SECT. LXXXVIII.—ON THE EXTRACTION OF WEAPONS.
That the extraction of weapons is a most important department of surgery is declared by the Poet Homer, when he says:
“The man of medicine can in worth with many warriors vie,
Who knows the weapons to excise, and soothing salves apply.”
We must first describe the different kinds of weapons. Warlike instruments, then, differ from one another in material, figure, size, number, mode, and power. In material, then, as the shafts are made of wood or of reeds; and the heads themselves are either made of iron, copper, tin, lead, horn, glass, bones, and of reeds, too, or of wood: and such differences are found especially among the Egyptians. In figure, inasmuch as some are round, some angled (as triangular), some pointed and lance-shaped, as some have three points; some are barbed and some are without barbs; and of the barbed, some have the barbs turned backwards, so that in attempting to extract them they may fasten in the parts; and some forwards, so that when pushed they may do the same thing: some have them diverging in opposite directions like the forked lightning, in order that whether pulled or pushed they may fasten in the parts. Some missiles have their barbs united by a hinge, which being expanded in the extraction, prevent the weapon from being drawn out. They differ in size, inasmuch as some are three fingers’ breadth in size, and some are as small as one finger, which are called micca in Egypt, and some are intermediate between them. In number, inasmuch as some are simple and some compounded. For certain small pieces of iron are inserted in them, which, in the extraction of the weapon, remain concealed in deep-seated parts. In mode, as some have the sharp extremity fixed to a tail and some to a shaft; and some have it carefully inserted in the shaft, and some carelessly, so that in the extraction they may separate and leave the head behind. In power, as some are not poisoned and some are poisoned. Such are the differences of weapons. We now proceed to treat of the extraction, both in cases of those who have been wounded in war and those not in war, whether voluntarily and involuntarily, under whatever circumstances, and of whatever materials they may be composed. There are two modes of extracting weapons from fleshy parts; either by pulling them backwards, or pushing them forwards. When the weapon is fixed superficially the extraction is made by pulling it back, and in like manner when it is lodged deep, but the opposite parts, if wounded, would occasion danger from hemorrhage or sympathy. It is to be pushed forwards when lodged deep, and the intervening substances between it and the opposite side are of small size, and neither nerve, bone, nor any such thing is an obstacle to the division. When a bone is wounded, the mode of extraction is by pulling; if, therefore, the head of the weapon be in sight, we make the extraction immediately; but, if it is hid, we must, says Hippocrates, get the wounded person to put himself in the same posture as when he received the wound, and thus make the examination; or, if this cannot be done, he is to be placed in the nearest possible to it, and thus it is to be examined with a sound. If the head of the weapon has fixed in the flesh, it is to be drawn out with the hands, or by laying hold of the appendage, which is called the shaft, if it has not fallen off. This part is mostly made of wood. When it has fallen off, we make the extraction by means of a tooth-extractor, or a root-extractor, or an instrument for extracting weapons, or any other convenient instrument. And sometimes we make an incision in the flesh around it in the first place, if the wound do not admit the instrument. And if the head of the weapon has passed to the opposite side, and it is found impossible to extract it by the way in which it entered, having divided the parts opposite we extract it through them, either drawing it out in the manner mentioned, or we make a hole with the weapon itself, pushing it either by the shaft, or, if it has come away, by an impellent instrument, taking care not to divide a nerve, vein, artery, or any important part, for it would be disgraceful if, in extracting the weapon, we should do more mischief than the weapon itself had done. If the weapon has a tail, which is ascertained by examination with the probe, having introduced the female part of the impellent instrument and fixing it, we push the weapon forwards, but if it has a shaft, the male part. And if the head when extracted appear to have notches, so that other small pieces of iron might be inserted in them, we make an examination again with the probe, if we find them we extract them in the same manner. And if the weapon has barbs in opposite directions, which do not yield to our pulling, we must make an incision in the adjacent parts, if no important vessel or the like lie there, and when the weapon is laid bare, we extract it without trouble. Some apply a tube about the barbs, so that when they draw out the weapon the flesh may not be torn by the barbs. If the wound does not become inflamed, we may use sutures, and heal it up like a bloody wound; but if it inflame we may remove the inflammation by embrocations, cataplasms, and the like. If the weapon be poisoned we must, if possible, cut off all the flesh which has imbibed the poison, which is known by its being altered from the sound flesh, for it appears pale, livid, and as it were dead. They say that the Dacians and Dalmatians touch the points of their weapons with elecampane, called also ninum, and that when it thus becomes mixed with the blood of the wounded animal it proves fatal, although it is eaten by them with impunity. If, again, the weapon fix in a bone, we make trial with the instrument, and, if flesh prevent the extraction, we cut it off, or separate it; but if it be lodged deep in the bone (which we know by its being so firm that it cannot be shaken with a considerable force) we first remove the remaining part of the bone with a cutting instrument, or bore it with trephines if it has considerable thickness, and thus disengage the weapon. If a weapon be lodged in any important part, such as the brain, heart, throat, lungs, liver, stomach, intestines, kidneys, womb, or bladder, and fatal symptoms have already shown themselves, as the extraction would occasion much laceration we must decline the attempt, lest while we do no good we expose ourselves to the reprobation of ignorant people. But if the result be dubious, we must make the attempt, having first given warning of the danger. For in many cases, when an abscess has formed in some vital part, recovery has unexpectedly taken place; and the lobe of the liver, part of the omentum and peritoneum, and the whole uterus are said to have been taken away, and yet death was not the consequence. And we often open the windpipe intentionally, in cases of angina, as we mentioned under the head of Laryngotomy. To leave the weapon then as it is, occasions certain death, and exhibits the art in an inhumane light, whereas by extracting it we might possibly save a life. It is not difficult to ascertain when an important part is wounded, this being discovered by the peculiarity of the symptoms, the discharges, and situation of the parts. When, therefore, the membranes of the brain are wounded, there is intense pain of the head, the eyes are fiery, the tongue red, and there is aberration of intellect; but if it is attended with a wound of the brain, there is prostration of strength, with loss of speech, distortion of the countenance, vomiting of bile, a discharge of blood from the nostrils, an evacuation of a white and pultaceous fluid by the auditory foramen, and of ichor, if it can find a passage by the wound. If the weapon has penetrated to the cavity of the chest, and sufficient room is left for it, the breath passes out. When the heart is wounded, the weapon appears at the left breast, and feels not as if in a cavity, but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats, and deliquium animi, and death follows in a short time. When the lungs are wounded, if the opening be sufficiently large, a frothy blood passes out at it; but if not, it is rather vomited up, the vessels of the neck are swelled, the tongue changes colour, and there is an urgent desire of cold things. When the diaphragm is wounded the weapon appears lodged about the false ribs, there are large inspirations with pain, sighs, and heavings of the parts about the shoulder-joints. If the viscera of the abdomen are wounded, the nature of the injury will be apparent from the discharge, if the wound be sufficiently large, or if the weapon be extracted, or if the shaft be broken internally; for chyle is evacuated from the stomach, and fæces from the intestines; sometimes the omentum or an intestine protrudes. When the bladder is wounded urine is discharged. When the membranes of the brain or the cerebrum itself is wounded, we extract the weapon by trepanning the skull, as will be described presently in fractures of the bones of the head. If the weapon is lodged in the chest, and does not come out readily, it is to be extracted by means of a moderate incision in the intercostal space, or by cutting out a rib with the assistance of the instrument called meningophylax. In like manner, when the stomach, bladder, and other deep-seated parts are wounded, if the weapon come out readily it is to be extracted without more ado; but if not, we must enlarge the wound, and afterwards use the dressings for fresh wounds. In wounds of the abdomen, gastroraphé as formerly described may be had recourse to, if necessary. But if the weapon has lodged in any of the larger vessels, such as the internal jugulars or carotids, and the large arteries in the armpits or groins, and if the extraction threaten a great hemorrhage, they are first to be secured with ligatures on both sides, and then the extraction is to be made. If parts have been fastened to one another, such as the arm to the chest, or the fore-arm to the other parts of the body, or the feet to one another, if the weapon (as a spear) do not penetrate through both parts, we are to take hold of the weapon externally and extract as if only one part were affected, but if it has passed through both, having sawed the wood through the middle, we extract each part singly, in the most convenient direction. But since often stones or the sharp points of rocks, or pieces of lead, or the like, are lodged in the body, either being impelled with force from a sling, or happening to be acuminated, they are to be known by the swelling being hard and irregular, and by the solution not being everywhere straight, but larger than common, and having the skin bruised and livid, and the pain being attended with a sense of weight. They are, therefore, to be dislodged by means of suitable instruments, or scraped out with the concave part of a specillum or of an ear-specillum adapted for wounds; or, if they can be applied, a tooth-extractor or a root-extractor may be used for pulling them out. In many instances weapons lodged in the body lie concealed, and a long time after, when the wounds are healed up, the part having suppurated bursts, and the weapon drops out.
Commentary. Hippocrates considered the extraction of weapons to be one of the most important departments of surgery. It is to be fully learned, he says, only by attaching oneself to a foreign army. (De Medico.) He makes some interesting remarks on the subject in his treatise ‘De Capitis Vulneribus.’
We must now attempt to give an abstract of Celsus’s very interesting chapter on the Extraction of Weapons. Every weapon is to be extracted either by the part at which it enters or by that to which it tends. If it is not deep-seated, or if it has not passed any great vessels or nerves, there is no better plan than to draw it out as it entered. But if there is a greater space through which it must return than there would be to push it out, and if it has already passed the vessels and nerves, it will be better to open what remains undivided, and extract it in this direction. If the weapon is to be drawn backwards, the opening is to be enlarged by a scalpel, which will occasion less inflammation and obstruction of the parts than if they are torn by the weapon itself. In whichever way it be extracted great care ought to be taken that no nerve, large vein, or artery be divided. If any of these parts be detected in the wound they are to be drawn aside with a blunt hook. These are his general directions. He then subjoins instructions for extracting particular kinds of weapons. An arrow being a slender body, and generally impelled with great force, is often lodged deep, and is to be extracted for the most part rather by the opposite side to which it entered, especially as it has barbs, which tear most if drawn backwards. The flesh about the weapon is to be separated by means of a suitable instrument, and then if the head (mucro) appear with the shaft (arundo) fixed to it, the weapon is to be propelled until it can be laid hold of at the opposite side and extracted; or if the shaft has fallen out and only the iron remain lodged within, the head is to be seized with the fingers or a forceps, and removed, and it is to be extracted by the opening at which it entered, upon the same principles; for the wound being enlarged, the weapon is to be drawn back by the shaft if it remain, or otherwise by the iron itself. If there appear to be barbs upon the arrow, and if short and small, they are to be broken off with a pair of pincers; or, if larger and stronger, they are to be covered with split writing-pens (fissis scriptoriis calamis) to prevent them from tearing the flesh during extraction. And here we may mention, that the common calamus scriptorius of the ancients was made from an Egyptian reed. See Montfauçon (Palæographia Græca, p. 3.) When the weapon which is lodged in the body is large it must not be extracted by the opposite side, as it would make the wound too large. He directs us to draw it back by means of an instrument invented by Diocles, of which he gives a description. Another class of weapons which must sometimes be extracted are leaden balls, stones, or any such thing which breaks the skin, and is buried within. In all such cases the wound, he says, must be enlarged and the body extracted with a forceps. A complication which increases the difficulty of extraction arises from the weapon being lodged in a bone, or between two bones at a joint. When lodged in a bone it is to be moved about until loosened, when it is to be grasped with a forceps and extracted in the same way that a tooth is pulled out. It rarely happens that the weapon cannot be removed in this way; but if it remain fixed in the bone, it is to be struck with some iron instrument until it be shaken from the place where it is lodged. When other means do not succeed, the bone is to be perforated with a trephine. When the body is lodged in a joint between two bones, the two members about the wound are to be wrapped round with strips of cloth, or leathern thongs, and thereby separated by pulling in opposite directions, by which means the space between them will be slackened, and then the weapon may be removed without difficulty. When the weapon had been poisoned, these things must be done with all possible despatch, and the remedies applied which are used when a poison has been swallowed, or a person has been stung by a serpent. The wound from which a weapon has been extracted requires no other treatment than what is applicable for ordinary injuries. (vii, 5.)
Albucasis borrows mostly from our author the account which he gives of the construction of weapons and the symptoms occasioned by the wounds which they inflict. He also relates some interesting cases of recovery from very severe wounds. An arrow entered at the root of a man’s nose and was extracted by Albucasis behind his ear; and the man recovered without having sustained any injury to the eye. He extracted another large arrow which had lodged deep below the eye of a Jew; and in this case also the sight was not impaired. He extracted a barbed arrow which had lodged in the throat of a Christian, by enlarging the wound, and the man recovered. An arrow had lodged in a man’s belly, so that, at first sight, Albucasis considered the case as hopeless; but, after thirty days, as no mortal symptoms had supervened, he enlarged the wound and extracted the weapon. He saw a man who had got an arrow lodged in his back; the wound healed, but after an interval of seven years the weapon came out below his buttocks. He knew a woman who had an arrow lodged in her belly, and the wound healed, and the weapon never afterwards occasioned her any inconvenience. He knew a man who had an arrow lodged in his face, and the wound healed up, and never gave him much trouble. He relates that he extracted an arrow which had been buried in the nose of a prince, after making various fruitless attempts for the space of four months. He then delivers general directions for the extraction of weapons, borrowing, as usual, very freely from our author. When a weapon cannot readily be got extracted at the time, he recommends us to let it alone until it become loosened by the putrefaction of the surrounding parts. When impacted in a bone, he directs us either to move it about until it is loosened, or to perforate the bone with a trephine. When lodged in the cranium, it is to be removed in like manner with a trephine, provided the dura mater is not injured, for if it is wounded the case must not be interfered with. When a weapon is lodged deep in any part of the body where there are no large nerves, veins, or bones, he directs us to enlarge the wound and extract the weapon; but if it has barbs, the fleshy parts about it must first be carefully separated to prevent them from being torn. When a weapon passes through a limb, or attaches one part of the body to another, he directs us to cut off the part which projects, and then extraction may easily be accomplished. If fastened in a bone, he advises us to turn it round so as to loosen it; and if that does not suffice, he recommends us to leave it for a few days, when it may be extracted without difficulty. If the shaft or wooden part of a weapon be broken off, he directs us to apply to the head an impellent instrument with a concave extremity, so as to adapt itself to the form of the body which is to be extracted. When the weapon is poisoned, he recommends us, if possible, to cut out the flesh around it. When a weapon lodges in the breast, belly, bladder, or side, and can be felt with a probe, he directs us to cut cautiously upon it, taking care not to wound a vein or nerve. He concludes with giving drawings of forcipes and impellents. (Chirurg. ii, 96.)
Rhases gives sensible directions for the management of these cases, but they are so similar to those of our author that we need not dwell upon them. If the size of the wound permit, he directs us to introduce a forceps to the iron head and draw it out. If the opening be too small, he recommends us to enlarge it. When the weapon has nearly passed through the limb, he advises us to push it out at the opposite side. Thorns and such like sharp things are to be removed by the application of extractive plasters. (Ad Mans. vii, 25.)
Avicenna gives a literal translation of the present chapter of Paulus, and supplies nothing additional of much interest. (iv, 4, 2, 10.)
The account given by Haly Abbas is full, but like that of Albucasis. He mentions that he had seen cases in which an arrow had been lodged in the intestines, and although fæces were discharged by the wound, the patient recovered. He adds that others relate cases in which recovery took place although the liver or omentum had been wounded. (Pract. ix, 15.)
The rules for the extraction of weapons laid down by Theodoricus and all the earlier authorities are mostly copied from the ancient authors. (i, 22.)
It would be naturally expected that we should give some account in this place of the surgery in the heroic ages, as far as it can be learned from the poems of Homer and the Commentary of Eustathius. The Commentator remarks that three methods of extracting weapons are mentioned by Homer: 1. By evulsion or pulling the weapon backwards, as in the case of Menelaus. (Iliad, iv, 214.) 2. By protrusion or pushing it forwards, as in the case of Diomedes. (Iliad, v, 112.) 3. By enlarging the wound and cutting out the weapon, as practised by Patroclus in the case of Eurypylus. (Iliad, xi, 218.) He further remarks that it appears to have been a common practice to suck a wound with the mouth; and, he adds, that this method was still in use among a barbarous people in his days. (Iliad, iv, 219.) The weapons used in the Trojan war were swords, spears or javelins, stones flung by the hand or by a sling, hatchets or axes, as used by the Trojans on certain occasions (Iliad, xii, 590), and arrows. Eustathius remarks, however, that there would appear to have been very few bowmen. In his Commentary on the Odyssey he states that poisoned arrows were never employed in war, but only for killing wild beasts. (Odyss. i, 260.) We believe that no weapons of iron were used in the war of Troy, and that they were all made of copper. (See Jameson’s Mineralogy, iii.) Little transpires from Homer with regard to the internal treatment. In one place (Iliad, xi, 638) mention is made of a mixture of wine and cheese having been given to a wounded warrior, which practice, Eustathius says, had given rise to a variety of conjectures. Some supposed that the wound in the case referred to was so slight as not to render the administration of stimulants improper; others rather believed that the loss of blood had been so great as to call for the use of wine to support the strength. But many, he adds, were of opinion that men in the heroic ages lived so temperately that their constitutions readily bore things on extraordinary occasions, which in after ages were reckoned to be of too inflammatory a nature. This explanation is advocated by Athenæus. (Deipnos, i.) In the Odyssey, mention is made of a hemorrhage being stopped by incantation, which shows, as Eustathius remarks, that amulets and incantations were as ancient as the heroic ages.