing more dense than the skin, so is a callus than the bone, so that through the more compact substance thereof, the blood can neither freely, nor plentifully sweat through for matter to regenerate flesh. Hence it is, that wheresoever any portion of the skull is wanting, you may there by putting too of your hand perceive and feel the beating of the brain, wherefore the skull must needs be much weaker in that place. Now to help this infirmity, I wished this Lackey to wear a cap made of thick leather, so more easily to withstand external injuries, and verily thereby he grew much better.
In light of this, I find it pertinent to share an account of an event I witnessed while serving as a surgeon in Piedmont under Marshal de Montejan, the King’s Lieutenant. A lackey of Monsieur de Goulaines came to me seeking treatment for a fracture of the bregma bone on the left side of his skull. Fortunately, the fracture had not penetrated to the inner table of the skull.
A few days after his injury had healed, a group of Gascon soldiers—his fellow countrymen—arrived in Turin. One morning, he indulged in an abundant meal of tripe fried with onions and spices, accompanied by copious amounts of strong wine. Soon after, he developed a persistent fever, losing both his speech and comprehension. His head began to swell, and his eyes turned red and bulging.
In response to these alarming symptoms, I bled him, having first administered an enema on the physician’s advice, and applied various appropriate treatments to his head. Additionally, I attempted to draw the excess humors downwards through frictions and the use of constrictive bandages. However, the previously injured area of his head began to form an abscess. When this was opened, a significant quantity of pus was released, and eventually, both the skin and the pericranium sank, leaving the two tables of the skull in a state of putrefaction, evidenced by their black color and foul odor.
To combat this corruption, I employed cauterization at intervals, aimed both at remedying the decay and isolating the damaged tissue. After some months, a large number of worms emerged from the openings in the rotting bone, revealing itself beneath the putrid skull. This prompted me to expedite the removal of the necrotic bone material. Remarkably, in the area where nature had redeveloped flesh, I noted three cavities—each roughly the size of a thumb—filled with worms, resembling point tags with black heads, entangled amongst one another.
The portion of bone that had separated was approximately the size of a palm, making it astonishing that such a substantial part of the skull could be discharged naturally without resulting in the patient’s demise. Defying expectations, he ultimately recovered, though the scar that formed was notably depressed, in accordance with Hippocratic doctrine.
It is known that flesh does not readily regenerate over a callus, as it is a foreign and unnatural formation. Furthermore, while a scar is denser than regular skin, a callus is denser than bone, resulting in poor blood circulation which hinders the formation of new flesh. Thus, in areas where skull sections are missing, one can often detect the pulsing of the brain through the skin. Consequently, the integrity of the skull is significantly compromised in those regions.
To assist with this limitation, I recommended that the lackey wear a cap made of thick leather, providing him with better protection against external injuries. Remarkably, this adjustment led to significant improvement in his condition.
Now I think good in this place to lay open the deceit and craft of some impostors falsely styling themselves surgeons, who when they are called to cure wounds of the head, wherein any part of the skull is lost, persuade the patient and his friends, that they must put a plate of gold in the place of the skull which is wanting. Wherefore they hammer it, in the presence of the patient, and turn it several ways and apply it to the part, the better to fit it; but presently after they slyly convey it into their purses, and so leave the patient thus cosened. Others brag that they are able to put the dried rind of a gourd into the place of the lost bone, and fasten it on to defend the part; and thus they grossly abuse those which are ignorant in the art. This is so far from being done that nature will not suffer nor endure so much as a hair, or any other small body to be shut up in a wound when it is cicatrized; neither is the reason alike of a leaden bullet which shot into the body lies there for many years without any harm to the patient; for although lead have a certain familiarity with mans body, yet is it at length (unless the density of the opposed flesh, ligament, tendon, or some other such substance hinder) thrust forth by nature impatient of all strange bodies. And thus much of the rottenness and corruption of fractured bones; now we must speak of the discommodities which befall the meninges by wounds whereby the skull is broken.
At this juncture, it seems appropriate to expose the deceit and cunning of certain charlatans who falsely claim to be surgeons. When summoned to treat head wounds, particularly those involving the loss of skull fragments, they misleadingly convince patients and their families that it is necessary to place a gold plate over the missing part of the skull. These impostors will often hammer the gold in front of the patient, manipulating it from side to side to ensure a better fit, only to discreetly pocket it afterward, leaving the patient deceived and without proper care.
Others boast that they can substitute the lost bone with dried gourd rind, securing it to protect the area. This is an egregious exploitation of the uninformed, as such practices are entirely unfounded. In fact, nature does not permit even a single hair or any small foreign object to remain trapped within a healing wound. The situation is different with a lead bullet embedded in the body, which may lie there for years without causing harm. While lead does have a certain compatibility with human tissue, it inevitably gets expelled by the body, unless obstructed by dense flesh, ligaments, tendons, or similar substances.
Thus, we see the profound rottenness and corruption surrounding the treatment of fractured bones. Now, let us turn our attention to the complications that arise for the meninges when the skull is fractured.
Many discommodities chiefly happen to the Crassa Meninx by a fracture of the skull and rash trepaning thereof; for it sometimes chances to be cut and torn. Agglutination is a remedy for this disease, which Hippocrates wishes to be procured with the juice of Nepeta [that is, of that calamint, which smells like Penny-royal] mixed with barley flour. Instead whereof this following powder having the like faculty may take place:
℞ Colophon. ʒiij. Myrrhae, aloes, mastiches, sanguinis Dracon. an. ʒj. croci, sarcocolle an ʒss. misce & fiat pulvis subtilis.
But to purge the blood and matter which is gathered and lies between the Crassa Meninx and skull, you shall put in a tent made of a rag twined up some four or five double, and steeped in syrup of roses or wormwood and a little aqua vita; for thus you shall press down both the Crassa Meninx, lest lifted up by the accustomed and native pulsation of the brain, it should be hurt by the edges of the skull yet rough due to the sharp splinters of the bone lately trepaned, and give freer passage forth for the matter there contained. But as oft as you shall dress the patient, you shall renew the aforementioned tent, until all the matter is purged forth. And so often also you shall press down with the following instrument the dura mater, and bid the patient to strive to put forth his breath, stopping his mouth and nose, so that the matter may more easily be evacuated. This instrument wherewith you shall hold down the dura mater, must have the end round, polished and smooth as it is here expressed.
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A fit instrument to press and hold down the dura mater, so to make way for the passage forth of the sanies or matter.
Many complications can arise in the Crassa Meninx due to a skull fracture and the hasty use of trepanation, which sometimes results in lacerations or tearing. A suitable remedy for this condition involves agglutination, which Hippocrates recommended be achieved using the juice of Nepeta (commonly known as calamint, which has a scent similar to pennyroyal), mixed with barley flour. Alternatively, the following powder, possessing similar properties, may be employed:
Take three drachms of colophonium, one drachm each of myrrh, aloes, mastic, and dragon’s blood, and one and a half drachms of saffron and sarcocolle. Mix and create a fine powder.
To cleanse the blood and fluid that accumulates between the Crassa Meninx and the skull, you should insert a tent made from a cloth twisted four or five times, soaked in syrup of roses or wormwood, along with a small amount of aqua vitae. This action will help compress the Crassa Meninx, preventing it from being pushed upwards by the natural pulsations of the brain, which could lead to injury from the jagged edges of the skull caused by recent trepanation. It will also facilitate the drainage of any trapped fluid. Each time you dress the patient, be sure to replace the tent until all the fluid has been expelled.
Additionally, you should press down on the dura mater with a specially designed instrument and instruct the patient to exhale forcefully while keeping their mouth and nose closed to assist in the expulsion of the fluid. This instrument should have a rounded, polished, and smooth end as illustrated here.
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A suitable instrument should be used to gently press down on the dura mater, allowing for the proper drainage of any fluid or matter.
And let there be laid upon the dura mater strewed over with the formerly mentioned powder, a sponge moistened and wrung forth of a drying decoction made of aromatic and cephalic things, such as this which follows:
℞, Fol. salviae, majoran. betonica, rosar. rub. absinth. Myrtil. florum chamam. melil. stoechad. utriusque an. M. iij. ss. rad. cyperi, calam. aromat. ireos, caryophyllatn; angelicae, an. ℥ss. bulliant omnia secundum artem cum aqua fabrorum & vino rubro, fiat decoctio ad usum dictum.
And instead hereof you may use claret with a little aqua vita, so that the contained matter may be evacuated and dried up. A sponge is fitter for this purpose to draw than a linen rag or any other thing, both because it is good of itself to draw forth the humidity, as also for that by its softness it yields to the pulsation of the brain. Then apply to the wound and all the adjoining parts, an emplaster of Diacalcitheos dissolved with vinegar, or wine, or oil of roses, so that the plaster may be the more cold and soft. In Hippocrates opinion, nothing which is any thing heavy or hard must be applied to wounds of the head, neither must it be bound with too straight, or hard a ligature, for fear of pain and inflammation.
For Galen tells (as he had it from Mantias) that a certain man lost his eyes by inflammation and impostumation arising, for that an Apothecary had used too straight a ligature to his head and face; for this straight ligature so pressed the sutures, that the fuliginous vapors, which used to pass through them and the pores of the skull, were stopped from passing that way; besides, the beating of the arteries was intercepted and hindered; by which means the pain and inflammation so increased, that his eyes were rent and broke in sunder and fell forth of their orb.
A sponge, dampened and well-wrung out from a decoction made from fragrant and calming herbs, should be applied to the dura mater, covered with the previously mentioned powder. The recipe for the decoction is as follows:
Take the following herbs: three and a half parts of sage leaves, marjoram, betonica, red roses, wormwood, myrtle, chamomile flowers, sweet clover, and two parts each of calamus, aromatic iris, cloves, and angelica root. Boil them all together in artisan’s water and red wine to create a decoction for the intended use.
Alternatively, claret mixed with a little aqua vitae can be used to help evacuate and dry up the accumulated matter. A sponge is more suitable for this purpose than a linen rag or any other material, as it is effective at absorbing moisture and, due to its softness, conforms to the movement of the brain.
Next, apply an emplaster of Diacalcitheos, dissolved in vinegar, wine, or rose oil, to the wound and surrounding areas, ensuring that the plaster is cool and gentle. According to Hippocrates, one should avoid applying anything heavy or hard to head wounds, and be cautious not to use overly tight or rigid ligatures due to the risk of pain and inflammation.
Galen recounts, via Mantias, that a certain man lost his eyesight due to inflammation and pus accumulation caused by an apothecary’s decision to use a ligature that was too tight around his head and face. This excessive pressure on the sutures blocked the passage of the vapors typically released through them and the pores of the skull; additionally, it impeded the flow of blood through the arteries. Consequently, the pain and inflammation intensified, leading to the man’s eyes being ruptured and falling from their sockets.
Wherefore Hippocrates rightly commends an indifferent ligature, also he fitly wishes us to let the emplaisters be soft which are applied to the head, as also the clothes wherewith it is bound up, to be of soft and thin linen, or of cotton, or wool. When the patient is in dressing, if there come much matter out of the wound, you shall wish him if he can, to lie upon the wound, and now and then by fits to strive to breathe, stopping his mouth and nose, so that the brain lifted and swollen upwards, the matter may be the more readily cast forth; otherwise suffer him to lie so in his bed, as he shall best like of, and shall be least troublesome to him.
You may with good success put upon the Crassa Meninx oil of turpentine with a small quantity of aqua vitae and a little aloes and saffron finely powdered, to cleanse or draw forth the sanies, or matter. Or else,
℞. Mellis rosar. ℥ij. sarinae hord. pulver. aloes, Mastich. & Ireos Florent. an. ʒss. aqua vitae parum; let them be incorporated together and make a detersive medicine for the foresaid use.
Sometimes also the Crassa Meninx is inflamed after trepaning, and swollen by a phlegmon, that impatient of its place, it rises out of the hole made by the trepan, and lifts itself much higher than the skull, whence grievous symptoms follow. Wherefore to prevent death, of which then we ought to be afraid, we must enlarge the former hole with our cutting mullets, that the matter contained under the skull, due to whose quantity the membrane swells, may the more freely breathe and pass forth; and then we must go about by the prescript of the physician to let him bleed again, to purge and diet him. The inflammation is resisted by the application of contrary remedies, as this following fomentation.
Hippocrates wisely advocates for the use of a gentle ligature and recommends that the dressings applied to the head be soft. The binding materials should be made of fine linen, cotton, or wool. While dressing the wound, if excessive discharge occurs, the patient should be encouraged, if possible, to lie directly on the wound and to take occasional deep breaths while obstructing their mouth and nose. This position allows for the brain to swell upwards, facilitating the expulsion of any fluid. If this is uncomfortable, the patient should be allowed to lie in whatever position they find most comfortable and least bothersome.
For effective treatment of the crassa meninx, oil of turpentine may be combined with a small amount of aqua vitae, aloes, and finely powdered saffron to cleanse and draw out any discharge. Alternatively, a mixture can be prepared using two ounces of rose honey, half an ounce of powdered barley, aloes, mastic, and iris, with a small amount of aqua vitae; this should be thoroughly mixed to create a cleansing remedy for the same purpose.
In certain cases, the crassa meninx may become inflamed after a trepanation, swelling due to a phlegmon and protruding through the opening made by the trephine, leading to severe symptoms. To avert the threat of death, which becomes a concern under these circumstances, the original opening should be enlarged with appropriate cutting instruments, allowing accumulated material under the skull to escape more easily. Following this, the physician’s guidance should be followed regarding bloodletting, purging, and dietary considerations. The inflammation can be addressed using counteractive treatments such as a suitable fomentation.
℞ Sem. lini, althae, soen. psillij, ros. rub. an. ℥j. solani, plantag. an. M. j. bulliant in aqua tepida communi, ex qua fiat fotus.
Anodyne and repelling medicines shall be dropped into his ears; when it is exceedingly swollen, that the tumor may subside, you shall cast upon it the meal or flour of lentils, or vine leaves beaten with goose grease. With all which remedies if the tumor does not vanish, and withall you conjecture that there is pus or matter contained therein, then you must open the dura mater with your incision knife, holding the point upwards and outwards, for so the matter will be poured forth and the substance of the brain not hurt nor touched. Many other surgeons, and I myself have done this in many patients with various success.
It is better in desperate causes to try a doubtful remedy than none at all; also it oft times happens whither by the violence of the contusion and blow, or concretion or clotting of the blood which is shed, or the appulse of the cold air, or the rash application of medicines agreeing neither in temper nor complexion with the Crassa Meninx, or also by the putrefaction of the proper substance, that the dura mater itself becomes black. Of which symptom the surgeon must have a great and special care.
Therefore that thou may take away the blackness caused by the vehemence of the contusion, you shall put upon it oil of eggs with a little Aqua Vitae, and a small quantity of saffron and orris roots in fine powder; you shall also make a fomentation of discussing and aromatic things boiled in water and wine; and Vigoes Cerat formerly described shall be applied. But if the harm come from congealed blood, you shall withstand it with this following remedy.
There are indeed many individuals who stubbornly refuse to accept the possibility of an abscess occurring in the brain. Furthermore, they bolster this misconception with the unfounded belief that those who have had a portion of their brain removed cannot recover. However, both the authority of ancient scholars and practical experience effectively disprove the fallacies upon which they base their arguments.
To address the first point, Hippocrates asserts that individuals suffering severe headaches accompanied by pus, fluid, or blood discharging from the nose, mouth, or ears experience alleviation of their condition. Similarly, Galen, Rhasis, and Avicenna maintain that any morbid fluid generated in the brain can be expelled through the nose, mouth, or ears, and I have personally witnessed numerous cases in support of this observation.
For example, I was informed by Prethais Coulen, the surgeon for Monsieur de Langey, about a young man in the town of Mans who frequently rang a large bell. One day, while playfully hanging from the rope, he was hoisted up and subsequently fell headfirst onto the pavement. He lay silent, devoid of senses and understanding, and was also severely constipated. Shortly thereafter, he developed a fever and delirium alongside other distressing symptoms, but a trepanation was not performed as there were no visible signs of a skull fracture. On the seventh day, he experienced a profuse sweating episode accompanied by frequent sneezing, which forcibly expelled a significant quantity of matter and pus from his ears, mouth, and nose. Following this, he found relief from all his symptoms and eventually regained his health.
Regarding the second point, Galen recounts witnessing a young boy in Smyrna, Ionia, who recovered from a substantial brain injury, though it was one that did not breach any of the ventricles. Additionally, Guido of Caulias notes that he observed a patient who survived and ultimately recovered after suffering a severe wound that caused a large portion of his brain to be dislodged from the back of his head.
℞ Aquae Vitae ℥ij. granor. tinctorum in tenuempulverem tritorum ʒiiss. croci, ℈1. Mellis rosat. ʒjss. sarcocol. ʒiij. Leviter & simul bulliant omnia, & de colatura infundatur, quousque nigrities fuerit obliterata.
If this affect come by the touch of the air, it shall be helped with this following remedy.
℞ Tereb. ven. ℥iij. Mellis ros. ℥ij. Vitellum ovi unum, sarin. hordei ʒiij. creci. ℈j. sarcocol. ʒij. aq. vitae ʒij. Incorporentur simul, & bulliant paululum.
This remedy shall be used until the blackness be taken away, and the membrane recover its pristine color.
But if this affect proceeds from the rash use of medicines, it must be helped by application of things contrary. For thus the offense caused by the too long use of moist and oily medicines, maybe amended by using catagmatic & cephalic powders; but the heat and biting of acrid medicines, shall be mitigated by the contrary use of gentle things; for both humid and acrid things somewhat long used make the part look black; that truly by generating and heaping up filth, but this by the burning and hardening heat. But when such blackness proceeds from putrefaction, John de Vigo commends the following remedy.
℞ aquae vitae ℥ij mellis rosat. ℥ss.
But if the affect be grown so contumacious that it will not yield to this gentle remedy, then this following will be convenient.
℞ Aq. vitae ℥iij. mellis ros. ℥j pulver. Mercur. ʒij. vnica ebullitione bulliant simul ad usum dictum.
**Prescription:** Take two ounces of Aqua Vitae and grind one and a half drachms of tincture grains into a fine powder. Add one drachm of saffron and one and a half ounces of rose honey, along with three drachms of myrrh. Lightly combine and bring to a gentle boil, then strain and infuse until the blackness dissipates. If this condition arises from exposure to the air, it can be treated with the following remedy: Take three ounces of Venice turpentine, two ounces of rose honey, one egg yolk, three drachms of barley meal, one scruple of salt, and two drachms of Aqua Vitae. Blend these ingredients together and simmer gently. Use this remedy until the discolouration fades and the membrane returns to its normal hue. However, if the condition results from the careless administration of medicines, it is essential to counteract it with opposing treatments. For example, the issues caused by the excessive use of moist and oily medicines can be remedied with drying and stimulating powders; conversely, the irritation caused by harsh and acrid medicines can be alleviated with milder substances. Both humid and acrid treatments, if used for an extended period, may cause the affected area to appear dark, either through the accumulation of filth or by burning and hardening the tissue. If the blackness stems from putrefaction, John de Vigo recommends this remedy: Take two ounces of Aqua Vitae and one ounce of rose honey. However, if the condition becomes so stubborn that it does not respond to this gentle remedy, consider using the following: Take three ounces of Aqua Vitae, one ounce of rose honey, and two drachms of powdered mercury. Bring to a boil, combining all ingredients for the prescribed use.
Or
℞ aquae vit. ℥iss. syrup. absinth & mellis ro (at. an. ʒij. unguenti aegyptiaci ʒijss. sarcocol. myrrha, aloes, an. ʒj. vini albi boni & odoriferi, ℥j. bulliant leviter omnia simul, colentur ad usum dictum.
But if the force of the putrefaction be so stubborn that it will not yield to these remedies, it will be helped with Aegyptiacum (made with plantain water instead of vinegar) used alone by its self, or with the powder of mercury alone by itself, or mixed with the powder of alum. Neither must we be afraid to use such remedies especially in this extreme disease of the dura mater; for in Galen’s opinion the Crassa Meninx after the skull is trepaned delights in medicines that are acrid, that is, strong and very drying, especially if it have no phlegmon; and this for two reasons; the first is, for that hard and dry bodies, such as membranous bodies are, are not easily affected unless by strong medicines; the other is, which must be the chief and prime care of the physician, to preserve and restore the native temper of the part by things of like temper to it. But if the auditory passage not only reaching to the hard membranes of the brain, but also touching the nerve which descends into it from the brain, suffer most vehement medicines, though it is placed so near; certainly the Crassa Meninx will endure them far more easily and without harm.
But if by these means the putrefaction is not restrained, and the tumor is increased so much that the dura mater rising far above the skull, remains unmoveable, black and dry, and the patient’s eyes look fiery, stand forth of his head and roll up and down with unquietness and a frenzy, and these so many ill accidents be not fugitive, but constant; then know that death is at hand, both due to the corruption of the gangrene of a noble part, as also by extinction of the native heat.
**Prescription:** Take one and a half ounces of Aqua Vitae, two drachms each of absinthe syrup and rose honey, two and a half drachms of Egyptian ointment, one drachm each of myrrh and aloes, and one ounce of good quality white wine with a pleasant aroma. Lightly bring all these ingredients to a gentle boil and strain for use as prescribed.
If the stubbornness of the putrefaction does not yield to these remedies, consider using the Egyptian remedy (prepared with plantain water instead of vinegar) on its own, or employ mercury powder either alone or mixed with alum powder. One should not hesitate to use these treatments, especially in severe cases affecting the dura mater; according to Galen, after trepanning the skull, the thick membrane (Crassa Meninx) benefits from potent, acrid, and highly drying medicines, provided no significant inflammation is present. This is for two reasons: first, hard and dry substances, such as membranes, are less affected unless met with strong treatments; second, it is the physician’s foremost duty to maintain and restore the natural condition of the affected area with similarly tempered substances.
Although the auditory canal leads directly to the hard membranes of the brain and touches the descending nerve, it can tolerate powerful medicines; thus, the Crassa Meninx will likely withstand such treatments even more effectively and without injury.
However, if these interventions do not contain the putrefaction, and if the swelling increases to the point where the dura mater bulges significantly above the skull, remaining immovable, black, and dry, while the patient’s eyes appear fiery, standing out and rolling restlessly, and if these distressing symptoms are persistent rather than transient, it is a sign that death is imminent. This is due both to the corruption caused by the gangrene of a vital area and the failure of the body’s innate heat.
We have formerly declared the causes, signs and symptoms of the concussion, or shaking of the brain, without any wound of the musculous skin, or fracture of the bone; wherefore for the present I will treat of the cure.
Therefore in this case, for that there is fear that some vessel is broken under the skull, it is fit presently to open the cephalic vein. And let blood be plentifully taken according to the strength of the patient, as also respectively to the disease both which is present, and like to ensue, taking the advice of a physician.
Then when you have shaven away the hair, you shall apply to the whole head and often renew the aforementioned cataplasm, Ex farinis, oleo rosacco, oxymelite, and other like cold and moist repelling medicines. But you must eschew dry, and too astringent medicines must be shunned, such as are unguentum de bolo and the like; for they obstruct too vehemently, and hinder the passage forth of the vapors both by the sutures and the hidden pores of the skull. Wherefore they do not only not hinder the inflammation, but fetch it when it is absent, or increase it, when present. The belly shall be loosed with a glister, and the acrid vapors drawn from the head; for which purpose also it will be good, to make frictions from above downwards, to make straight ligatures on the extreme parts, to fasten large cupping-glasses with much flame to the shoulders and the origin of the spinal marrow, so that the revulsion of the blood running violently upwards to the brain, and ready to cause a phlegmon, may be the greater. The following day it will be convenient to open the Vena Puppis, which is seated upon the Lambdoid suture, due to the community it has with the veins of the brain, and shutting the mouth and nose to strive powerfully to breathe. For thus the membranes swell up, and the blood gathered between them and the skull is thrust forth; but not that which is shut up in the brain and membranes, of which if there is any great quantity, the case is almost desperate, unless nature assisted with stronger force, cast it forth turned into pus. But also after a few days the vena frontis or forehead vein may be opened, as also the temporal arteries and veins under the tongue, that the conjunct matter may be drawn forth by so many open passages.
In the mean space, the patient must keep a spare diet, and abstain from wine, especially until the fourteenth day, for that until that time the fearful symptoms commonly reign. But repelling medicines must be used until the fourteenth day is past, then we must come to discussing medicines, beginning with the more mild, such as is this following decoction.
℞. rad. Alth. ℥vj. ireos, cyperi, calami arom. an. ℥ij. fol. salviae, Majoran, betonic. flor. chamaem. melil. ros. rub. stoechad. an. M. ss. salis com. ℥iij bulliant omnia simul secundumartem cum vino rub. & aqua fabrorum, fiat decictio.
Previously, we discussed the causes, signs, and symptoms of a concussion—an impact to the brain without any external wound to the skin or fracture of the skull. Now, let us turn our attention to treatment.
In such cases, there is concern that a vessel may have ruptured beneath the skull. Therefore, it is advisable to promptly open the cephalic vein, allowing for a generous amount of blood to be drawn, tailored to the patient’s strength and the severity of the condition, based on the physician’s judgment.
Once the hair has been shaved, you should apply a cold and moist poultice to the entire head, frequently refreshing the application. This poultice can be made from flour, rose oil, oxymel, and other similar cooling and soothing substances. It is important to avoid dry and overly astringent remedies, such as those containing bole, as they can obstruct the flow of vapors through the sutures and natural openings of the skull, potentially aggravating inflammation rather than alleviating it.
To relieve pressure on the abdomen, a gentle laxative can be administered, helping to draw acrid vapors away from the head. It is also beneficial to perform downward frictions and apply firm ligatures to the extremities, along with the use of large cupping glasses heated with flame on the shoulders and at the base of the spine. This technique encourages a diversion of blood flow away from the brain, which may help to prevent or reduce the risk of phlegmon.
The following day, it would be appropriate to open the vena puppis located along the lambdoid suture, as it connects with the veins of the brain. This should be done while occluding the mouth and nose to promote forceful breathing. Such actions will encourage swelling of the membranes and assist in expelling any blood that may have collected between the membranes and the skull. However, any blood trapped within the brain itself is a more serious concern—if significant, it presents a dire situation unless nature, with a strong force, can expel it as pus.
After a few days, it may also be wise to open the frontal vein and the temporal arteries and veins beneath the tongue to facilitate the drainage of any problematic matter through multiple openings.
Meanwhile, the patient should adhere to a light diet and avoid wine, particularly until the fourteenth day, as distressing symptoms often persist until that point. During this period, continue to use cooling medicines until the fourteenth day has passed, after which treatment can shift to more moderate medications, starting with the following decoction:
**Prescription:** Take six ounces of marshmallow root, two ounces each of iris, cyperus, and aromatic calamus, and one and a half ounces each of sage leaves, marjoram, betony flowers, wild chamomile, sweet clover, red rose petals, and stoechas. Add three drams of common salt. Boil all ingredients together with red wine and water from a local stream to create a decoction.
Let the head be washed therewith twice a day with a sponge. But yet when you do this, see that the head is not too much heated by such a fomentation, or any such thing, for fear of pain and inflammation.
Then you shall apply the cerate of Vigo which has power to discuss indifferently, to dry, and draw forth the humors which are under the skull, and by its aromatic force and power to confirm and strengthen the brain; it is thus described.
℞. Furfuris bene triturati ℥iij. farin. lentium ℥ij. ros. myrtillor. foliorum & granorumejus, an. ℥j. calam. aromat. ℥iss. chamaemel. melil. an. M. ss. nuces cupressi num. vj. olei rosacei, & chamaem. an. ℥iij. ceraealbae ℥iiss, thuris, mastichis, an. ʒiij. myrrhae ʒij. Inpulverem quae redigi debent redactis, & liquefactis oleis cum cera, omnis misceantur simul, & fiat mixtura, quae erit inter formam emplastri & ceroti.
Vigo says, that one of the Duke of Urbins Gentlemen found the virtue hereof to his great good. He fell from his horse with his head downwards upon hard marble, he lay as if he had been dead, the blood gushed out of his nose, mouth and ears, and all his face was swollen and of a livid color; he remained dumb twenty days, taking no meat but dissolved jellies, and chicken, and capon broths with sugar; yet he recovered, but lost his memory, and faltered in his speech all his life after. To which purpose is that aphorism of Hippocrates; Those which have their brain shaken by what cause soever, must of necessity become dumb; yea also, as Galen observes in his commentary, lose both their sense and motion. That Cerat is not of small efficacy, but of marvelous and admirable force, which could hinder the generating of an abscess, which was incident to the brain due to the fall.
Wash the head with this mixture twice daily using a sponge. However, be cautious not to overheat the head with this application or similar methods, as this could lead to pain and inflammation.
Next, you should apply the Cerate of Vigo, which is effective in dispersing and drying out the humors that may be present beneath the skull. Its aromatic properties also help to fortify and strengthen the brain. The formulation is as follows:
Take 3 ounces of well-ground bran, 2 ounces of lentil flour, 1 ounce each of rose, myrtle leaves and berries, 1.5 ounces of aromatic calamus, and 1.5 ounces of chamomile and melilot. Add 6 cypress nuts, 3 ounces of rose oil and chamomile, and 1.5 ounces of white wax, along with 3 drams of incense and mastic, and 2 drams of myrrh. Blend the powdered ingredients with the melted oils and wax to create a mixture that resembles a cross between a plaster and a pomade.
Vigo recounts a case involving one of the Duke of Urbino’s attendants who experienced the remarkable benefits of this cerate. After falling from his horse onto hard marble, he lay as if lifeless; blood flowed from his nose, mouth, and ears, and his face became swollen and discolored. He was mute for twenty days, subsisting solely on dissolved jellies and broths made from chicken and capon with sugar. Ultimately, he did recover, but he suffered from memory loss and speech difficulties for the remainder of his life. This situation brings to mind Hippocrates’ adage that those with shaken brains, regardless of the cause, are bound to become mute. Galen, too, notes that they may lose both sensation and motion.
The effectiveness of this cerate should not be underestimated, as it possesses remarkable qualities that can prevent the formation of abscesses in the brain that may arise from such trauma.
Yet there are many men so far from yielding to reason, that they stiffly deny, that any impostumation can be in the brain, and augmenting this error with another, they deny that any who have a portion of the brain cut off can recover, or rise again; but the authority of ancient writers and experience do abundantly refell the vanity of the reasons whereon they rely. Now for the first in the opinion of Hippocrates; If those which have great pain in their heads have either pus, water or blood flowing from their nose, mouth or ears, it helps their disease.
But Galen, Rhasis and Avicenne affirm that sanies generated in the brain disburdens itself by the nose, mouth or ears; and I myself have observed many who had the like happen to them.
I was told by Prethais Coulen, surgeon to Monsieur de Langey, that he saw a certain young man in the town of Mans, who often used to ring a great bell; he once hanging in sport upon the rope, was snatched up therewith and fell with his head full upon the pavement: he lay mute, was deprived of his senses and understanding, and was besides hard bound in his belly. Wherefore presently a fever and delirium with other horrid symptoms assailed him, for he was not trepaned because there appeared no sign of fracture in the skull: on the seventh day he fell into a great sweat with often sneezing, by the violence whereof a great quantity of matter and pus flowed forth of his ears, mouth and nose, then he was eased of all his symptoms, and recovered his health.
Now for the second, Galen affirms that he saw a boy in Smirna of Ionia that recovered of a great wound of the brain, but yet such an one as did not penetrate to any of the ventricles.
But Guido of Caulias says, he saw one which lived and recovered after a great portion of the brain fell out due to a wound received on the hind part of his head.
Nevertheless, there are many individuals so stubborn in their beliefs that they categorically refuse to accept that abscesses can form in the brain. They compound this error with another, asserting that anyone who has had a portion of their brain removed cannot recover or regain consciousness. However, the authority of ancient scholars and practical experience thoroughly debunk the fallacies upon which they base their arguments. To address the first point, Hippocrates posited that when individuals experience severe headaches accompanied by pus, fluid, or blood draining from their nose, mouth, or ears, it indicates a beneficial resolution of their condition. Moreover, Galen, Rhazes, and Avicenna claim that pus generated in the brain can discharge through the nose, mouth, or ears, a phenomenon I have personally witnessed in several cases. I was informed by Prethais Coulen, the surgeon to Monsieur de Langey, about a particular young man in the town of Mans who frequently rang a large bell. On one occasion, while playfully hanging from the rope, he was suddenly lifted and fell headfirst onto the pavement. He was left mute and devoid of senses, and suffered from severe abdominal tightness. Soon after, he developed a fever, delirium, and other alarming symptoms. He was not trepanned, as there were no visible signs of a skull fracture. On the seventh day, he broke into a profuse sweat and experienced frequent sneezing, which resulted in a significant discharge of pus and matter from his ears, mouth, and nose. Subsequently, he found relief from his symptoms and recovered his health. Regarding the second assertion, Galen recounted witnessing a boy in Smyrna, Ionia, who recovered from a severe brain injury, though it did not penetrate any of the ventricles. In addition, Guido of Caulias noted a case in which a person survived and recovered after a significant portion of their brain had been expelled due to a wound to the back of the head.
In the year of our Lord 1538, while I was surgeon to the Marshall of Montejan at Turin, I had one of his Pages in cure, who playing at quoits received a wound with a stone upon the right bregma with a fracture, and so great a fracture of the bone, that the quantity of half a hazel nut of the brain came forth thereat. Which I observing, presently pronounced the wound to be deadly; a physician which was present contradicted my opinion, affirming that substance was no portion of the brain, but a certain fatty body. But I with reason and experience in presence of a great company of gentlemen, convinced the pertinacy of the man; with reason; for that fat cannot be generated under the skull, for although the parts there contained are cold, yet because they are heated by the abundance of the most hot and subtle animal spirits, and the heat of vapors rising thither from all the body, they do not suffer fat to concrete about them. But with experience, for that in the dissecting of dead bodies, there was never any fat observed there; besides also fat will swim on the top of water; but this substance as marrowy, cast into the water presently sunk to the bottom.
Lastly, fat put to the fire becomes liquid and melts; but this substance being laid upon a hot iron, became dry, shrank up and contracted itself like a piece of leather; but dissolved not at all. Wherefore all those which were present cried out, that my judgment was right of that substance that came forth of the skull. Yet though it was cut away, Page recovered perfectly, but that he continued deaf all his life after.
In the year of our Lord 1538, while I served as the surgeon to the Marshall of Montejan in Turin, one of his pages sustained an injury while playing quoits. He was struck on the right side of his head with a stone, resulting in a fracture so severe that a portion of the brain, roughly the size of a half hazelnut, was expelled through the wound. Upon observing this, I immediately declared the injury to be fatal. However, a physician present at the scene opposed my assessment, insisting that the substance involved was not brain tissue, but rather a fatty substance. In the presence of numerous gentlemen, I was able to reason with and ultimately convince this obstinate physician. I argued that fat cannot form beneath the skull; although the interior is cold, it is warmed by the abundant and highly refined animal spirits, along with vapors that rise from the body. These conditions prevent fat from solidifying in that region. Moreover, my experience in dissecting cadavers had shown me that fat is never found in the cranial cavity, and fat itself floats atop water, while the substance I had encountered, resembling marrow, sank immediately when placed in water. To further support my case, I noted that fat melts and becomes liquid when heated, whereas the substance in question, when placed on a hot iron, dried up, contracted, and shrank in a manner akin to leather, without dissolving at all. Consequently, the gathered company acknowledged that my judgment regarding the nature of the substance expelled from the skull was correct. Remarkably, despite the trepidation surrounding the injury, the page made a complete recovery, though he remained deaf for the rest of his life.
Having treated of the wounds of the head by their causes, signs and cure, it follows that we now speak of the wounds of the face, if but for this, that when they are carelessly handled, they leave deformed scars in the most specious and beautiful part of the body. The causes are the same which are incident to the skull, that is, external. But this may be added to the kinds and differences of the wounds, that the life may be out of danger though any one whole part of the face, (as the ear, eye, nose, lip) may be cut away by a wound, but not so in the head or skull. Wherefore beginning at the wounds of the eye brows, we will prosecute in order the wounds of the other parts of the face.
This is chiefly to be observed in wounds of the eyebrows, that they are oft times cut so overthwart, that the muscles, and fleshy pannicle which move and lift them up, are wholly rent and torn. In which case the eyelids cannot be opened, and the eyes remain covered, and shut up in the cases of their lids; so that even after the agglutination of the wound, if the patient would look upon any thing, he is forced to hold up the eyelids with his hand; with which infirmity I have seen many troubled, yet oft times not so much by the violence of the wound, as by the unskilfulness of the surgeon who cured them; that is, by the negligent application of bolsters, an unfit ligature and more unfit suture. In this case the skillful surgeon which is called to the patient shall cut off as much of the skin and fleshy pannicle as shall serve the eyelids, so that they may by their own strength hold and keep open, without the help of the hand: then he shall sew the wound as is fit, with such a stitch as the furriers, and glovers use; and then he shall pour thereon some of the balsam of my description, and shall lay such a medicine to the neighboring parts.
℞. Olei rosar. ℥ss. album. ovor. nu. ij. boli armni, sanguinis Dracon. Mastich. an ʒj. agitentur simul, fiat medicamentum.
Then let the part be bound with a fitting ligature. Afterwards you shall use Emplaster degratia Dei, Emplaster de Betonica, Diacalcitheos, or some other like, until the wound is cicatrized. But such and all other wounds of the face may be easily healed, unless they are associated with some malign symptoms, or the patient’s body is replete with ill humors.
There sometimes happens a quite contrary accident in wounds of the eyebrows, that is, when the eyelids stand so up that the patient is forced to sleep with his eyes open, wherefore those which are so affected are called by the Greeks Lagophthalmi. The cause of this affect is often internal, as a carbuncle or other kind of abscess, as a blow or stroke. It shall be cured by a crooked or semicircular incision made above the eyelids, but so that the extremes of the semicircle bend downwards, that they may be pressed down and joined as much as is needful to amend the stiffness of the eyelid. But you must not violate the gristle with your instrument, for so they could no more be lifted up; the residue of the cure must be performed as is fit.
Having addressed the wounds of the head, including their causes, signs, and treatments, we now turn our attention to facial wounds. This shift is warranted, particularly because when such injuries are not handled with the utmost care, they can result in unsightly scars on the most attractive and prominent parts of the body. The causes of these wounds are similar to those affecting the skull, as they are primarily external in nature. However, it is noteworthy that while an injury may necessitate the removal of an entire section of the face—such as an ear, eye, nose, or lip—and yet the individual’s life may remain unthreatened, the same cannot be said for wounds to the head or skull.
Therefore, we shall begin with wounds of the eyebrows and proceed in an orderly fashion to discuss injuries to other areas of the face.
Particular attention must be paid to eyebrow wounds, which are frequently inflicted in such a way that the muscles and tissue responsible for their movement are severely damaged. In these cases, the eyelids may become immobile, leaving the eyes unable to open, effectively trapping them beneath their lids. Even after the wound has healed, the patient often must use their hands to lift their eyelids when attempting to see; I have witnessed numerous patients endure this affliction, often not due to the severity of the injury itself but rather due to the ineptitude of the surgeon who treated them—resulting from careless application of dressings, poor ligatures, and unsuitable sutures.
In cases of this nature, a competent surgeon should remove sufficient skin and underlying tissue to facilitate the eyelids’ ability to remain open independently, without assistance from the hands. Subsequently, the wound should be sutured appropriately, using techniques comparable to those employed by furriers and glovers. Following this, the surgeon should apply a specially formulated balsam, as described previously, and dress the surrounding area.
**Prescription:** Take 1.5 ounces of rose oil, two egg whites, a quantity of dragon’s blood, and one drachm of mastic. Mix these ingredients thoroughly to create a medicinal preparation.
The affected area should then be secured with an appropriate bandage. Following this, dressings such as “Emplaster of the Grace of God,” “Emplaster of Betonica,” or “Diacalcitheos,” or similar preparations, should be used until the wound is completely healed. Generally, facial wounds can be effectively treated, unless they are accompanied by severe symptoms or the patient has an excess of harmful humors in their body.
There are instances whereby eyebrow wounds can lead to an entirely opposite condition, wherein the eyelids are raised to such an extent that the patient struggles to close their eyes, forcing them to sleep with their eyes open. Those afflicted by this condition are referred to as Lagophthalmi in Greek. The underlying cause of such an issue is often internal, potentially arising from a carbuncle or other types of abscesses, usually due to impact or trauma. Treatment typically involves a curved or semi-circular incision made above the eyelids, ensuring that the ends of the semicircle curve downward. This design allows for the eyelids to be pushed down and restored as necessary to alleviate the stiffness. It is crucial to avoid damaging the cartilage with surgical instruments, as this would hinder any future ability to lift the eyelids. The remainder of the treatment should proceed as is deemed appropriate.
Wounds of the eyes are made by the violence of things pricking, cutting, bruising, or otherwise losing the continuity. But the cure must always be varied according to the variety of the causes and differences. The first head of the cure is, that if any strange and heterogeneous body shall fall into the eyes, let it be taken forth as soon as you can, lifting and turning up the eyelid with the end of a spatula. But if you cannot discern this moat or little body, then put three or four seeds of clary, or Oculus Christi into the pained eye. For these seeds are thought to have a faculty to cleanse the eyes and take out the moats, which are not fastened deep in, nor do too stubbornly adhere to the membranes. In this case, you shall use this following instrument, for herewith we open the eyelids the further, putting it between them and the eye, and also keep the eye steady by gently pressing it, so that with our mullets we may pull out the extraneous body; this is the figure of such an instrument.
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The deliniation of a Speculum oculi, fit to dilate and hold asunder the eyelids, and keep the eye steady; it is so made, that it may be dilated and contracted according to the greatness of the eyes.
Wounds to the eyes can be caused by various forms of violence, including pricking, cutting, bruising, or other injuries that disrupt normal continuity. Treatment must always be tailored to the specific cause and nature of the injury.
The first step in treatment is to remove any foreign object that may have entered the eye as quickly as possible. This can be achieved by lifting the eyelid with the end of a spatula and gently turning it back. However, if the foreign particle is not visible, you may place three or four seeds of clary (also known as Oculus Christi) into the affected eye. These seeds are believed to possess the ability to cleanse the eye and dislodge foreign particles that are not embedded deeply or stubbornly adhere to the eye’s membranes.
In this situation, you will require a specific instrument to assist in the process. This tool enables us to further open the eyelids by placing it between the lid and the eye, while also keeping the eye steady through gentle pressure. This allows us to carefully remove the foreign body with the appropriate implements. An illustration of this instrument can be provided for clarity.
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The description of an ocular speculum, designed to separate and hold the eyelids apart while stabilizing the eye, is crafted in such a way that it can be adjusted in width to accommodate the size of the eyes. This allows for both dilation and contraction as needed.
All strange bodies taken out, let this medicine be put into the eye. Take the strains of a dozen eggs, let them be beaten in a lead mortar with a little rose water, and so put into the eye; but let this repercussive be laid upon the eye and the neighboring parts.
℞. albumin. ovor. nu. iiij. pulver. aluminis rochae combusti ʒij. sanguinis Draconis ʒj. aquae rosar. & plantag. an. ℥ij. agitentur simul,
Make a repercussive, which you may frequently use. Or else apply cheese curds well wrung, mixed with rosewater, the white of an egg, and as much acacia as shall suffice. This which follows does more powerfully stay the flowing humor.
℞. gum▪ arab & tragac. an. ʒij psilij. cydon. semin. portul. plant. s•mach. an. ʒij fiat mucag. cum aqua plantag. solan. & rosar. concinnetur collyrium,
of which you may drop some both within and about the eye.
But note, that all such remedies must be applied warm, both that they may the better penetrate by their moderate heat, as also for that all actual cold things are hurtful to the eyes and sight, because they dull the sight by incrustating the visive spirits. I have known many who have become dull of sight by the frequent using of medicines actually cold to the eyes.
I have on the contrary seen not a few, who have recovered with the fit use of such medicines, who have had any part of their eye (so it were not the pupilla or Apple of the eye) so pricked with a needle or bodkin, that much of the watery humor ran forth thereat.
The milk of a woman which suckles a girl (for that is reputed the cooler) mitigates pain and cleanses, if it is milked out of the dug into the eye; to which purpose also the blood of turtles, pigeons or chickens much conduces, being dropped into the eye by opening a vein under their wings. Also this following cataplasm assuages pain and inflammation, and hinders defluxion, being applied to the eye and the adjacent parts.
℞ Carnis pomorum sub cinere calido decoctorum ℥v. vitellos ovorum num. iij, cassiae fistulae recenter extractae ℥ss, macaginis psilij, altheae & cydon. an. ℥j. farin. hordeiparum, incorporentur omnia simul, fiat cataplasma.
Also sheep’s lungs boiled in milk and applied warm, and changed as they grow cold, are good to assuage pain. But if the too violent heat and pain shall not yield to such medicines, but require more vehemence, then
Foliorum Hyoscyami, m. j. sub cineribus coquatur, atque in mortario cum mucagine seminis psilij, & cydonier, extract in aquis solani & plantag. pistetur:
then let this medicine be wrapped in a linen cloth and applied to the eyes and temples. The mucilages of Psilium, or Flea-wort, and Quince seeds extracted in a decoction of poppy heads and mixed with a little Opium and rose water, are used for the same purpose.
But when there is need of detergent and sarcotic medicines, then:
℞ syrup. rosar. siccar. ℥j. aq faenic. & ruta an. ʒij, aloes lotae, olibani an. ℥ss.
mix them for the aforesaid use. The galls of scates, hares, and partridges dissolved in eye-bright and fennel water, are fit for cleansing such wounds; as also this following Collyrium.
℞ Aquae hordei ℥j. mellis despumati ʒiij. aloes ter lotae in aqua plantaginis and sacchari cand. an ʒj. fiat collyrium.
Also this ensuing medicine is very sarcotic.
℞ mucagin. gummi olibani, arabici, tragacanth. & sarcocol. in aq. hordei extract. an. ʒiij. aloes ter lota in aq. rosarum ʒj. cerus. ustae & lotae, tutia prapar. an. ʒss fiat collyrium.
But here you must note, that the coat adnata often swells so much due to a wound or some other injury, and stands so forth by the falling down of humors, access and mixture of flatulencies, that it hides the whole Pupilla, and hangs forth of the eyelids, like as if it were an unnatural fleshy excrescence, and it loses the native color, and looks very red; so that the eye can neither be shut nor opened.
Wherewith a young surgeon being deceived, determined to cut away this protuberance of the adnata, as though it had been some superfluous flesh, and then to waste it with cathaeretic powders, had I not forbidden him, telling him of the certain danger of blindness which would thereupon befall the patient. Wherefore I prescribed a fomentation of chamomile, melilote, roses leaves, wormwood, rue, fennel, and aniseeds boiled in milk with the roots of orris and marigolds. Then I presently added this following fomentation, being more powerful and drying.
℞ Nucis cupressi, gallar. balaust. an. ℥j. plantag. absinth. hippuris, flo. chamaem. ros. rub.an. M. ss. bulliant simul cum aqua fabrorum, & fiat decoctum pro fotu cum spongia.
Besides also you may apply a cataplasm made of barley and bean flower, the powders of mastick, myrrh, and aloes, and some of the last described decoction. The tumor beginning to decline; I dropped the flowing liquor into the eye, which has a very astringent, drying and strengthening faculty.
Roast a new laid egg in embers until it is hard, then pill off the shell, take forth the yolk, and in place thereof put a scruple of Roman Vitriol in fine powder, then put it in a linen cloth and wring it hard forth into some clean thing, and drop thereof for some days into the eye, with a little smith’s water wherein sumach and rose leaves have been boiled. I have found by experience the certain force of this remedy; but if notwithstanding there is a true fleshy excrescence upon the coat adnata, it may be taken away by this following powder.
℞ Ossis sepiae, & testae ovorum calcinatae an. ʒj, fiat pulvis. Calcined Vitriol, burnt alum and the like may be commodiously used to this purpose. Yet you must warily make use of all such things, and always lay repercussives about the eye, that no harm ensue thereof.
For several times acrid humors fall down into the eye with such violence, that they break the Horny coat, whereupon the humors of the eye are poured out. Remember also, that in diseases of the eyes, the patient lie with his head somewhat high, and that he keep shut not only the pained, but also the sound eye, because rest is always necessary for the grieved part. But one eye cannot be moved without some motion of the other due to the connection they have by their optic and moving nerves, both the meninges, the pericranium; veins, and arteries; which is the cause that when the one suffers, the other in some sort partakes therewith.
But if we cannot prevail by all these formerly prescribed medicines fit to stay the defluxion, then it remains, that we apply a seton to the neck; for it is a singular remedy against inveterate defluxions into the eyes. For we know by daily experience, that many who have had their sight dulled by a long and great defluxion, so that they were almost blind, have little by little recovered their former splendor and sharpness of sight, when matter once begun to be evacuated by the seton.
The truth hereof appeared in Paul the Italian Goldsmith, who dwelt near the Austine Friers. For he having used many medicines of several physicians, and surgeons in vain, when he was almost blind, he applying a seton, by mine advice, began little by little to see better according to the quantity of the matter which was evacuated, until at length he perfectly recovered his sight. But at last growing weary of the seton which he had worn for a year (although matter came daily forth thereof) yet he would have it taken forth, and healed up; but this way of evacuation being shut up, and the humor again beginning to flow into his eyes, so that he was in danger to become blind, he called me and made me again to apply the seton in his neck. Whereby recovering his former soundness and perfection of sight, he yet wears the seton.
I also once freed by this kind of remedy, by the appointment of the most learned physician Hollerius, a certain young man of twenty years old, from the falling sickness, who before had many fits thereof; the Ichorous humors the feeders of this disease being by these means, as it is most probable, drawn away and evacuated.
Wherefore seeing a seton is of this use, I have thought good in this place to set down in writing and by figure, the manner of making thereof, for the behoof of young practitioners. Wish the patient to sit on a low stool, and to bend down his head, so that the skin and fleshy pannicle may be relaxed; then you must with your fingers pluck up and sever the skin from the muscles, and take hold of as much hereof as you can with your pincers, not touching the muscles of the neck for fear of a convulsion and other symptoms; you shall then twitch the skin which is held in the pincers, most hard, when you shall thrust the hot iron through the holes made in the midst of them; that also the nerves being so twitched, the dolorific sense may the less come to the part. The wound must be made or burnt in long ways and not twharting, so that the matters may be the better evacuated by the straight fibers. But the cautery or hot iron must have a three or else a four-square point and that sharp, so that it may the more easily and speedily enter. Then keeping the pincers immoveable, let him draw through the passage made by the cautery a needle thread with a three or four doubled thread of cotton [or rather a skeane of silk] moistened in the white of an egg and oil of roses; then after you have applied pledgets dipped in the same medicine, bind up the part with a convenient ligature. The day following the neck must be anointed with oil of roses, and the pledgets dipped in the former medicine applied for some days after. But it will be convenient to moisten the seton with a digestive made of the yolk of an egg and oil of roses, until the ulcer cast forth much matter; then you shall anoint the cotton thread with this following remedy.
℞. terebinthinae ven. ℥iiij. syrupirosat. & absinthij. an. ℥ss. pulveris Ireos, diacrydij, agarici trochiscati, & Rhei, an. ℥ss. incorporentur omnia simul & siat medicamentum.
Which you shall use so long, as you intend to keep open the ulcer. It has a faculty to draw the humors from the face, and cleanse without biting.
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A figure of the pincers, actual cautery and needle used in making a seton.
I have found not long since by experience, that the apertion made with a long thick triangular needle of a good length like to a large pack-needle, is less painful than that which is performed with the actual cautery, which I formerly mentioned. Wherefore I would advise the young surgeon, that he no more use the foresaid actual cautery. I have here given you the figure of the needle.
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The figure of a triangular needle.
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A figure of the pincers, actual cautery and needle used in making a seton.
I have found not long since by experience, that the apertion made with a long thick triangular needle of a good length like to a large pack-needle, is less painful than that which is performed with the actual cautery, which I formerly mentioned. Wherefore I would advise the young surgeon, that he no more use the foresaid actual cautery. I have here given you the figure of the needle.
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Seeing a wound of the cheek seems to require a suture, it must have a dry suture lest that the scar should become deformed. For that deformity is very grievous to many, as to women who are highly pleased with their beauties. Therefore you shall spread two pieces of new cloth of an indifferent fineness, and proportionable size with this ensuing medicine.
℞. pulveris mastichini, sanguinis Draconis, thuris, farinae volatilis, tragacantha contusae, gypsi, picis, sarcocollae an. ʒij. picis nigra ʒiss. albumina ovorum quae sufficiant, fiatmedicamentum.
Apply the pieces of cloth spread with this on each side of the wound one, some fingers breadth asunder, and let it alone till it is hard dried to the skin. Then you shall so draw them together with your needle and thread, that the flesh by their sticking may also follow, and be mutually adjoined, as you may see it here expressed. The wound shall be agglutinated by these means, together with the use of fit medicines, pledgets, ligatures. But all the ligatures and stays which shall be used for that purpose must be fastened to the patients night-lap.
But when the wound is great and deep, and the lips thereof are much distant from one another, there can be no use of such a dry suture. Wherefore you must use a three or four square needle (so that it may the more readily and easily enter into the flesh) being thread with a waxed thread; and with this you must thrust through the lips of the wound, and leave the needle sticking in the wound, and then wrap the thread to and again over the ends thereof eight or ten times, just after that manner which women use to fasten a needle with thread in it, upon their sleeves, or tailors to their hats or caps, that they may not lose them.
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When addressing a wound on the cheek that appears to require stitching, it is advisable to employ a dry suture to prevent the scar from becoming deformed. This deformity can be particularly distressing for many individuals, especially women who take great pride in their appearance. To proceed, you should prepare two pieces of new cloth, of an appropriate fineness and size, along with the following medication:
℞. Mastic powder, Dragon’s blood, frankincense, finely ground wheat flour, crushed tragacanth, gypsum, pitch, and sarcocolla, each in the amount of two drachms, and black pitch in the amount of one and a half drachms. Additionally, use enough egg whites to create a suitable compound.
Apply the cloth pieces, coated with this mixture, on either side of the wound, positioned a few fingerbreadths apart. Allow them to remain until they thoroughly adhere to the skin. Next, carefully suture the edges together with your needle and thread, ensuring that the flesh adheres as well, as illustrated here. The wound will be closed using these methods in conjunction with appropriate medications, dressings, and ligatures. It is essential that all ligatures and stays used for this purpose are securely attached to the patient’s nightgown.
However, when dealing with a large and deep wound where the edges are significantly apart, a dry suture technique is not suitable. In such cases, you should employ a square or rectangular needle, which facilitates easier insertion into the flesh, threaded with waxed thread. Insert the needle through the wound edges and leave it in place, then wrap the thread over the ends eight to ten times, similar to how women secure a needle with thread on their sleeves or how tailors fasten their hats or caps to prevent losing them.
The needle thus fastened, shall be there until the perfect agglutination of the wound; this kind of suture is used in the wounds of the lips, as also in hare-lips, for so we commonly call lips which are cleft from the first conformation in the womb by the error of the forming faculty. But such a suture will help nothing to agglutination, if there lie or remain any skin between the lips of the wound; Wherefore you shall cut away whatsoever thereof shall be there, otherwise you must expect no union. Other kind of sutures are of no great use in wounds of these parts, for out of the necessity of eating and speaking, they are in perpetual motion; wherefore a third would cut the flesh; for which reason you shall take up much flesh with such needles mentioned in this last described kind of suture, as this following figure shows.
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The figure of the suture fit for cloven or Hare lips, as also the delineation of the needle about whose ends the thread is wrapped over and under, to and again.
To this purpose I will recite a history, to the end, that if any such thing happen to come to your hands, you may do the like. A certain Gascoine in the battle at Saint Laurence had his upper jaw cut overthwart even to his mouth, to the great disfiguring of his face. The wound had many worms in it, and stank exceedingly, because he could get no surgeon until three days after he was hurt. Wherefore I washed it with a decoction of wormwood, aloes and a little Aegyptiacum, both to kill the worms, and to fetch away all the putrid matter; I discussed the tumor with a dissolving fomentation and cataplasm, I joined together the lips of the wound with the last described suture. But I applied this following medicine to the whole part.
℞ Terebinth. venet a ℥vj. gumml elemi. ℥ij. pulver is boli armni, san. drac. Mastiches, myrrhae, aloes an. ʒss. incorporentur simul, fiat medicamentum.
The wound was agglutinated within a few days, but that there remained a certain little whole at the joining of the lower jaw with the upper, wherein you could scarce put the head of a pin; out whereof nevertheless much serous and thin moisture flowed, especially when he either ate or spoke; which I have also observed in many others. But for staying of this watery humidity I dropped Aqua fortis into the bottom of the ulcer, and many times put therein a little of the powder of burnt vitriol. Thus by God’s grace he recovered and became whole.
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The needle thus fastened, shall be there until the perfect agglutination of the wound; this kind of suture is used in the wounds of the lips, as also in hare-lips, for so we commonly call lips which are cleft from the first conformation in the womb by the error of the forming faculty. But such a suture will help nothing to agglutination, if there lie or remain any skin between the lips of the wound; Wherefore you shall cut away whatsoever thereof shall be there, otherwise you must expect no union. Other kind of sutures are of no great use in wounds of these parts, for out of the necessity of eating and speaking, they are in perpetual motion; wherefore a third would cut the flesh; for which reason you shall take up much flesh with such needles mentioned in this last described kind of suture, as this following figure shows.
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The figure of the suture fit for cloven or Hare lips, as also the delineation of the needle about whose ends the thread is wrapped over and under, to and again.
To this purpose I will recite a history, to the end, that if any such thing happen to come to your hands, you may do the like. A certain Gascoine in the battle at Saint Laurence had his upper jaw cut overthwart even to his mouth, to the great disfiguring of his face. The wound had many worms in it, and stank exceedingly, because he could get no surgeon until three days after he was hurt. Wherefore I washed it with a decoction of wormwood, aloes and a little Aegyptiacum, both to kill the worms, and to fetch away all the putrid matter; I discussed the tumor with a dissolving fomentation and cataplasm, I joined together the lips of the wound with the last described suture. But I applied this following medicine to the whole part.
℞ Terebinth. venet a ℥vj. gumml elemi. ℥ij. pulver is boli armni, san. drac. Mastiches, myrrhae, aloes an. ʒss. incorporentur simul, fiat medicamentum.
The wound was agglutinated within a few days, but that there remained a certain little whole at the joining of the lower jaw with the upper, wherein you could scarce put the head of a pin; out whereof nevertheless much serous and thin moisture flowed, especially when he either ate or spoke; which I have also observed in many others. But for staying of this watery humidity I dropped Aqua fortis into the bottom of the ulcer, and many times put therein a little of the powder of burnt vitriol. Thus by God’s grace he recovered and became whole.
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The nose can in many ways suffer solution of continuity; as by a wound, fracture and contusion, and it is sometimes battered and broken on the upper part; which when it happens, you shall restore the depressed bones to their native seat and figure, with the end of a spatula or fit stick wrapped about with towe, cotton or a linen rag. Then with pledgets dipped in an astringent medicine composed ex albumine ovi, mastich, bole armno, sanguine drac. & Alumine ufto, and applied to the side of the nose, he shall labor to strengthen the restored bones, and then bind them with a convenient ligature, which may not press them too much, lest the nose should become flat, as it happens to many through the unskilfulness of surgeons. Then you must put little pipes into the nostrils, and these not exactly round, but somewhat flat and depressed, tied to the night-cap on each side with a thread, lest they should fall out. By the help of these pipes the bones of the nose will be kept in their place, and there will be passage forth for the matter, and for inspiration and expiration. But if all the nose, or some portion thereof shall be wholly cut off, we must not hope to restore it.
But if the nose is so cut, that as yet it adheres to much of the adjacent flesh, from whence it may receive life and nourishment, then sew it up. For the lower part of the nose it may be shaken, depressed and wristed aside, seeing it is gristly; but it cannot be broken as the other which is of a bony nature.
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The figure of pipes to be put into the nostrils.
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The tongue may be so wounded, that either it may be wholly cut off and deprived of some portion of the substance, or only slit long ways or athwart. The loss of the substance cannot be repaired, because every part separated and plucked from the living body, from whence it had life, spirit and blood, presently dies. As the philosophers say, A privatione ad habitum non est regressus. But when it is cut or slit longways or sideways, it is easily restored by suture, if so be that the cloven part yet adhere to the living body from whence it may draw both matter and form of life. Therefore a careful servant shall straightly hold with a soft and clean linen cloth the body of the tongue, lest it should slip away due to its slipperiness, whilst the surgeon stitch it above and below; when he thinks he has sufficiently sewn it, let him cut off the thread as near to the knot as he can, lest being left too long it might be tangled with the teeth as he eats, and so cause a hurtful laceration or rending of the sewn parts. In the meantime let the patient eat barley creams, almond milks, jellies, cullisses and broths, and the yolks of eggs; and let him often hold in his mouth sugar of roses and syrup of Quinces; for such things besides their nourishing faculty, perform the part of an agglutinating and detergent medicine.
I have learned these things I have here set down, neither from my masters whom I have heard with attention, nor by reading of books, but they have been such as I have tried with happy success in many; as in the son of Monsieur de Marigny president of the Inquisition, in John Piet a Carpenter dwelling in the suburbs of Saint German.
But most apparently in a child of three years old, the son of the great Lawyer Monsier Couet, who fell with his chin upon a stone, and so cut off a large piece of the end of his tongue, which chanced to be between his teeth, it hung but at a very small fiber of flesh, so that I had very little or no hope to agglutinate and unite it, which thing almost made me to pluck it quit away; yet I changed that determination by considering the loss of the most noble action of speaking, which would thereupon ensue, and weighing the providence of nature often working wonders and such things as exceed the expectation of the physician in curing diseases.
I also thought thus with myself, the flesh of the tongue is soft, loose, and spongie, neither is it altogether obvious to the external injuries of the air, wherefore after that I had once or twice thrust through the needle and thread upwards and downwards, and for the rest ordered the child to be used and after the manner I lately mentioned, he grew well within a short time, and yet remains so, speaking well and distinctly.
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The ears are sometimes wholly cut off, sometimes but in part, otherwhiles they are only slit, so that the rent portion as yet adhering to the rest, is joined with it in communion of life. In this last case it is fit to use a suture; but yet so that you touch not the gristle with your needle; for thence there would be in danger of a gangrene which happens to many by foolish curing; therefore you shall take up and comprehend with your needle only the skin, and that little flesh which encompasses the gristle.
You shall perform the rest of the cure with pledgets and ligatures artificially fitted, and shall resist inflammation and other symptoms with fit medicines. But you must take special care that no superfluous flesh grow in the auditory passage, which may hinder the hearing; wherefore you shall keep that passage free by stopping it with a piece of sponge. But you shall procure agglutination and consolidation of the gristly part (and therefore next to a bone most dry) with dry medicines. But those who have their ears quite cut off, can do nothing but hide the deformity of their mis-hap with a cap, stuffed with cotton on that side.
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The wounds of the neck and throat are somewhiles simple, as those which only use the continuity of the muscles; other whiles compound, such as those which have conjoined with them a fracture of the bones, as of the vertebrae, or hurt of the internal and external jugular veins, or sleepy arteries; sometimes the trachea arteria, or weasand, and the esophagus or gullet are wounded; sometimes wholly cut off, whence present death ensues. Wherefore let not the surgeon meddle with such wounds, unless he first foretell the danger of death, or the loss of some motion to those that are present. It often happens that some notable nerve or tendon is violated by a wound in the neck, whence a palsy ensues, and that absolutely incurable, if the wound shall penetrate to the spinal marrow, also hurt therewith. Wounds of the gullet and weasand are difficultly cured because they are in perpetual motion; and chiefly of the latter by reason it is grisly and without blood. The wounds of the gullet are known, by spitting of blood, by the breaking forth of meat and drink by the wound; but if the gullet be quite cut asunder, the patient cannot swallow at all. For the cut parts are both contracted in themselves, the one upwards, and the other downwards. But we know the weasand is hurt, by casting up blood at the mouth with a continual cough, and by the coming forth of the breath or wind by the wound. The wounds of the jugular veins and sleepy arteries, if they are great, are usually deadly, because they cannot be straightly bound up; for you cannot bind the throat hard without danger of choking or strangling the patient. But for defect of a straight ligature in this case the flux of blood proves deadly. If the recurrent nerve of either side is cut, it makes the voice hoarse; if cut on both sides, it takes away the use of speech, by hurting these instruments which impart motion to the muscles of the larynx. For the cure if the wound be small, & not associated with the hurt of any notable vessel, nor of the weasand and gullet, it is speedily and easily cured; and if there shall be need you shall use a suture, then you shall put therein a sufficient quantity of Venice Turpentine mixed with bole-armenic; or else some of my balsam of which this is the receipt.
℞. Terebinth. venetae lb ss. gum. elemi ℥iiij. olei hypericon is ℥iij. boli armni, & sang. draconis an. ℥j. aqua vita ℥ij. liquefiant simul omnia lento igne, & fiat Balsamum ut artis est, addendo pusveris ireos Florent. aloes, Mastiches, myrrhae, an. ʒj.
I have done wonders with this balsam in the agglutination of simple wounds, wherein no strange body has been.
Now when you have put it in, lay upon it a plaister of Diacalcitheas dissolved in oil of roses and vinegar, as that which has power to repress the flowing down of humors, and hinder inflammation, or instead thereof you may apply Emp. de Gratia, Dei, or Emp. de Ianua.
But if the jugular veins and sleepy arteries are cut, let the bleeding be stayed, as we have showed in a chapter, treating thereof. When the weasand or gullet are wounded, the surgeon shall sew them up as neatly as he can; and the patient shall not endeavor to swallow any hard thing, but be content to be fed with jellies and broths. When a gargarism is needful, this following is very good.
℞. hordei M. j. florum rosar. p. j. passul. mund. jujubarum an. ℥ss, glycyrhizae ℥j. bulliantomnia simul, addendomellis ros. & Iulep. ros. an. ℥ij. fiat gargarisma, ut artis est.
With which being warm the patient shall moisten his mouth, and throat, for it will mitigate the harshness of the part, assuage pain, cleanse and agglutinate, and make him breathe more freely. But that the surgeon may not despair of, or leave any thing unattempted in such wounds, I have thought good to demonstrate by some examples, how wonderful the works of nature are, if they are assisted by art.
A certain servant of Monsieur de Champaigne, a gentleman of Anjou, was wounded in the throat with a sword, whereby one of the jugular veins was cut together with his weasand. He bled much and could not speak, and these symptoms remained, until such time as the wound was sewn up, and covered with medicines, But if the medicines at any time were more liquid, he sucked them by the wound and spaces between the stitches, and presently put forth at his mouth that which he had sucked or drawn in. Wherefore more exactly considering with myself, the greatness of the wound, the spermatic, and therefore dry and bloodless nature unapt to agglutination, of the affected part, but chiefly of the weasand & jugular vein; as also for that the rough artery is obnoxious to these motions which the gullet performs in swallowing, due to the inner coat, which is continued to the coat of the gullet, by which means these parts mutually serve each other with a reciprocal motion, even as the ropes which run to the wheel of a pulley; furthermore weighing that the artery was necessary for the breathing, and tempering the heat of the heart, as the jugular veins served for the nourishment of the upper parts; and lastly weighing with myself the great quantity of blood he had lost, which is the treasure of nature, I told those which were present, that death was near and certainly at hand. And yet beyond expectation, rather by divine favor than our art, he recovered his health.
Equally admirable is this history following. Two Englishmen walked out of the city of Paris for their recreation to the wood of Vincenne; but one of them lying in wait to rob the other of his money and a massie chain of gold which he wore, set upon him at unawares, cut his throat and robbed him, and so left him amongst the vines which were in the way, supposing he had killed him having with his dagger cut the weasand and gullet. This murderer came back to the city; the other half dead, crawled with much ado to a certain peasant’s house, and being dressed with such medicines as were present and at hand, he was brought to the city, and by his acquaintance committed to my cure to be cured.
I at the first, as diligently as I could, sewed up the weasand which was cut quite asunder, and put the lips of the wound as close together as I could; I could not get hold of the gullet because it was fallen down into the stomach, then I bound up the wound with medicines, pledgets and fit ligatures. After he was thus dressed he begun to speak, and tell the name of the villain the author of this fact, so that he was taken and fastened to the wheel, and having his limbs broken lost his wretched life, for the life of the innocent wounded man who died the fourth day after he was hurt.
The like hurt befell a certain German, who lay at the house of one Perots in the street of Nuts; he being frantic in the night cut his throat with a sword: I being called in the morning by his friends who went to see him, dressed him just after the same manner as I dressed the Englishman. Wherefore he presently recovering his speech, which before could not utter one syllable, freed from suspicion of the crime and prison the servant who lying in the same chamber with him, was upon suspicion committed to prison, and confessing the thing as it was done, living four days after the wound, being nourished with broths put into his fundament like clysters, and with the grateful vapor of comfortable things, as bread newly drawn out of the oven and soaked in strong wine. Having thus by the art of surgery made the dumb speak for the space of four days.
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Some wounds of the chest are on the fore side, some behind, some penetrate more deep, others enter not into the capacity thereof, other some pierce even to the parts contained therein, as the mediastinum, lungs, heart, midriff, hollow vein, and ascendent artery; Others pass quite through the body; whereby it happens that some are deadly, some not.
You shall thus know that the wound penetrates into the capacity of the chest, if that when the patient’s mouth and nose be shut, the breath, or wind breaks through the wound with noise, so that it may dissipate, or blow out a lighted candle being held near it. If the patient can scarce either draw, or put forth his breath, which also is a sign that there is some blood fallen down upon the diaphragm.
By these signs you may know that the heart is wounded: If a great quantity of blood gushes out, if a trembling possesses all the members of the body; if the pulse is little and faint, if the color becomes pale, if a cold sweat and frequent swooning assails him, and the extreme parts become cold, then death’s at hand.
Yet when I was at Turin, I saw a certain gentleman who was fighting a duel with another, and received a wound under his left breast which pierced into the substance of his heart, yet for all that he struck some blows afterwards, and followed his flying enemy some two hundred paces until he fell down dead upon the ground; having opened his body, I found a wound in the substance of the heart, so large as would contain one’s finger; there was only much blood poured forth upon the midriff.
These are the signs that the lungs are wounded, for the blood comes foamy or frothy out of the wounds the patient is troubled with a cough, he is also troubled with a great difficulty of breathing and a pain in his side, which he formerly had not; he lies most at ease when he lies upon the wound, and sometimes it comes so to pass, that lying so he speaks more freely and easily, but turned on the contrary side, he presently cannot speak.
When the diaphragm or midriff is wounded, the party affected is troubled with a weight or heaviness in that place, he is taken with a delirium, or raving, due to the sympathy of the nerves of the sixth conjugation which are spread over the midriff; difficulty of breathing, a cough and sharp pain trouble the patient, the guts are drawn upwards; so that it sometimes happens by the vehemence of breathing, that the stomach and guts are drawn through the wound into the capacity of the chest; which thing I observed in two.
The one of these was a mason, who was thrust though the midst of the midriff, where it is nervous, and died the third day following. I opening his lower belly, and no finding his stomach, thought it a monstrous thing; but at length searching diligently, I found it was drawn into the chest, though the wound which was scarce an inch broad. But the stomach was full of wind, but little humidity in it.
The other was called Captain Francis d’ Alon, a Native of Xantoigne, who before Roshell was shot with a musket bullet, entering by the breast-bone near to the sword-like gristle, and passing through the fleshy part of the midriff, went out at the space between the fifth and sixth bastard ribs. The wound was healed up on the outside, yet for all that there remained a weakness of the stomach, whereupon a pain of the guts like to the cholic took him especially in the evening, and on the night; for which cause he durst not sup but very sparingly. But on the eighth month after, the pain raging more violently in his belly than it was accustomed, he died; though for the mitigating of the vehemency thereof Simon Malmedy and Anthony du Val both learned physicians, omitted no kind of remedy. The body of the diseased was opened by the skillful surgeon, James Guillemeau, who found a great portion of the cholic gut swelled with much wind gotten into the chest, through the wound of the diaphragm, for all it was so small that you could scarce put your little finger in thereat, But now let us return from whence we digressed.
We understand that there is blood poured forth into the capacity of the chest by the difficulty of breathing, the vehemency of the increasing fever, the stinking of the breath, the casting up of blood at the mouth, and other symptoms which usually happen to these who have putrified and clotted blood poured out of the vessels into the belly, infecting with the filthy vapor of the corrupt substance, the parts to which it shall come.
But also, unless the patient cannot lie upon his back, he is troubled with a desire to vomit, and covets now and then to rise, whence he often falls into a swoon, the vital faculty which sustains the body being broken and debilitated both due to the wound, and concrete or clotted blood; for so putting on the quality of poison, it greatly dissipates and dissolves the strength of the heart.
It is a sign the spinal marrow is hurt, when a convulsion or palsy, that is, a sudden loss of sense and motion in the parts thereunder, an involuntary excretion of the urine and other excrements, or a total suppression of them, seizes upon the patient.
When the hollow vein and great artery are wounded, the patient will die in a short time, due to the sudden and abundant effusion of the blood and spirits, which intercepts the motion of the lungs and heart, whence the party dies suffocated.
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We have read in John de Vigo that it is disputed amongst surgeons concerning the consolidation of wounds of the chest. Some think that such wounds must be closed up and cicatrized with all possible speed, lest the cold air come to the heart, and the vital spirits fly away and be dissipated. Others on the contrary think that such wounds ought to be long kept open; and also if they are not sufficiently large of themselves, that then they must be enlarged by surgery, so that the blood poured forth into the capacity of the chest may have passage forth, which otherwise by delay would putrefy, whence wound ensue an increase of the fever, a fistulous ulcer, and other pernicious accidents.
The first opinion is grounded upon reason and truth, if so be that there is little or no blood poured forth into the capacity of the chest; But the latter takes place where there is much more blood contained in the empty spaces of the chest. Which least I may seem rashly to determine, I think it not amiss to ratify each opinion with a history thereto agreeable.
Whilst I was at Turin, surgeon to the Marshall of Montejan, the King of France his general, I had in cure a soldier of Paris, whose name was L’evesque, he served under Captain Renouart. He had three wounds, but one more grievous than the rest, went under the right breast, somewhat deep into the capacity of the chest, whence much blood was poured forth upon the midriff, which caused such difficulty of breathing, that it even took away the liberty of his speech; besides, though this occasion he had a vehement fever, coughed up blood, and a sharp pain on the wounded side. The surgeon which first dressed him, had so bound up the wound with a straight and thick suture, that nothing could flow out thereat. But I being called the day after, and weighing the present symptoms which threatened speedy death, judged that the sewing of the wound must straight be loosed; which being done, there instantly appeared a clot of blood at the orifice thereof; which made me to cause the patient to lie half out of his bed, with his head downwards, and to stay his hands on a settle which was lower than the bed, and keeping himself in this posture, to shut his mouth and nose so that his lungs should swell; the midriff be stretched forth, and the intercostal muscles and those of the abdomen should be compressed, that the blood poured into the chest might be evacuated by the wound; but also that this excretion might succeed more happily, I thrust my finger somewhat deep into the wound, so that I might open the orifice thereof being stopped up with the congealed blood; and certainly I drew out some seven or eight ounces of putrified and stinking blood by these means. When he was laid in his bed, I caused frequent injections to be made into the wound of a decoction of barley with honey of roses and red sugar, which being injected I wished him to turn first on the one, and then on the other side and then, again to lie out of his bed as before: for thus he evacuated small, but very many clots of blood, together with the liquor lately injected; which being done, the symptoms were mitigated, and left him little by little. The next day I made another more detergent injection, adding thereto wormwood, centaury, and aloes; but such a bitterness did rise up to his mouth together with a desire to cast, that he could not longer endure it. Then it came into my mind that formerly I had observed the like effect of the like remedy in the Hospital of Paris, in one who had a fistulous ulcer in his chest. Therefore when I had considered with myself that such bitter things may easily pass into the lungs, and so may from thence rise into the weasand and mouth, I determined that thence forwards I would never use such bitter things to my patients, for the use of them is much more troublesome than any way good and advantageous. But at length this patient by this and the like means recovered his health beyond my expectation.
But on the contrary, I was called on a time to a certain German gentleman who was run with a sword into the capacity of his chest; the neighboring surgeon had put a great tent into the wound at the first dressing, which I made to be taken forth, for that I certainly understood there was no blood poured forth into the capacity of the chest because the patient had no fever, no weight upon the diaphragm, nor spitted forth any blood. Wherefore I cured him in few days by only dropping in some of my balsam and laying a plaster of Diacalcitheos upon the wound.
The like cure I have happily performed in many others. To conclude, this I dare boldly affirm, that wounds of the chest by the too long use of tents degenerate into Fistula’s. Wherefore if you at any time shall undertake the cure of wounds which penetrate into the capacity of the chest, you shall not presently shut them up at the first dressing, but keep them open for two or three days; but when you shall find that the patient is troubled with no or very little pain, and that the midriff is pressed down with no weight, and that he breathes freely, then let the tent be taken forth, and the wound healed up as speedily as you can by covering it only with lint dipped in some balsam which has a glutinative faculty, and laid somewhat broader than the wound; never apply liniments to wounds of this kind, lest the patient by breathing draw them into the capacity of the chest. Wherefore also you must have a care that the tent put into those kinds of wounds may be fastened to the pledgets, and also have somewhat a large head, lest they should be drawn as we said into the capacity of the chest, for if they fall in, they will cause putrefaction and death.
Let Emplaster Diacalcitheos or some such be applied to the wound. But if, on the contrary, you know by proper, and certain signs, that there is much blood fallen into the spaces of the chest, then let the orifice of the wound be kept open with larger tents, until all the sanies or bloody matter, wherein the blood has degenerated, shall be exhausted. But if it happens at any time, as assuredly it sometimes does, that notwithstanding the art and care of the physician, the wound degenerates into a fistula, then the former evil is become much worse. For fistulas of the chest are scarce cured at any time, and that for many causes. The first is, for that the muscles of the chest are in perpetual motion. Another is, because they on the contrary inside are covered only with the membrane investing the ribs, which is without blood. The third is, for that the wound has no stay, by means whereof it may be compressed, sewn, and bound, whereby the lips being joined together, the wound may at length be replenished with flesh, and cicatrized.
But the reason why wounds of the chest do every day heap up and pour forth so great a quantity of matter, seems to be their vicinity to the heart, which being the fountain of blood, there is a perpetual efflux thereof from thence to the part affected. This is nature’s care in preserving the affected parts, that continually and abundantly without measure or mean it sends all its supplies, that is, blood and spirits, to the aide. Add hereto, that the affected parts by pain, heat and continual motion of the lungs and midriff, draw and allure much blood to themselves. Such blood defiled by the malignity and filth of the wound, is speedily corrupted; whence it is that from the perpetual afflux of blood, there is a continual efflux of matter or filth, which at the last brings a man to a consumption; because the ulcerated part, like a ravenous wolf, consumes more blood by the pain, heat and motion than can be ministered thereto by the heart. Yet if there is any hope to cure and heal the fistula, it shall be performed, (after the use of diet, phlebotomy, and according to the prescript of the physician) by a vulnerary potion, which you shall find described when we treat of the caries or rottenness of the bones. Wherefore you shall make frequent injections therewith into the fistula, adding and mixing with it syrupus de rosis ficcis and mel rosarum. Neither do I, if the putrefaction is great, fear to mix therewith Aegyptiacum. But you must have a care to remember and observe the quantity of the injected liquor, that you may know whether it all come forth again after it has performed its detergent office. If any thereof remain behind in the corners and crooked passages, it hurts the part, as corrupted with the contagion thereof.
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The form of a syringe fit to make injection, when a great quantity of liquor is to be injected into any part.
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After the injected liquor is come forth, a pipe of gold, silver or lead, shall be put into the fistulous ulcer; and it must have many holes in it, so that the filth may pass forth at them; it must be fast tied with strings, that it may not fall into the capacity of the chest.
A great sponge steeped in aqua vita and wrung forth again, shall be laid hot to the end or orifice thereof, both to hinder the entrance of the air into the fistulous ulcer, as also to draw forth the filth thereof by its gentle heat, the which thing the patient shall much further if often times both day and night he hold his breath, stopping his mouth and nose, and lying upon the diseased side, so that the sanies may be the more forcibly evacuated; neither must we leave putting in the pipe, before that this fistulous ulcer is almost dry, that is, whole, as when it yields little, or no matter at all; then it must be cicatrized. But if the orifice of this fistulous ulcer being in the upper part hinder the healing thereof, then by a surgical section, a passage shall be made in the bottom, as we said before in an empyema.
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The delineation of the pipes with their strings and sponges.
The reader must note that the pipes which are fit for this use, need not have so many holes as these here expressed; but only two or three in their ends: for the flesh growing and getting into the rest, make them that they cannot be plucked forth without much pain.
A wound made in the lungs admits cure, unless it is very large; if it is without inflammation; if it is on the skirts of the lungs, and not on their upper parts; if the patient contains himself from coughing much, and contentious speaking, and great breathing: for the wound is enlarged by coughing, and thence also arises inflammation; the pus and sanies whereof, whilst the lungs again endeavor to expel by coughing, by which means they are only able to expel that which is hurtful and troublesome to them, the ulcer is dilated, the inflammation augmented, the patient wastes away, and the disease becomes incurable.
There have been many Eclegma’s described by physicians for to cleanse the ulcer; which when the patient uses, he shall lie on his back, to keep them long in his mouth, so to relax the muscles of the larynx; for thus the medicine will fall little by little along the coats of the weasand, for if it should fall down in great quantity, it would be in danger to cause coughing. Cow’s, ass’s, or goat’s milk with a little honey, lest they should corrupt in the stomach, are very fit remedies for this purpose; but woman’s milk exceeds the rest.
But sugar of roses is to be preferred before all other medicines, in the opinion of Avicenne, for that it has a detergent, and also an astrictive and strengthening faculty, than which nothing is more to be desired in curing of ulcers. When you shall think it time to agglutinate the cleansed ulcer, you must command the patient to use emplastic, austere, and astringent medicines, such as are Terra sigillata, bolus armenus, hypocystis, plantain, knot-grass, sumach, acacia and the like, which the patient shall use in his broths and Eclegma’s, mixing therewith honey of roses, which serving for a vehicle to the rest, may carry away the impacted filth which hinders agglutination. But seeing a hectic fever easily follows upon these kinds of wounds, and also upon the affects of the chest and lungs, it will not be amiss to set down somewhat concerning the cure thereof, so that the surgeon may know to administer some help to his patient, whilst a physician is sent for, to overcome this disease with more powerful and certain remedies.
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A hectic fever is so called; either for that it is stubborn and hard to cure and loose, as things which have contracted a habit; for Hexis in Greek signifies a habit; or else for that it seizes upon the solid parts of our bodies called by the Greeks Hexeis; both which the Latin word Habitus does signify.
There are three kinds, or rather degrees of this fever. The first is when the hectic heat consumes the humidity of the solid parts. The second is when it feeds upon the fleshy substance. The third and incurable is, when it destroys the solid parts themselves. For thus the flame of a lamp first wastes the oil, then the proper moisture of the wick. Which being done there is no hope of lighting it again what store of oil soever you pour upon it. This fever very seldom breeds of itself, but commonly follows after some other.
Wherefore the causes of a hectic fever are sharp and burning fevers not well cured, especially if their heat were not repressed with cooling epithemes applied to the heart and Hypochondria. If cold water was not fitly drunk. If may also succeed a Diary fever which has been caused and begun by some long, great and vehement grief or anger, or some too violent labor, which any of a slender and dry body has performed in the hot sun. It is also oft time caused by an ulcer or inflammation of the lungs, an empyema of the chest, by any great and long continuing phlegmon of the liver, stomach, mesentery, womb, kidneys, bladder, of the guts jejunum and colon, and also of the other guts, of if the phlegmon succeed some long diarrhea; Lienteria or bloody flux; whence a consumption of the whole body, and at last a hectic fever, the heat becoming more acrid, the moisture of the body being consumed.
This kind of fever as it is most easily to be known, so is it most difficult to cure; the pulse in this fever is hard, due to the dryness of the artery which is a solid part; and it is weak due to the debility of the vital faculty, the substance of the heart being assaulted. But it is little and frequent because of the distemper and heat of the heart, which for that it cannot due to its weakness cause a great pulse to cool itself, it labors by the oftenness to supply that defect
But for the pulse, it is a proper sign of this fever, that one or two hours after meat the pulse feels stronger than usual; and then also there is a more acrid heat over all the patient’s body. The heat of this flame lasts until the nourishment is distributed over all the patient’s body; in which time the dryness of the heart in some sort tempered and recreated by the appulse of moist nourishment, the heat increases no otherwise than lime which a little before seemed cold to the touch, but sprinkled and moistened with water grows so hot, as it smokes and boiled up. At other times there is a perpetual equality of heat and pulse in smallness, faintness; obscurity, frequency, and hardness, without any exacerbation, so that the patient cannot think himself to have a fever, yea he cannot complain of any thing, he feels no pain, which is another proper sign of an hectic fever.
The cause that the heat does not show itself is, it does not possess the surface of the body, that is, the spirits and humors, but lies as buried in the earthy grossness of the solid parts. Yet if you hold your hand somewhat, you shall at length perceive the heat more acrid and biting, the way being opened thereto by the skin rarified by the gentle touch of the warm and temperate hand. Wherefore if at any time in these kind of fevers the patient feels any pain, and perceive himself troubled with an inequality and excess of heat, it is a sign that the hectic fever is not simple, but conjoined with a putrid fever, which causes such inequality, as the heat does more or less seize upon matter subject to putrefaction; for a hectic fever of itself is void of all equality unless it proceed from some external cause, as from meat; certainly if an Hippocratique face may be found in any disease, it may in this, due to the colliquation, or wasting away the triple substance. In the cure of this disease, you must diligently observe with what affects it is entangled, and whence it was caused. Wherefore first you must know whether this fever is a disease or else a symptom. If it is a symptom, it cannot be cured, as long as the disease the cause thereof, remains uncured; as if an ulcer of the guts occasioned by a bloody flux shall have caused it, or else a fistulous ulcer in the chest caused by some wound received on that part; it will never admit of cure, unless first the fistulous or dysenteric ulcer shall be cured; because the disease feeds the symptoms, as the cause the effect. But if it is a simple and essential hectic fever, for that it has its essence consisting in a hot and dry distemper, which is not fixed in the humors, but in the solid parts, all the counsel of the physician must be to renew the body, but not to purge it; for only the humors require purging, and not the defaults of the solid parts. Therefore the solid parts must be refrigerated and humected; which we may do by medicines taken inwardly and applied outwardly.
The things which may with good success be taken inwardly into the body for this purpose, are medicinal nourishments. For hence we shall find more certain and manifest good, than from altering medicines, that is, wholly refrigerating and humecting without any manner of nourishment.
For due to that portion fit for nutriment which is therewith mixed, they are drawn and carried more powerfully to the parts, and also converted into their substance: whereby it comes to pass that they do not humect and cool them lightly and superficially, like the medicines which have only power to alter and change the body, but they carry their qualities more thoroughly even into the innermost substance.
Of these things some are herbs, as violets, purslane, bugloss, endive, ducks-meat, or water lentil, mallows, especially when the belly shall be bound. Some are fruits, as gourds, cowcumbers, apples, prunes, raisins, sweet almonds, and fresh or new pine-apple kernels. In the number of seeds are the four greater and lesser cold seeds, and these new, for their native humidity, the seeds of poppies, berberries, quinces. The flours of bugloss, violets, water lilies, are also convenient; of all these things let broth be made with a chicken, to be taken in the morning for eight or nine days, after the first concoction.
For meats; in the beginning of the disease, when the faculties are not too much debilitated, he shall use such as nourish much and long, though of hard digestion; such as the extreme parts of beasts, as the feet of Calves, hog’s feet not salted, the flesh of a tortoise, which has lived so long in a garden, as may suffice to digest the excrementitious humidity; the flesh of white snails, and such as have been gathered in a vineyard, of frogs, river crabs, eels taken in clear waters and; well cooked, hard eggs eaten with the juice of sorrel without spices; Whitings and stockfish. For all such things because they have a tough and glutinous juice, are easily put & glutinated to the parts of our body, neither are they so easily dissipated by the feverish heat. But when the patient languishes of a long hectic, he must feed upon meats of easy digestion, and these boiled rather than roasted; for boiled meats humect more, and roasted more easily turn into choler. Wherefore he may use to eat veal, kid, capon, pullet, boiled with refrigerating and humecting herbs; he may also use barley creams, almond milks, as also bread crumbed and moistened with rose water and boiled in a decoction of the four cold seeds with sugar of roses; for such a Panada cools the liver, and the habit of the whole body, and nourishes withall. The testicles, wings, and livers of young cocks, as also figs and raisins. But if the patient at length begin to loathe and grow weary of boiled meats, then let him use roast, but so that he cut away the burnt and dried part thereof, and feed only on the inner part thereof, and that moistened in rose water, the juice of citrons, oranges or pomegranates. Let him abstain from salt and dry fishes, and choose such fishes as live in stony waters, for the exercise they are forced to undergo in shunning the rocks beaten upon by the waves. Ass’s milk newly milked and seasoned with a little salt, sugar, honey, or fennel, that it may not corrupt, nor grow sour in the stomach; or woman’s milk sucked from the dug by the patient, to the quantity of half a pint is much commended; verily woman’s milk is the more wholesome, as that which is more sweet and familiar to our substance, if so be that the nurse be of a good temper and habit of body. It is very good against the gnawings of the stomach, and ulcers of the lungs, from whence a consumption often proceeds. Let your milk ass be fed with barley, oats, oak leaves; but if the patient chance to be troubled with the flux of the belly, you shall make the milk somewhat astringent by gently boiling it, and quenching there in pebble stones heated red hot. But for that all natures cannot away with ass’s milk, such shall abstain from it, as it makes to have acrid belchings, difficulty of breathing, a heat and rumbling in the Hypochondria, and pain of the head. Let the patient temper his wine with a little of the waters of lettuce, purslane and water-lilies, but with much bugloss water, both for that it moistens very much; as also for that it has a specific power to recreate the heart, whose solid substance in this kind of disease is grievously afflicted. And thus much of things to be taken inwardly.
These things which are to be outwardly applied, are inunctuous, baths, epithemes, clysters. Inunctions are varied, according to the various indication of the parts whereto they are applied. Galen anoints all the spine with cooling & moderate astringent things, as which may suffice to strengthen the parts, and hinder their wasting, and not let the transpiration; for if it should be letted, the heat would become more acrid, by suppressing the vapors. oil of roses, water lilies, quinces, the mucilages of gum tragacanth and arabic extracted in water of night shade, with some small quantity of camphire, and a little wax if need require; but on the contrary, the parts of the breast must be anointed with refrigerating and relaxing things; by refrigerating I mean things which moderately cool, for cold is hurtful to the breast. But astringent things would hinder the motion of the muscles of the chest, and cause a difficulty of breathing. Such inunctions may be made of oil of violets, willows, of the seeds of lettuce, poppies, water-lilies, mixing with them the oil of sweet almonds to temper the astriction which they may have by their coldness. But you must have great care that the apothecary for covetousness instead of these oils newly made give you not old, rancid and salted oils, for so instead of refrigerating, you shall heat the part; for wine, honey and oil acquire more heat by age; in defect of convenient oils, we may use butter well washed in violet and nightshade water. The use of such inunctions is to cool, humect and comfort the parts whereto they are used; they must be used evening and morning, chiefly after a bath.
Now for baths, we prescribe them either only to moisten, and then plain warm water wherein the flowers of violets and water lilies, willow leaves and barley have been boiled, will be sufficient; or else not only to moisten, but also to acquire them a fairer and fuller habit, and then you may add to your bath the decoction of a sheep’s head and Gather, with some butter. But the patient shall not enter into the bath fasting, but after the first concoction of the stomach, so that the nourishment will be drawn by the warmness of the bath into the whole habit of the body, for otherwise he which is sick of a consumption and shall enter the bath with his stomach empty, shall suffer a greater dissipation of the triple substance, by the heat of the bath, than his strength is well able to endure. Wherefore it is fit thus to prepare the body before you put it into the bath. The day before in the morning let him take an emollient clyster, to evacuate the excrements backed in the guts by the hectic dryness; then let him eat to his dinner some solid meats about nine of the clock; and let him about four of the clock eat somewhat sparingly, meats of easy digestion to his supper. A little after midnight let him sup of some chicken broth or barley cream, or else two raw eggs tempered with some rose water and sugar of roses instead of salt. Some 4 or 5 hours later, let him enter into the bath, these things which I have set down, being observed. When he comes out of the bath, let him be dried and gently rubbed with soft linen clothes, and anointed as I formerly prescribed, then let him sleep if he can for two or three hours in his bed: when he wakes let him take some Prisan, or some such thing, and then repeat his bath after the aforesaid manner. He shall use this bath thrice in ten days; But if the patient be subject to crudities of the stomach, so that he cannot sit in the bath without fear of swooning and such symptoms, his stomach must be strengthened with oil of quinces, wormwood and Mastich, or else with a crust of bread toasted, and steeped in muscadine, and strewed over with the powders of roses, sanders, and so laid to the stomach, or behind near to the thirteenth vertebra of the back, under which place, anatomy teaches, that the mouth of the stomach lies. Epithemes shall be applied to the liver and heart, to temper the too acrid heat of these parts, and correct the immoderate dryness by their moderate humidity.
Now they shall be made of refrigerating and humecting things, but chiefly humecting; for too great coldness would hinder the penetration of the humidity into the part lying within. The waters of bugloss, and violets, of each a quarterne with a little white wine is convenient for this purpose. But that which is made of French barley, the seeds of gourds, pompions, or cowcumbers of each three drams in the decoction, and mixed with much tempering with oil of violets, or of sweet almonds, is most excellent of all other. Let clothes be dipped and steeped in such epithemes, and laid upon the part, and renewed as oft as they become hot by the heat of the part. And because in hectic bodies, due to the weakness of the digestive faculty, many excrements are usually heaped up, and dried in the guts, it will be convenient, all the time of the disease to use frequently glisters made of the decoction of cooling and humecting herbs, flowers, and seeds wherein you shall dissolve Cassia with sugar and oil of violets, or water-lilies. But because there often happen very dangerous fluxes in a confirmed hectic fever, which show the decay of all the faculties of the body, and wasting of the corporeal substance, you shall resist them with refrigerating and assisting medicines; and meats of grosser nourishment, as rice, and Cicers; and application of astringent and strengthening remedies; and using the decoction of oats or parched barley for drink. Let the patient be kept quiet and sleeping as much as may be, especially if he is a child.
This fever frequently invades children by anger, great and long fear, or the too hot milk of the nurse, overheating in the sun, the use of wine and other such causes; they shall be kept in a hot and moist air, have another nurse, and be anointed with oil of violets; to conclude, you shall apply medicines which are contrary to the morbific cause.
TBD
The wounds of the lower belly are sometimes before, sometimes behind, some only touch the surface thereof, others enter in; some pass quite through the body, so that they often leave the weapon therein, some happen without hurting the contained parts; others grievously offend these parts, the liver, spleen, stomach, guts, kidneys, womb, bladder, ureters, and great vessels, so that oft times a great portion of the caul falls forth. We know the liver is wounded when a great quantity of blood comes forth of the wound, when a pricking pain reaches even to the swordlike gristle, to which the liver adheres. Oft times more choler is cast up by vomit, and the patient lies on his belly with more ease and content.
When the stomach or any of the small guts are wounded, the meat and drink break out at the wound, the ilia or flanks swell and become hard, the hiccups troubles the patient, and oft times he casts up more choler, and grievous pain wrings his belly, and he is taken with cold sweats, and his extreme parts wax cold.
If any of the greater guts shall be hurt, the excrements come forth at the wound:
When the spleen is wounded, there flows out thick and black blood, the patient is oppressed with thirst, and there are also the other signs, which we said use to accompany the wounded liver. A difficulty of making water troubles the patient whose reins are wounded, blood is pissed forth with the urine, and he has a pain stretched to his groins and the regions of the bladder and Testicles.
The bladder or ureters being wounded, the flanks are pained, and there is a tension of the Pecten or share, blood is made instead of urine, or else the urine is very bloody, which also many times comes forth at the wound. When the womb is wounded, the blood breaks forth by the privities, and the symptoms are like those of the bladder.
The wounds of the liver are deadly, for this part is the work house of the blood, wherefore necessary for life; besides by wounds of the liver the branches of the Gate or Hollow veins are cut, whence ensues a great flux of blood not only inwardly, but also outwardly, and consequently a dissipation of the spirits and strength.
But the blood which is shed inwardly amongst the bowels putrefies and corrupts, whence follows pain, a fever, inflammation, and lastly death. Yet Paulus Aegineta writes, that the lobe of the liver may be cut away without necessary consequence of death. Also the wounds of the ventricle and of the small guts, but chiefly of the jejunum are deadly; for many vessels run to the jejunum or empty gut, and it is of a very nervous and slender substance, and besides it receives the choleric humor from the bladder of the Gall. So also the wounds of the spleen, kidneys, ureters, bladder, womb and gall, are commonly deadly, but always ill, for that the actions of such parts are necessary for life; besides, many of these are without blood and nervous, others of them receive the moist excrements of the whole body, and lie in the innermost part of the body, so that they do not easily admit of medicines. Furthermore, all wounds which penetrate into the capacity of the belly, are judged very dangerous, though they do not touch the contained bowels; for the encompassing and new air entering in amongst the bowels, greatly hurts them, as never used to the feeling thereof; add hereto the dissipation of the spirits which much weakens the strength. Neither can the filth of such wounds be wasted away according to the mind of the surgeon, whereby it happens, they many times turn into fistulas, as we said of wounds of the chest, and so at length by collection of matter cause death. Yet I have dressed many who by God’s assistance and favor have recovered of wounds passing quite through their bodies.
I can bring as a witness the steward of the Portingall Embassadour, whom I cured at Melun, of a wound made with a sword so running through his body, that a great quantity of excrements came forth of the wounded guts, as he was a dressing, yet he recovered.
Not long ago Giles le Maistre, a gentleman of Paris, was run quite through the body with a rapier, so that he voided much blood at his mouth and fundament many days together, whereby you know the guts were wounded; and yet he was healed in twenty days. In like sort the wounds of the greater vessels are mortal, due to the great effusion of blood and spirits which ensues thereupon.
TBD
The first cogitation in curing of these wounds ought to be whether they pierce into the capacity of the belly; for those which pass no further than to the peritoneum shall be cured like simple wounds which only require union. But those which enter into the capacity must be cured after another manner. For oft times the caul or guts, or both fall forth at them.
A gut which is wounded must be sewn up with such a seam as Furriers or Glovers use, as we formerly told you; and then you must put upon it a powder made of Mastich, myrrh, aloes and Bole. Being sewn up, it must not be put up boisterously together and at once into its place, but little by little, the patient lying on the side opposite to the wound. As for example, the right side of the guts being wounded and falling out by the wound, the patient shall lie on his left side, for the more easy restoring of the fallen down gut, and so on the contrary. If the lower part of the guts being wounded slide through the wound, then the patient shall lie with his head low down, and his buttocks raised up by putting a pillow under them; If the upper part is hurt, then he must lie quite contrary, that the guts falling down-wards by such a site, may give way to these which are fallen out through the wound. But often in this case, the guts having taken cold by the encompassing air, swell up & are distended with wind, the which you must discuss before you put them into their place, with a fomentation of the decoction of chamomile, melilote, aniseeds and fennel applied with a sponge or contained in a bladder; or else with chickens, or whelps cut alive in the midst and laid upon the swelling; for thus they do not only discuss the flatulency, but also comfort the afflicted part. But if the inflation cannot thus be discussed, the wound shall be dilated, so that the guts may return the more freely to their place.
If the caul shall fall out, it must be speedily restored to its place, for it is very subject to putrify; for the fat, whereof for the most part it consists, being exposed to the air, easily loses its native heat, which is small and weak, whence a mortification ensues. Hence is that of Hippocrates; If the caul fall out, it necessarily putrifies. The surgeon shall know whether it putrifies, or not, by the blackness and the coldness you may perceive by touching it; neither you must when it putrifies presently restore it to its place, for so the contagion of the putrefaction would spread to the rest of the parts: but what soever thereof is putrefied shall be twitched and bound hard with a string and so cut off, and the rest restored to his proper place: but it’s good after cutting it away to leave the string still hanging thereat, so that you may pluck and draw forth whatsoever thereof may by being too straight bound fall away into the capacity of the belly. Some think it to be better to let the caul thus bound to hang forth until that portion thereof which is putrified fall away of itself, and not to cut it off. But they are much deceived, for it hanging thus would not cover the guts, which is the proper place. The guts and caul being put up, if the wound is great and worth speaking of, it must be sewn with that suture which is termed Gastroraphia; but this kind of suture is thus made:
The needle at the first putting in must only take hold of the peritoneum, & then on the opposite side only of the flesh, letting the peritoneum alone, and so go along putting the needle from without inwards, and from within outwards, but so that you only take the musculous flesh and skin over it, and then only the peritoneum, until you have sewn up all the wound. He which does otherwise shall undergo this danger, that whereas the coat peritoneum is of itself without blood, it being divided, or wounded cannot of itself be united to itself, therefore it requires an intercourse of flesh: otherwise unless it is thus united by the benefit of the flesh intermixed therewith, there would remain an incurable tumor after the wound is cicatrized on the outside. But that which we said before according to Galen’s mind, that all the wounds must be sewn, it is not so to be taken as if that the wound must be sewn up to the very end; for in the lower part of the wound there must be left a certain small vent by which the quitture may pass forth, which being wholly cleansed and exhausted, the wound must be quite healed up. But the wounds which shall penetrate into the substance of the liver, spleen, ventricles, and other bowels, the surgeon shall not suffer them to be without medicines as if they were desperate, but here shall spare neither labor nor care to dress them diligently. For doubtful hope is better than certain despair. The bladder, womb, and right gut being wounded, detergent and agglutinative injections shall be put up by their proper passages. I have read nothing as yet in any author of the wounds of the fat, for all of them refer the cure thereof to the wounds of the muscles. Yet I will say this by the way, that wounds of the fat how deep soever they be, if they are only simple, may be dressed without putting in of any tent, but only dropping in some of my balsam, and then laying upon it a plaister of Gratia Dei, or some such, for so they will heal in a short time.
TBD
When the groin and neighboring parts are wounded, we must first consider whether they pierce to within: and if they do penetrate, to what inward parts they come, whether to the bladder, the womb, or right gut: for these parts are such near neighbors that oft times they are all wounded with one blow. But for the wounds of the testicles and genital parts, because they are necessary instruments for the preserving the species by generation, or a succession of individuals, and to keep all things quiet at home, therefore the surgeon ought to be very diligent and careful for their preservation. Wherefore if they should chance at any time to be wounded, they shall be dressed as we have formerly delivered, the medicines being varied according to the state of the wound, and the appearing and happening symptoms; for it would be a thing of immense labor to handle all things in particular.
TBD
Wounds which have been received on the inside of the thighs have often caused sudden death, if they have come to the vein saphena, or the great artery, or the nerves the associates of these vessels. But when they are simple, there is nothing which may alter the usual manner of cure. Yet the patient must be careful to lie in his bed: for the vulgar Italian proverb is true. La mano al petto, la gamba al letto, [that is, the hand on the breast, and the leg on the bed.]
But when they penetrate more deeply into the substance of the part, they bring horrid and fearful symptoms, as an inflammation, an abscess, from whence oft times such abundance of matter issues forth, that the patient falls into an atrophia and consumption. Wherefore such wounds and ulcers require a careful and industrious surgeon, who may fitly make incisions necessary for the corrupt parts, and callosity of the fistulous ulcer. Some surgeons have been so bold as to sew together the end of the tendons of the ham, and of other joints, when they have been quite cut asunder. But I durst never attempt it for fear of pain, convulsions and the like horrid symptoms. For the wounds of that large tendon which is composed in the calf of the leg by the concourse of three muscles, and goes to the heel, I have observed that when it has been cut with a sword, that the wounds have been long and hard to cure; and besides when at the last they have been healed, as soon as the patient has got out of his bed, and endeavored to go, they have grown ill and broke open again. Wherefore in such wounds let the patient have a care that he begin not to go, or too boldly to use his hurt leg before it is perfectly cicatrized and the scar grown hard. Therefore that the patient may be in more safety, I judge it altogether necessary, that he use to go with crutches, for a good while after the wound is perfectly healed up.
TBD
The continuity of the nervous parts is divers ways loosed by the violent incursion of external things; as by things which contuse, batter and grind in sunder, as by the blow of a stone, cudgell, hammer, lance, bullet out of a gun, or crossbow; by the biting of greater teeth; or the pricking of some sharp thing, as a needle, bodkin, penknife, arrow, splinter; or the puncture of some venomous thing, as of a Sea Dragon; or the edge of some cutting thing, as a sword or rapier; or of stretching things which violently tear asunder the nervous bodies. Hence therefore it is, that of such wounds some are simple, others compound, and the compound, some more compound than other. For of these some are superficiary and short, others deep and long; some run along the nervous body, others run broadways; some cut the part quite asunder, others only a portion thereof. The symptoms which follow upon such wounds are vehement pain, and de fluxion, inflammation, abscess, fever, delirium, swooning, convulsion, gangrene, sphacel; whence often death ensues due to that sympathy, which all the nervous parts have with the brain. Amongst all the wounds of the nervous parts, there is none more to be feared than a puncture, or prick, nor any which causes more cruel and dangerous symptoms. Due to the straightness of the wound, medicines can neither be put in, nor the sanious matter pass forth: now the sanious matter by long stay acquires virulence, whereby the nervous parts are tainted and swollen, suffer pain, inflammation, convulsions and infinite other symptoms; of these the wounds are most dangerous, by which the nervous and membranous bodies are but half cut asunder. For the portion whereof which remains whole, by its drawing and contracting itself towards the origin, causes great pain and convulsion by sympathy. The truth hereof is evident in wounds of the head, as when the pericranium is half cut, or when it is cut to apply a trepan. For the cutting thereof infers far greater pain, than when it is cut quite asunder. Wherefore it is safer, to have the nervous body cut quite off, for so it has no community, nor consent with the upper parts, neither does it labor, or strive to resist the contraction of itself; now this contrariety, and fight, is the cause of pain; yet there arises another misery from such a wound, for the part whereinto the nerve which is thus cut insunder passes, thence forwards loses its action.
TBD
It is the ancient doctrine of the ancient physicians, that the wounds of the nervous parts should not presently be agglutinated (which notwithstanding the general and first indication usually taken from the solution of continuity requires) but rather, chiefly if they are too straight, that the punctures should be dilated, by cutting the parts which are above them, and let them be kept long open that the fifth may pass freely forth and the medicine enter well in. Yet I in many cures have not followed this counsel, but rather that which the common indication requires.
That cure is in fresh memory which I performed upon Monsieur le Coc{que} a Procter of the spiritual court, who dwelt in our Ladies street; he gathering and binding up some loose papers, run a penknife which was hid amongst them, through his hand. Also, one of his neighbors, who went to spit a piece of beef, thrust the spit through the midst of his hand. But I presently agglutinated both their wounds, without any danger, dropping presently in at the first dressing a little of my balsam warm, & putting about it a repelling & astringent medicine, & by these means they were both of them healed in a short time, no symptom thereupon happening. Yet I would not have the young surgeon to run this hazard, for first he must be well practiced and accustomed to know the tempers and habits of men; for this manner of curing would not do well in a plethoric body, or in a body replete with ill humors, or endued with exquisite sense. Therefore in such a case it will be safer to follow the course here set down.
Wounds of the nerves do not only differ from other wounds, but also among themselves in manner of curing. Although all medicines which draw from far, and waste sanious humors, may be reputed good for the wounds of the nerves; yet those which must be applied to punctures and to those nerves which are not wholly laid open, ought to be far more powerful, sharp and drying, yet so that they are not without biting, so that penetrating more deep they may draw forth the matter, or else consume and discuss that which either lies about the nerves, or moistens their substance. On the contrary when the sinews are bared from flesh and the adjoining particles, they stand in need but of medicines, which may only dry. Here you may furnish yourselves with sufficient store of medicines good for the nerves howsoever pricked.
As
℞. Terebinth. ven. & olei veteris an. ℥j. aquae vitae parum.
Or
℞. olei Terebinth. ℥j. aquae vitae ʒj. euphorb. ʒss.
Or
℞. radices Dracotia, Brionia, valeriana, & gentiana exsiccatas, & in pulverem redactas, misce cum decocto centaurij, aut oleo, aut exungia veteri;
drop hereof warm into the wound as much as shall suffice.
Or else put some hog’s, goose, capons, or bear’s grease, old oil, oil of Lilies or the like, to Galbanum, pure Rozin, opopanax dissolved in aqua vitae and strong vinegar.
Or
℞. olei hypericonis, sambuci, & de euphorbio an. ℥j. sutphuris vivi subtiliter pulverisati ℥ss. gummi ammoniaci, bdellij, an. ʒij. aceti boni ℥ij. vermium terrest. praeparat. ℥j. bulliant omnia simul ad consumptionem aceti.
Let as much hereof as shall suffice be dropped into the wound; then apply this following cerate, which draws very powerfully.
℞. olei suprà scripti ℥j. terebinth. venet. ℥ss. diachylonis albi cum gummi, ʒx. ammoniac. bdellij in aceto dissolutorum an. ʒij. resin. pint, gum. elemi, picis navalis an. ʒv. cerae quod sufficit, fiat ceracum satis molle.
We must use somewhiles one, somewhiles another of these medicines in punctures of the nerves with choice and judgment, according to their conditions, manner, depth, and the temperaments and habit of the wounded bodies. But if the pain yield not to such remedies, but rather increase, with the inflammation of the affected part, a swelling of the lips of the wound, and sweating forth of a serous, thin and virulent matter or filth, then you shall pour into it scalding oil, and shall touch three or four times not only the surface of the wound but the bottom thereof with a rag dipped therein and tied to the end of a spatula. This will take away the sense from the nerve, tendon, or membrane, like as if they were burnt with a cautery, and so the pain will be eased. So in the most grievous pains of rotten teeth, the thrusting of an hot iron into their roots, or stopping them with cotton dipped in oil of vitriol, or aqua vitae, gives most certain ease; for by burning the nerve which is inserted into their roots, the sense and so consequently the pain is taken away. So also in malignant, gnawing, eating, and spreading ulcers, which are always associated with much pain, the pain ceases by applying an escharotic, as the powder of Alum, or mercury, or aegyptiacum made somewhat more strong than usual. That the young surgeon may be more ready for this practise and the use of the former remedies, I have thought good to insert the following History both for the lateness of the thing and the pleasing memory of the most laudible Prince.
Charles the Ninth the French King being sick of a fever, Monsieur Chapellan and Castellan his physicians thought it fit he should be let blood; for the performance whereof, there was called a surgeon wondrous famous for that business; but when as he by chance had pricked a nerve instead of a vein, the King cried out, that he felt a mighty pain in that place. Then I bid, that the ligature should straight ways be loosed, otherwise the arm would presently be much swelled. But he going slowly about it, behold the arm begun to swell with such contraction, that he could not bend it, nor put it forth, and cruel pain molested not only the pricked particle, but all the whole member besides. I forthwith laid upon the wound a plaister of Basilicon, to hinder the agglutination thereof, & then I wrapped all the arm in a double linen cloth dipped in oxycrate, putting upon it an expulsive ligature, which beginning at the wrist & ending at the top of the shoulder, might keep the blood and spirits from fear of defluxion and inflammation. This being thus performed, we went aside to consult what was necessary to be done, both to assuage the pain, as also to divert the other symptoms, which usually happen upon punctures of the nerves. I being desired, thus delivered my opinion, that in my mind, there were nothing better, than presently to drop into the wound some oil of Turpentine warmed and mixed with a little aqua vitae. And then all the arm should be covered with a plaister of Diacalcitheos dissolved in vinegar and oil of roses, bound over and besides with the expulsive ligature, which we formerly mentioned. For the oil and aqua vitae have a faculty to penetrate into the bottom of the wound, & to exhaust and dry up, the serous and virulent humor, which sweats from the substance of the pricked nerve; and also to mitigate the pain by its actual heat.
Furthermore the emplaster Diacalcitheos has a faculty to dissolve the humor which has already fallen down into the arm, and to hinder the entrance and defluxion of any new matter. And the ligature is such as by its moderate astriction would serve to strengthen the muscles, and to press out and repel the humors which were fallen down into the upper part, and to prohibit that which is ready to fall down. Mine advice being approved of the physicians both in word and deede, the pain was mitigated. But the humor stayed in the part, for the dissolving and drying whereof, this following remedy was used.
℞ far. hordei & orobi, an. ʒij. flor. chamaem. & melilot. an. p. ij butyr. recentis sine sale ℥jss. lixivij barbitonsoris quod sufficit, fiat cataplasma ad formam poultice.
By these remedies the King at the last after three months space was perfectly healed, so that there remained no sign of the depraved action in the part. But if at any time there shall be so great contumacy, that it will not yield to these means, but that there is imminent danger of a convulsion; it will be better to cut it in sunder whether nerve, tendon or membrane, than to expose the patient to the danger of a deadly convulsion; for thus indeed the peculiar action of that part will be lost, but the whole body preserved thereby; for so we had determined by common consent, that if the pain which afflicted the King would not yield to the prescribed remedies, either to pour in scalding oil, or else to cut the sinew quite asunder.
For the late and sad memory of Mistress Courtin dwelling in the street of the holy-cross was in our minds, who of a vein not well opened in her arm fell into a gangrene and total mortification of that whole part, of which she died, because she was not dressed with the formerly mentioned medicines. Yet we must abstain from these too powerful remedies, when the pricked nerve shall lie bare, for else the pain would be increased, and more grievous symptoms follow. Wherefore as I have formerly wished, more mild medicines must be applied, which may dry up the serous humor without biting or acrimony, as
℞. terebinth. venet. in aq. ros. lotae ℥ij. boli armn. subtiliter pulverisati, ʒij. incorporentur simul.
Our balsam also is excellent in this case, and this of Vigoes which follows.
℞. olei. rosar. omphacini ℥jss. olei de terebinth. ʒiij. succiplaniag. ℥ss. semin. hypericonis aliquantulii contriti. m. ss. tutiaepraepar. ʒiij. calcis decies lotae cum aqua plantagin. ʒij. antimonij ʒi. sevi hircini, & vitulini, an ʒv. vermium terrestrium cum vino lotorum ℥jss. bulliant omnia simul dempta tutia in cyatho decoctionis hordei, ad comsumptionem aquae & vini, colentur, rursum{que} igni admoveantur, addendo tutiam, & fiat linimentum cum cera alba, & ʒss. croci.
This liniment assuages pains, and covers the bared nerves with flesh. This cure of punctured nerves, may with choice and judgment and observing the proportion of the parts be transferred to the pricked tendons and membranes. But take this as a general and common rule, that all nervous bodies how soever hurt, are to be comforted by anointing them with hot oils, such as the oils of bays, lilies, of worms, sage, or some other such remedy being applied to their origins and more notable passages; as to the origin of the spinal marrow, the armpits and groins. Neither do I think it fit in this place to omit an effect which sometimes happens to the large tendon of the heel, of which we formerly made mention. It oft times is rent or torn by a small occasion without any sign of injury or solution of continuity apparent on the outside as by a little jump, the slipping aside of the foot, the too nimble getting on horseback, or the slipping of the foot out of the stirrup in mounting into the saddle. When this chance happens it will give a crack like a coachman’s whip; above the heel, where the tendon is broken, the depressed cavity may be felt with your finger, there is great pain in the part, & the party is not able to go. This mischance may be amended by long lying and resting in bed, and repelling medicines applied to the part affected in the beginning of the disease, for fear of more grievous symptoms; & then applying the black plaister, or Diacalcitheos or some other such, as need shall require; neither must we hereupon promise to ourselves or the patient certain or absolute health. But on the contrary at the beginning of the disease we must foretell, that it will never be so cured but that some relics may remain, as the depression of the part affected and depravation of the action and going; for the ends of this broken or relaxed tendon due to its thickness and contumacy cannot easily be adjoined, nor being adjoined, united.
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Because the wounds of the joints have something proper and peculiar to themselves, besides the common nature of wounds of the nerves, therefore I intend to treat of them in particular. Indeed they are always very dangerous, and for the most part deadly, due to the nervous productions and membranous tendons wherewith they are bound and engirt, and into which the nerves are inserted: whereby it comes to pass, that the exquisite sense of such parts will easily bring malign symptoms, especially if the wound possesses an internal, or as they term it, a domestic part of them; as for example, the armpits, the bending of the arm, the inner part of the wrist, and ham, due to the notable veins, arteries and nerves of these parts, the loosed continuity of all which brings a great flux of blood, sharp pain and other malignant symptoms, all which we must resist according to their nature and condition, as a flux of blood with things staying bleeding; pain with anodynes. If the wound is large and wide, the severed parts shall be joined with a suture, leaving an orifice in the lower part, by which the quitture may pass forth. This following powder of Vigoes description must be strewed upon the suture.
℞. thuris, sang. draconis, boli armn. terrae sigill. an. ʒij. aloes, mastich. an. ʒj. fiat pulvis subtilis.
And then the joint must be wrapped about with a repercussive medicine composed of the whites of eggs, a little oil of roses, Bole, Mastich, and barley flour. If it is needful to use a tent, let it be short and according to the wound thick, lest it cause pain: and moreover let it be anointed with the yolk of an egg, oil of roses, washed turpentine and a little saffron. But if the wound is more short and narrow, it shall be dilated, if there is occasion, so that the humor may pass away more freely. You must rest the part, and beware of using cold, relaxing mollifying, humecting, and unctuous medicines, unless peradventure the sharpness of the pain must be mitigated. For on the contrary, astringent and desiccant medicines are good, as this following cataplasm.
℞. furtur, macri, farin. hordei, & fabarum. an. ℥iiij. florum cham ae. & melil. an m. ss. terebinth. ℥iij. mellis communis ℥ij. ol. myrtini ℥j oxymelitis, vel oxycrat. vellixivij com. quantum sufficit, fiat cataplasma ad formam poultice.
Or you may compose one of the Lees of wine, wheat bran, the powder of oak bark, cypress nuts, galls and turpentine and such, that have an astringent, strengthening and drying quality, and thereby assuaging pain, and hindering the defluxion of humors. This following medicine is astringent and agglutinative.
℞. Terebinth. venet. ℥ij. aq. vitaeparum, pulveris mastich. aloes, myrrhae, boli armn. an. ℈ij.
And also our balsam will be good in this case, if so be that, you add hereto so much powder which dries without acrimony as occasion shall serve. I admonished you before to take heed of cold, and now again; for it is hurtful to all wounds and ulcers, but especially to these of the nervous parts; hence it is that many die of small wounds in the winter, who might recover of the same wounds though greater in the summer. For cold according to Hippocrates is nipping to ulcers, hardens the skin, and hinders them from suppuration, extinguishes natural heat, causes blackness, cold aguish fits, convulsions and distentions. Now divers excrements are cast forth of wounds of the joints, but chiefly albugineous, that is, resembling the white of an egg, and mucous, and sometime a very thin water, all which favour of the nature of that humor which nourishes these parts. For to every part there is appropriate for his nourishment and conservation, a peculiar balsam, which by the wound flows out of the same part, as out of the branches of the vine when they are pruned, their radical moisture or juice flows; whence also a callus proceeds in broken bones.
Now this same mucous and albugineous humor, slow and frozen flowing from the wounded joints, shows the cold distemper of the parts, which causes pain, not to be orecome by medicines only potentially hot. Wherefore to correct that, we must apply things actually hot, as beasts and swine’s bladders half full of a discussing decoction, or hot bricks quenched in wine. Such actual heat helps nature to concoct and discuss the superfluous humor impact in the joints, and strengthens them; both which are very necessary, because the natural heat of the joints is so infirm that it can scarce actuate the medicine unless it is helped with medicines actually hot. Neither must the surgeon have the least care of the figure and posture of the part, for a vicious posture increases ill symptoms, uses to bring to the very part though the wound is cured, distortion, numbness, incurable contraction; which fault lest he should run into, let him observe what I shall now say; If the forepart of the shoulder is wounded, a great bolster must be under the armpit, and you must carry your arm in a scarf, so that it may bear up the lower part of the arm, so that the top of the shoulder may be elevated somewhat higher, and so that it may be thereby more speedily and happily agglutinated and consolidated. If the lower part is wounded, when flesh begins to be generated and the lips of the wound to meet, you must bid the patient to move and stir his arms divers ways ever and anon, for if that is omitted or negligently done, when it is cicatrized then it will be more stiff and less pliable to every motion; and yet there is a further danger lest the arm should totally lose its motion. If the wound is upon the joint of the elbow, the arm shall be placed and swathed in a middle posture, that is, which neither too straightly bows it, nor holds it too stiffly out; for otherwise when it is cicatrized, there will be an impediment either in the contraction or extension. When the wound is in the wrist, or joints of the fingers either externally or internally, the hand must be kept half shut, continually moving a ball therein. If the fingers are held straight stretched forth, after it is cicatrized, they will be unapt to take up or hold anything, which is their proper faculty. But if after it is healed, it remain half shut, no great inconvenience will follow thereon; for so he may use his hand divers ways to his sword, pike, bridle and in anything else. If the joints of the hip are wounded, you must so place the patient that the thigh bone may be kept in the cavity of the hucklebone, & may not part a hair’s breadth therefrom, which shall be done with linen bolsters and ligatures applied as is fitting, and lying full upon his back. When the wound shall begin to cicatrize, the patient shall use to move his thigh every way, lest the head of the thigh-bone stick in the cavity of the huckle-bone without motion. In a wound of the knee, the leg must be placed straight out, if the patient desire not to be lame. When the joints of the feet and toes are wounded, these parts shall neither be bended in nor out, for otherwise he will not be able to go.
To conclude, the site of the foot and leg, is quite contrary to that of the arm and hand.
TBD
The wounds of the ligaments, besides the common manner of curing these of the nerves, have nothing peculiar, but that they require more powerful medicines, for their agglutination, desiccation and consolidating; both because the ligament parts are harder, and dryer, and also for that they are void of sense. Therefore the aforesaid cure of nerves and joints may be used for these wounds: for the medicines in both are of the same kind, but here they ought to be stronger and more powerfully drying. The Theory and cure of all the symptoms which shall happen thereupon have been expressed in the chapter of curing the wounds of the nervous parts, so that here we shall need to speak nothing of them, for there you may find as much as you will. Wherefore here let us make an end of wounds, and give thanks to God the author and giver of all good for the happy process of our labors, and let us pray that, that which remains may be brought to a happy end, and secure for the health and safety of good people.
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