SECT. LIV.—ON WOUNDS OF THE NERVES.
When the nerves are wounded or pricked, they experience great inflammation and pain owing to their great sensibility; and therefore fever and convulsions supervene upon them, and in some cases delirium, owing to the continuity of the nerves with the brain. And sometimes phlegmons and abscesses form in the other parts adjacent to the wound, arising from the wounded nerve, owing to their continuity with it. Wherefore we must preserve the wound of the skin from adhering, that the ichor may escape by it. And in punctures, if they appear blind, the part must be divided by two incisions intersecting one another. With regard to the treatment, if the body is plethoric, and the inflammation strong, it will be proper to begin with venesection; and when the body appears to be in a state of cacochymy, purging must also be had recourse to. We must apply to the wound medicines for allaying pain, and for increasing the discharge, more especially if the cross incisions have not been practised. It is necessary to know that warm water, which is most applicable to other inflammations, is inimical in these cases, and it is better to bathe the part with a thin oil which has no astringency and is warm to the feeling; for nothing either very cold or very hot can be applied without detriment. Of medicines turpentine-rosin is beneficial by itself in the case of children, women, and persons of tender flesh, but softened with euphorbium for those of a firmer fibre; and if it become too hard it is to be mixed with some of the thinner oils. To nerves in a state of inflammation and mortifications, we may use cataplasms consisting of the flour of barley or of beans, or by boiling that of tares in trained lye with oxymel. But without boiling we may use the following cerate for punctures: of wax, oz. iij; of euphorbium, oz. j; or of pigeon’s dung; for harder parts, of oil, oz. ij; and sometimes of turpentine, oz. j. When you wish to give the medicine the form of a plaster, you may add to the preparation from euphorbium, of wax, of boiled rosin, of oil, and of fat pitch, of each, oz. vj; but you will make it better by substituting the fattest bee-glue instead of the rosin. The following is a good remedy for punctured nerves, applying also to persons bitten by mad animals: Of vinegar one sextarius, of fat pitch, lb. j; of opoponax, oz. iij; having dissolved the opoponax in the vinegar triturate it more, and having melted the pitch, boil. This medicine is applicable to punctures of the nerves not allowing the mouth of the puncture to close up, as in the case of persons bitten by rabid animals it does not permit the wound to cicatrize. But it answers only with hard bodies, and when you wish to apply it to the punctures of children, or of persons of soft skin, you must melt it in some discutient article such as the oil of marjoram, of opobalsam, or old oil.—Another suitable application is basilicon with the addition of natron, or quicklime, or euphorbium, or sulphur vivum, or wild pigeon’s dung, or opoponax, or sagapene, or Cyrenaic juice, or castor, adding to a pound of the ointment an ounce of one of these medicines. It answers well for wounds of nerves, and more especially punctures. And in the country when one is not supplied with any other medicines, one may apply fresh and fat bee-glue to the wound, or leaven more especially if old, by itself or mixed with bee-glue, or with the juice of tithymal. But cataplasms may be applied made of oxymel, or of strained lye, with the flour of beans, or of tares, or of chick-peas, or of bitter lupines, or of barley, or of the flour of polenta, not only when in a state of inflammation, but they may be used from the commencement. But relaxing cataplasms are to be entirely rejected for wounds of nerves. If the nerve is not cut, but laid bare by a wound, the surrounding skin being divided so that the nerve appears naked, and is wounded longitudingly and not transversely, we must use none of the afore-mentioned from euphorbium, nor any thus acrid, for the nerve being bare will not bear their power which is strong, but one may use lime that has been washed often in the warm season mixed with much honey. The preparation from pompholyx, and that from honey melted with much rose-oil, are also excellent ones. But these things must not touch the wound, for the nerve is sensitive, of a cold temperament, and continuous with the most important part. And neither is it proper to bathe such an ulcer with oil, for it will make it become foul, and we must only wipe away the ichor with soft wool wrapped about a probe. When all things succeed agreeably to our wish, there will be no danger in fomenting with must. For stronger persons the trochisk of Polyides with sodden must may be used upon a warm pledget. After the exposed nerve has been covered over, we must apply externally pledgets, with some of those things which are fitting for narrow wounds, such as that from euphorbium, or that from pigeon’s dung, taking in also much of the sound parts. When the wound is transverse there is greater danger of convulsions, but everything relating to the cure is in this case the same, except that while the wound is recent some have used sutures and certain of the agglutinative applications; but the sutures must not be applied very superficially lest the part below remain ununited, but more deeply, taking care however that the nerve be not punctured by the needle. It is to be known once for all, that in wounds of the nerves the medicine which cures punctures being of a bitter nature, it is not possible to cure with it the division of the nerve, as the parts cannot endure pungency and inflammation. And neither does the medicine which cures incisions answer with punctures. For its strength does not reach the bottom of it, the incision of the skin being narrow. A spare diet is to be allowed, and a soft couch; and warm oil is to be applied to the armpits, head, and neck; but when the wound is in the leg, the medicine is to be applied to the groins, pubes, and the parts there. Baths, until the inflammation is on the decline, are to be abstained from, water not agreeing with these wounds, as we have said. But since some from habit cannot bear to want the bath, if the wounded part be the hand it must not, if possible, be wet in hot water, and still less in cold; but when the wound is in the foot, since it is impossible to preserve it from being wet, when about to go into the bath apply to the wounded part some of the plasters, and externally a compress consisting of many folds and moistened with oil; and again external to that a linen bandage; and after having done these things when the person affected is about to take his seat in the bath pour oil once more upon the bandage. When he comes out of the bath take away all those applications, and have recourse to the treatment described above. When there is only contusion of the nerve, if along with it there be contusion of the skin and ulceration, the cataplasm of the flour of beans and of oxymel will be a fit one, but you may add sometimes the flour of tares, and some iris; and when the contusion is attended with pain, you may mix a little liquid pitch with it. If there be no contusion of the skin, it will be more discutient to bathe frequently with an oil of a heating nature, I mean that of dill, of rue, of iris, or of marjoram. When the whole nerve is cut asunder no danger will result from it, but the part will be mutilated; and the treatment is to be conducted as in the case of other ulcers. The treatment of the wounds of nerves by simples is sufficient for accomplishing the whole cure, but some are in the practice of using compound applications in such cases, as the plaster from metals, those called barbarous, and the cissinum, that from groundsel, the melanchlorum, the indicum, harmonica, and athena, the composition of which, and the manner of using them you will find described in the [Seventh Book]. And since some very wealthy people are fond of using expensive applications to wounds of the nerves, Galen has described the following for punctures of the nerves: Of cinnamon, oz. j; of dittany, oz. j; of marum, oz. j; of amaracus, dr. ij; of wax, oz. viij; of opobalsam, oz. x; of turpentine, oz. x.—Another: of cyrenaic juice, oz. j; of wax, oz. iij; of opobalsam, oz. xij. This is an application for exposed nerves: Of wax used for ointments, oz. iij; of the ointment called spicatum, or foliatum, or that of nard, oz. xij; of washed pompholyx, oz. j; of spikenard, oz. j; of amomum, oz. j; of the leaf (malabathrum), oz. j. And these, Galen says, are superlatively excellent.
Commentary. Galen has devoted a whole book of his work ‘De Med. sec. genera’ to the consideration of wounds of tendons, membranes, ligaments, and nerves properly called, and he also treats of them more generally in the sixth book of his work ‘Meth. Med.’ He professes to have had ample experience in the treatment of these cases while attending wounded gladiators. As our author has given a very comprehensive abstract of Galen’s principles of cure, it will be unnecessary for us to enter into any minute detail of them. He states very decidedly that cold applications, especially cold water, are highly dangerous, and inculcates that calefacient oils are the most proper applications. He particularly praises oils medicated with spurge, or sagapene, or turpentine-rosin. They are to be applied upon soft wool. In certain cases, he says, I have mixed the powerfully desiccant substances, such as quicklime, misy, chalcitis, pompholyx, arsenic, and sandarach, with the oils or cerates. When tendons are cut across he directs us to unite the ends together by sutures. Wounds of membranes and ligaments are said to be less dangerous than those of tendons. In general he further recommends either bloodletting or purging.
Oribasius, Aëtius, and, in short, all the subsequent authorities, like our author, copy everything from Galen. As a specimen we shall give an abstract of the method of treatment recommended by Octavius Horatianus, who, it is probable, belonged to the Methodical sect. He commences with stating that wounds of nervous parts are in general very dangerous, and recommends applications of a digestive nature to avert the violent symptoms and pains. In such cases he directs us to bleed and purge, forbids all fomentations of warm water, but approves of those made with tepid oil, after which dressings composed of turpentine-rosin, either by itself or with some sponge, are to be applied. But for women and children of a delicate frame he recommends turpentine alone; for others, however, he recommends turpentine with spurge and oil, to which occasionally may be added bee-glue, sagapene, assafœtida, and opoponax. He also from personal experience speaks favorably of an application prepared from lime washed in water, spurge, sulphur, turpentine, wax, and pitch. He mentions other preparations from rosin, spurge, with oil and sea water.
The Arabians copy from Galen very closely. Thus Avicenna condemns cold applications, and recommends calefacient ones. He approves of sutures when the tendons are cut asunder. Haly Abbas cautions against cold water, and particularly commends wool dipped in hot oil of violets. When spasm (tetanus) supervenes owing to the wound of a nerve, he directs us to divide it asunder lest the affection of it spread to the brain and prove fatal. Rhases also forbids all relaxing applications. He commends hot stimulant oils, and basilicon mixed with spurge, natron, lime, assafœtida, castor, &c.
Gulielmus de Saliceto, Guido de Cauliaco, Severinus, and Lanfrancus in laying down the treatment of wounded nerves and tendons, follow closely the principles delivered by their Arabian masters. They approved of sutures when the tendon is cut across.
SECT. LV.—ON ANCYLOSIS.
Contractions of joints arising from impacted humours, or some nervous tension, we are accustomed to call ancylæ and ancylosis, which cases require emollient and relaxing applications. Wherefore, in general, those things recommended for scirrhous parts, but still more particularly the applications to paralysed members will be proper, and more especially pouring upon the part water and oil, in which linseed, fenugreek, marshmallows, bay, the root of the wild cucumber, and the Sicyonian oil itself, have been boiled. After bathing we may apply first the more simple acopa, such as that from poplar, that from fir, the one called bromium, that ascribed to Basilius, and the pyxis; and after these the Aristophanian, and that ascribed to Azanites. But the strongest are those called lysoponium and varium. Of plasters, that ascribed to Amathaon, and the anicetum. This is a most excellent one: Of bdellium, of calves’ fat, of ammoniac perfume, of Illyrian iris, of each, dr. xvj; of opoponax, of galbanum, of the seeds of rosemary, of storax, of frankincense, of each, dr. viij; of pepper, clx grains; of wax, lb. ss.; of turpentine-rosin, lb. ss.; of the lees of the oil of iris, q. s.; of wine, q. s.; the medicine is pounded. It forms a good acopum when diluted with oil of iris, of privet, or of bay. Intermediate between the acopa and plasters is the preparation from bacon called polymigmaton. The acopa are to be used with soft and continued friction, along with gentle attempts to bend and stretch the affected joint.
Commentary. The principles of treatment here laid down are the same as those inculcated by all the other authorities. For a complete account of the formation of malagmata, we refer the reader to Galen (Med. sec. gen. vii), and to Aëtius (xii, 42.)
Actuarius recommends an acopum composed of old oil, the oils of bay, iris, and storax, with turpentine, spurge, castor, ammoniac, pepper, opoponax, galbanum, and stag’s marrow. He remarks that emollient and relaxing medicines are indicated. (iv, 16.)