Puncture and perforation are close to each other, because with each of them there is a penetration of a sharp, hard object into the body. They differ only in regard to the volume of the object penetrated, and it seems that in piercing something thin and small is meant, while in perforation it is an object of larger size and volume. It also seems that when piercing, along with a small amount of penetrating object, it is required that the hole be shallow and that the object does not penetrate further than the skin. The puncture causes only slight damage, and if it is not attended to and left, it will go away on its own, even if the puncture is in bad meat, unless, of course, the meat is too bad. In this case, the damaged area sometimes swells and rotting occurs in it, especially when the injection and puncture cause severe pain, which becomes stabbing and reaches the meat. The most that can be done in this case is to calm the pain and swelling, and no wound care is required.
As for perforation, along with use for pain and swelling, wound care is also required. Enough has already been said regarding the care of the wound and the use of the tumor, and here, in relation to puncture and perforation, it is necessary to mention only measures for removing objects stuck in the body and causing the perforation or puncture, be it a thorn, an arrowhead, or something like that .
Extraction is carried out either with instruments that grasp and pull out the object, or through squeezing and similar techniques, and sometimes special properties of pulling drugs are used for this, which remove objects against which pincers and other tools are powerless. As for the rule of extraction with the help of gripping tools, for example, extracting the ends of arrows with pliers with file-shaped ends so that they grip more strongly, then this rule should be taken care that the object captured by the pliers does not break, and the path of passage of the pliers to the object being removed must be sufficient wide so as not to interfere with a strong grip. To remove it, you should choose the easiest path, and if the object sticks out on both sides, then expand, as far as necessary, the side from which it can be pulled out most quickly. As for the trick to prevent the object from breaking, then for this you should not pull it strongly and at once, but it would be better to grab it and swing it to determine whether it has penetrated deeply and is stuck, or, conversely, is wobbling and then is pulled into forward direction. Often you have to leave the object in the wound for several days so that it loosens on its own, and then it is pulled out.
One of the scholars, versed in this art, said the words, which we will quote as they are. When extracting arrows, you must first recognize what type of arrow it is, for some arrows are made of wood, others of reeds, and the tips on them are iron, copper , tin, horn, bone, stone, reed or wood. Some tips are round, and some are triangular or tetrahedral; some are equipped with two or three tongues. Arrows come with tips, and there are also without tips. If the arrow has a point, sometimes the point is tilted back so that when the arrow is pulled outward it grabs into the body, and some arrows have points angled forward so they dig deeper into the body. Some arrows have points that ride on something like a spring, and when the arrow is pulled out, the spring stretches and prevents it from coming out. Sometimes the pieces of iron on an arrow are very large, with an end the size of three fingers, and some have an end the size of one finger, and such tips are called tailed. Some tips are smooth, while others have thin glands attached, and when the arrow is removed, these glands remain deep in the body. Sometimes the tip is stuck into the arrow, and sometimes it has a tube into which the arrow is inserted. Sometimes the tip is firmly attached to the arrow and sometimes not so tightly, so that when the arrow is pulled out, the tip separates from the arrow and remains in the body. There are tips that are poisoned, and there are also non-poisoned ones.
The arrow is removed in two ways, it is either pulled out or pushed out. If the arrow is embedded in the outer surface of the body, it is removed by pulling. Pulling is also used if the arrow is deeply embedded in the body, but we are afraid that when removing the arrow, the organs opposite it may be injured and this will cause disastrous bleeding and severe suffering.
The arrow is removed by pushing out if it is embedded in the meat and the organs opposite it are small, and nothing prevents the cut - neither a nerve, nor a bone, nor anything else similar to them. If the bone is wounded, then we use traction, if the arrow is visible, then we pull it out, and if it is not visible, then the wounded person, as Hippocrates says, should, if possible, take the same position in which he was when he was wounded , and this will allow you to detect the arrow. If this is not possible, then the wounded person should be placed in a position that is possible for him and begin searching and palpating. If an arrow, especially an arrow not made of reed, has stuck into the meat, then it is pulled out by hand by the shaft, if it has not fallen off, and if the shaft has fallen off, then the piece of iron is removed with pliers, tweezers or a special tool for removing arrows. In some cases, if the piece of iron cannot be pulled out through the original hole, the meat should be cut a little more. If the arrow lies across the wounded organ and cannot be removed from the side from which it entered, then an incision must be made in opposite places and either remove the arrow by pulling or push it out. If the shaft is preserved, then the tip is pushed out with the shaft, and if the shaft has fallen off, then it is pushed out with something else and taken out. We must push the shaft out so as not to injure a nerve or artery with it. If the tip has a tail, then we recognize this by feeling it, and the tail should be inserted into the tube of the instrument with which we push the arrow, and push it out in the tube. If we remove the tip and see hollowed-out indentations on it, then it is possible that there were some other thin glands there. Then we search again, and if we find such glands, we extract them using the same methods. If there are various branches on the tip and they do not want to come out, then we must widen the incision, if there is no organ near this place for which we fear, and when the tip is exposed, we carefully remove it; some people enclose such branches in a tube so as not to injure meat.
If the wound is calm and there is no hot swelling on it, then we first stitch it up and then apply a treatment that builds up the meat, and if a hot tumor has already formed from the wound, then this should be treated with watering and medicinal dressings.
As for poisoned arrows, if possible, we should cut a circle around the meat that was hit by the arrow; this meat is different from healthy meat; poisoned meat has a dark, bad color and looks like dead meat. If the arrow is deeply embedded in the bone, then you remove it with the above-mentioned tool, but if there are any tissues that prevent this, then we should cut them out in a circle or cut them lengthwise. If the arrow is deeply embedded in the bone, then we recognize this by the stability of the arrow, which does not move well if it is moved. In this case, we should first cut the bone above the arrow with a chisel, or gouge it around with a chisel if the bone is dense, and thus release the arrow.
If the arrow has penetrated deeply into any of the major organs, for example, the brain, the heart, the lungs, the stomach, the intestines, the liver or the bladder and there are signs of imminent death, then we should refrain from removing the arrow - this will cause great anxiety and give all sorts of ignorant people the opportunity to gossip about us, and we will help the patient very little. If there are no bad signs, then we inform the patient what phenomena we fear, and first we warn that death often occurs from this, and then we begin treatment, for many of the victims of such wounds were miraculously saved in the complete absence of hope. In this case, a piece of the liver or part of the membrane located on the abdomen, or the entire omentum, or the uterus often comes out, and death does not occur from this. However, if we left the arrow in these dominant organs, then death would occur in any case, and a lack of mercy would be attributed to us; if we remove the arrow, then sometimes, in some cases, the patient is saved.