A wound is defined as a discontinuity caused by factors such as a blow, fall, or bite, characterized by fresh bleeding and the presence of decay or filth. It is often referred to as a new simple ulcer, as the discontinuity can occur in various parts of the body. Different Greek terms are used to describe these wounds based on their specific locations: in the flesh, it is called “Helcos”; in the bone, “Catagma”; in the nerve, “Spasma”; in the ligament, “Thlasma”; in the vessels, “Apospasma”; and in the muscles, “Regma.” Furthermore, the type of discontinuity that occurs in the vessels, where their openings are exposed, is known as “Anastomasis.” Erosion-related discontinuities are termed “Aneurosis,” while those resulting from sweating or translocation are referred to as “Diapedesis.” To facilitate understanding, I have organized these concepts in the following table.
Any external forces that assail the body with violence can be classified as causes of wounds, commonly referred to as green wounds and, more specifically, bloody wounds. These forces can be either animate or inanimate.
– Animate sources include bites and stings from animals.
– Inanimate sources encompass impacts from arrows, swords, clubs, firearms, stones, daggers, and similar implements.
Due to the diversity of these causes, various terms are used to describe the resulting injuries: wounds inflicted by sharp or pointed objects are termed punctures; those resulting from cutting instruments are referred to as wounds or gashes; and injuries caused by heavy or blunt objects are classified as contusions.
Wounds are initially identified through visual observation and the signs that are evident. The surgeon must first and foremost determine which wounds are curable and which are not, as well as those that are unlikely to respond to treatment versus those that can be easily healed. A prudent surgeon should refrain from guaranteeing a cure for a severe or life-threatening wound, as this could lead to the misperception that the surgeon’s lack of skill was responsible for the patient’s demise, when in fact it was the severity of the wound itself that proved fatal.
When faced with a dangerous wound that still allows for the hope of recovery, it is incumbent upon the surgeon to inform the patient’s friends about the current risks and the uncertain nature of the injury. This ensures that if the healing process is unsuccessful due to the severity of the wound, the surgeon will not be perceived as inept or deceitful.
While this responsibility falls to a competent and conscientious surgeon, it is the mark of a deceitful charlatan to exaggerate the seriousness of minor wounds in order to make his efforts appear more impressive than they truly are.
A surgeon who asserts that a condition is easily treatable has an obligation to uphold that claim and will be motivated to explore every possible avenue for the patient’s swift recovery. Otherwise, a wound that is inherently minor risks escalating in severity due to the surgeon’s negligence. Thus, it is crucial for the surgeon to accurately assess which wounds should be classified as significant.
According to Galen, there are three ways to determine the seriousness of a wound. The first criterion is the significance and location of the affected part; for instance, wounds to the brain, heart, or major blood vessels, despite their small size, are considered grave. The second criterion pertains to the extent of the disruption in continuity; thus, wounds may be classified as serious when a substantial amount of tissue is lost in all dimensions, even if the affected area is generally regarded as minor. The third criterion concerns the nature of the wound; wounds in the joints are often deemed serious due to their tendency to become problematic or poorly healing.
Wounds are considered dangerous if they involve any major nerve, vein, or artery. Injuries to nerves raise the risk of convulsions, while damage to large blood vessels can result in significant venous or arterial blood loss, leading to a weakened state. Wounds located in sensitive areas such as the armpits, groin, legs, joints, or between the fingers are also viewed with concern. Additionally, injuries affecting the head or the ends of muscles are classified as serious. In contrast, wounds that only damage the fleshy tissue are generally deemed less perilous. However, wounds that penetrate vital organs such as the bladder, brain, heart, liver, lungs, stomach, or small intestines are considered potentially fatal. Furthermore, injuries that sever any bone, cartilage, nerve, or sections of the cheek or prepuce cannot be repaired.
Contused wounds present a greater challenge for healing compared to wounds caused by a simple disruption of continuity. Before healing can commence, contused wounds must undergo a process of suppuration and cleaning, which takes considerable time. Moreover, round and circular wounds are particularly problematic because they lack the angles necessary for proper healing; unity in healing requires the convergence of lines, which is not achievable in circular wounds due to their singular, oblique contour. Additionally, the severity of a wound is proportional to the degree of separation between its edges; in the case of round wounds, the edges are often more widely apart. In contrast, wounds that are angular or follow the lines of muscle fibers tend to heal more easily.
Wounds tend to heal more easily in young men than in older individuals due to the greater vitality found in their bodies. Young individuals possess a more abundant supply of nourishing blood, which facilitates the restoration of lost tissue. In contrast, the healing process is slower in older bodies, as they typically have a reduced quantity of blood that is often drier, and their natural vigor is diminished.
Wounds sustained in the spring are generally easier to heal than those incurred in winter or summer. Both extreme heat and cold can adversely affect the healing process. The occurrence of convulsions at the site of a wound is particularly concerning, as it indicates potential injury to the nervous system, which is intricately connected to the brain—the origin of the nerves.
The formation of a tumor around significant wounds is typically a positive sign, as it demonstrates the body’s natural ability to expel harmful substances and alleviate discomfort in the affected area. However, when essential organic structures are completely severed, they cannot be reconnected. A vital part, once detached from the body, loses its ability to receive nourishment from the heart, akin to a plant severed from its root, which is necessary for survival.
In some cases, the continuity of nerves, veins, arteries, and even bones can be partially restored, but not in a manner that fully replicates the original structures. This restoration occurs not according to the “first intention,” which involves the conversion of nourishing blood into the specific tissue of the injured area, but rather through a “second intention,” where the lost tissue is replaced by a different material.
The first intention primarily concerns the fleshy parts, while the second intention is evident in reproductive tissues, where the healing process involves the introduction of a non-identical substance that nature selects in its efforts to preserve the body. Consequently, what forms during healing may not be true bone but rather a callus, derived from a substance that is somewhat coarser than that from which bones originally develop.
When this humor reaches the site of the fracture, it effectively binds the ends of the bones together—something that would otherwise be impossible due to their inherent hardness. The bones of children unite more easily and rapidly owing to the pliability of their soft, tender material.
Finally, it is important to remind the surgeon that even small wounds, which may not initially seem fatal to any craftsman, can sometimes lead to death. This may occur due to an underlying, unseen condition of the wounded area and the surrounding tissues. For this reason, Hippocrates noted that it is not enough for the physician to simply fulfill their duties; the external conditions must also be appropriately managed and configured.
For the effective treatment of wounds, the surgeon must focus on a fundamental and universal objective: the rejoining of the severed parts. This principle is so widely understood that even laypersons are aware of it; when something is separated, there is an inherent desire for it to be united, as union opposes division. However, the methods by which such a union can be achieved are known only to a skilled practitioner.
Thus, we reach this primary goal through the assistance of nature, which serves as the main agent, while the surgeon acts as nature’s facilitator. If nature is not robust, the surgeon will never achieve his desired outcome. To support this process, the surgeon must undertake five essential actions. The first of these is the removal of any foreign objects—such as pieces of wood, metal, bone, bruised flesh, or clotted blood—that may be lodged in the wound, whether from external sources or from within the body. The presence of these materials must be addressed; otherwise, true union cannot be anticipated.
Another essential step for the surgeon is to align the edges of the wound, as they cannot be properly agglutinated and united without this alignment. The third step involves keeping the joined edges tightly together. Fourth, it is crucial to maintain the proper condition of the wounded area, as any underlying imbalance will prevent the restoration of unity. Finally, the surgeon must address any complications that may arise, as the practitioner is often required to adjust the treatment plan accordingly.
All foreign and external materials must be removed as swiftly as possible, as they obstruct nature’s efforts to achieve union, particularly if they exert pressure on any nerve or tendon. Such interference can lead to pain or the development of an abscess in a vital area or in tissues that support essential functions.
However, if the prompt and overly hasty removal of foreign bodies poses a risk of severe pain or significant blood loss, it is often better to allow nature to manage the situation rather than exacerbate the wound through excessive force. Nature, in its own time, will gradually expel any foreign objects deemed detrimental, along with any pus present in the wounded area.
On the other hand, if a delay in intervention poses a real threat, it is essential for the surgeon to act swiftly, safely, and as gently as the situation permits. Rough or forceful treatment of wounds can lead to complications such as excessive bleeding, fainting, convulsions, and other alarming symptoms, placing the patient at greater risk than the original wound itself.
Therefore, the practitioner may extract foreign bodies using either his fingers or appropriate instruments designed for this purpose. The ease of extraction can vary significantly depending on whether the embedded object is hard or soft, as well as on its visibility and accessibility. This variance is influenced by the shape of the object and the characteristics of the affected area, which may be soft, hard, or deeply embedded, thus securing the object more tightly or loosely. Additionally, there is always a concern about potentially causing further harm, such as damaging a blood vessel. A detailed explanation of how to carry out this procedure, along with the necessary instruments, will be provided in dedicated sections focusing on wounds caused by gunshots, arrows, and similar injuries.
The surgeon can achieve the second and third objectives of wound healing through two primary methods: ligatures and sutures. However, before employing these techniques, he must carefully assess whether there is significant bleeding. If the hemorrhage is excessive, it should be controlled; conversely, if it is insufficient, the surgeon may encourage it—unless the blood is accumulating in a cavity or abdominal area. This approach helps ensure that the affected area, relieved of any excess blood, is less prone to inflammation.
Consequently, the edges of the wound must be approximated and secured using sutures and ligatures. It is important to note that this method applies only to those wounds that are suitable for both treatments, based on their nature, size, and the condition of the surrounding tissue. For minor and small wounds, particularly in the arms or legs, a single ligature—known as the incarnative ligature—may suffice. However, for wounds that sever muscle fibers transversely, both sutures and ligatures are necessary to bring together the edges, which may be somewhat distant from each other, allowing them to connect effectively.
When a significant cut causes a portion of flesh to hang down, it must be carefully sutured back into place. Larger and more substantial wounds in certain areas, such as the ears, nose, scalp, eyelids, lips, abdomen, and throat, require sutures, as these regions may not easily accommodate a ligature due to their shape and location.
According to the consensus of ancient practitioners, there are three types of ligatures. The first is known as the Glutinative or Incarnative ligature; the second is the Expulsive ligature; and the third is the Retentive ligature. The Glutinative or Incarnative ligature is suitable for simple, clean, and still-bloody wounds. It consists of two ends and should be applied by starting from the opposite side of the wound, proceeding upwards, crossing over the wound, and then moving downwards to closely approximate the edges of the wound. Care must be taken to ensure that the ligature is neither too tight— which could lead to inflammation or pain— nor too loose, which would render it ineffective in securing the wound edges properly.
The Expulsive ligature is suitable for managing sanious and fistulous ulcers, as it helps to expel the impurities contained within them. This technique involves using a single roll with a simple head. The binding process begins at the bottom of the sinus or cavity, where tighter binding is applied. Gradually, as you move upwards, you should loosen the binding slightly, ultimately reaching the ulcer’s opening. This method facilitates the expulsion of the unhealthy discharge, as previously mentioned.
The Retentive ligature is designed for areas that cannot withstand tight binding, such as the throat and abdomen, as well as any regions suffering from pain, since painful areas resist constriction. Its purpose is to maintain local treatments and is executed using a roller that may consist of either one or multiple heads. All these rollers should be made of linen that is neither too new nor too old, and not excessively coarse or too fine. Their width must be appropriate for the body part to which they are applied, with the dimensions being determined based on the size, shape, and location of the area. This will be discussed in greater detail in our forthcoming texts on fractures and dislocations.
The surgeon’s initial responsibility in the wound healing process is to maintain the condition of the injured area through a carefully structured diet, as prescribed by a physician, in conjunction with the application of both universal and local remedies. During the initial stages, a delicate, cooling, and moist diet should be adhered to until the patient is deemed safe and free from the usual risks associated with their condition. In this regard, the patient should be fed sparingly, particularly if they exhibit signs of plethora; they must avoid salt, spiced meats, and wine. For those with a choleric or sanguine temperament, alternatives to wine include barley decoction, liquorice, or a mixture of water and sugar.
It is crucial for the patient to remain calm and rested, as rest is considered, according to Celsus, the finest medicine. They should steer clear of sexual activity, disputes, quarrels, anger, and any other mental disturbances. Once the patient appears to have passed the critical phase, they may gradually return to their usual diet and lifestyle. Among the universal remedies are phlebotomies and purging, which serve to redirect and prevent excessive flow, thereby safeguarding the balance of the affected area.
Phlebotomy is not always necessary, particularly for minor wounds or in individuals who do not suffer from ill humors or plethoric conditions. It is, however, crucial for severe wounds where there is a risk of defluxion, pain, delirium, agitation, and restlessness; and especially so in plethoric bodies or when there is damage to the joints, tendons, or nerves. Gentle purgation is advised because stronger agents can agitate the humors, leading to risks of defluxion and inflammation. Therefore, such procedures should never be carried out without the guidance of a physician.
Regarding topical and specific treatments, using agglutinative medicines is recommended. These should possess drying and binding properties to help close the wound edges and reduce the risk of defluxion, taking into account the nature of the affected area and the severity of the condition. Simple medicinal agents include olibanum, aloes, Sarcocolla, Bole-armenick, Terra sigillata, Sanguis Draconis, common and Venice turpentine, gum elemni, plantain, horse-tail, greater comfrey, Parina Volatilis, among many others. Details on these will be discussed further in our upcoming Antidotary.
The fifth objective in healing wounds is to address the complications and symptoms that typically arise post-injury, which significantly increases the surgeon’s responsibilities. Often, the surgeon must prioritize managing these complications—such as bleeding, pain, inflammation, fever, convulsions, paralysis, delirium, or distraction—over treating the primary wound itself. We will discuss these issues in greater detail, providing specific guidance after an initial discussion on sutures, to the extent deemed appropriate for this context.
When wounds occur along the thighs, legs, and arms, they often do not require sutures as the continuity of tissue can be readily restored using ligatures. However, crosswise incisions demand suturing because the flesh and similar tissues, once cut, tend to retract towards the intact areas. This separation necessitates joining and securing the tissue through stitching. If the wound is deep, the needle must capture a substantial amount of flesh; superficial stitches that only secure the upper layer can result in the entrapment of discharge within the wound, potentially leading to abscesses and deep ulcers. Therefore, it is imperative to discuss the techniques of suturing.
The first technique, known as Interpunctus, is characterized by spacing stitches approximately a finger’s breadth apart. This method is suitable for fresh, fleshy wounds that cannot be closed with ligatures and contain no foreign bodies. The procedure is carried out as follows:
To begin, you will need a smooth needle threaded with a triple-point design, which facilitates easier penetration through the skin. The needle’s head should be slightly hollowed to accommodate the thread, allowing for a smoother passage. Additionally, a small tube with an opening at the end is essential; this should be positioned against the edge of the wound to prevent movement while you insert the needle. The window in the tube enables visibility as the needle passes through, while keeping the edge of the wound secure during the threading process.
After piercing the wound’s edges, tie a knot close to the entry point and trim the excess thread. This prevents any remaining thread from sticking to the dressings, which can cause discomfort upon removal. Note that the first stitch should be inserted at the center of the wound, while the second stitch should be placed between the center and one of the ends.
When completing your stitches, ensure that the lips of the wound are not overly compressed; a small gap should remain to allow for the discharge of fluids and to minimize inflammation and pain. If the lips are tightly pressed together, a swelling could occur as the wound begins to supurate, potentially causing the edges to stretch and break due to the tension of the thread.
Be mindful not to capture too much or too little flesh with your needle. Insufficient tissue will not provide a secure hold, while too much can lead to pain, inflammation, and undesirable scarring. In deeper wounds, particularly those situated in thicker muscle tissue, it is crucial that the needle be inserted deeply enough to grasp adequate fleshy substance; this prevents the thread from breaking due to the weight of any ungrasped tissue.
In some cases, wounds may be located in areas that necessitate the use of a curved needle and tube for successful suturing. Therefore, I have deemed it beneficial to illustrate both types, allowing you to choose the appropriate tool based on the situation at hand.
The design features pipes with windows, known as fenestels, and needles specifically tailored for suturing.
The second suture is performed in the same manner as skinners sew their fells or furs. It is essential to use this type of suture for the guts when they are wounded, ensuring that excrement does not escape through the wound.
The third suture involves one or more needles threaded through the wound, with the thread wrapped around both the head and the point of the needle. This technique resembles how boys secure their needles in their caps or clothing to prevent loss. This particular suture is suitable for the treatment and healing of hare-lips, which we will illustrate in a figure later on.
The fourth type of suture, known as Gastroraphia, is specifically designed for repairing and reconnecting the large muscles of the epigastrium, or lower abdomen, when they have been severely wounded, along with the underlying peritoneum. We will present the details of this technique at the appropriate juncture.
The fifth type is referred to as the dry suture. We employ this method exclusively for facial wounds, and we will provide a detailed description of this technique in its relevant context.
Blood loss commonly occurs in wounds due to the cutting, breaking, or tearing of certain vessels. It is essential to address and treat this bleeding promptly, as blood is nature’s vital treasure, essential for sustaining life. When blood flows from an artery, it is typically characterized by its more vigorous and vibrant nature, seeming to leap forth due to the vital spirit contained within the arteries. In contrast, blood drawn from a vein appears darker, thicker, and flows more slowly. Various methods exist for staunching blood flow effectively.
The most common method involves closing the lips of the wound, which is usually effective for superficial injuries. This is achieved by applying medications that possess astringent, cooling, drying, and adhesive properties to hold the wound edges together.
Prescription:
Prepare a powder to be taken with egg white.
Or
Prescription:
Mix them with egg white and rabbit down, then soak the dressings in this mixture, applying them both directly to the wound and around it. Afterward, secure the wound with a double cloth and a snug bandage, positioning the affected area in the most comfortable and pain-free manner possible.
If bleeding persists despite these measures, remove all coverings, then firmly press on the wound and the vessel’s opening with your thumb. Maintain the pressure until the blood forms a thick clot that seals the vessel effectively.
If the bleeding cannot be controlled, the suture (if present) must be opened, and the mouth of the vessel, near its origin or root, should be grasped and secured with a needle and thread, including as much surrounding flesh as the situation allows. I have successfully managed severe hemorrhages this way, even during amputations, as I will illustrate at an appropriate time.
To carry out this procedure, it is often necessary to incise the skin covering the wounded vessel. For instance, when the jugular vein or artery is severed, it tends to retract both upwards and downwards. Thus, the skin must be opened to expose it. A needle and thread should be passed underneath, and the vessel secured as I have frequently done. However, it is crucial to ensure that the surrounding flesh has healed sufficiently before loosening the knot to avoid further bleeding from the vessel.
If the condition of the affected area prohibits the effective clamping and binding of the vessel, we must resort to escharotics. These include the powder of burnt vitriol, powder of mercury, and a small quantity of burnt alum—caustics that induce the formation of an eschar. The natural sloughing of this eschar should not be hastened through artificial means, to prevent premature detachment before the vessel’s orifice is securely sealed by either flesh or clotted blood.
However, there are instances where the surgeon may be compelled to completely sever the vessel. By doing so, the ends of the cut vessel retract and are concealed by the surrounding tissues, thereby allowing the previously uncontrollable bleeding to be more easily halted. Nonetheless, this is a drastic measure and should only be considered after all other less invasive techniques have been exhausted.
The pain that follows wounds should be alleviated promptly, as it can quickly undermine the body’s vitality and lead to an increased discharge, regardless of the individual’s overall health and condition. Nature, eager to assist the injured area, often directs an excess of humors to it, which can contribute to an exacerbation of the discharge—whether through an increase in quantity, quality, or both.
To relieve this pain and counteract the discharge, the author recommends applying medications to the affected area that possess both repelling and soothing properties, such as:
Prescription:
Melt the wax in the oils, then mix in the remaining ingredients. Prepare the medicine according to established methods for application to the affected area.
or
Prescription:
Melt the rose oil and vinegar together. For soothing treatments, irrigations of rose oil and myrtle oil, combined with either the white of an egg or a whole egg, can be effective if there is no significant inflammation. Additionally, rollers and double cloths moistened with oxycrate can also be beneficial for the same purpose. However, it is important to frequently renew these applications, as once they dry, they can exacerbate the pain. If these methods do not alleviate the pain, we should then resort to narcotic remedies, such as poppy oil, mandrake oil, and a poultice made from henbane and sorrel, incorporating mallows and marshmallows as previously discussed in relation to treating phlegmon.
Lastly, attention must be paid to the underlying cause of the pain, the type and nature of the humor involved, and the manner in which Nature reacts. The treatment must be adapted accordingly: if heat is the cause of pain, it can be alleviated by applying cooling agents. A similar rationale applies to the opposite scenario. If Nature is working towards suppuration, it is crucial to support this process with medicines that promote suppuration.
A convulsion is an involuntary contraction of the muscles, specifically those parts of the body that we normally move at our discretion, such as those connected to the brain and spinal cord. During a convulsion, the affected member or even the entire body (if the convulsion is generalized) cannot be moved voluntarily. Unlike in paralysis, where motion is completely lost, in a convulsion, movement is impaired but not entirely absent. It is important to note that convulsions can affect the entire body or just specific areas, leading to the classification of three general types of convulsions. The first type, referred to by the Greeks as “Tetanos,” is characterized by a complete stiffness of the body, rendering it motionless akin to a stake.
The second type of convulsion is known as Opisthotonos, where the entire body arches backward. The third type, called Emprosthotonos, occurs when the entire body bends or curves forward. A specific convulsion affects individual muscles supplied by a nerve, such as those in the eye or tongue.
Convulsions can be triggered by various factors including repletion (overfullness) or inanition (emptiness), sympathetic responses, or interconnected pain. An excess of bodily fluids, often due to overeating, excessive drinking, lack of exercise, or failure to maintain regular bodily functions such as the suppression of hemorrhoids or menstrual cycles, can lead to repletion. This condition causes these fluids to accumulate in the nerves, stretching and ultimately constricting them excessively, which leads to convulsions.
This phenomenon can be likened to how leather or the strings of a lute or violin react to humidity: swelling with moisture, they eventually stretch and may snap due to being overly taut.
Excessive vomiting, diarrheal fluxes, and severe bleeding can lead to inanition, or emptiness, which makes convulsions caused by wounds particularly fatal, as well as those induced by severe fevers. These conditions deplete the intrinsic moisture of the nerves, causing them to contract much like leather that has been withdrawn too close to a fire, or like violin strings that snap under the stress of excessive summer heat. Such convulsions are often incurable.
Hippocrates teaches us that it is preferable for a fever to occur following a convulsion rather than the other way around. This is only effective if the fever corresponds to the intensity of the underlying cause of the convulsion, especially when that convulsion arises from repletion. In this scenario, the abundant and thick bodily humors responsible for the convulsion are gradually digested and diminished by the heat of the fever.
The causes of a convulsion due to pain can stem from various sources. These include the puncture of a nerve either by the bite of a venomous animal or by the sting of an inanimate object such as a needle, thorn, or pen-knife. Extreme and piercing cold can also trigger convulsions, particularly harming the wounds in the nervous tissues, leading to significant and acute pain. This pain causes nerves to contract toward their origin, the brain, as if seeking relief from a source of protection during distress.
Additionally, harmful vapors carried to the brain from some form of putrefaction can irritate the brain, causing it to contract. This contraction pulls together all the nerves and muscles, as observed in individuals suffering from epilepsy. From this, it is evident that the brain and nerves are interdependent, each suffering with the other.
The symptoms of a convulsion include laborious, painful, and disordered movements, either in part or across the entire body, an abnormal turning of the eyes and face, a contraction of the lips, a pulling in of the cheeks resembling laughter, and a generalized sweating.
The treatment for convulsions should be tailored to the specific cause of the condition, as the approach varies depending on whether the convulsion is due to repletion, inanition, or pain. For convulsions caused by repletion, the remedy involves the use of discussing and evacuating medicines. This may include a carefully prescribed diet, purgatives, bloodletting, local digestive medicines, exercise, massage, sulfurous baths, and other treatments recommended by a knowledgeable physician overseeing the care. These interventions aim to eliminate excess and wasteful humors that affect the nerves and the overall state of the body.
Local remedies such as oils, ointments, and liniments should be applied to the neck, spine, and any contracted areas. Recommended oils include those derived from foxes, bay leaves, chamomile, worms, turpentine, Costus, and Castorcum. Suitable ointments may consist of unguentum Arragon, Agrippae, Althaea, and Martiatum. An example of a liniment formulation may include a combination of these oils and ointments.
Prescription:
Make a Liniment for your use, or
Prescription:
Make a Liniment, or
Prescription:
Make into a liniment.
This condition can be effectively treated with a light diet and sweating induced by decoctions of guaiacum, as these remedies help to digest the coarse, thick, and viscous waste that contributes to the ailment.
For convulsions caused by starvation, the remedy lies in employing substances that provide wholesome and moderate nourishment. Thus, it is essential to prescribe a diet rich in nourishing foods, such as broths and potages made from capons, pigeons, veal, and mutton, boiled together with violet and mallow leaves. Additionally, conserves should be included to strengthen weakened bodily functions and hydrate the system, such as conserves made from bugloss, violets, borage, and water lilies.
The following broth will be beneficial:
Prescription:
Let them all be boiled with a chicken and let him take the broth every morning. If thirst oppress him, the following julep will be good:
Prescription:
Make a syrup; let it be used for thirst.
If the patient is experiencing physical confinement (constipation), emollient and hydrating clysters should be prescribed, prepared from a decoction of sheep’s head and feet, along with mallow, marshmallow, Pellitory of the wall, violet leaves, and other similar ingredients. To facilitate a quicker and more convenient remedy, the clysters may alternatively consist of oil and milk. Topical treatments will include liniments and baths. An example of a liniment is as follows:
Prescription:
Make a liniment with which the entire spine and the affected area should be anointed. This will serve as the formulation for an emollient and hydrating bath.
Prescription:
Cook them in common water, adding 8 pounds of Lily oil (Olei Lillior).
Prepare a warm bath for the patient to enter. After bathing, they should be dried with warm towels or allowed to rest in bed, avoiding perspiration. However, if the patient can tolerate it, it would be beneficial to arrange a bath using either milk or oil, or a combination of both in equal parts.
A convulsion induced by a combination of pain and the transmission of the affliction can be effectively treated with remedies that counteract the source of the pain. For instance, if the convulsion results from a puncture or venomous bite, the wound should be incised to allow the toxic material to drain more easily. Additionally, fluids with a thin, liquid consistency that also possess drying and digestive properties should be applied to help neutralize and dissolve the venom, such as treacle and mithridate diluted in Aqua vitae, along with a small amount of mercurial powder, which serves as a powerful antidote. Cupping glasses and scarification can also be beneficial.
Furthermore, all painful causes can be addressed through the use of opposing remedies. If the pain arises from a pinched nerve or tendon, it should be treated promptly with appropriate solutions, such as oil of turpentine and euphorbium mixed with Aqua vitae, along with other remedies suitable for nerve punctures. If the pain stems from excessive cold—which can be detrimental to the brain, spinal cord, and nerves—the patient should be placed in a warm environment, like a hot house or stove. The entire spine and any affected areas should be anointed with the warm liniments mentioned before, as this method is safer than abruptly exposing the patient to intense heat or a warm bath.
Throughout this process, the surgeon must remain vigilant for any signs of an impending convulsion. If such signs, whether prominent or imminent, are observed, it is essential to place a stick between the patient’s teeth to prevent them from clenching tightly due to the involuntary contraction of the jaws. Many individuals in such situations have bitten off their tongues. For this purpose, the surgeon should utilize an instrument called a Speculum Oris, which can be adjusted in size by means of a screw, as illustrated in the accompanying figures—one demonstrating the instrument fully opened and slightly twisted, and the other showing it closed.
The figure of a speculum oris used to open the teeth when they are locked or held fast together.
Palsy is characterized by the weakening or softening of the nerves, resulting in a loss of sensation and movement. This condition typically affects only one part of the body, such as the right or left side, which is why it is specifically referred to as palsy. In a broader and less precise sense, the term may also be applied to the resolution of a single limb. However, when the entire body experiences this resolution, it is termed apoplexy.
Palsy can manifest in various ways; it may affect half of the body, the upper regions from the navel to the head, the lower areas extending from the navel to the feet, or even specific parts such as the tongue, throat, bladder, penis, eyes, and, ultimately, any of the body’s appendages.
Palsy is fundamentally different from a convulsion in its very nature. While a convulsion is characterized by the contention and contraction of a body part, palsy involves a resolution and relaxation of that same area. Additionally, in cases of palsy, the sense may be significantly impaired or entirely absent, whereas sensory perception typically remains intact during a convulsion. Some individuals may also experience a sensation of pricking or substantial pain in the affected region.
The causes of palsy can be classified as internal or external. Internal causes arise from humors that obstruct one of the brain’s ventricles or one side of the spinal cord, preventing the animal faculties responsible for sensation and movement from transmitting signals through the nerves to the affected body parts. External causes, on the other hand, include falls, blows, and similar injuries that may result in dislocations of joints, displacement of the spinal cord, and constrictions or compressions of the vertebrae. These factors impede the passage of the animal spirit to the organs in their entirety.
Through a solid understanding of anatomy, one can accurately identify the location of the underlying pathological cause by examining the affected area. For instance, when palsy manifests predominantly on either the right or left side, it indicates an obstruction in the brain or spinal cord. Conversely, when the head remains unaffected while one side of the body is impaired, the issue likely resides at the origin of the spinal cord. If the arms are involved, it suggests that the pathology may be located within the fifth, sixth, or seventh cervical vertebrae. In the case of lower limb weakness, the underlying cause is likely associated with the lumbar vertebrae and sacrum. It is crucial for the surgeon to diligently consider these origins to effectively address the disease.
Palsy resulting from a severed or severely bruised nerve is typically incurable because the pathway for the animal spirit to reach the affected part is obstructed. Elderly individuals seldom recover from palsy due to diminished vital heat and an accumulation of excess humors, and chronic palsy, which has persisted for an extended period, particularly following an apoplectic event, offers little hope for recovery.
Interestingly, the onset of a fever following a palsy may be beneficial, as it suggests the possibility of reabsorbing the excess resolving and relaxing humors. However, if the affected limb becomes significantly atrophied while the opposite limb dramatically increases in size, heat, and coloration, this is concerning. Such a condition indicates extreme weakness in the afflicted area, leaving it susceptible to further depletion of nutrition while resources are diverted to the healthier or opposing side.
In the treatment of palsy, it is essential to commence with general remedies, dietary adjustments, and purging before considering any specific interventions. This foundational care should be entrusted to a knowledgeable and skilled physician. One effective remedy for this condition is the decoction of guaiacum, as it promotes sweating and helps to attenuate, digest, and eliminate excess moisture that may be hampering the nerves.
If sweating does not occur, it may be beneficial to apply heated bricks, tempered by soaking in a mixture of wine, vinegar, and resolving herbs, around the affected limbs. Alternatively, stone bottles or the bladders of oxen and swine, partially filled with the same decoction, can also be used. The application of this heat serves to invigorate and restore vitality to the affected area, which often experiences significant languor in this condition.
Subsequently, the patient should enter a bathing tub, which should be adequately draped as outlined in our Treatise on Baths, to allow them to absorb the vapor from the aforementioned decoction.
Prescription:
Place all ingredients into the vessel specified in the aforementioned Treatise. The patient should remain in the bathing tub for as long as his strength permits. Afterward, he should be carefully moved to his bed, where he should be warmly covered to encourage additional sweating. Once he has perspired, he should be gently dried and allowed to rest. Subsequently, he should be promptly anointed with the ointment strongly recommended by Leonellus Faventinus:
Prescription:
All should be ground and mixed together with the oils and wine; allow to boil in a double boiler until the wine is completely consumed, yielding a strong extract. Then add galbanum, bdellium, euphorbia, myrrh, castoreum, bear fat, duck fat, and stork fat.
Prepare an ointment in the form of a liniment, adding a small amount of wax if necessary. Alternatively, you may use the following remedy that has been endorsed by numerous physicians:
Prescription:
All should be ground into a powder, and the gums should be dissolved with a little aqua vitae and vinegar.
Ensure that all ingredients are placed in suitable containers to be distilled in a water bath (Balneo Mariae). The resultant liquid should be applied to the spine and any paralyzed limbs. I have frequently tested the efficacy of the following remedy:
Prescription:
All should be chopped and crushed, and infused in the aqua vitae and mulled wine.
Distill the substances in a water bath (Balneo Mariae) as previously described. Moisten the affected areas with the distilled liquid, and also offer the patient a spoonful to drink in the morning, sweetened with sugar. This will warm the stomach and help to eliminate the excess phlegm that fuels the disease.
You should also prescribe exercises for the affected areas, along with frequent and vigorous massage using hot linen cloths. This will help stimulate the body’s natural heat and aid in the digestion of accumulated waste in those areas. Additionally, you may utilize the essential oils of rosemary, thyme, lavender, cloves, nutmeg, and other spices. The method for extracting these oils will be discussed in detail in a separate treatise.
Swooning is a sudden and persistent loss of all bodily powers, particularly vital functions. During a swoon, patients lie motionless and unresponsive, leading ancient observers to believe it differed from death only in its duration. In cases of swooning, especially among those who are wounded, the primary cause is bleeding, which results in a depletion of vital spirits. Fear can also trigger swooning by causing a rapid retreat of these spirits back to the heart, leading to a temporary cessation of normal bodily functions and a suspension of the other faculties.
Additionally, swooning can occur due to exposure to putrid and poisonous vapors that travel to the heart through the arteries and to the brain via the nerves. Thus, we can identify three primary causes of swooning: first, a depletion of spirits and native heat, as seen in significant blood loss; second, the oppression of spirits due to obstruction or compression, which can arise from fear or turmoil, prompting a swift withdrawal of spirits from the body’s surface to the heart; and third, corruption stemming from an accumulation of harmful humors or poisonous wounds.
The signs of swooning include pallor, the sudden onset of a cold, clammy sweat, a weak or failing pulse, and a sudden collapse to the ground without sensibility or motion, causing the individual to appear more dead than alive. Many who experience a swoon may not survive without immediate assistance.
To assist individuals who are on the verge of fainting, you should splash cool water onto their faces if the swooning is due to a depletion of vital spirits. Alternatively, you can position them gently on their backs, whether on a bed or the ground. Offering them bread soaked in wine to hold and chew may also be beneficial.
If the swooning is a result of noxious vapors and poisonous air, administer a small amount of mithridate or treacle mixed with Aqua Vitae using a spoon, as I typically recommend for those afflicted with the plague or suffering from gangrene.
However, if the patients remain unresponsive due to persistent oppression and compression of the spirits around the heart, you must provide them with substances known to invigorate and revive the spirits. These include strong wines to drink and sweet fragrances to inhale. Address them by name in a firm voice, and gently tug at their hair near the temples and neck to stimulate them. Additionally, you should rub their temples, nostrils, wrists, and palms with Aqua Vitae infused with cloves, nutmeg, and ginger.
Doting, or idle talk, refers to a symptom commonly observed in fevers resulting from wounds and inflammation. This condition represents a temporary disturbance of the mind’s functions and faculties, typically lasting a short duration. Such doting occurs in response to wounds that cause significant pain and fever, particularly when the nerves in vulnerable areas, such as the joints, stomach, and diaphragm, are affected.
The ancients referred to the diaphragm as “Phrenae,” as injury to this area can manifest as an affliction of the mind, resulting in a frenzy or temporary disruption of rational thought. This connection is due to the network of nerves from the sixth cranial nerve, which links the diaphragm to the brain and the stomach.
Doting may also arise from excessive bleeding, which depletes vital spirits and leads to erratic thoughts and movements of the mind, a phenomenon often observed in individuals who have suffered significant blood loss during amputations. Other causes may include envenomation from a poisonous creature, retained or corrupted seed in the womb, gangrene, exposure to noxious and putrid air, or even sudden panic and fear. Ultimately, any condition that generates excessive heat or distress can impair mental clarity, particularly through the influx of harmful humors, especially those associated with a choleric temperament, as well as the dissipation, oppression, or corruption of spirits.
If doting stems from inflammation of the brain and its meninges, appropriate treatment should follow the guidance of a physician, including purging and bloodletting. After shaving or cutting the hair, foment the head with rose vinegar, followed by the application of an emplastrum made from diacalcitheos dissolved in oil and rose vinegar. To promote sleep, administer barley creams infused with boiled white poppy seeds and broths from cooling herbs such as lettuce, purslane, and sorrel.
Additionally, apply cold substances to the nostrils, such as gently crushed poppy seeds mixed with rosewater and a splash of vinegar. Surround the patient with cheerful and pleasant companions who can divert their attention from sorrowful thoughts, alleviating cares and helping them regain their composure. However, if the doting arises from a deficit of spirits, seek remedies as outlined in the section regarding swooning.
The End of the Ninth book.
For the effective treatment of wounds, the surgeon must focus on a fundamental and universal objective: the rejoining of the severed parts. This principle is so widely understood that even laypersons are aware of it; when something is separated, there is an inherent desire for it to be united, as union opposes division. However, the methods by which such a union can be achieved are known only to a skilled practitioner.
Thus, we reach this primary goal through the assistance of nature, which serves as the main agent, while the surgeon acts as nature’s facilitator. If nature is not robust, the surgeon will never achieve his desired outcome. To support this process, the surgeon must undertake five essential actions. The first of these is the removal of any foreign objects—such as pieces of wood, metal, bone, bruised flesh, or clotted blood—that may be lodged in the wound, whether from external sources or from within the body. The presence of these materials must be addressed; otherwise, true union cannot be anticipated.
Another essential step for the surgeon is to align the edges of the wound, as they cannot be properly agglutinated and united without this alignment. The third step involves keeping the joined edges tightly together. Fourth, it is crucial to maintain the proper condition of the wounded area, as any underlying imbalance will prevent the restoration of unity. Finally, the surgeon must address any complications that may arise, as the practitioner is often required to adjust the treatment plan accordingly.
All foreign and external materials must be removed as swiftly as possible, as they obstruct nature’s efforts to achieve union, particularly if they exert pressure on any nerve or tendon. Such interference can lead to pain or the development of an abscess in a vital area or in tissues that support essential functions.
However, if the prompt and overly hasty removal of foreign bodies poses a risk of severe pain or significant blood loss, it is often better to allow nature to manage the situation rather than exacerbate the wound through excessive force. Nature, in its own time, will gradually expel any foreign objects deemed detrimental, along with any pus present in the wounded area.
On the other hand, if a delay in intervention poses a real threat, it is essential for the surgeon to act swiftly, safely, and as gently as the situation permits. Rough or forceful treatment of wounds can lead to complications such as excessive bleeding, fainting, convulsions, and other alarming symptoms, placing the patient at greater risk than the original wound itself.
Therefore, the practitioner may extract foreign bodies using either his fingers or appropriate instruments designed for this purpose. The ease of extraction can vary significantly depending on whether the embedded object is hard or soft, as well as on its visibility and accessibility. This variance is influenced by the shape of the object and the characteristics of the affected area, which may be soft, hard, or deeply embedded, thus securing the object more tightly or loosely. Additionally, there is always a concern about potentially causing further harm, such as damaging a blood vessel. A detailed explanation of how to carry out this procedure, along with the necessary instruments, will be provided in dedicated sections focusing on wounds caused by gunshots, arrows, and similar injuries.
The surgeon can achieve the second and third objectives of wound healing through two primary methods: ligatures and sutures. However, before employing these techniques, he must carefully assess whether there is significant bleeding. If the hemorrhage is excessive, it should be controlled; conversely, if it is insufficient, the surgeon may encourage it—unless the blood is accumulating in a cavity or abdominal area. This approach helps ensure that the affected area, relieved of any excess blood, is less prone to inflammation.
Consequently, the edges of the wound must be approximated and secured using sutures and ligatures. It is important to note that this method applies only to those wounds that are suitable for both treatments, based on their nature, size, and the condition of the surrounding tissue. For minor and small wounds, particularly in the arms or legs, a single ligature—known as the incarnative ligature—may suffice. However, for wounds that sever muscle fibers transversely, both sutures and ligatures are necessary to bring together the edges, which may be somewhat distant from each other, allowing them to connect effectively.
When a significant cut causes a portion of flesh to hang down, it must be carefully sutured back into place. Larger and more substantial wounds in certain areas, such as the ears, nose, scalp, eyelids, lips, abdomen, and throat, require sutures, as these regions may not easily accommodate a ligature due to their shape and location.
According to the consensus of ancient practitioners, there are three types of ligatures. The first is known as the Glutinative or Incarnative ligature; the second is the Expulsive ligature; and the third is the Retentive ligature. The Glutinative or Incarnative ligature is suitable for simple, clean, and still-bloody wounds. It consists of two ends and should be applied by starting from the opposite side of the wound, proceeding upwards, crossing over the wound, and then moving downwards to closely approximate the edges of the wound. Care must be taken to ensure that the ligature is neither too tight— which could lead to inflammation or pain— nor too loose, which would render it ineffective in securing the wound edges properly.
The Expulsive ligature is suitable for managing sanious and fistulous ulcers, as it helps to expel the impurities contained within them. This technique involves using a single roll with a simple head. The binding process begins at the bottom of the sinus or cavity, where tighter binding is applied. Gradually, as you move upwards, you should loosen the binding slightly, ultimately reaching the ulcer’s opening. This method facilitates the expulsion of the unhealthy discharge, as previously mentioned.
The Retentive ligature is designed for areas that cannot withstand tight binding, such as the throat and abdomen, as well as any regions suffering from pain, since painful areas resist constriction. Its purpose is to maintain local treatments and is executed using a roller that may consist of either one or multiple heads. All these rollers should be made of linen that is neither too new nor too old, and not excessively coarse or too fine. Their width must be appropriate for the body part to which they are applied, with the dimensions being determined based on the size, shape, and location of the area. This will be discussed in greater detail in our forthcoming texts on fractures and dislocations.
The surgeon’s initial responsibility in the wound healing process is to maintain the condition of the injured area through a carefully structured diet, as prescribed by a physician, in conjunction with the application of both universal and local remedies. During the initial stages, a delicate, cooling, and moist diet should be adhered to until the patient is deemed safe and free from the usual risks associated with their condition. In this regard, the patient should be fed sparingly, particularly if they exhibit signs of plethora; they must avoid salt, spiced meats, and wine. For those with a choleric or sanguine temperament, alternatives to wine include barley decoction, liquorice, or a mixture of water and sugar.
It is crucial for the patient to remain calm and rested, as rest is considered, according to Celsus, the finest medicine. They should steer clear of sexual activity, disputes, quarrels, anger, and any other mental disturbances. Once the patient appears to have passed the critical phase, they may gradually return to their usual diet and lifestyle. Among the universal remedies are phlebotomies and purging, which serve to redirect and prevent excessive flow, thereby safeguarding the balance of the affected area.
Phlebotomy is not always necessary, particularly for minor wounds or in individuals who do not suffer from ill humors or plethoric conditions. It is, however, crucial for severe wounds where there is a risk of defluxion, pain, delirium, agitation, and restlessness; and especially so in plethoric bodies or when there is damage to the joints, tendons, or nerves. Gentle purgation is advised because stronger agents can agitate the humors, leading to risks of defluxion and inflammation. Therefore, such procedures should never be carried out without the guidance of a physician.
Regarding topical and specific treatments, using agglutinative medicines is recommended. These should possess drying and binding properties to help close the wound edges and reduce the risk of defluxion, taking into account the nature of the affected area and the severity of the condition. Simple medicinal agents include olibanum, aloes, Sarcocolla, Bole-armenick, Terra sigillata, Sanguis Draconis, common and Venice turpentine, gum elemni, plantain, horse-tail, greater comfrey, Parina Volatilis, among many others. Details on these will be discussed further in our upcoming Antidotary.
The fifth objective in healing wounds is to address the complications and symptoms that typically arise post-injury, which significantly increases the surgeon’s responsibilities. Often, the surgeon must prioritize managing these complications—such as bleeding, pain, inflammation, fever, convulsions, paralysis, delirium, or distraction—over treating the primary wound itself. We will discuss these issues in greater detail, providing specific guidance after an initial discussion on sutures, to the extent deemed appropriate for this context.
When wounds occur along the thighs, legs, and arms, they often do not require sutures as the continuity of tissue can be readily restored using ligatures. However, crosswise incisions demand suturing because the flesh and similar tissues, once cut, tend to retract towards the intact areas. This separation necessitates joining and securing the tissue through stitching. If the wound is deep, the needle must capture a substantial amount of flesh; superficial stitches that only secure the upper layer can result in the entrapment of discharge within the wound, potentially leading to abscesses and deep ulcers. Therefore, it is imperative to discuss the techniques of suturing.
The first technique, known as Interpunctus, is characterized by spacing stitches approximately a finger’s breadth apart. This method is suitable for fresh, fleshy wounds that cannot be closed with ligatures and contain no foreign bodies. The procedure is carried out as follows:
To begin, you will need a smooth needle threaded with a triple-point design, which facilitates easier penetration through the skin. The needle’s head should be slightly hollowed to accommodate the thread, allowing for a smoother passage. Additionally, a small tube with an opening at the end is essential; this should be positioned against the edge of the wound to prevent movement while you insert the needle. The window in the tube enables visibility as the needle passes through, while keeping the edge of the wound secure during the threading process.
After piercing the wound’s edges, tie a knot close to the entry point and trim the excess thread. This prevents any remaining thread from sticking to the dressings, which can cause discomfort upon removal. Note that the first stitch should be inserted at the center of the wound, while the second stitch should be placed between the center and one of the ends.
When completing your stitches, ensure that the lips of the wound are not overly compressed; a small gap should remain to allow for the discharge of fluids and to minimize inflammation and pain. If the lips are tightly pressed together, a swelling could occur as the wound begins to supurate, potentially causing the edges to stretch and break due to the tension of the thread.
Be mindful not to capture too much or too little flesh with your needle. Insufficient tissue will not provide a secure hold, while too much can lead to pain, inflammation, and undesirable scarring. In deeper wounds, particularly those situated in thicker muscle tissue, it is crucial that the needle be inserted deeply enough to grasp adequate fleshy substance; this prevents the thread from breaking due to the weight of any ungrasped tissue.
In some cases, wounds may be located in areas that necessitate the use of a curved needle and tube for successful suturing. Therefore, I have deemed it beneficial to illustrate both types, allowing you to choose the appropriate tool based on the situation at hand.
The design features pipes with windows, known as fenestels, and needles specifically tailored for suturing.
The second suture is performed in the same manner as skinners sew their fells or furs. It is essential to use this type of suture for the guts when they are wounded, ensuring that excrement does not escape through the wound.
The third suture involves one or more needles threaded through the wound, with the thread wrapped around both the head and the point of the needle. This technique resembles how boys secure their needles in their caps or clothing to prevent loss. This particular suture is suitable for the treatment and healing of hare-lips, which we will illustrate in a figure later on.
The fourth type of suture, known as Gastroraphia, is specifically designed for repairing and reconnecting the large muscles of the epigastrium, or lower abdomen, when they have been severely wounded, along with the underlying peritoneum. We will present the details of this technique at the appropriate juncture.
The fifth type is referred to as the dry suture. We employ this method exclusively for facial wounds, and we will provide a detailed description of this technique in its relevant context.
Blood loss commonly occurs in wounds due to the cutting, breaking, or tearing of certain vessels. It is essential to address and treat this bleeding promptly, as blood is nature’s vital treasure, essential for sustaining life. When blood flows from an artery, it is typically characterized by its more vigorous and vibrant nature, seeming to leap forth due to the vital spirit contained within the arteries. In contrast, blood drawn from a vein appears darker, thicker, and flows more slowly. Various methods exist for staunching blood flow effectively.
The most common method involves closing the lips of the wound, which is usually effective for superficial injuries. This is achieved by applying medications that possess astringent, cooling, drying, and adhesive properties to hold the wound edges together.
Prescription:
Prepare a powder to be taken with egg white.
Or
Prescription:
Mix them with egg white and rabbit down, then soak the dressings in this mixture, applying them both directly to the wound and around it. Afterward, secure the wound with a double cloth and a snug bandage, positioning the affected area in the most comfortable and pain-free manner possible.
If bleeding persists despite these measures, remove all coverings, then firmly press on the wound and the vessel’s opening with your thumb. Maintain the pressure until the blood forms a thick clot that seals the vessel effectively.
If the bleeding cannot be controlled, the suture (if present) must be opened, and the mouth of the vessel, near its origin or root, should be grasped and secured with a needle and thread, including as much surrounding flesh as the situation allows. I have successfully managed severe hemorrhages this way, even during amputations, as I will illustrate at an appropriate time.
To carry out this procedure, it is often necessary to incise the skin covering the wounded vessel. For instance, when the jugular vein or artery is severed, it tends to retract both upwards and downwards. Thus, the skin must be opened to expose it. A needle and thread should be passed underneath, and the vessel secured as I have frequently done. However, it is crucial to ensure that the surrounding flesh has healed sufficiently before loosening the knot to avoid further bleeding from the vessel.
If the condition of the affected area prohibits the effective clamping and binding of the vessel, we must resort to escharotics. These include the powder of burnt vitriol, powder of mercury, and a small quantity of burnt alum—caustics that induce the formation of an eschar. The natural sloughing of this eschar should not be hastened through artificial means, to prevent premature detachment before the vessel’s orifice is securely sealed by either flesh or clotted blood.
However, there are instances where the surgeon may be compelled to completely sever the vessel. By doing so, the ends of the cut vessel retract and are concealed by the surrounding tissues, thereby allowing the previously uncontrollable bleeding to be more easily halted. Nonetheless, this is a drastic measure and should only be considered after all other less invasive techniques have been exhausted.
The pain that follows wounds should be alleviated promptly, as it can quickly undermine the body’s vitality and lead to an increased discharge, regardless of the individual’s overall health and condition. Nature, eager to assist the injured area, often directs an excess of humors to it, which can contribute to an exacerbation of the discharge—whether through an increase in quantity, quality, or both.
To relieve this pain and counteract the discharge, the author recommends applying medications to the affected area that possess both repelling and soothing properties, such as:
Prescription:
Melt the wax in the oils, then mix in the remaining ingredients. Prepare the medicine according to established methods for application to the affected area.
or
Prescription:
Melt the rose oil and vinegar together. For soothing treatments, irrigations of rose oil and myrtle oil, combined with either the white of an egg or a whole egg, can be effective if there is no significant inflammation. Additionally, rollers and double cloths moistened with oxycrate can also be beneficial for the same purpose. However, it is important to frequently renew these applications, as once they dry, they can exacerbate the pain. If these methods do not alleviate the pain, we should then resort to narcotic remedies, such as poppy oil, mandrake oil, and a poultice made from henbane and sorrel, incorporating mallows and marshmallows as previously discussed in relation to treating phlegmon.
Lastly, attention must be paid to the underlying cause of the pain, the type and nature of the humor involved, and the manner in which Nature reacts. The treatment must be adapted accordingly: if heat is the cause of pain, it can be alleviated by applying cooling agents. A similar rationale applies to the opposite scenario. If Nature is working towards suppuration, it is crucial to support this process with medicines that promote suppuration.
A convulsion is an involuntary contraction of the muscles, specifically those parts of the body that we normally move at our discretion, such as those connected to the brain and spinal cord. During a convulsion, the affected member or even the entire body (if the convulsion is generalized) cannot be moved voluntarily. Unlike in paralysis, where motion is completely lost, in a convulsion, movement is impaired but not entirely absent. It is important to note that convulsions can affect the entire body or just specific areas, leading to the classification of three general types of convulsions. The first type, referred to by the Greeks as “Tetanos,” is characterized by a complete stiffness of the body, rendering it motionless akin to a stake.
The second type of convulsion is known as Opisthotonos, where the entire body arches backward. The third type, called Emprosthotonos, occurs when the entire body bends or curves forward. A specific convulsion affects individual muscles supplied by a nerve, such as those in the eye or tongue.
Convulsions can be triggered by various factors including repletion (overfullness) or inanition (emptiness), sympathetic responses, or interconnected pain. An excess of bodily fluids, often due to overeating, excessive drinking, lack of exercise, or failure to maintain regular bodily functions such as the suppression of hemorrhoids or menstrual cycles, can lead to repletion. This condition causes these fluids to accumulate in the nerves, stretching and ultimately constricting them excessively, which leads to convulsions.
This phenomenon can be likened to how leather or the strings of a lute or violin react to humidity: swelling with moisture, they eventually stretch and may snap due to being overly taut.
Excessive vomiting, diarrheal fluxes, and severe bleeding can lead to inanition, or emptiness, which makes convulsions caused by wounds particularly fatal, as well as those induced by severe fevers. These conditions deplete the intrinsic moisture of the nerves, causing them to contract much like leather that has been withdrawn too close to a fire, or like violin strings that snap under the stress of excessive summer heat. Such convulsions are often incurable.
Hippocrates teaches us that it is preferable for a fever to occur following a convulsion rather than the other way around. This is only effective if the fever corresponds to the intensity of the underlying cause of the convulsion, especially when that convulsion arises from repletion. In this scenario, the abundant and thick bodily humors responsible for the convulsion are gradually digested and diminished by the heat of the fever.
The causes of a convulsion due to pain can stem from various sources. These include the puncture of a nerve either by the bite of a venomous animal or by the sting of an inanimate object such as a needle, thorn, or pen-knife. Extreme and piercing cold can also trigger convulsions, particularly harming the wounds in the nervous tissues, leading to significant and acute pain. This pain causes nerves to contract toward their origin, the brain, as if seeking relief from a source of protection during distress.
Additionally, harmful vapors carried to the brain from some form of putrefaction can irritate the brain, causing it to contract. This contraction pulls together all the nerves and muscles, as observed in individuals suffering from epilepsy. From this, it is evident that the brain and nerves are interdependent, each suffering with the other.
The symptoms of a convulsion include laborious, painful, and disordered movements, either in part or across the entire body, an abnormal turning of the eyes and face, a contraction of the lips, a pulling in of the cheeks resembling laughter, and a generalized sweating.
The treatment for convulsions should be tailored to the specific cause of the condition, as the approach varies depending on whether the convulsion is due to repletion, inanition, or pain. For convulsions caused by repletion, the remedy involves the use of discussing and evacuating medicines. This may include a carefully prescribed diet, purgatives, bloodletting, local digestive medicines, exercise, massage, sulfurous baths, and other treatments recommended by a knowledgeable physician overseeing the care. These interventions aim to eliminate excess and wasteful humors that affect the nerves and the overall state of the body.
Local remedies such as oils, ointments, and liniments should be applied to the neck, spine, and any contracted areas. Recommended oils include those derived from foxes, bay leaves, chamomile, worms, turpentine, Costus, and Castorcum. Suitable ointments may consist of unguentum Arragon, Agrippae, Althaea, and Martiatum. An example of a liniment formulation may include a combination of these oils and ointments.
Prescription:
Make a Liniment for your use, or
Prescription:
Make a Liniment, or
Prescription:
Make into a liniment.
This condition can be effectively treated with a light diet and sweating induced by decoctions of guaiacum, as these remedies help to digest the coarse, thick, and viscous waste that contributes to the ailment.
For convulsions caused by starvation, the remedy lies in employing substances that provide wholesome and moderate nourishment. Thus, it is essential to prescribe a diet rich in nourishing foods, such as broths and potages made from capons, pigeons, veal, and mutton, boiled together with violet and mallow leaves. Additionally, conserves should be included to strengthen weakened bodily functions and hydrate the system, such as conserves made from bugloss, violets, borage, and water lilies.
The following broth will be beneficial:
Prescription:
Let them all be boiled with a chicken and let him take the broth every morning. If thirst oppress him, the following julep will be good:
Prescription:
Make a syrup; let it be used for thirst.
If the patient is experiencing physical confinement (constipation), emollient and hydrating clysters should be prescribed, prepared from a decoction of sheep’s head and feet, along with mallow, marshmallow, Pellitory of the wall, violet leaves, and other similar ingredients. To facilitate a quicker and more convenient remedy, the clysters may alternatively consist of oil and milk. Topical treatments will include liniments and baths. An example of a liniment is as follows:
Prescription:
Make a liniment with which the entire spine and the affected area should be anointed. This will serve as the formulation for an emollient and hydrating bath.
Prescription:
Cook them in common water, adding 8 pounds of Lily oil (Olei Lillior).
Prepare a warm bath for the patient to enter. After bathing, they should be dried with warm towels or allowed to rest in bed, avoiding perspiration. However, if the patient can tolerate it, it would be beneficial to arrange a bath using either milk or oil, or a combination of both in equal parts.
A convulsion induced by a combination of pain and the transmission of the affliction can be effectively treated with remedies that counteract the source of the pain. For instance, if the convulsion results from a puncture or venomous bite, the wound should be incised to allow the toxic material to drain more easily. Additionally, fluids with a thin, liquid consistency that also possess drying and digestive properties should be applied to help neutralize and dissolve the venom, such as treacle and mithridate diluted in Aqua vitae, along with a small amount of mercurial powder, which serves as a powerful antidote. Cupping glasses and scarification can also be beneficial.
Furthermore, all painful causes can be addressed through the use of opposing remedies. If the pain arises from a pinched nerve or tendon, it should be treated promptly with appropriate solutions, such as oil of turpentine and euphorbium mixed with Aqua vitae, along with other remedies suitable for nerve punctures. If the pain stems from excessive cold—which can be detrimental to the brain, spinal cord, and nerves—the patient should be placed in a warm environment, like a hot house or stove. The entire spine and any affected areas should be anointed with the warm liniments mentioned before, as this method is safer than abruptly exposing the patient to intense heat or a warm bath.
Throughout this process, the surgeon must remain vigilant for any signs of an impending convulsion. If such signs, whether prominent or imminent, are observed, it is essential to place a stick between the patient’s teeth to prevent them from clenching tightly due to the involuntary contraction of the jaws. Many individuals in such situations have bitten off their tongues. For this purpose, the surgeon should utilize an instrument called a Speculum Oris, which can be adjusted in size by means of a screw, as illustrated in the accompanying figures—one demonstrating the instrument fully opened and slightly twisted, and the other showing it closed.
[image]
The figure of a speculum oris used to open the teeth when they are locked or held fast together.
Palsy is characterized by the weakening or softening of the nerves, resulting in a loss of sensation and movement. This condition typically affects only one part of the body, such as the right or left side, which is why it is specifically referred to as palsy. In a broader and less precise sense, the term may also be applied to the resolution of a single limb. However, when the entire body experiences this resolution, it is termed apoplexy.
Palsy can manifest in various ways; it may affect half of the body, the upper regions from the navel to the head, the lower areas extending from the navel to the feet, or even specific parts such as the tongue, throat, bladder, penis, eyes, and, ultimately, any of the body’s appendages.
Palsy is fundamentally different from a convulsion in its very nature. While a convulsion is characterized by the contention and contraction of a body part, palsy involves a resolution and relaxation of that same area. Additionally, in cases of palsy, the sense may be significantly impaired or entirely absent, whereas sensory perception typically remains intact during a convulsion. Some individuals may also experience a sensation of pricking or substantial pain in the affected region.
The causes of palsy can be classified as internal or external. Internal causes arise from humors that obstruct one of the brain’s ventricles or one side of the spinal cord, preventing the animal faculties responsible for sensation and movement from transmitting signals through the nerves to the affected body parts. External causes, on the other hand, include falls, blows, and similar injuries that may result in dislocations of joints, displacement of the spinal cord, and constrictions or compressions of the vertebrae. These factors impede the passage of the animal spirit to the organs in their entirety.
Through a solid understanding of anatomy, one can accurately identify the location of the underlying pathological cause by examining the affected area. For instance, when palsy manifests predominantly on either the right or left side, it indicates an obstruction in the brain or spinal cord. Conversely, when the head remains unaffected while one side of the body is impaired, the issue likely resides at the origin of the spinal cord. If the arms are involved, it suggests that the pathology may be located within the fifth, sixth, or seventh cervical vertebrae. In the case of lower limb weakness, the underlying cause is likely associated with the lumbar vertebrae and sacrum. It is crucial for the surgeon to diligently consider these origins to effectively address the disease.
Palsy resulting from a severed or severely bruised nerve is typically incurable because the pathway for the animal spirit to reach the affected part is obstructed. Elderly individuals seldom recover from palsy due to diminished vital heat and an accumulation of excess humors, and chronic palsy, which has persisted for an extended period, particularly following an apoplectic event, offers little hope for recovery.
Interestingly, the onset of a fever following a palsy may be beneficial, as it suggests the possibility of reabsorbing the excess resolving and relaxing humors. However, if the affected limb becomes significantly atrophied while the opposite limb dramatically increases in size, heat, and coloration, this is concerning. Such a condition indicates extreme weakness in the afflicted area, leaving it susceptible to further depletion of nutrition while resources are diverted to the healthier or opposing side.
In the treatment of palsy, it is essential to commence with general remedies, dietary adjustments, and purging before considering any specific interventions. This foundational care should be entrusted to a knowledgeable and skilled physician. One effective remedy for this condition is the decoction of guaiacum, as it promotes sweating and helps to attenuate, digest, and eliminate excess moisture that may be hampering the nerves.
If sweating does not occur, it may be beneficial to apply heated bricks, tempered by soaking in a mixture of wine, vinegar, and resolving herbs, around the affected limbs. Alternatively, stone bottles or the bladders of oxen and swine, partially filled with the same decoction, can also be used. The application of this heat serves to invigorate and restore vitality to the affected area, which often experiences significant languor in this condition.
Subsequently, the patient should enter a bathing tub, which should be adequately draped as outlined in our Treatise on Baths, to allow them to absorb the vapor from the aforementioned decoction.
Prescription:
Place all ingredients into the vessel specified in the aforementioned Treatise. The patient should remain in the bathing tub for as long as his strength permits. Afterward, he should be carefully moved to his bed, where he should be warmly covered to encourage additional sweating. Once he has perspired, he should be gently dried and allowed to rest. Subsequently, he should be promptly anointed with the ointment strongly recommended by Leonellus Faventinus:
Prescription:
All should be ground and mixed together with the oils and wine; allow to boil in a double boiler until the wine is completely consumed, yielding a strong extract. Then add galbanum, bdellium, euphorbia, myrrh, castoreum, bear fat, duck fat, and stork fat.
Prepare an ointment in the form of a liniment, adding a small amount of wax if necessary. Alternatively, you may use the following remedy that has been endorsed by numerous physicians:
Prescription:
All should be ground into a powder, and the gums should be dissolved with a little aqua vitae and vinegar.
Ensure that all ingredients are placed in suitable containers to be distilled in a water bath (Balneo Mariae). The resultant liquid should be applied to the spine and any paralyzed limbs. I have frequently tested the efficacy of the following remedy:
Prescription:
All should be chopped and crushed, and infused in the aqua vitae and mulled wine.
Distill the substances in a water bath (Balneo Mariae) as previously described. Moisten the affected areas with the distilled liquid, and also offer the patient a spoonful to drink in the morning, sweetened with sugar. This will warm the stomach and help to eliminate the excess phlegm that fuels the disease.
You should also prescribe exercises for the affected areas, along with frequent and vigorous massage using hot linen cloths. This will help stimulate the body’s natural heat and aid in the digestion of accumulated waste in those areas. Additionally, you may utilize the essential oils of rosemary, thyme, lavender, cloves, nutmeg, and other spices. The method for extracting these oils will be discussed in detail in a separate treatise.
Swooning is a sudden and persistent loss of all bodily powers, particularly vital functions. During a swoon, patients lie motionless and unresponsive, leading ancient observers to believe it differed from death only in its duration. In cases of swooning, especially among those who are wounded, the primary cause is bleeding, which results in a depletion of vital spirits. Fear can also trigger swooning by causing a rapid retreat of these spirits back to the heart, leading to a temporary cessation of normal bodily functions and a suspension of the other faculties.
Additionally, swooning can occur due to exposure to putrid and poisonous vapors that travel to the heart through the arteries and to the brain via the nerves. Thus, we can identify three primary causes of swooning: first, a depletion of spirits and native heat, as seen in significant blood loss; second, the oppression of spirits due to obstruction or compression, which can arise from fear or turmoil, prompting a swift withdrawal of spirits from the body’s surface to the heart; and third, corruption stemming from an accumulation of harmful humors or poisonous wounds.
The signs of swooning include pallor, the sudden onset of a cold, clammy sweat, a weak or failing pulse, and a sudden collapse to the ground without sensibility or motion, causing the individual to appear more dead than alive. Many who experience a swoon may not survive without immediate assistance.
To assist individuals who are on the verge of fainting, you should splash cool water onto their faces if the swooning is due to a depletion of vital spirits. Alternatively, you can position them gently on their backs, whether on a bed or the ground. Offering them bread soaked in wine to hold and chew may also be beneficial.
If the swooning is a result of noxious vapors and poisonous air, administer a small amount of mithridate or treacle mixed with Aqua Vitae using a spoon, as I typically recommend for those afflicted with the plague or suffering from gangrene.
However, if the patients remain unresponsive due to persistent oppression and compression of the spirits around the heart, you must provide them with substances known to invigorate and revive the spirits. These include strong wines to drink and sweet fragrances to inhale. Address them by name in a firm voice, and gently tug at their hair near the temples and neck to stimulate them. Additionally, you should rub their temples, nostrils, wrists, and palms with Aqua Vitae infused with cloves, nutmeg, and ginger.
Doting, or idle talk, refers to a symptom commonly observed in fevers resulting from wounds and inflammation. This condition represents a temporary disturbance of the mind’s functions and faculties, typically lasting a short duration. Such doting occurs in response to wounds that cause significant pain and fever, particularly when the nerves in vulnerable areas, such as the joints, stomach, and diaphragm, are affected.
The ancients referred to the diaphragm as “Phrenae,” as injury to this area can manifest as an affliction of the mind, resulting in a frenzy or temporary disruption of rational thought. This connection is due to the network of nerves from the sixth cranial nerve, which links the diaphragm to the brain and the stomach.
Doting may also arise from excessive bleeding, which depletes vital spirits and leads to erratic thoughts and movements of the mind, a phenomenon often observed in individuals who have suffered significant blood loss during amputations. Other causes may include envenomation from a poisonous creature, retained or corrupted seed in the womb, gangrene, exposure to noxious and putrid air, or even sudden panic and fear. Ultimately, any condition that generates excessive heat or distress can impair mental clarity, particularly through the influx of harmful humors, especially those associated with a choleric temperament, as well as the dissipation, oppression, or corruption of spirits.
If doting stems from inflammation of the brain and its meninges, appropriate treatment should follow the guidance of a physician, including purging and bloodletting. After shaving or cutting the hair, foment the head with rose vinegar, followed by the application of an emplastrum made from diacalcitheos dissolved in oil and rose vinegar. To promote sleep, administer barley creams infused with boiled white poppy seeds and broths from cooling herbs such as lettuce, purslane, and sorrel.
Additionally, apply cold substances to the nostrils, such as gently crushed poppy seeds mixed with rosewater and a splash of vinegar. Surround the patient with cheerful and pleasant companions who can divert their attention from sorrowful thoughts, alleviating cares and helping them regain their composure. However, if the doting arises from a deficit of spirits, seek remedies as outlined in the section regarding swooning.
The End of the Ninth book.