In the section relating to the treatment of such traumatic affections of nerves, Guy makes the remark that the measures called for are, for the most part, the same as those required for wounds involving simply the fleshy parts of the body.
The element of pain, however, is one of the factors which distinguish wounds of a nerve from ordinary flesh wounds, and it may necessitate some slight modification of the treatment. Aside from this, one of the first things that should be done is to remove from the wound all foreign substances; after which the edges of the cavity should be brought together and held firmly in this position by appropriate means. Last of all, care should be taken to protect the parts. These are the general principles which are to guide the surgeon’s action. As to the special details, they must depend upon the different conditions presented by each individual case. Thus, for example, if we are dealing with a punctured wound of a nerve, there will be no edges of an excavation to bring together.
If the object which produced the puncture is still lodged in the tissues, it must, as a matter of course, be withdrawn. After which, the further measures to be adopted may be enumerated under the following heads: careful regulation of the manner of living; removal from the system of all material which—attracted to the wounded part by the pain—might there cause irritation or inflammation; and protection of the body against any harm that might come to it through the occurrence of convulsions. These three measures are indicated for all wounds of nerves. But, in the case of a punctured wound, still other procedures should be employed, as will be discussed under a fourth head.
The four heads mentioned by Guy may be briefly stated in the following terms: I. The patient should be put upon a light and very simple diet; and, in addition, he should be given a bed that is soft and humid (“humidus et mollis”). His surroundings should be kept quiet, and nothing should be permitted to disturb his peace of mind. II. To protect his tissues from the injurious influence of any superfluous matters of an irritating nature that may be circulating in the blood (i.e., cacochyme), a vein on the opposite side of the body should be opened and a certain amount of this fluid withdrawn. In certain cases, furthermore, it may be well, in addition, to administer an aperient remedy. III. If convulsions develop, the head, neck and the entire back should be anointed with well-warmed linseed oil or common (? olive) oil, as recommended by Galen. IV. Special measures should be adopted for providing a free outlet for any pus that may form in the deeper parts of the wound; and here again Galen recommends for this purpose the employment of one of several medicinal preparations which he enumerates. “But the more certain course,” Guy adds, “is to make an opening in the skin either with the razor or with the actual cautery (which latter, according to Henri de Mondeville, is the better plan of the two), and then to apply some subtle drying remedy which possesses the power to penetrate into the deepest recesses of the injured nerve—for example, savin oil.” (Guy has a good deal more to say on the subject of wounds of nerves, but the few extracts given above should suffice.)
It is now a well-known fact that Guy de Chauliac was in the habit of treating fractures of the thigh by the employment of the weight and pulley as means of keeping up a continuing extension of the damaged limb. As his description of the method in question is very brief, it may not seem out of place to reproduce it here. Translated into English it reads as follows:—
As to the plan which I employ, it is this: After making fast to the fractured thigh splints which extend down as far as the feet, I reinforce the support which they give, either by placing the limb in a box or by applying to its sides bundles of straw (appuyements). [These are shown in the left-hand lower corner of Fig. 12.] I then attach to the foot a mass of lead as a weight, taking care to pass the cord which supports the lead over a small pulley in such a manner that it shall pull upon the leg in a longitudinal direction. And if it then be found that there is not complete equality between the fractured limb and its fellow as regards length, the discrepancy may be corrected by gently pulling upon the former. Every nine days the limb should be cautiously handled; and at the end of about fifty days it will be found that firm union has taken place.
One more remark seems to be called for in reference to the fact that Guy de Chauliac, although he was avowedly a surgeon, managed to win as great a reputation and as high a social position as was possessed by any physician of that period. The medical practitioner, it will be remembered, held himself, during the Middle Ages, and was universally held, to be a much higher type of man than the surgeon. The relative standing of the two is well shown in the accompanying sketch (Fig. 13), in which all the details (attitude, head gear, gown, etc.) have evidently been carefully studied by the artist. Guy, however, through the sheer force of his character, and also probably because he was known to have won the highest medical honor (the grade of “Master of Medicine”) which it was in the power of the university to confer, pushed his way to the top, and held, for a period of twenty years, the position of private physician to three Popes in succession—Clement VI., Innocent VI. and Urban V. In other words, the prevailing prejudices and jealousies were not sufficiently powerful to block the triumphant career of this man of solid merit and high character.
FIG. 12. ONE OF THE WARDS IN THE HÔTEL-DIEU OF PARIS.
As it appeared in the sixteenth century.