Chirurgorum comes, or, The whole practice of chirurgery begun by the learned Dr. Read ; continued and completed by a Member of the College of physicians in London.

CHAP. XXXIII.

Of Wounds of the Nervous Parts.

BY the Nervous Parts, here I understand three sorts of parts: to wit, Nerves, Tendons and Liga∣ments.

That a Nerve is wounded, you shall know first by the part: If great and many Nerves be in the place wounded, or pass by it; A∣natomy teacheth this. Secondly, you shall know this by the Symp∣toms, for there will ensue a Pulsa∣tion, Inflammation, Convulsion, Raving, if it be cut asunder, and at last sometimes Mortifica∣tion.

The Solutions of Unity which happen unto Nerves, are four; a Puncture, an Incision, a Contusi∣on, and a Distortion.

Of the Wounds of Nerves re∣ceive these Prognosticks: First, Wounds of the Nerves are dange∣rous. First, because they are of an exquisite sense or feeling, both because the Membrane, wherewith they are covered, proceeds from Meninges, and that they are im∣pregnate with plenty of Animal Spirits. Secondly, by reason of the consent which they have with the Brain, and the Spinalis Medulla: For according to Galen, lib. 12. de usu partium c. 11. the Brain is the Well-spring, the Spinalis Me∣dulla the River, and the Nerves the Creeks. Thirdly, by reason of the fearful signs, which follow after that a Nerve is wounded, which are extreme pain, afflux of Humors, a Gangrene, a sharp Fever, Raving, and a Convul∣sion.

As for a Puncture, it is either not conspicuous, not to be discern∣ed by the sight; or it is conspicu∣ous: The first is called Punctura Caeca; the second, Punctura A∣perta: of the two, the Caeca is the worst; for local Medicaments cannot so well be applied to the part wounded.

Before I come to the cure of this particular Solution of Unity in Nerves, I will acquaint you with the general indications required in the cure of Wounds of Nervous Parts in general: First, Blood is to be let. Secondly, the Body is to be purged: See Galen, c. 2. lib. 6. Method. Aeginet. lib. 4. c. 54. these prevent the afflux of Humors. Thirdly, the party must use a ve∣ry slender Diet. Fourthly, we must provide that the Air which the Patient doth enjoy, be warm; for if Air be cold, a Convulsion must ensue. Peruse Apher. 15. Sect. 5. Wherefore when you dress

such Wounds, you are to use warm Cloaths and Stupes, and the Medi∣caments warmed.

Now to come to the cure of a Puncture in particular: if it be Punctura Caeca, these local Medi∣caments are apt. These Medica∣ments must be hot, drying, of sub∣til parts, to digest, dry putrefacti∣on, and attract. See Galen, lib. 6. Method. c. 2. & l. 3. secundum genera: such are Ol. Rutaceum, Chamaemelinum, Anethinum, Costi∣num, Liliorum Alh••rum, Ʋulpi∣man, de Castoreo, de Euphorbio, Lianbricorum, Hyperici cum Gum∣mi, de Scorpionibus, Terebinthinae. Galen advises, to use Sallet Oyl warmed, and applied with Wooll; old Oyl is best. Paraeus lib. 9. c. 38. ••dvises to add to it Aqua Vitae; for the thin and virulent Humor, which issues from the Nerve, is spent and dried the more. Galen, lib. 6. method. c. 2. & lib. 3. secun∣dum genera, commends a Medica∣ment made of Buphorbium, which is this: ℞ Cer. part. 1. Terebinthin. pic. an. part. dimid. Euphorb. part. 12. According to the tenderness or the hardness of the Body, more or less of the Euphorbium is to be used. You shall know your Me∣dicament to be proportionate to the grief; First, if the party feel a pleasant heat, as is that of the Sun in temperate weather: Se∣condly, if the party do pleasantly itch. If the party feel no heat, then there can be no attraction; if it be immoderate, it will attract Humors, and cause Inflamma∣tion.

If by the Application of these Medicaments, the Pain and other Symptoms cease not, then cross incision of the Skin is to be made, that the Medicaments in their full force may be applied to the pun∣ctured Nerve. When the Pun∣cture is either thus laid bare by In∣cision, or at the first by the wound∣ing Instruments; it is not requi∣site to apply to it Medicaments so hot and drying, and when it is hid to shun Inflammation: Wherefore your ordinary artificial Balsam dropped in warm will serve; for by this Unctuosity they smooth the part, by their Heat they make attraction, and so mitigate Pain by discharging the place of the Sanies, and by their Moisture they open the Orifice, and keep it open.

The Incision of the Nerve is ei∣ther streight and direct, or trans∣verse. If it be transverse, it is either quite cut asunder, or but in part.

A Nerve quite divided is less dan∣gerous, than that which is but on∣ly cut in part, according to Guid. Magn. Chir. tract. 4. docl. 1. c. 4. See Galen. l. 6. methed. c 2. Av. •• cen. l. 3. c. 4. Fen. tract. 4. c. 1, 2, 3, 4, 5, 6 & 7. The reason of this is, because a Nerve being quite cut asunder, cannot send any harm to the Brain.

A Nerve quite cut asunder can∣not admit any consolidation, ac∣cording to the first intention. See Hip. Aphor. 19. sect. 6. where he saith, when the Bone is wounded, or the Cartilages, or a Nerve, or the thin part of the Cheek, or the Praeputium, it doth not grow a∣gain or unite. He hath the like Aphor. 28. lib. 7. Arist••t. lib. 3. Histor. Animal. subscribeth to him: for these Parts are spermatick.

As for the cure of such a Wound, the Topicks which are used ought to dry with little mordication or biting, according to Galen, lib. 6. method. c. 3. & lib. 3. secundum genera. c. 2. such are Ʋnguentum de ca••ce lotà, & Ʋnguentum Dia∣p••mpholygos. If the whole Nerve be cut asunder, no Convulsion can ensue, because both the ends give way. This kind of Wound is cured easily by sarcotical Medica∣ments, whereof I have spoken here∣tofore sufficiently. In this kind of Wound the motion of the part in∣to which the Nerve is implanted to move, is abolished. If the Nerve be cut asunder but in part, first it is to be dressed with the Medica∣ments before prescribed; but if the Symptoms, as Pain, &c. and a Convulsion he like to ensue, the best course is to cut the Nerve or Tendon quite asunder rather than by deferring of the Incision to ex∣pose the party wounded to the dan∣ger of death. This being done, use Anodyne and desiccative Medi∣caments. When you have thus dressed the Wound above your Pledgets, either in Diapalma or Diachylon simplex in the Summer malaxed with the Oyl of Roses, Quinces, or Myrtils; for the ten∣derness of the part will hardly ad∣mit the application of any firm Emplaster. Last of all, you are to roll up the part with Fascia Expulsiva, whereof I have spoken in its proper place, partly to ex∣press the Santes which doth gather in the place, partly to stay the af∣fluxion of new Humors.

Now it is time to come to the Contusion of a Nerve. This may be either a solitary, or with some Solution of Unity. If it be solita∣ry then you are to foment the part with Sallet-Oyl hot, and to apply it with Wooll. If the Skin be divided, then Medicaments drying and uniting the parts are to be used. Such is Emplastrum Fodi∣cationis malaxed with Oyl of Hy∣pericum.

Last of all, a distortion may happen to a Nerve by a fall, ex∣traordinary motion, or some other violent external cause, which may hinder the motion of the part. In this case apply Emplastrum de mucilaginibus, or Diapalma, having Gummi Ammoniacum added to it.

After Contusion and Distortion of Nerves, a hardness often re∣mains, which causes a numness of the part. This proceeds from the setling of gross Humors in the place. In this case you are to use Medicaments which soften and di∣gest, as the Oyl of white Lillies, Goose-grease with Bd••llium; but the Oyl of Sheeps and Neats-feet impregnate with the Mucilage of Marsh-mallow, Linseed and Fenu∣greek, exceeds all other Medica∣ments. Let the part be embrocated with this Medicament warmed; and let Emplastrum magnum cum Gummi malaxed with Storax li∣quida be applied. Now it remains that I speak somewhat of accidents which usually fall out when a Nerve is wounded.

The first of these is an Inflam∣mation: you must meet with this by applying Medicaments, which are cooling and drying; for these both abate the Inflammation, and correct Putrefaction, such are

Bean-meal, Barley-flowre, the Meal of Vetches, Cich-pease, or Millet boiled with sufficient store of Oxymel, until they be brought to the consistence of a Poultice. But before you apply this Medica∣ment to the Member, embrocate it with Oyl of Elders, having min∣gled with it a little Rose-vine∣gar.

The second Symptom is Pain: Here you must use liberal Phlebo∣tomy, purging, and a spare Diet. If the party cannot admit Bleed∣ing, then Ventoses with Scarifica∣tion, Leeches, Vesicatories in the opposite parts; for a local Me∣dicament, use a Cataplasm made of Bean-flowre, Mallows, Groun∣sel, Violet-leaves boiled in Milk, and having Ʋnguentum Populeum mingled with the Cataplasm, when it is taken from the fire.

The third Symptom which may trouble both you and the Patient is a Convulsion: Of this Accident Hippocrates Aphor. 2. Sect. 5. so pronounceth: If a Convulsion en∣sue upon a Wound, it is deadly. But this must happen after too great effusion of Blood, as he ex∣plaineth himself in the next A∣phorism; for if a Convulsion fall out by reason of repletion, it is cured by bringing the Body low, by using the general curative means in that measure as the cir∣cumstances shall shew. If a Con∣vulsion happen, then you must em∣brocate all the Spinalis Medulla from the Head to the Coccyx with Sallet-Oyl warmed, and afterwards applying Rolls of Wooll, or a Sheeps-skin, newly killed, to the part: Then the Member wound∣ed is also to be dressed; so if the Wound be in the hand, you must begin to foment in the Arm-pits, by which the Nerves march, and then to proceed to the Vertebrae of the Neck and Breast with Oyl and Wooll. But if the Foot be wounded, then you must begin the Fomentation at the Vertebrae of the Loyns, and Os Sacrum, and so proceed to the ends of the Toes. It is not amiss to hold the whole Member in warm Oyl, as in a Bath, if it may conveniently be done. So much then of Wounds of a Nerve.

If a Tendon be wounded, you shall perceive it by these two Signs: The first is, if the Wound be near to the Joints, for the Tendons are the endings of the Muscles, and the ends of Muscles ever end ei∣ther at the Joints, or near to them. The second is, if the Wound be re∣ceived in parts which are not fleshy: such are the Backs of the Hands and Feet. As for the cure of these Wounds, the indications set down in the Cure of the Wounds of a Nerve will serve.

If Ligaments be wounded, see∣ing they are not so sensible as those of the Nerves and Tendons, they procure not so fearful Accidents: only drying Medicaments, and not too hot, are here to be used to con∣sume the Sanies, lest the Ligament rot. Stronger Medicaments may here be used, because a Tendon is not so sensible; in this case use Oyl of Mastick, the natural Bal∣sam, artificial Balsam, and dry∣ing and consolidating Powders; above apply Emplastrum Fodicati∣onis. In curing of these Wounds which happen to the Nervous parts, take heed that you use not a Fo∣mentation:

for that moistens and increases Putrefaction.

This one thing let me insinuate unto you, that if one be offered to you, who hath the great Ten∣don, inserted into the Heel wound∣ed, that you suffer him not to walk before it be perfectly united and skinned, for otherwise it will break open again.