At the beginning of the sixteenth century the city of Lyons possessed

(and it still possesses) the oldest hospital in France--viz., the

Hôtel-Dieu,--which was founded by Childebert the First in 542 A. D.

The city itself was at that period second in importance only to

Paris, and in some respects it was the equal of the metropolis in

celebrity. The art of printing was introduced there in 1472, and the

presses of that city were soon reckoned the best in Europe. Many

medical books were published at Lyons. François Rabelais (1483–1553),

the celebrated author of the humorous and satirical works “Gargantua”

and “Pantagruel,” was a regularly educated physician, and during his

residence at Lyons he edited various works of Hippocrates and Galen.

Michael Servetus, who displayed such marked ability by his researches

in regard to the circulation of the blood, was also a resident of Lyons

from 1530 to 1543. Some idea of the way in which a large hospital was

managed in those early days may be gained from the following statement

of facts: In 1619 as many as five patients were permitted to occupy

one bed in Hôtel-Dieu at Lyons. Although the hospital possessed

accommodations for a total of five hundred and forty-nine patients

(including pilgrims and poor people), there was only one medical man

whose duty it was to look after the surgical cases, and he resided

outside the building. At a somewhat later date there was provided a

“_chirurgien principal_,” whose duty it was to give the needed

surgical care to this class of patients, and who was obliged to

reside in the hospital. When this chief surgeon required assistance

in the dressing of wounds, etc., he was authorized to make use of

the “apothecary’s boy.” The stock of surgical instruments possessed

by the hospital in 1543 comprised the following items: One uterine

speculum; one trephine, which was composed of thirteen separate

parts; one mouth-plug, for use in keeping the jaws separated; one

ear speculum; and one elevatorium. All these facts, taken together,

furnish strongly corroborative evidence of the statement made by von

Gurlt in his _Geschichte der Chirurgie_, viz., that in France,

during the sixteenth century, the occupation of surgeon was considered

by the community but little better than that of a hair-cutter. It

is therefore not surprising that the great hospital of Lyons should

have been managed at that time in accordance with such a low sanitary

standard and with an almost total disregard of the purposes for which

a hospital exists. So far as I am able to learn, the conditions just

described were not peculiar to the city of Lyons. “During the reign of

Francis the First (1515–1547) there were in the main room (thirty-six

feet wide) of the Infirmary of Hôtel-Dieu at Paris,” says Boisseau,

“six rows of beds (three feet wide), each one of which accommodated

ordinarily three (at times even four) sick persons, who necessarily

were very uncomfortable. This is not all; for there were also in this

same infirmary seven or eight beds which were designed to accommodate

from twenty-five to thirty infants or young children, the great

majority of whom died from the poor quality of air which they had to

breathe in that institution.” I do not need to furnish additional

proofs in corroboration of the truth of the statement that during the

Renaissance the French civil hospitals contributed practically nothing

to the advance of medical science. It is possible that in Italy these

institutions may have been better managed, for, in the account which he

gives of his trip to Rome, Luther speaks of having visited a hospital

which particularly attracted his notice by reason of its orderliness

and the conspicuous cleanliness of every part of the building. As an

offset, however, to this favorable testimony I should state that in

some documents discovered in comparatively recent times there are

memoranda relating to the duties of the medical staff in the civil

hospital of Padua (1569)--a city in which was located the most famous

medical school to be found anywhere in Europe during the sixteenth

century. These memoranda read as follows: “There shall be a doctor of

physic upon whom rests the duty of visiting all the poor patients in

the building, females as well as males; a doctor of surgery whose duty

it is to apply ointments to all the poor people in the hospital who

have wounds of any kind; and a barber who is competent to do, for the

women as well as for the men, all the other things that a good surgeon

usually does.” (The word “surgeon” is evidently employed here in the

sense of barber-surgeon, and not in the modern sense of the word.) This

testimony and that furnished on a preceding page with regard to the

management at the two leading civil hospitals in France amply justify

the statement that during the sixteenth century medicine received no

aid whatever from these institutions in its efforts to advance.

For the sake of orderliness I shall, from this point onward, arrange

the information which I may find it desirable to furnish, under the

headings of the different countries of Europe; and in carrying out

this plan I shall begin with Germany, as it was there that the oldest

fifteenth-century treatises on practical surgery were first printed.

CHAPTER XXXVI

SURGERY IN GERMANY AND SWITZERLAND DURING THE FIFTEENTH AND

SIXTEENTH CENTURIES

There were five men in Germany and German Switzerland who, during the

Renaissance, attained distinction as surgeons, and who at the same

time contributed, by their published writings as well as by the force

of example, to the advancement of medical science. The names of these

five surgeons are: Pfolspeundt, Brunschwig, von Gerssdorff, Fabricius

of Hilden and Felix Wuertz. The first three mentioned were born in the

early part of the fifteenth century, and all five of them derived their

practical knowledge of surgery in large measure from their experience

in warfare. Individual sketches of these men will be furnished farther

on, but I believe that these will be better understood if a brief

account of the state of medical education in general throughout

Germany, at the period which I am now considering, be first supplied.

_State of Medical Education in General Throughout Germany

(1400–1600)._--The University of Heidelberg was founded in 1386,

but it was not until about 1550 that the first beginnings of medical

teaching made their appearance in that institution. Equally feeble

attempts were made, twenty years later, to organize the teaching of

medicine at the University of Wuertzburg; but very little appears to

have been accomplished during the immediately following years, as may

be judged from the official announcement, in 1587, of what things

the Professor of Surgery would teach in the three-years’ course.

“_First year_: Lectures on the subject of tumors, in accordance

with the teachings of Galen; _Second year_: Lectures on the

subjects of wounds and ulcers, in accordance with the teachings of

Galen and Hippocrates and the Arabian medical writers; _Third

year_: Lectures on fractures and dislocations, in accordance with

the teachings of Galen and Hippocrates. Then, if sufficient time

is available during this last year of the course, a certain amount

of anatomy is to be taught (during the winter season) from Galen’s

writings on this subject. In the summer time the subject of simple

remedies may be taken up advantageously, and botanical demonstrations

may also be given.” Von Gurlt quotes Koelliker as his authority for

the statement that throughout the seventeenth century the medical and

surgical teaching at the University of Wuertzburg was very defective,

“almost nothing worthy of mention being accomplished during that long

period in the departments of anatomy and physiology.” In the University

of Basel, Switzerland, which was founded in 1460, medical teaching

was as barren as it was in all the German universities at that early

period. It was only in 1542 that the first public dissection of a

human body took place there. Vesalius was visiting the city at that

time for the purpose of superintending the printing of his great work

on anatomy, and the university authorities availed themselves of the

opportunity to secure from him not only this single demonstration, but

also in addition a course of lectures on anatomy. Fifteen years later,

Felix Platter, a native of Basel and a man of exceptional ability

(see sketch on pp. 332 _et seq._), made the first postmortem

examination known to have been made in that city. Two years later

still (1559), following in the footsteps of Vesalius, he made a public

dissection of a criminal’s corpse in the Church of St. Elizabeth.

From 1581 onward, with occasional omissions, a public dissection of

the corpse of a criminal was made by the professor of anatomy once

every year. In 1590 the question was discussed by the Faculty whether

it “might not also be practicable to secure from the hospital, for

dissection, an occasional corpse.” The first body obtained from this

source was dissected in 1604, but it was not until 1669 that a second

one was available. There was no museum of anatomy and the medical

school owned only two human skeletons--one male, that had been set

up by Vesalius, and one female which had been prepared by Platter.

During the first two hundred years of the existence of this university,

only twenty-three copies of the different writings of Hippocrates, of

Galen, of Dioscorides and of Paulus Aegineta were available for the

instruction of the medical students. “These books should be diligently

read aloud to the young men if their contents are to furnish the

maximum of useful information.” As for clinical instruction, each

student was expected to secure for himself, by private arrangement

with some active practitioner, the position of assistant, or to obtain

from the Archiater or City Physician an occasional opportunity of

seeing patients at the hospital. According to the rules established by

the Faculty the students were permitted to take private courses with

different physicians. Another and very valuable source of information

that was within the reach of these young men, was supplied by the

public disputations which were held quite frequently.

The preceding brief account, which I have compiled from von Gurlt’s

work, will serve, as I believe, to convey a fairly clear idea of the

primitive and very limited opportunities of acquiring a knowledge of

medicine and surgery which were afforded the student in Germany during

the fifteenth and sixteenth centuries. (It should be borne in mind that

Basel, although located in Switzerland, was in nearly all respects a

German city.) It was not until a much later period that the schools of

that country, in nearly every department of human knowledge, caught

up with and eventually surpassed--at least for a number of years--the

similar institutions in Italy and France.

[Illustration: FIG. 18. CONSULTATION BY THREE PHYSICIANS UPON A CASE

OF WOUND IN THE CHEST.

(From a woodcut in the _Surgery of Hieronymus Brunschwig_,

Strassburg, 1508.)

This treatise, which was written by the author in 1497, passed

through nine successive editions, the last one in 1539. Probably

no woodcuts of a higher order of merit than those represented in

this and the two following illustrations (Figs. XIX and XX) are

to be found in medical literature.]

_Hieronymus Brunschwig._--Hieronymus Brunschwig was born at

Strassburg during the early part of the fifteenth century, the exact

date not being known. It is believed that he attained a great age, some

even claiming that he was one hundred and ten years old at the time of

his death. His treatise on surgery, bearing the simple title “_Das

buchler Wund Artzeny_,” was first published in 1497,

when he was already an old man, and it passed through nine editions

during the following forty-two years. It was also twice translated

into English. Up to the time of the discovery of Pfolspeundt’s work

it was believed to be the oldest German treatise on surgery known. It

was very freely illustrated with original woodcuts, not a few of which

possess considerable artistic merit. (See accompanying reproduction.)

The following headings of some of the more important chapters will

convey at least a fair idea of the character of the book: “Definition

of the Word ‘Surgeon’”; “Anatomy”; “Fatality of Wounds in Different

Parts of the Body”; “Different Kinds of Wounds”; “Different Kinds of

Surgical Instruments”; “Different Modes of Ligating Blood-Vessels”;

“Wounds of Blood-Vessels and Nerves”; “Methods of Arresting Bleeding”;

“Foreign Bodies in Wounds”; “Treatment of Wounds Inflicted by Poisoned

Arrows”; “Bruised or Crushed Wounds”; “Stab Wounds”; “Bites and

Stings”; “Wounds of the Head”; “Operations for Hare-Lip”; and several

other chapters on wounds and pathological conditions of other parts of

the body. Syphilis is not once mentioned in the book; and from this

circumstance von Gurlt infers that a knowledge of the existence of

this disease had not yet, at that early date (1497), reached Germany.

In Brunschwig’s _Liber pestilentialis, etc._, however, which was

printed three years later, syphilis is incidentally mentioned as the

“_malefrancose_” or “_malum mortuum_.” That Brunschwig was

well informed in the earlier surgical literature is shown by the fact

that he quotes from the writings of Theodoric, Guillaume de Saliceto,

Guy de Chauliac, Henri de Mondeville, and many others. A hasty and

necessarily very superficial perusal of the text of a few of the more

important chapters of this remarkable book satisfies me that Brunschwig

deserves to be classed among the really great surgeons of the fifteenth

and sixteenth centuries. A copy of this rare book may be seen in the

Surgeon-General’s Library at Washington, D. C.

_Heinrich von Pfolspeundt._--The earliest German treatise

relating to surgery is that which bears the title “_Buch der

Bündth-Ertznei_,” by Heinrich von Pfolspeundt, “_Bruder des

deutschen Ordens_.” It was written in 1460, and was first published

in printed form in 1868 by H. Haeser and A. Middeldorpf, Berlin.

The text of this very early German work on the practice of surgery

furnishes ample evidence to show that the author was worthy to be

ranked among the leading surgeons of the fifteenth century. At page

fifty-seven, says von Gurlt, may be read the remarkable statement that,

in the case of a wound of the intestinal canal, one may cut through

that organ at the point of injury and then introduce into the opposite

ends of the divided bowel a silver tube the margins of which have been

carefully bent so as not to offer at any point a cutting edge. The

tube may then be tied in place with thread of green silk. (Von Gurlt

speaks of this as the forerunner of Murphy’s button.) Speaking of

wounds caused by arrows, Pfolspeundt says that, to insure the patient’s

recovery, the planet under which he happens at that time to be, should

be in favorable conjunction. In one case which came under Pfolspeundt’s

care he was obliged to pay an astrologer the sum of fifty gulden in

order to ascertain whether the planet in question was or was not in a

favorable conjunction.

There is only one place in the entire book, says von Gurlt, where a

gunshot wound is mentioned, and then only incidentally; but this is

positively the first reference (about the middle of the fifteenth

century) to such wounds discoverable in medical literature.

Among the topics which are treated quite fully and in such a manner as

to show clearly that the author was well versed in at least this part

of operative surgery, those relating to rhinoplasty deserve to receive

special mention. From the viewpoint of history, this part of the book

is of very great importance. In no other treatise, says von Gurlt, do

we find an equally detailed and satisfactory account of the operative

method employed by the Two Brancas (father and son, from Catania,

Italy), who were contemporaries of Pfolspeundt. The latter learned this

method from an Italian surgeon, whose name he does not mention, and

he was particularly careful not to divulge the essential details to

anybody except two of his brethren in the Order to which he belonged.

For anaesthetic purposes in operative cases, Pfolspeundt was in the

habit of employing sponges saturated with the juices of opium, Atropa

mandragora, Conium maculatum, Hedera helix or arborosa, Lactuca and

Daphne mezereum; his technique resembling very closely that employed by

Guy de Chauliac, Theodoric and others. (See the appropriate chapters in

the earlier part of this volume.)

In his remarks upon the manner of bringing about the healing of an open

wound, Pfolspeundt says that “in all cases he tries to dispense with

stitches, but that, when he finds such support necessary, he first

spreads a thick layer of adhesive material over both margins of the

wound and afterward introduces the threaded needle through the mass

into the skin. Then, in order to bring the edges of the wound together,

he draws the thread taut and makes it fast by means of a very small

knot.... Whether the sharp fever which sometimes sets in afterward as

a complication, is due to simple inflammation or to erysipelas, is a

question which cannot always be decided; and it is still more difficult

to determine whether the thin watery secretion which sometimes develops

in a wound may not signify--as some writers maintain--the beginning of

suppuration in a joint.”

Were it not for the difficulty which one experiences in translating

correctly the ancient provincial German of Pfolspeundt’s text, I might

readily furnish further examples of his surgical pathology and methods

of treatment. The few, however, which I have already given will have to

suffice.

[Illustration: FIG. 19. BARBER-SURGEON (_WUNDARZT_) EXTRACTING

AN ARROW FROM A WOUNDED SOLDIER’S CHEST WHILE THE BATTLE IS STILL IN

PROGRESS.

(From the _Feldbuch der Wundarznei_ of Hans von Gerssdorff, first

published in 1517; many later editions followed.)]

_Hans von Gerssdorff._--Hans von Gerssdorff, who was also called

“Schielhans” (squint-eyed Hans), was born in Strassburg about the

middle of the fifteenth century. He was a bold and skilful surgeon,

and acquired a wide experience and great self-confidence from his long

service in connection with the army. He was present, for example, at

the famous battles of Grandson (1476, in Switzerland) and Nancy (1477,

in France), in both of which the slaughter was very great, and in both

also Charles the Bold, Duke of Burgundy, was badly beaten. In 1517 von

Gerssdorff published at Strassburg a treatise on military surgery,

under the title: “_Feldbuch der Wundartzney_.” This book, which

is illustrated with exceptionally good woodcuts, two specimens of

which are here reproduced (Figs. 19 and 20), contains the earliest

discussion of gunshot wounds; and, in his remarks on the proper manner

of treating such wounds, von Gerssdorff leads one to infer that he

shared, although somewhat hesitatingly, the at that time prevailing

belief that these wounds are poisoned. He was a pronounced advocate of

the use of the red-hot cautery in cases of serious hemorrhage from a

wound. When it was found that the ball had penetrated the flesh to some

depth, he recommended that it be cut out; and if, after the removal

of the missile, the patient complained of much pain in the wound, hot

oil was to be poured into it freely. Before the employment of firearms

in warfare, amputation of a limb was rarely performed--that is, only

in cases where gangrene had developed in the corresponding hand or

foot. But von Gerssdorff assures us that, up to the time of writing

his “_Feldbuch_,” he had personally performed “nearly two hundred

amputations.” This great increase in the frequency of performing this

operation is clearly to be attributed to the increased use of the new

agent--gunpowder--in warfare. In this operation, according to his own

declaration, von Gerssdorff was not in the habit of suturing the flaps.

Instead, he brought the opposing edges together and then covered the

stump thus formed with the bladder of some animal. There are a number

of other interesting details relating to von Gerssdorff’s manner of

conducting this important operation, but it is not practicable to give

up the space that would be required for a satisfactory description of

them. There is one point, however, to which I may be permitted to refer

very briefly in this place, viz., the manner in which the surgeons of

this and even much earlier periods secured a fairly satisfactory degree

of local anaesthesia when they had occasion to perform an amputation.

They produced insensibility of the part by tying a band tightly around

the limb a short distance above the spot at which the amputation was

to be performed. At a somewhat later period, as in the middle of the

seventeenth century, artificial anaesthesia was also effected through

the application of snow or ice to the part.

The date of von Gerssdorff’s death is not known.

[Illustration: FIG. 20. AMPUTATION OF THE LEG.

(From Hans von Gerssdorff’s _Feldbuch der Wundarznei_.)

Von Gurlt says that this is the earliest known pictorial

illustration of the amputation of a limb.]

_Fabricius of Hilden._--Fabricius Hildanus--or Fabricius of

Hilden, near Düsseldorf--was born in 1560 and received his early

training in surgery from Cosmas Slotanus, a pupil of Vesalius and the

first barber-surgeon of Duke Wilhelm of Guelich-Cleve-Berg (eighteen

miles northeast of Aix-la-Chapelle). In 1585 he visited Geneva,

Switzerland, and continued his studies in that city under the guidance

of Jean Griffon, one of the most distinguished surgeons of that period.

After leaving Geneva he practiced medicine at Cologne, and during that

period (1591–1596) steadily increased his reputation as a skilful

surgeon, particularly well versed in anatomy. But he appears to have

acquired a strong liking for Switzerland and for the professional

friends whom he had gained in that country; and consequently it is not

surprising to learn that, during the later years of his life, he spent

long periods of time in Geneva, Lausanne and Berne, in the last of

which cities he filled the office of City Physician. He died in 1634,

at the age of seventy-four, full of honors and greatly beloved by all

who knew him.

Fabricius of Hilden laid great stress upon the importance, to the

surgeon, of a thorough grounding in anatomy. He had been profoundly

impressed by the fact that his instructor at Geneva, Jean Griffon,

never undertook an important operation until after he had refreshed

his memory by a dissection of the region involved. He was also much

interested in pathological anatomy, and always availed himself of every

possible opportunity for making a postmortem examination. As evidence

of the slowness with which news of important scientific discoveries,

particularly in the domain of medicine, traveled in those days I may

mention here the fact that, up to the time of his death in 1634,

Fabricius had not heard of Harvey’s great discovery of the circulation

of the blood (1628). Although he gained distinction in more than one

field of medicine his greatest reputation was unquestionably gained in

that of surgery; and his success in this field was to be ascribed to

his profound knowledge of anatomy, to his inventive genius, and to his

great technical skill. He insisted very strongly upon the importance,

for the surgeon, of possessing good instruments and well-constructed

apparatus.

If we compare Fabricius of Hilden with Ambroise Paré we are obliged

to admit that the latter, although decidedly inferior to his rival in

scientific training, was the greater surgeon of the two. It is perhaps

worth recording that Paracelsus and Wuertz were Fabricius’ bitter

opponents.

Of his published contributions to surgical literature, the most

important are to be found in the work entitled: “_Observationum et

curationum chirurgicarum centuriae VII._,” published at Lyons in

1641.

_Felix Wuertz._--Felix Wuertz was born at Zurich, Switzerland,

between the years 1500 and 1510 (the exact date is not known). As to

his early life and surroundings I am only able to say that his father

was a painter, that he himself took service under a barber, and that

at the end of two or three years, after he had learned the details of

this branch of work, he started out on his travels over Europe in the

character of a barber’s apprentice, as was, in those days, the regular

custom with apprentices of all trades or occupations. In this way he

visited such cities as Bamberg, Pforzheim, Nuernberg, Padua and Rome,

in each of which he spent a certain length of time as an aid to those

surgeons who were willing to employ him. It is not unlikely that it was

during this wandering period of his life that he gained some experience

in the treatment of gunshot wounds. In 1536, after an absence of

four or five years, he returned to his native city and was regularly

enrolled as a member of the barbers’ guild. During the following twenty

years he carried on the practice of medicine and surgery, but more

particularly the latter, with ever-increasing success. In 1559, for

reasons which are not mentioned by any of his biographers, he left

Zurich and established himself in Strassburg; and then, at the end of

another ten or twelve years, he again changed his residence, this time

giving the preference to Basel, a Swiss city located at the boundary

line between Germany and Switzerland. The exact date of Wuertz’s

death is not known, but--from various facts which he mentions in his

book--it may be inferred that it occurred in 1576, and that he was

residing at the time in the house of his son, who had the same name

as himself and was also a surgeon. The title of the treatise which he

wrote and which passed through a number of editions between the years

1563 and 1651,--not to mention translations into the French and Dutch

languages--was: “_Practica der Wundarznei_” (The Treatment of

Surgical Affections).

Malgaigne--says von Gurlt, in his History of Surgery--does not hesitate

to speak of Wuertz as one of the three greatest surgeons of the

sixteenth century (Franco and Ambroise Paré being the other two); and

von Gurlt adds that Wuertz’s “_Practica_” is rich in facts which

he had gathered from his own experience in everyday practice, and upon

which he makes comments that really represent his own views and not

those of various other authors. The leading principles which guided

Wuertz in his treatment of wounds of all kinds are thus formulated by

him:--

Keep them as neat and clean as possible, and disturb them as

little as you can; so far as may be practicable, exclude the

air; favor healing under a scab; and do not give the patient a

lowering diet, but feed him as you would a woman recovering from

her confinement.

According to von Gurlt, Wuertz attached relatively small importance

to healing by first intention, and only in rare cases did he make

special efforts to secure this result. On the other hand, he availed

himself of every opportunity to enter his protest against some of

the bad tendencies which had somewhat suddenly made their appearance

in the practice of surgery in his day, and more especially “against

the almost universal employment of caustics and the red-hot iron for

arresting bleeding; against the uncalled-for and positively harmful

habit of repeatedly probing a wound; against the unreasonable practice

of inserting tents into wounds; against the uncontrolled application

of mushy poultices to wounds; and against the excessive employment of

bloodletting in the treatment of wounds.” He exhibited his conservatism

in still other ways. Thus, for example, he was very slow in reaching a

decision to amputate a limb or to remove splinters or larger portions

of loose bone from a wound, for he put greater trust in the reparative

powers of Nature than did most of the surgeons of that day. Wuertz was

also slower than were most of them in resorting to the operation of

trephining the skull. His ideas with regard to the nature of gunshot

wounds were not very clear, for he still believed that the projectile

caused some burning and a certain degree of poisoning of the wound;

but he condemned all unnecessary efforts at extraction, especially by

means of complicated instruments. It was better, he said, to wait until

the bullet or other missile manifested its presence at some easily

accessible spot in the body.

The statements made above bring out some of the good features

of Wuertz’s treatise. This work, however, says von Gurlt, also

contains not a few bad features, and among them he mentions the fact

that it abounds in repetitions and in evidences of the author’s

superstitiousness.

Some of Wuertz’s comments on the symptoms which occasionally develop in

cases of injury to the head, and the suggestions which he makes as to

the treatment that should be adopted, throw considerable light upon his

mode of procedure in the presence of certain surgical phenomena. The

following clinical lesson is based upon three hypothetical developments

in a case of cranial injuries:--

(1) The patient’s wound in the head, let us suppose, has to

all appearances healed, when it unexpectedly becomes swollen

and painful and begins to discharge again. What measures are

indicated under these circumstances? The wound should at once

be freely reopened, for it may confidently be assumed that such

a lighting up of the local symptoms is due either to a loose

splinter of bone that is trying to escape or to the presence of

a small area of bone caries. If, under these circumstances, you

should not establish a free opening a large abscess will surely

collect in that region and will soon make for itself a new

outlet.

(2) If the patient complains that he has constant pain in his

head on the same side as that on which the injury was originally

inflicted, that the pain is steadily increasing in severity,

and that in addition he feels a sensation of pulsation in his

head; and if, furthermore, you inspect closely the site of

the original wound, and pass your finger cautiously over the

spot, but fail to discover any appreciable external swelling,

you may feel almost certain that a splinter or a spicule of

bone projects from the inner table of the skull cap into the

substance of the brain. Then, when the surgeon believes that

the condition as just described truly represents the existing

intracranial lesions, he should not hesitate to make an opening

in the calvarium over the affected spot and remove the offending

splinter.

(3) If the patient, after the external wound has healed,

complains of a throbbing and roaring in his head, not merely in

the region of the actual injury but involving the entire head,

and if the symptoms tend rather to increase than to diminish,

and eventually become so severe that the patient is almost

beside himself with the pain, then is the surgeon justified in

believing that a clot of blood is imprisoned somewhere beneath

the cranium and is gradually being converted into an abscess or

a condition of ulceration. And if at the same time some swelling

appears in the vicinity of the eyes, or if a bloody and purulent

discharge begins to flow from the nose or the ears, he may not

merely entertain a belief that his diagnosis is correct, but

may assert with positiveness that the lesions just named really

exist. And then the proper treatment for him to adopt is [in

essentials] the following: The head having first been shaved

over the site of the original wound, make a crucial incision

through the scalp and pericranium, turn the flaps back, apply

a strong, sharp-edged chisel to the surface of the bone, and

remove enough of the cranium to afford a satisfactory view

of the underlying parts. [Among the effects first observed]

probably pus will well up into the opening, and the patient will

then experience relief; and if a spicule of bone comes into

view, remove it forthwith. The plan of treatment here suggested

is the only one which can be trusted to effect a cure in a

case like that which is now being considered.... If a boring

instrument is employed for making an opening in the bone, be

careful not to allow any of the chips made by the borer to enter

or remain in the cranial cavity. Some surgeons teach that, if

pus be not found at the first opening, a second one should be

made at the distance of a finger’s breadth from the first, and

that the intervening bone should be broken down with a strong

and sharp knife so as to convert the two into a single opening.

[Wuertz adds that he had never found it necessary to act in

accordance with this advice.] After the pus or clot of blood

has been removed, one may as a rule readily discover the true

cause of the pain and other symptoms. As a final step, suitable

dressings should be applied to the wound.

Another important department of practical surgery, in which Wuertz

appears to have gained special distinction, is that which relates to

wounds and certain diseases of the abdomen. Owing to lack of space it

will not be practicable to reproduce here any histories of the cases of

this nature which came under his observation, but I believe that the

following brief extracts from his remarks upon the best way of treating

them may in some measure answer the same purpose:--

Penetrating wounds of the abdomen are universally admitted to

be very dangerous, no matter what organs (stomach, intestines,

liver, gall-bladder, spleen or kidneys) be involved in the

injury. In the case of a wound of the liver or spleen it is not

advisable to employ sutures; instead, one may use some kind of

sticking plaster for bringing the edges of the wound together.

Proper regulation of the diet plays an important part in the

treatment of these conditions, and so also may venesection. When

an intestine is the organ wounded I adopt the plan of treatment

recommended by most authorities; that is, I stitch together the

opposite edges of the wound and I cleanse the surface of the

bowel carefully with milk that has been well saturated with the

juice of anise seeds.

In his remarks about the treatment of suppurative processes involving

the thigh in the vicinity of the knee, Wuertz gives the following

advice:--

Do not allow the knee to remain quiet, but stretch the

surrounding parts and manipulate them as much as you can, in

order that the joint may not become permanently rigid; for if

you wait until the healing is completed before you resort to

these measures you will often find that it is already too late.

Separate chapters are devoted to such topics as would to-day receive

the designations “pyaemia,” “hospital gangrene,” and “septicaemia”;

and in a separate short treatise which deals with the various ailments

of young children, Wuertz mentions the fact that he once suffered

greatly for ten days from an attack of migraine (hemicrania) and that

he experienced marked and permanent relief only after the operation

of arteriotomy had been performed upon his left temporal artery. In

another part of the volume he expresses himself in terms which justify

the belief that he must have performed amputation of the thigh on

one or more occasions. He does not, it is true, furnish any details

regarding the indications that point to the necessity of resorting

to this operation, nor does he state how it should be carried out;

he simply makes the remark, while speaking of the employment of the

red-hot cautery iron in arresting hemorrhage, that “it is useful in

amputation of a limb, particularly in the thicker part of the thigh,

and occasionally in other places, as in the removal of a tumor by the

use of the knife.” So far as I am aware, Celsus was the first among

ancient writers on surgery to say anything about amputations, and what

he does say on this subject consists simply of quotations from still

earlier writers--from Archigenes, Leonides and Heliodorus, surgeons

whose writings no longer exist except in the form of detached extracts

that appear in more modern treatises. The portions of text which Celsus

quotes show clearly that the surgeons whom I have just named were in

the habit of making flap operations in cases of amputation above the

elbow and above the knee; and Archigenes even taught the advisability

of first ligating the larger supply blood-vessels before one proceeds

to the amputation of a limb.

From the remarks which Wuertz makes in one or two places it is easy

to see that he was often not a little annoyed by the criticisms which

his professional brethren made with regard to some of his methods of

procedure. Thus, for example, he boldly declares that one’s experience

is of much greater value than any rule that may have been laid down by

the ancients.

There can be no doubt, he says, that the ancients occasionally

displayed great ignorance and great want of judgment, just as

happens in our own time.... How much do you suppose I care

whether Galen’s, or Avicenna’s, or Guy de Chauliac’s opinion

does or does not agree with mine? Every such opinion--it should

be remembered--was, at one time or another in their day, a new

[and therefore unproved] opinion.... In practical surgery much

more importance attaches to the manner in which one carries out

one’s manipulations, and to the amount of experience which one

may have acquired, than to the length of time which one devotes

to windy consultations.

Fortune conferred very few favors upon Wuertz in the course of his

career; the aid granted by kings and princes played no part in the

moulding of his character; his greatness was entirely due to his

own unaided efforts. Paré, on the other hand, was certainly one of

Fortune’s favorites. He, too, like Franco and Wuertz, began his

professional life as a barber’s apprentice, but, as he was made of

a much finer clay, the ultimate product of his development was a

princely surgeon, perhaps no more efficient or skilful than his two

distinguished contemporaries, but unquestionably more many-sided,

more lovable than either of them. On the other hand, Wuertz rendered

a most valuable service to the science of surgery by his close and

patient study of certain symptoms which his confrères had overlooked

or incorrectly interpreted (such, for example, as pyaemia, hospital

gangrene and septicaemia); and he thus established the fact that these

were in reality independent diseases.

CHAPTER XXXVII

THE DEVELOPMENT OF SURGERY IN ITALY DURING THE RENAISSANCE

During the latter part of the fifteenth, all of the sixteenth and the

early part of the seventeenth centuries quite a large number of Italian

surgeons attained honorable distinction by the contributions which they

made to the science of medicine; and even in the neighboring Latin

countries of Spain and Portugal,--countries in which the force of the

revival of all departments of learning had made itself felt to a much

feebler degree, and in which at the same time the opposition to such

revival was much more active,--several surgeons succeeded in winning

creditable places for themselves in the history of their art. The names

of the Italian surgeons are as follows: Giovanni da Vigo, Bartolommeo

Maggi, Marianus Sanctus, Fallopius, Carcano Leone, Fabricius ab

Acquapendente, Aranzi and Tagliacozzi. I will now add brief notices of

the careers of all these men, in order to convey at least some idea of

the grounds upon which their claim to honorable distinction rests.

Giovanni da Vigo--perhaps more frequently referred to in literature

by the French form of his name, “Jean de Vigo”--was born at Rapallo,

near Genoa, Italy, about the year 1460. He was the son of Bernardo di

Rapallo, who was also a surgeon; and he himself was the founder of a

school which sent out quite a number of practical surgeons. In 1485 he

began the practice of his profession at Saluzzo, a small town about

forty miles south of Turin; and ten years later he settled at Savona,

which is located on the Mediterranean, a short distance to the west

of Genoa. In 1503 he was chosen the personal physician of Cardinal

Giuliano della Rovere, who resided at Savona, and he continued to hold

this position after the cardinal was elected to the papal office under

the name of Julius the Second.

Da Vigo’s great treatise on surgery (“_Practica in arte chirurgica

copiosa continens novem libros_,” Rome, 1514) owed its celebrity,

during the early part of the sixteenth century, chiefly to the fact

that he was the first author to write somewhat thoroughly upon syphilis

and upon gunshot wounds--two surgical disorders of great importance

at that time. As to gunshot wounds, da Vigo was one of the first to

maintain that they were poisoned wounds; and for a long time afterward

this was the generally accepted opinion. Like all his contemporaries,

da Vigo was not willing to undertake such operations as those for the

cure of stone in the bladder, for the relief of cataract, and for the

cure of hernia. He left these, says Haeser, to the itinerant surgeons.

But he gained well-merited credit by his employment of ligatures for

the arrest of bleeding in a variety of conditions--not, however,

in amputations, as he appears to have avoided cutting operations.

According to the same authority, the circular pattern of trephine (the

kind which the surgeons of the present day prefer) was first introduced

by da Vigo. The following passage copied from his “_Practica_”

shows that he was familiar with the use of the ear speculum: “...

_si ad solem speculo instrumento aure ampliata_.” Da Vigo died

soon after 1517.

Bartolommeo Maggi, who was born at Bologna either in 1477 (Haeser)

or in 1516 (von Gurlt), held the Chair of Anatomy and Surgery in the

medical school of his native city, and then at a later date accepted

the position of private physician to Pope Julius the Third (1550–1555).

He held this position, however, only for a short time, as he found that

the climate of Rome did not agree with him. His posthumous fame rests

largely on the treatise which he wrote on gunshot wounds and which

was published by his brother a short time after the former’s death.

His treatise, says von Gurlt, is one of the best of those which were

published on this subject during the sixteenth century. Henry the

Second, King of France, expressed his gratitude to Maggi for the care

which he took of the wounded French soldiers who fell into the hands of

the papal troops at the sieges of Parma and Mirandola. Maggi maintained

firmly the belief that gunshot wounds are either poisoned or burned.

His death occurred in 1552. The title of his treatise on gunshot wounds

is: “_De vulnerum bombardarum etc._,” Bologna, 1552.

Marianus Sanctus of Barletta near Naples (born in 1489, died at some

unknown date after 1550) is credited with having been the first to

publish a description of the so-called “_apparatus magnus_”--the

name given in those early days to the method of extracting a calculus

from the urinary bladder through an incision in the perineum after a

grooved sound or director had first been passed into this organ by

way of the urethra. The title of the book in which this description

is given is the following: “_De lapide renum liber et de lapide ex

vesica per incisionem extrahendo_,” Venice, 1535. Marianus, however,

does not claim to have been the inventor of this method. Some writers

give the credit for this to Jean da Vigo’s father, Bernardo di Rapallo,

who communicated a knowledge of the method to Giovanni de Romanis,

who in turn instructed Marianus Sanctus. It is believed, furthermore,

by some writers that Giovanni de Romanis was the inventor of

lithontripsy[86]--the operation of crushing a stone in the bladder or

urethra. Laurent Colot, the famous French lithotomist of the eighteenth

century, obtained his knowledge from a certain Octavianus de Villa, a

friend of Marianus Sanctus, and then kept the matter secret for many

years.

Fallopius, the famous anatomist of the early part of the sixteenth

century, does not appear to have attained equal distinction in the

field of surgery. So far as one may judge from the portions of the

text selected from his writings by von Gurlt, Fallopius was a very

conservative if not a very timid surgeon, in this respect being not

unlike Fabricius ab Acquapendente. In the text to which reference has

just been made, I find a brief mention of a case which passed under

Fallopius’ observation and which, perhaps, is of sufficient interest

to be recorded here. The patient’s--a German student’s--finger had

been nearly severed by some cutting instrument, and the greater part

of the member remained attached to the hand only by a narrow strip of

flesh. “I stitched together the separated edges, and at the end of

three or four days I was astonished to find that firm union between the

separated parts had already taken place. This result seemed to me like

something miraculous.”

Carcano Leone was born at Milan in 1536, his parents being people of

good social standing. After receiving a thorough classical education,

he began his medical studies in his native city, under the guidance

of Pietro Martire, a pupil of Vesalius. He next continued his studies

at the University of Pavia, but eventually went to Padua, where he

enrolled himself among the pupils of Fallopius. After a residence of

two years in that city, he returned to Milan and opened a medical

school of his own. Upon the occasion of the death of the Cardinal and

Archbishop Carlo Borromeo, whose remains now rest in the cathedral of

Milan, it was Carcano Leone who was invited to make the postmortem

examination. He carried on the practice of his profession during a

period of about twenty-eight years, his death occurring--so far as may

now be learned--in 1606.

Carcano Leone’s reputation as a surgeon rests mainly on the treatise

which he wrote on the wounds of the head, and which was published at

Milan in 1583. From among the numerous cases of this character which

came under his observation, and of which a certain number are reported

by von Gurlt, I have selected the very brief histories of three that

seem to me well adapted to serve as examples of Leone’s knowledge of

surgery and also of his ability to cope with problems of so serious

a character. They reveal the fact that he was a surgeon of excellent

judgment, most persevering, and very resourceful. Briefly told, the

accounts of the three cases to which I have referred read as follows:--

Case I.--A small boy was hit on the right temple by a stone

that had been thrown by one of his companions. Unconsciousness

resulted and lasted for six days. On the seventh day signs of

returning consciousness manifested themselves, but inability to

speak persisted. By the end of another week the boy had already

made some efforts to speak, but his speech was incomprehensible.

After the twentieth day it was possible to understand a little

of what the boy was trying to say; and from this time onward

steady improvement in this respect was recognizable from day

to day; but the boy’s speech did not become quite normal until

after the lapse of about a year.

When Carcano Leone was called to see the patient he found that

the entire temporal muscle had been crushed and that almost the

entire right side of the head was occupied by a fluctuating

swelling. By making a free incision in the swelling Leone gave

exit to a large quantity of black coagulated blood. On the

following day, when he made an examination with the probe, he

found that the entire squamous portion of the temporal bone was

in a fractured state, one part of it overriding the rest. By the

aid of elevators he succeeded in lifting up the depressed part

of the bone, but the accomplishment of this result left a large

gap between the opposite edges of the fragments, and through

this opening one could see the movements of the dura mater.

Complete healing took place only after the lapse of twelve

months.

When Leone reported the case to his former teacher, Fallopius,

the latter replied that he would not have had the courage to

adopt the course which his former pupil had pursued.

Case II.--In another case the patient, a full-grown man, was

struck on the right temple by a highwayman with a heavy cane

which broke in two in the middle under the great force which

the assailant had employed. He was left lying on the roadside

in a state of unconsciousness until some passers-by discovered

him and carried him to his home. He remained unconscious for

several days. Before the physician was summoned all sorts of

measures had been resorted to for the purpose of dissipating the

swelling in the temporal region, but without success. Leone, on

arriving upon the scene, made a free incision which afforded

escape to a large quantity of decomposing blood that appeared to

be collected, not between the muscle and the skin, but between

the muscle and the bone. The latter was found to be fractured

transversely and depressed; and, in order to lift it back to

its proper level, it became necessary first to incise the

muscle transversely. At the end of three months the wound had

completely healed and the patient had regained his health.

Speaking of the cases just narrated and of others of a similar nature,

Leone remarks that he has never had any experience that would justify

the fear expressed by Hippocrates that convulsions are likely to result

from dividing the temporal muscle.

With reference to the value of trephining the skull in cases of injury

to the head, Leone narrates the following experience:--

Case III.--A man was struck by a heavy stone on the upper part

of the forehead close to where the hair grows, and was thrown

to the ground by the force of the blow. Here he lay as if dead.

When Leone was called, a short time afterward, to see the

patient he found the skin unbroken except at one small spot,

and from this point he made an incision of such length that he

was thereby enabled to explore the surface of the skull. In

this way he discovered that there was a fracture which appeared

to extend through the entire thickness of the skull. He then,

without further delay, trephined the cranium over the line

of the fracture. This was followed by such a copious flow of

blood that Leone was obliged to adopt measures for arresting

any further hemorrhage. During the following fourteen days (the

summer season then being at its height) large quantities of

decomposed and evil-smelling blood escaped from the wound; but

the dura mater gradually assumed a more natural appearance, many

splinters of bone were ejected, and finally--at the end of forty

days--the wound healed. (As no further details are given in the

text, it is fair to assume that there were no sequelae of an

unfavorable nature.)

The whole subject of injuries to the skull is treated in a most

thorough manner by Leone, and the book is pronounced by Scarpa

(1752–1832), the famous anatomist, the best that, up to his time, had

been written on the subject. The three histories of cases which I have

here reproduced and which furnish such striking proof of what surgery

may accomplish when practiced by a man of good courage as well as of

good judgment, certainly justify the favorable opinion expressed by

Scarpa upon Leone’s work.

Fabricius ab Acquapendente, of whom I have already given some account

on a previous page, was distinguished not only as an anatomist and as a

physiologist, but also--which was true of his instructor, Fallopius--as

a surgeon. From his published writings, however, it appears very

clearly that, like Fallopius, he had a decided aversion to the use

of the knife; his activities as a surgeon being restricted largely

to the improvement of certain of the more bloodless operations (for

example, tracheotomy and thoracentesis and operations for the relief

of stricture of the urethra). He also invented several new surgical

instruments and devised a number of machines for use in orthopaedic

practice. He attached great value to the teachings of Celsus and Paulus

Aegineta, his writings containing frequent and copious references

to these authorities and relatively few data based upon his own

experience. In the section which he devotes to the subject of wounds of

the abdomen, Fabricius confirms the opinion very generally held by the

ancients, viz., that a wound of the small intestine is invariably fatal.

Gaspare Tagliacozzi was born at Bologna in 1546. He studied medicine

under Girolamo Cardano, Professor of Medicine, first at Pavia and

afterward at Bologna, and received his degree (“Doctor of Philosophy

and Medicine”) in 1570. Very soon afterward he began teaching surgery,

and a little later he also taught anatomy and the theoretical part of

medicine. In this work he was so successful that in 1576 he was made

a member of the Faculty. He died on November 7, 1599, at the age of

fifty-three.

The Italian method of performing plastic operations, says von Gurlt,

had already flourished for about one hundred and fifty years before

Tagliacozzi took up the subject in serious earnest and attained results

of decided scientific value. There are some doubts, however, as to the

precise degree of credit that should be awarded Tagliacozzi for his

share in the development of the operation which bears his name. The

facts which throw some light upon this question may be stated in the

following paragraphs:--

(1.) Tagliacozzi’s Latin is not easy to understand, and he

certainly does not furnish satisfactory information as to the

manner in which he learned the details of the operation which we

are here considering. Vesalius, Paré and other surgical authors

of that period throw no light upon that question and furnish

erroneous descriptions of the steps of the operation. Apparently

they had never witnessed one of that character. (Von Gurlt.)

(2.) The records seem to warrant the statement that, about

the middle of the fifteenth century a surgeon by the name of

Branca, who lived in the city of Catania on the southeast coast

of Sicily, devoted himself largely to the reconstruction of

damaged or defective noses. At first he transplanted a flap from

the forehead or cheek; but afterward his son sought to improve

the method by utilizing a flap of skin taken from the arm. By

this plan the disfiguring of the patient’s face was avoided.

The son employed the same method in repairing the lips and the

ears. Pupils of the latter carried a knowledge of the method to

the Bojano (Vianea or Vieneo) family in Tropea, Calabria, and

from them it was transmitted, about the middle of the sixteenth

century, to Tagliacozzi and eventually to the medical profession

in every part of the world.

(3.) In 1581 there was published at Cracow, Galicia (formerly

Poland), a book which bore the title “Przymiot” and which gave

a most complete account of the disease syphilis in all its

manifestations and complications. This book, in its original

form, is to-day one of the greatest bibliographical rarities;

but a reprint of the work was published in 1881 by the Warsaw

Surgical Society. In this volume Wojciech Oczko, the personal

physician and secretary of the Polish kings Stephan Bathory and

Sigismund the Third, discusses other surgical topics beside

syphilis. He states, for example, that Aranzio (or Arantius),

who was Professor of Surgery at Bologna at the time (1569) when

he frequented that medical school, was successful in making a

new nose by transplanting a flap of skin from the patient’s

arm; and that he performed this operation without injuring the

muscles of the arm, and also with perfect success as regards

the creation of a straight and shapely nose. “This statement,”

says von Gurlt, “coming as it does from an eye-witness who was

at Bologna several years before Tagliacozzi’s time, furnishes

satisfactory proof that rhinoplasty was successfully performed

in that city several years before the date of publication

(1586) of Tagliacozzi’s earliest comments on the subject,

and that the credit for first bringing the operation to the

knowledge of European surgeons is due to Aranzio rather than

to Tagliacozzi.” The latter’s famous treatise on rhinoplasty

(“_De chirurgia curtorum per insitionem_”) was published at

Venice in 1597.

[Illustration: FIG. 21. THE MANNER IN WHICH THE SO-CALLED

TAGLIACOTIAN OPERATION FOR REPAIRING A DEFECTIVE NOSE SHOULD BE

CARRIED OUT.

(From the treatise published by Tagliacozzi, Venice, 1597.)]

(4.) Fabricius of Hilden, the distinguished German surgeon

of the sixteenth century, assures us that his teacher, Jean

Griffon, at that time the leading surgeon of Lausanne (but, at

an earlier period, of Geneva), performed the same operation in

1592. The patient was a young Genevese woman whose nose had been

cut off by some soldiers belonging to the army of the Duke of

Savoy who were enraged at the resistance which she offered to

their familiarities; and the operation proved most successful,

“the new nose eliciting the admiration of all who saw it.”

Fabricius adds that during the winter seasons, up to the year

1613, the tip of this nose presented a somewhat purplish hue.

The woman married in 1603.

(5.) During the short lifetime of Tagliacozzi several tablets,

on which laudatory inscriptions were engraved, were erected in

the high school (_archiginasio_) of Bologna, and after his

death a bust that represented him holding a nose in his hand was

erected in the same building. Corradi, the medical historian

(1833–1892), writes that in his time both bust and tablets had

disappeared. Tagliacozzi’s remains were temporarily lodged in

the cloisters of the church of San Giovanni Battista, and the

report was circulated that, a few weeks after his death, a

voice was heard saying that he was among the damned. Thereupon

the remains were removed to the walls of the city, and the

Tagliacotian method was soon forgotten, to be revived only after

the lapse of many years.

All the data which I have reproduced in the preceding paragraphs

seem to point to the conclusion suggested by von Gurlt, viz., that

Tagliacozzi was willing to accept for himself a credit which belonged

in reality to another, and that there would be more justice in calling

the famous rhinoplastic method of procedure “the Arantian operation”

than the Tagliacotian; especially as our knowledge of the method

adopted by the younger Branca is entirely too vague to justify us in

bestowing this honor upon him.

Giulio Cesare Aranzio (or Arantius) was born at Bologna about the year

1530. He studied medicine first in his native city, under the guidance

of his uncle, Bartolommeo Maggi, and then afterward went to Padua,

where he may possibly have been one of Vesalius’ pupils. In 1548 he

made, at Padua, his first anatomical discovery--that of the _musculus

levator palpebrae superioris_. Before he was twenty-seven years

old he was chosen Professor of Medicine, Surgery and Anatomy in the

University of Bologna, and he filled the position with distinction up

to the time of his death on April 7, 1589--_i.e._, during a period

of thirty-three years.

The part taken by Aranzio in the advancement of surgery was apparently

of small importance. He succeeded, it is true (see remarks on page

479), in reviving the interest of contemporary surgeons in the

possibility of restoring damaged parts of the human face by means

of flaps taken from the patient’s arm. But I have not been able

to discover that he made any other material contributions to this

department of the science of medicine. It is possible, however, that

his plan of illuminating the interior of the nose and of operating upon

nasal polypi may possess some measure of originality; but I do not

feel competent to decide this question. As regards the procedure just

referred to, it may be stated briefly that Aranzio was in the habit,

when operating within the nasal cavity, of using by preference, for

illuminating purposes, the direct rays of the sun, which were allowed

to enter the room through a slit or hole in the wooden window blind;

and, when sunlight was not available, he used as a source of light

the rays emanating from a lighted wax candle. In the latter case he

increased the brilliancy of the illumination by interposing between the

flame of the candle and the illuminated field, a glass globe filled

with water,--an idea which probably originated with the goldsmiths or

the shoemakers. The employment of light reflected from a concave mirror

supplanted this method somewhere about the year 1866.

In Italy, during the sixteenth century, there were several

surgeons--uneducated empirics--who contributed not a little to our

knowledge of the radical cure of hernia; and of this number the

members of the Norsa family (from Norsa, a small town in the district

of Naples) were undoubtedly the best known and most experienced

operators. Horazio Norsa, for example, is reputed to have performed the

radical operation (in combination with castration) no less than two

hundred times. It was this same Horazio Norsa who, in the latter part

of his career, complained to Fabricius ab Acquapendente that, since the

wearing of trusses had become so common a custom as it then was, the

number of operations for the cure of hernia had greatly diminished.

CHAPTER XXXVIII

THE DEVELOPMENT OF SURGERY IN SPAIN AND PORTUGAL DURING THE RENAISSANCE

According to the authority of Morejon, who published (1842–1852) an

elaborate history of medicine in Spain and Portugal, these countries

almost rivaled Italy, during the sixteenth century, in the number and

excellence of their physicians. But, so far as I am able to judge

from the record, very few of these men appear to have taken a strong

interest in surgery, and of these few there are only three--Daza

Chacon, Francisco Arceo and Amatus Lusitanus--who left behind them

treatises which seem to call for a brief notice.

Dionisio Daza Chacon, who was born in 1503 at Valladolid, about one

hundred miles north of Madrid, received his early training partly in

his native city and partly at the University of Salamanca. After being

engaged for some time in private practice he joined the imperial army

(Charles the Fifth) in the capacity of a field surgeon in charge of a

corps of three thousand men. In addition to these troops there were

six thousand English archers, in the pay of the Emperor. At the two

sieges in which these men participated--the siege of Landrecy in 1543

and that of Saint Dizier in 1544--Daza Chacon acquired an extensive

experience in the treatment of both arrow and gunshot wounds, for the

number of those injured on those occasions was very great. In 1545,

after he had been chosen personal physician of Charles the Fifth, he

returned home by way of Madrid, and distinguished himself greatly in

1547 by his self-sacrificing attendance upon the victims of the Plague

in his native city. In 1557 he offered himself as a candidate for the

position of Surgeon-in-Chief of the hospital at Valladolid, and, after

passing with great credit the competitive examination, he was given the

appointment. During the following six years he served that institution

with conspicuous ability, and then accepted the position of private

physician to Prince Don Carlos, the son of Philip the Second, King of

Spain. Four years later he entered the service of Don Juan of Austria

(the natural brother of Philip the Second), and accompanied this prince

on his sea voyages to various parts of the Mediterranean; being with

him, for example, on the occasion of the bloody sea fight in the Gulf

of Lepanto in 1571. On reaching the age of seventy, Daza Chacon retired

from active practice and devoted himself to the writing of his great

work on surgery--“_Practica y teorica de cirujia, en Romance y en

Latin_,” Valladolid, 1600; and several later editions. The date

of Chacon’s death is not known, but it certainly occurred before the

publication of his book.

Von Gurlt says that Chacon’s treatise is distinguished by the

systematic and clear manner in which the author treats the subjects

with which he deals, and it shows him to be well versed in the

teachings of other writers on surgery, that he is ready at all times

to give them full credit for any contributions which they may have

made to this branch of medicine, and that he is remarkably free from

the superstitiousness which was so prevalent in his day. Of all the

treatises on surgery which have been written by Spaniards, either

during the sixteenth century or at a more recent date, this work, says

von Gurlt, is unquestionably the best.

The edition of the treatise published at Madrid in 1626 contains 922

pages--a large work. Among the reports of cases published in Part II.,

there are several which possess features of considerable interest, but

I shall be able to reproduce only one of them here:--

The young prince, Don Carlos, aged seventeen, while residing

temporarily at Alcalá de Henares, plunged head foremost, in

the dark, down a steep staircase and struck his head against a

closed door. When the lad was picked up it was found that, at

the back of his head, there was an open wound about the size of

a man’s thumbnail, that the surrounding scalp showed evidences

of being bruised, and that the pericranium in this region

had been laid bare. During the first three days following the

accident the patient manifested only a moderate degree of fever,

but on the fourth day the fever became more pronounced. The

wound, which by this time was discharging actively, presented at

first a healthy appearance, but it soon acquired an unhealthy

aspect, and the patient began to complain of numbness in the

right leg. Vesalius, the private physician of Charles the Fifth,

the boy’s grandfather, was one of the many physicians who were

called in to consult about the treatment of this case; he was

sent for on the eleventh day following the accident. On the

seventeenth day the wound was enlarged and the bone carefully

examined, but no evidence of a fracture or a fissure was

discovered. On the following day erysipelas manifested itself on

the head and neck and extended downward until it had involved

both arms. At the same time the fever increased very markedly,

and for five days the patient was delirious. As by this time

there was ample reason for suspecting that some intracranial

injury had occurred, it was decided to trephine the skull. The

operation was performed on the twenty-first day, but nothing of

importance was discovered. The patient’s life was now evidently

in great peril, and an unfavorable prognosis was pronounced.

Four days later, however, complete consciousness returned.

On the twenty-ninth day a quantity of pus was evacuated from

the very much swollen eyelids; and, three days later still,

the patient was found to be quite free from fever. On the

forty-sixth day he left his bed for the first time, and at the

end of ninety-three days the wound was found to have firmly

cicatrized.

[Some interesting details concerning the subsequent life of Don

Carlos will be found in Motley’s “Rise of the Dutch Republic.”

They suggest the possibility that his attacks of violent temper

may have resulted from the lesions produced by the accident

narrated above.]

Francisco Arceo was born, about the year 1493, at Fregenal in the

Province of Badajoz, Spain. It is not known at what university or other

educational institution he received his early training in the science

of medicine. It is a well-established fact, however, that at quite an

early stage of his professional career he acquired great celebrity for

his skill in treating both surgical and internal maladies, and that,

as a consequence, patients flocked in large numbers from all parts of

Spain to consult him. Rather late in life he wrote two treatises--one

on the treatment of wounds, as well as on ulcers and syphilis, and

another on the management of fevers. These two works were published at

Antwerp, in the year 1574, as a single volume, the author being at that

time, despite his advanced age (eighty), still in vigorous health and

able to practice with skill both branches of the science of medicine.

In 1658 a second edition of Arceo’s two treatises was published

at Amsterdam; and even at an earlier date there were published an

English translation (1588) and a German version (1614). A perusal of

the chapter which he devotes to the treatment of clubfoot gives the

impression that Arceo was an excellent surgeon--eminently practical

in his choice of means for securing certain results, and thoroughly

familiar with the extent to which he might depend upon the powers of

Nature to aid his efforts. The date of his death is not known.

Amatus Lusitanus is the name by which the Portuguese medical writer,

Juan Rodriguez de Castel Bianco, is commonly known. He was born in the

Province of Beira, Portugal, in 1511, of Jewish parents, and studied

medicine at the University of Salamanca. After doing duty as a surgeon

in two of the hospitals of that city, he took up his residence, for

short periods of time, first in Antwerp and then in Ragusa, Dalmatia,

on the eastern coast of the Adriatic. At this period of our history

the Inquisition was extremely active throughout the domains that were

under the rule of Charles the Fifth, and as a result Amatus soon

found himself obliged to abandon all his books, instruments, etc.,

and flee for his life to Northern Greece. As the Turks, who were in

possession of that country, were perfectly indifferent with regard to

the religious beliefs of the Jews, Amatus was allowed to settle down

quietly for the rest of his life at Thessalonica, in Macedonia.

During the later years of his career he published several books on

topics relating to the science of medicine--two of them on materia

medica and two on the cases of special interest which had come under

his personal observation during the course of his practice. The

latter work, which is entitled “_Curationum medicinalium centuriae

VII._,”[87] was printed in its entirety in Venice, in 1556 (2

vols.). Von Gurlt speaks of Amatus as a cultivated scholar and an

excellent observer. Of the seven hundred cases reported in this work

only a very few are of interest to the surgeon. Von Gurlt calls

attention to the fact that, during the earlier years of his practice,

Amatus devoted a fair share of his attention to surgery, but that

subsequently he performed no operations whatever; it being his rule to

intrust this work entirely to a regular surgeon or to a specialist.

In my search among the dozen or more histories of cases selected by

von Gurlt from the seven “Centuries” (700) of the complete treatise

as suitably illustrating Amatus’ manner of reporting the cases which

he had seen in practice, the various methods of treatment which he

adopted in his efforts to relieve the diseases or injuries that came

under his observation, and the demeanor of the man in the presence of

the ever-changing problems presented to the physician, I have succeeded

in finding only four that seem to furnish in even a slight degree the

information which I have just outlined. Unsatisfactory as these four

reports are in certain respects,--especially in their failure to reveal

to us the more strictly surgical capabilities of Amatus,--they at least

show that he was an able and conscientious practitioner, and to this

extent they possess value.

The first case reported in Century I. is that of a peasant girl,

aged thirteen, who, while walking barefooted in a field was

bitten by a viper. Amatus did not see the patient until three

hours later, but already at this early stage he observed many

blue and red patches, scattered over the leg and thigh of the

side on which the bite had been inflicted. Near the base of

the foot there were two quite black spots corresponding to the

bites of the reptile; and from the fact that there were only two

such spots Amatus inferred that the snake must have been a male

viper, which has only two poison fangs and is therefore less

dangerous than the female which has four. The symptoms which

the girl experienced were faintness, trembling and dizziness.

As regards the treatment adopted, the skin in the immediate

neighborhood of the bites was scarified and suction by the means

of cupping glasses was employed; afterward a plaster, which was

composed in part of theriaca, was applied to this region. The

patient made a complete recovery.

In Century V., Amatus gives an account of a fatal case of ear

disease. The patient, a sickly-looking boy of eight who had

been affected for a long time with a discharge from one ear,

presented a non-sensitive lump on the side of the head. “As he

began to show signs of feverishness it was decided to incise the

lump; and when the incision had been made, it was found that a

large part of the skull in this region had been destroyed by

caries, as a result of which there was left a cavity in the side

of the head, and this cavity was filled with a foul-smelling

pus, débris, and granulation tissue that apparently rested on

the dura mater. Three days later the surgeon[88] succeeded in

removing from the cavity only a small quantity of the sanious

material. On the fourth day, after an attack of convulsions, the

patient died.”

In Century VII. there is given an account of a man of the

wealthy class who had been exposed to an excessive degree of

cold for so long a time that he was literally almost half

frozen. “As he was being carried into the village he gave orders

that an ox should be slaughtered and that he himself should be

snugly stowed away inside the carcass of the animal as soon

as its interior furnishings had been removed. Thus he escaped

freezing to death.”

In the same century Amatus speaks of having seen a rather

interesting case of _Filaria Medinensis_ (called by the

Arabs “_vena medena_”) in a negro boy, eighteen years old,

who had come to Thessalonica from Memphis, Egypt. “The worm

had caused the production of an ulcer close to the boy’s heel,

and in this the creature’s head, which looked very much like a

vein, was recognizable. After the Turks had correctly diagnosed

the nature of the trouble an Arabian physician, who had managed

to secure a purchase on the worm, began rolling it up on a

small stick. Gradually, after the lapse of several days, he

succeeded in uncoiling the animal in its entire length (three

cubits), as shown by the construction of the end of the tail,

and thus permanently freed the boy from his trouble. The ancient

authors express doubts as to the true nature of the object found

in these ulcers, but I, Amatus, having examined the slender

white creature and having witnessed its curved outlines as it

projected itself outside the opening, do vouch for the fact that

it possesses all the characteristics of a true worm.”

CHAPTER XXXIX

THE DEVELOPMENT OF SURGERY IN FRANCE DURING THE RENAISSANCE.--PIERRE

FRANCO

Von Gurlt speaks of Pierre Franco as “one of the most skilful surgeons

and at the same time one of the most original medical writers of the

sixteenth century.” He and his contemporary, Ambroise Paré, were

of French birth, and to France therefore belongs the conspicuous

distinction of having contributed to medical science during the

Renaissance two of its most illuminating and efficient laborers. These

men, who were the leading operative surgeons in France during the

first half of the sixteenth century, did not owe their education as

physicians to the official training provided by the Medical Faculty,

but partly to the men who were classed as barbers and surgeons, or

barber-surgeons (_Collège de St. Côme_), and still more to

their own efforts. They gathered practical knowledge wherever they

might--largely from their official connection with armies during the

progress of different wars. Further details with regard to their

personal characters and the principal events of their professional

careers will be furnished in the following brief sketches.

_Pierre Franco._--Pierre Franco was born in the village of

Turriers, in Provence (now the Department of Basses-Alpes), about

the year 1500. He received his instruction in surgery from itinerant

lithotomists, operators for cataract, hernia-healers and men of

that class; and it is quite likely that, in the early days of his

professional career in Provence, he was himself a practitioner of this

humble type. At a somewhat later date he left the southern part of

France and took up his residence in Switzerland, first at Berne and

then at Lausanne. He probably left Provence because, in the early

part of the sixteenth century, the Protestants of that region were

being subjected to every form of persecution; and it is almost certain

that Franco belonged then to the Reformed Church, for he accepted the

salaried office of City Surgeon at Berne, the authorities of which city

were bitterly opposed to everybody and everything connected with the

Roman Catholic Church. Franco held the office named during a period

of ten years, the first part of the time at Berne, and afterward at

Lausanne, which latter city was then under the control of the Bernese

Government. He was a very close observer, a most enthusiastic student

of his art, and a man of intensely religious nature. Malgaigne, the

distinguished editor of the modern edition of Paré’s writings, speaks

thus of Franco: “I have no intention of writing here the history of

this man who was endowed with such a fine surgical genius; I may say,

however, that his was a life devoted entirely to the advancement of

surgery as a science.”

As an operative surgeon, says Edouard Nicaise, Franco ranked higher

than any of his contemporaries. Strange as it may appear, Ambroise Paré

frequently refused to take charge of cases in which an operation for

stone in the bladder, for hernia, or for cataract was required, whereas

Franco owed much of his reputation to the success which he had in

operating upon these three classes of cases. The latter, furthermore,

did most of his work on patients who belonged to the middle class, and

consequently his operations were characterized by very little of the

éclat which marked a large part of the work done by Paré, who from the

very beginning was befriended by Royalty and the Court circle. At the

same time, says Nicaise, Franco did more than any other man of that

period to enrich surgery with new discoveries.

Franco has written only two treatises. The first one, which was

published in Lyons, France, in 1556, bears the title: “A Small

Treatise on the Operative Treatment of Hernia”--one of the most

important departments of surgery (a book of 144 pages, 8vo). The second

work, which was issued in 1561, also at Lyons but by a different

publisher, bears the title: “_Traité des hernies contenant une

ample déclaration de toutes leurs espèces, etc._” (a book of 554

pages, 8vo). This work goes very thoroughly into the subject of hernia

in all its bearings, and also deals with several other important

surgical topics, such as genito-urinary diseases (in both the male

and the female), affections of the eyes, hare-lip, tumors, wounds in

general, dislocations, fractures, amputations, etc.; in short, it is

a fairly complete and decidedly original treatise on general surgery.

When Franco wrote the smaller work (that of 1556), he was settled at

Lausanne; but in 1561 he was living in Orange, which at that time was

the capital of a Principality that belonged to the House of Nassau.[89]

A few brief citations from the larger of the two treatises will suffice

to give our readers some idea of the manner in which Franco deals with

the subject-matter of the book.

Franco, says von Gurlt, was one of the first surgeons--perhaps the

very first--to perform the operation required for the relief of

strangulated hernia and at the same time to furnish a description of

the manner in which it should be performed. After mentioning the fact

that the strangulation of a portion of the intestine is attended with

considerable danger to the patient’s life, Franco proceeds to consider

the subject in greater detail:--

Owing to the large amount of the fecal matter and gas contained

within the portion of the intestine that is imprisoned in

the scrotum, and also owing to the inflamed condition of

the parts, it is frequently not possible to push the bowel

back through the narrow aperture in the peritoneum; and this

condition of things is apt to be aggravated by the constipation

or by the efforts at vomiting that frequently accompany such

strangulation. The vomiting, it is true, may in certain cases

facilitate the desired reduction, but in others it does harm,

especially by forcing more fecal matter into the scrotum. If

the conditions described are permitted to continue unrelieved,

death may certainly be expected to result. In a few cases the

timely administration of medicine internally may overcome the

difficulty, but, if this measure fail to produce the desired

result, recourse must be had to surgery--not, however, if

already the scrotum and neighboring genital parts have changed

their color to a black, livid, bluish or some other unnatural

hue, or if the hernial tumor manifest a round rather than an

elongated shape, for all these signs are harbingers of death;

and, as further unfavorable signs, should be reckoned a livid

or black mucous membrane of the patient’s mouth, contracted

nostrils, and an appreciably sunken condition of the eyes. But

if, on the other hand, the scrotum possess a natural color and

if it have not a spherical form but rather an oval shape, then

it is proper, after a failure to secure the desired reduction by

the internal use of medicine, to resort to a surgical operation.

For the proper performance of this operation the surgeon

should be provided with a nicely rounded metal staff, flat on

one side, and a little larger than a goose’s quill. [Paré’s

grooved sound or director, says von Gurlt, had not yet at that

time been invented, and this staff was intended to serve, in

a crude fashion, the same purpose.] The first step is to make

an incision in the upper part of the scrotum, the direction in

which it is to be carried being toward the symphysis pubis. When

the hernial sac is reached the staff is introduced into the slit

and pushed upward between the wall of the sac and the fleshy

part of the penis, the flat side of the instrument being kept

uppermost, as it is upon this surface that the cutting with the

scalpel or the razor is to be done. After the end of the staff

has been pushed well upward the flesh of the scrotum is to be

divided upon the flat surface of this instrument; all danger

of injuring the intestine being thus avoided. Then the attempt

should cautiously be made to reduce or replace the intestinal

folds. But if these efforts fail,--owing to the excessive

distension of the bowel or because the constricting band has

not yet been sufficiently relaxed,--then the following steps

should be taken:--Grasp the spermatic cord (“_didymis_”),

lift up its enveloping membranes one by one with hooks, and

divide each one of them completely upon one’s finger nail, up

to the point where the intestine is encountered. Then, having

established, between the intestinal wall and the membranous

coverings of the cord, an aperture large enough to admit the end

of the metal staff, push the instrument onward and upward while

at the same time it is held as it were balanced in the air, so

that early warning may be communicated to the holding fingers in

case the instrument, as it travels onward, should become caught

in the folds of the intestine--an accident, however, which the

slippery nature of the outer surface of the intestine renders

improbable, but which nevertheless may occur if at any point

there happen to be a break in the continuity of the tissues. As

the next step in the operation the cord should be completely

divided high up (the incision being made upon the staff) close

to the opening in the peritoneum through which the folds of the

intestine forced their way, in the first instance, into the

scrotum; but the surgeon must, without fear of doing harm, and

remembering that he is dealing with conditions of a desperate

nature, see to it that the opening made in the peritoneum is

amply large. Finally, with the aid of a soft piece of linen

he should return the folds of the intestine to the peritoneal

cavity, etc. [The remaining portions of the description are of

minor importance and may well be omitted here.]

Franco, speaking of those cases in which a portion of the omentum is

found projecting into the hernial sac, lays great stress upon the

importance of “not doing what many a surgeon has done in the past

and what not a few are still doing in our time, viz., simply cutting

off the imprisoned distal portion of this membrane and returning

the remainder to the peritoneal cavity without first ligating the

divided blood-vessels and then cauterizing the cut surface; the

danger being that a failure to take these steps frequently leads to

a fatal hemorrhage into the peritoneal cavity--an occurrence which

actually happened to one of our most experienced surgeons in a case of

enterepiplocele.”

There were certain operative procedures in which Franco took a greater

interest than in others. Thus, for example, he was particularly fond of

operating for the relief of cataract, and the results which he obtained

were exceptionally favorable (180 cures out of a total of 200 cases

subjected to operation). Von Gurlt quotes him as saying:--

If I had to choose between operations for the cure of cataract

and abandoning all the rest of my surgical practice, I should

prefer to adopt the latter course, so highly do I estimate the

amount of good which I can do in this line of work, so very

important does it appear to me, and so small is the amount of

labor and worry which it entails.

Franco was also greatly interested in the cure of stone in the bladder,

and it was while treating cases of this character that he invented the

very important surgical procedure known in France as the “Franconian

operation for stone in the bladder” (hypogastric cystotomy, suprapubic

lithotomy). Here is the account which he gives of the circumstances

under which he was led to devise this method of removing a stone from

the bladder:--

I will mention here an experience which I had on one occasion

when I tried to remove a calculus from the bladder of a boy

about ten years of age. The stone was about as large as a

hen’s egg and resisted all my efforts to extract it by way of

the incision made in the perinaeum. Being in a quandary as to

how I should proceed next, and the parents and friends being

greatly demoralized by the suffering to which I was unavoidably

subjecting their child,--they maintained, I should add, that

they would rather have him die than be subjected to such awful

suffering;--and being influenced also by the thought that I

could not afford to have it charged against me that I was not

able to extract the calculus, I deliberately decided that I

would make an opening above the pubic bone, and would remove

the stone in this manner. Accordingly I incised the skin above

the pubes, a little to one side of the base of the penis, and

carried the knife through the soft tissues down to the calculus,

which I had simultaneously pushed upward by pressing the fingers

of my left hand against the perinaeum, while at the same time

my assistant made counter-pressure against the stone by firmly

compressing the abdominal wall above the object. This method of

extraction proved successful.

In due time the wounds healed firmly and the patient was

relieved of his trouble, but only after a long and most serious

illness.

Franco does not appear to have performed the suprapubic operation

for the extraction of a cystic calculus more than once (the case

just narrated), and he carefully refrains from recommending it to

other physicians. Most surgical authors, says Edouard Nicaise, blame

Franco very strongly for not having dared to recommend his suprapubic

operation. “But I do not agree with this judgment; Franco should rather

be praised for his prudence in not immediately announcing to the world

his invention of an important surgical operation.”[90]

The subsequent history of suprapubic lithotomy shows that Franco was

laboring under an exaggerated idea of the dangers attending this

operation. The comments of Pascal Baseilhac--a nephew of “Brother

Cosmas” (the famous French lithotomist of the early part of the

eighteenth century) and himself a skilled lithotomist--are worthy

of being repeated here. He says (p. 318 of his “_Traité sur la

lithotomie_,” Paris, 1804): “Franco based his unwillingness to

recommend the operation of suprapubic lithotomy on the belief which

was then widely prevalent, and which still persists even in our time

(middle of the eighteenth century), that the making of an incision into

the main body of the urinary bladder is sure to prove fatal, a belief

which experience and observation have now shown to be unwarranted.”

The Franconian operation, the great value of which was not sufficiently

appreciated by its inventor nor by contemporary surgeons, was revived

in 1719 by an Englishman, John Douglas, the distinguished surgeon of

Westminster Hospital, London, and the brother of James Douglas--the

anatomist who in 1730 described so minutely the relations of the

peritonaeum to the bladder (Douglas’ cul-de-sac).

In the case the history of which has just been narrated, the

circumstances attending the invention of the operation known to-day as

suprapubic cystotomy[91] or “suprapubic lithotomy,” were certainly of

such an unfavorable character as to call for the display of an unusual

degree of courage, wisdom, patience and manual skill on the part of

the surgeon in charge; and it was through a careful consideration of

these facts that Edouard Nicaise was led to award such high praise to

Franco for the work which he had done. Scarcely less remarkable is

the talent which the latter displayed in the invention of a forceps

(Fig. 22) strong enough to crush all but the hardest calculi and

yet so cleverly planned that it is practicable, while the crushing

end of the instrument is lying inside the bladder, to separate the

blades sufficiently far apart to render possible the grasping of the

stone between the jaws of the instrument without at the same moment

injuriously crushing the soft parts in the narrow channel of the wound

or opening.[92]

[Illustration: FIG. 22. PIERRE FRANCO’S FORCEPS FOR CRUSHING CALCULI

IN THE URINARY BLADDER.

(From Edouard Nicaise’s _Pierre Franco_, Paris, 1895.)

_a_, closed; _b_, open.]

In Franco’s day the belief was widely prevalent that there were

remedies which possessed the power of dissolving a cystic calculus.

His own opinion in regard to this matter is expressed in the following

words: “I am astonished that there should be many men who do not

hesitate to undertake the disintegration and pulverization of a stone

in the bladder by the employment of remedies which are either to be

administered by the mouth or to be injected _per urethram_ into

that organ.” He adds that a remedy strong enough to dissolve even the

softer stones would become so changed and weakened in passing through

the various organs which it must traverse on its journey from the

mouth to the bladder that it could not possibly produce the desired

effect; nor could a chemical solution strong enough to dissolve such

a calculus be injected into the bladder by way of the urethra without

either causing inflammation and ulceration of the walls of that organ

or promptly exciting muscular contraction that would effectively expel

the solution.

This seems to be an appropriate place in which to state that lithotrity

was practiced at an earlier date by Antonio Beniveni (1440–1502), a

Florentine physician whose writings reveal him to have been a man of

a very practical and unprejudiced type of mind, a very clear writer,

and a practitioner of wide experience. He also deserves credit for

having been the first surgeon to revive the operation of tracheotomy, a

procedure which was carried out by Antyllus fourteen centuries earlier,

but which appears to have been forgotten during this long interval. He

saved a patient’s life by means of the operation.

The date of Franco’s death is not known.

CHAPTER XL

THE DEVELOPMENT OF SURGERY IN FRANCE (Continued).--AMBROISE PARÉ

Ambroise Paré was born, about the year 1517, at Laval, a small town in

the Department of Mayenne, France. His father was probably the valet

and barber of the Count of Laval. He went to Paris in early manhood

and spent three years, at this period, in fitting himself for the

career of a surgeon. He attended lectures on anatomy and surgery, did a

certain amount of dissecting, served for over two years as a surgeon’s

assistant in the great hospital of Hôtel-Dieu, made notes of some of

the cases which he saw, and was occasionally permitted to prescribe

for patients and even to perform some minor operations. From 1536

onward, nearly up to the time of his death, he was almost continuously

engaged, in the capacity of a surgeon, in accompanying different

French armies on their military expeditions. His professional title

at first was that of “barber,” but he doubtless very soon discovered

that, if he wished to advance, it would be absolutely necessary for

him to secure a higher title. Accordingly, in 1541, he and his friend

Thierry de Héry presented themselves for, and passed successfully,

the required examination and were accepted as “master-barbers.” It is

an interesting fact that, during his long professional career, Paré

was Chief Surgeon to four Kings of France in succession--first to

Henry the Second (1547–1559), next to Francis the Second (1559–1560),

then to Charles the Ninth (1560–1574), and finally to Henry the Third

(1574–1589). The last-named King bestowed upon him the additional

honor of “Councilor to his Majesty.” He also served, during a certain

period of his career, as an attending surgeon at Hôtel-Dieu. The three

large volumes of Paré’s writings (Malgaigne’s edition) are filled with

the rich experience which this great surgeon gained in the course

of a large private practice and in the field expeditions and sieges

conducted during the reigns of these Kings. Interspersed among the

reports of cases and descriptions of operations are to be found not a

few comments of a more general character and some biographic details

which add greatly to the charm of the work as a whole, and which at

the same time make it possible to form a general idea of Paré’s traits

of character. On almost every page one finds statements which reveal

the fact that he weighed almost all the duties of his daily life in a

profoundly religious manner. He showed himself warmly sympathetic for

all those whose ailments he was called upon to treat, and he was always

as ready to bestow his best services upon the Roman Catholics as upon

the Huguenots--to which latter denomination (if we may so call it) he

himself is commonly reported to have belonged. It seems to me more

probable, however, that he was a liberal-minded Roman Catholic rather

than a Protestant, for there is trustworthy evidence showing that all

his ten children were baptized in that faith and that he himself,

nineteen years before the night of Saint Bartholomew (August 24, 1572),

held the office of “_Pathe_” in the church of the parish in which

he lived. Another prominent trait of Paré’s character was the modest

estimate which he placed upon his own professional achievements. One of

his sayings, which occurs a number of times in his writings and which

has since become famous, is this:--

_Je le pansay, et Dieu le guarist._

[I dressed his wound and God caused it to heal.]

Some of the other sayings attributed to his pen and printed under

the heading “Surgical Canons and Rules,” at the end of Book XXVI.,

are characterized by a homely type of wisdom which seems to have

secured for them a permanent place in French literature. I give here

in the form of English translations six or seven of the more striking

specimens:--

Mere knowledge without experience does not give the surgeon much

self-confidence.

Small will be the influence exerted by him who chooses surgery

as a career simply for what he may make out of it.

The frequent changing of physicians is not likely to bring

comfort to the patient.

The facts already discovered are few in comparison with those

which are yet to be brought to light. We must not allow

ourselves to lie down or fall asleep under the impression

that the ancients knew all or have divulged all that is worth

knowing. What they have accomplished should be utilized by us as

a sort of scaffolding from which a more extensive view may be

obtained.

In another place Paré expresses the same sentiment in a somewhat

different form, as follows:--

My professional brethren must not expect to find any new and

startling facts [Paré is speaking here of his treatise on

surgery], but simply here and there some little addition to

our previous stock of knowledge; for the good Guy de Chauliac

has taught us that we are like the child who sits astride the

giant’s neck; that is, we can see all that he sees and just a

little more--or, in other words, we are able, through the aid

afforded by the writings of our predecessors, to learn all that

they have learned, and may at the same time acquire a little

further knowledge through our own observations.

A remedy that has been thoroughly tested is better than one

recently invented.

An injury which opens a large blood-vessel is likely to lead the

victim of such a wound to the tomb.

It is always wise to hold out hope to the patient, even if the

symptoms point strongly to a fatal issue.

All through his professional career, but more especially during the

later years, Paré was repeatedly annoyed by the efforts which the

Medical Faculty made to bring him into disrepute. These men were

bitterly jealous of him on account of the great favor which he enjoyed

at Court, and so they adopted every possible means to injure his

reputation. When the complete collection of his writings was published

in 1575, they petitioned the authorities not to allow these “works of

a very impudent and ignorant man” to be sold until they should have

received the official sanction of the Faculty. One of Paré’s chief

offenses, as it appears, was that of not writing his treatises in

Latin, and among the twenty-nine specifications of his shortcomings was

that of plagiarism. (See remarks on this subject further on.)

In his efforts to extend his knowledge of the science of medicine, and

in particular to learn what the ancients had written on the subject,

Paré soon discovered that many obstacles stood in his way. He did not

allow himself, however, to be discouraged by this fact, but set to

work, without delay and in his usual resolute fashion, to remove them.

He found, in the first place, that all the available treatises of the

ancient medical authors were written in Latin, a language of which he

possessed scarcely any knowledge. So he was obliged to hire men to

translate for his own use large portions of these books. Then, at a

later date, after he had begun to accumulate notes for the treatises

in which he proposed to publish his own experiences and his own views

about the surgical topics in which he was interested, he saw clearly

that suitable pictorial illustrations would add materially to the

value of the written text, and he therefore did not hesitate to spend

a considerable sum of money--Malgaigne says three thousand livres--in

having the needed drawings made. Paré was also in no small degree

a public benefactor, for he purchased the formulae of some of the

more valuable of the remedies employed by the leading charlatans, in

order that he might print them and so place them within the reach of

everybody.

Paré gives the following picturesque account of his first experiences

as an army surgeon in actual warfare:--

In 1536, he says, I accompanied the large army sent to Turin by

Francis the First, King of France, to retake certain castles and

fortifications which were held at that time by the troops of

the Emperor Charles the Fifth. My official position was that of

surgeon to the foot soldiers; and when our men took possession

of Susa, after the enemy had been defeated, I was among the

first to enter the city. Our horses rode rough-shod over the

dead bodies lying on the roadway, and over the bodies of many

who were simply wounded. It excited my compassion strongly

to hear the cries of those who were thus subjected to great

additional suffering, and I could not help wishing that I had

never left Paris. Once actually in the city, I began to look

around for a stable in which the horses of myself and my orderly

might find shelter. The one I entered contained the corpses of

four soldiers who had presumably died there, and three badly

wounded men who were still alive, but whose faces were greatly

disfigured by the wounds which they had received, and who--as we

soon learned--were unable to see, hear or speak. An old soldier

who entered the stable at that moment, and whose pity was

excited by what he saw, asked me if it would be possible to save

the lives of the men who were so badly injured. I replied “No.”

He thereupon proceeded, without the least excitement and with

due gentleness, to cut the throats of all three. At the sight of

this act, of what seemed to me to be great cruelty, I exclaimed,

“You are a wicked man!” His reply was: “I pray God that, if it

should ever be my fate to be situated as these three men were

when I entered the stable, there may be somebody at hand who

will do to me what I have just done to these men, and will save

me from a lingering and painful death.”

When the fighting was entirely over, we surgeons had much work

to do. I had not yet had any personal experience with the

treatment of gunshot wounds, but I had read in Giovanni da

Vigo’s work that such injuries should be considered poisoned

wounds, by reason of their contact with gunpowder, and that the

correct way of treating such wounds was to cauterize them with

oil of sambucus (elder flowers) that was actually boiling and

to which a little theriaca had been added. At first I hesitated

somewhat about carrying out this practice, but after watching

the other surgeons, in order to learn exactly how they applied

the boiling oil, I plucked up my courage and did exactly what

they did. My supply of oil, however, soon gave out, and I then

decided to use as a substitute a healing preparation composed of

yolk of egg, oil of roses, and turpentine. I slept badly that

night, as I greatly feared that, when I came to examine the

wounded on the following morning, I should find that those whose

wounds I had failed to treat with boiling oil had died from

poisoning. I arose at a very early hour, and was much surprised

to discover that the wounds to which I had applied the egg and

turpentine mixture were doing well; they were quite free from

swelling and from all evidence of inflammatory action; and the

patients themselves, who showed no signs of feverishness, said

that they had experienced little or no pain and had slept quite

well.

On the other hand the men to whose wounds I had applied the

boiling oil said that they had experienced during the night, and

were still suffering from, much pain at the seat of the injury;

and I found that they were feverish and that their wounds were

inflamed and swollen. After thinking the matter over carefully,

I made up my mind that thenceforward I should abstain wholly

from the painful practice of treating gunshot wounds with

boiling oil.

In 1545, when he was about twenty-eight years of age, Paré was sent as

a military surgeon to Boulogne-sur-Mer, which at that moment was being

besieged by the French. In 1544 the city had been captured by the army

of Henry the Eighth of England, and fighting of a desultory character

was in progress between the besiegers and the besieged at the time of

Paré’s arrival. He had not been there a long time when he was asked to

see professionally Francis of Lorraine, Duke of Guise, who had been

seriously wounded by a lance in a recent encounter with the enemy. The

metal head of the weapon, under the impulse of a glancing blow, had

penetrated the skin just above the right eye, had then traveled toward

the left side and in a slightly downward direction, along the surface

of the skull, and had finally come to rest at a point behind and below

the left ear, near the nape of the neck. When the lance had penetrated

thus far the wooden shaft broke in two, leaving the metal head in its

entirety and a part of the shaft so firmly lodged in the wound that

great force had to be employed before it was found possible, with the

aid of strong pincers, to extract it from its bed. An examination of

the injured parts then showed that there had been some fracturing of

the bony structures and extensive laceration of the arteries, veins,

nerves, etc., but that the left eye had apparently not been seriously

damaged. The onlookers were naturally impressed with the belief that

the Duke could not possibly recover from such a slashing of the face

and head; and Paré himself was careful at first not to commit himself

to a prognosis of too favorable a nature. However, he treated the

wound with the greatest care and in the course of a few weeks had the

satisfaction of seeing his patient restored to perfect health, but with

a deeply scarred face.

As can readily be imagined, this experience proved a splendid triumph

for Paré, and speedily brought him into great favor at Court and among

the nobility throughout France.

For several years subsequent to these events, Paré continued to serve

actively as a surgeon in the frequent wars which took place between

the royal troops of France and the armies of other European monarchs.

In 1552, when he was thirty-five years of age, his rank in the army

was raised to that of “Surgeon to the King,” the entire medical staff

of that period consisting of twelve surgeons of this rank. In 1554 he

was admitted to the _Collège de Saint Côme_ in Paris, the highest

professional honor to which a barber-surgeon might aspire; and in 1563,

after the siege of Rouen, he received the appointment of “First Surgeon

to Charles the Ninth.” After the latter’s death, Henry the Third also

appointed Paré to the same position in his Court. Thus, from almost the

very beginning of his professional career to the time of his death,

Paré was honored in every possible way by four successive Kings of

France. It was Charles the Ninth, however, who appears to have taken

a greater interest in Paré’s prosperity than did either of the other

three Kings. It was at Charles the Ninth’s request, for example, that

the brother-in-law of the Duke of Ascot, the Marquis of Auret, sent

for Paré to undertake the treatment of a wound which he had received

from a harquebus ball seven months previously. Paré gives the following

account of this interesting case which foreshadows--for example, in the

changing of the patient’s bed and linen and keeping him entertained

during convalescence--the best modern hospital nursing:--

On arriving at the Chateau of Auret, writes Paré, which is

located not far from Mons in Belgium, I learned that the

harquebus ball had entered the thigh near the knee, had done

considerable damage to the soft parts, and had fractured the

femur. When I was ushered into his bedchamber, I found the

Marquis very much emaciated, his eyes deeply sunken in their

sockets, his skin hot and of a yellowish hue, and his voice

feeble like that of man very near to death.... The leg was drawn

up against the wall of the abdomen, and two large bedsores

were visible posteriorly--one near the root of the spine and

the other somewhat higher up. Thus it was impossible for the

patient to assume any posture in which he would be free from

suffering.... All things considered, it did not seem to me that

the Marquis could possibly recover from such a combination of

bodily ills. Nevertheless, to give him some encouragement,--for

he was very low in spirits,--I told him that, with the aid of

God and the assistance of his regular medical attendants, I

would soon have him on his feet again....

After dinner, in the presence of the Duke of Ascot, a few

friends of the family, and the assembled physicians and

surgeons, I expressed considerable surprise that free openings

had not been made in the Marquis’s wounded thigh, in which bone

caries and decomposition of the resulting discharge were already

well established. The medical attendants replied that the

patient was unwilling to submit to any such measures, and that

he had even forbidden them to substitute clean linen bedclothes

for those which were soiled and which had not been changed

during the previous two months....

When the consultation had come to an end and the local medical

attendants had given their full approval of the different

measures which I recommended, ... I proceeded to carry them out

without further delay.

Two or three hours after the completion of this operative work I

instructed the house servants who were in immediate attendance

upon the Marquis to place alongside his bed a second one

equipped with a soft mattress, over which a fresh linen sheet,

etc., had been spread. The transfer from one bed to the other

was easily effected by a strong attendant, and when the change

had been made the Marquis manifested great contentment. Two

feather pillows were so placed under his back and loins that no

pressure whatever would be made upon his bedsores. A refreshing

sleep of four hours’ duration followed the adoption of these

different measures, and there was much rejoicing in the entire

household.

After a course of treatment lasting several weeks, Paré says:--

Under this treatment the fever steadily diminished, the pain

grew less and less, and the patient’s strength increased. When

the proper moment arrived, I advised the Marquis to engage the

services of some musicians (players on stringed instruments)

and one or two comedians, in order that his spirits might be

cheered by occasional entertainments of this character. Already

at the end of one month we found it practicable to carry him

in a chair into the garden and as far as the entrance gate,

where he could watch the passers-by. When it became known among

the peasants that he was in the habit of sitting close to the

highway, they came from far and near to sing and dance in groups

for his entertainment. He was greatly loved by both the common

people and the nobility.

At the end of six weeks the Marquis was able to get about on

crutches, and two weeks later still I bade him good bye and

returned to Paris. Before I left he presented me with a gift of

great value, and the Duchess of Ascot insisted on my accepting

a beautiful diamond ring as a mark of her appreciation of the

services which I had rendered her brother.

Among the varied experiences which fell to the lot of Paré during

his association with Charles the Ninth, there is one which throws a

little additional light upon the man’s manner of promptly dealing with

an event which, without such promptness of action, might have led to

serious consequences.

He was passing through Montpellier one day in company with the King,

when he stopped for a few minutes at the shop of an apothecary for the

purpose of ascertaining how he preserved alive the vipers which he used

in compounding the remedy which is called “theriaca,” and which has

been used from time immemorial as an antidote to the poison of venomous

serpents. The apothecary placed before him a glass jar in which were

kept a number of these reptiles; and, when Paré took one of them up in

his fingers in order to obtain a better view of his fangs, the reptile

bit him near the tip of his index finger, between the nail and the

flesh. The pain which immediately followed was severe, partly, as Paré

explains, because the tip of the finger is a very sensitive part, and

probably also on account of the irritating effect of the venom. Then,

to quote Paré’s own words, “after making firm pressure upon the soft

parts above the wound, to prevent the poison from traveling upward, I

crowded the skin downward in the hope of forcing as much of the venom

as possible out of the finger. While doing these things I instructed

the apothecary’s assistant to mix some old theriaca with brandy, and

then to apply a pledget of cotton, saturated with the mixture, over

the wound. In the course of a few days, and with no other treatment,

all effects of the bite disappeared.”

In 1536, two years after his first experience with actual warfare in

the vicinity of Susa, Italy, and while he was still very young to

assume so great a responsibility, Paré--as we learn from the text of

Chapter 28, Book X., of Malgaigne’s edition--performed the operation

of exarticulation of the elbow-joint (the first recorded instance of

this operation, says von Gurlt). The case was that of a common soldier

who had been shot through the forearm, a little above the wrist, who

had been treated unsuccessfully by other surgeons, and who, at the

time when he came under Paré’s care, was suffering from a variety of

complications--viz., gangrene extending as high up as the shoulders,

extensive inflammation of the integuments on the adjacent side of

the thorax, and other symptoms that pointed toward a fatal issue. To

complicate matters, it was winter and the only approximately warm

shelter available was a cow-stable. At this early date, in the history

of surgery, the practice of ligating the blood-vessels which had been

divided in the course of an amputation had not yet been adopted, and

consequently the red-hot cautery had to be employed for arresting

the bleeding which followed the operation. (See also page 512.) In

addition to the amputation it was found necessary to make a number of

long and deep incisions into the inflamed tissues and to apply the

actual cautery freely “for the purpose of drying up and destroying

the virulent matters that had penetrated these parts.” Then, fourteen

days later, the patient, who had been lying all this time, exposed to

draughts of air, upon a receptacle intended for the storage of grain,

and who was protected from the cold by only the scantiest coverings,

developed trismus (lockjaw). When this new complication appeared Paré,

already at his wits’ end to find means with which to overcome the

difficulties which surrounded the case, decided first to have the man

removed to an adjacent stall in which there were several cows, the

presence of which in such a confined space might be counted upon to

increase appreciably the warmth of the surrounding air. Next, he gave

orders to rub briskly the back of the patient’s neck, as well as the

shoulders, the uninjured arm and the legs, with heated cloths which

were immediately afterward to be wrapped around him; and then, for

an outside covering, he utilized the straw and cows’ dung which were

plentifully within reach. In addition, two braziers which had been

procured from a neighboring dwelling, were charged with coals and kept

burning close to him. During three successive days and nights these

measures were kept up faithfully, and from time to time a mixture of

milk and soft egg was introduced into the patient’s mouth through a

suitable tube, after the jaws had first been pried open by a bit of

willow wood. The effect of these measures was to make the patient

perspire copiously and to induce a gentle action of the bowels; and,

as a further effect, the trismus was also overcome. For some time

afterward, in addition to the ordinary dressing of the healing wounds,

it was thought best to apply the red-hot cautery regularly at certain

intervals to the end of the bone of the upper arm. (This practice was

abandoned by Paré at a later date.) Final and perfect healing took

place after several large splinters of bone had been exfoliated.

At the end of his account of what one is tempted to call the wonderful

victory of a surgeon over the death that threatened to carry off this

gravely wounded soldier, Paré adds one of his characteristic appeals to

the oncoming younger generation of physicians:--

Both God and Nature constantly remind the surgeon that, no

matter how poor, in a given case, the prospect of a cure may

seem, he should not for one moment cease doing his full duty;

for Nature often accomplishes what the surgeon believes to be

impossible. Cornelius Celsus [about the time of Jesus Christ]

says: “_Contingunt in morbis monstra, sicut et in natura_.”

[Marvels are observed in diseases, very much in the same manner

as they are frequently encountered in nature.]

In the two preceding histories of actual cases treated,--one of these

patients being a wealthy officer of high rank and birth, and the other

a common soldier of the peasant class,--we obtain the best of evidence

that Paré was not influenced by the wealth, rank or social position of

his patients. Upon both classes he bestowed freely the fruits of his

knowledge, experience and skill.

The first mention, in medical literature, of a fracture through the

neck of the femur close to the joint, is to be found in Chapter 21,

Book XIII., of Paré’s treatise (page 753, Vol. II., of Malgaigne’s

edition). Furthermore, the first published account of a case of

diaphragmatic hernia is that given by Paré. (Von Gurlt.)

In 1538, during a visit to Turin in the capacity of surgeon to the

Mareschal de Montjean, Paré was asked by the latter to take charge of

one of his pages who had been wounded by a stone which struck him on

the right side of the head, causing a fracture of the parietal bone,

with escape of a portion of the brain substance from the external

wound. The subsequent history of this case is given by Paré in the

following words:--

As soon as I fully realized the true nature of the injury and

had examined the mass of tissue (about the size of a small nut)

which had been expelled from the wound, I predicted that the

patient would probably not recover. A young surgeon who happened

to come into the room at this moment, examined the mass of

tissue which had escaped from the wound and at once pronounced

it to be fat. I assured him that, if he would wait until I had

finished dressing the patient’s wound, I would prove to him that

the mass was in reality cerebral tissue and not fat.... If this

substance, I said, is fat, it will float on the water; but, if

it is brain tissue, it will sink at once to the bottom of the

dish. And, again, if it is fat it will promptly melt on exposure

to heat, whereas brain substance will simply become desiccated.

These tests were applied and it was shown that the tissue

consisted, as I had declared, of brain substance.

Notwithstanding the apparently serious damage which had been

inflicted upon his brain the page made a good recovery, but

remained permanently deaf in the right ear.

Among Paré’s numerous reports of cases there is one which possesses,

as I believe, sufficient interest--as well from the viewpoint of the

pathologist as from that of the surgeon--to justify me in reproducing

it, in a somewhat condensed form, in the present chapter.

Henry the Second, King of France, while tilting (June 30, 1559)

with Gabriel, Count of Montgomery, an officer of that sovereign’s

Scottish Lifeguard, received injuries which soon afterward proved

fatal. Montgomery’s lance--so Paré’s account states--struck the King’s

vizor and, breaking off at the spot where the metal tip or head is

attached to the wooden shaft, carried away this part of the helmet.

Then, impelled by the force which had originally been communicated

to the lance, the splintered end of its shaft struck the King’s now

unprotected head with great violence just above the right eyebrow,

tore up the skin and underlying muscular tissue of the forehead as

far as the outer angle of the left orbit, and finally destroyed the

adjacent eye. Five or six of the most experienced surgeons of France

were immediately summoned, and Philip the Second, King of Spain, sent

Vesalius from Brussels to aid them in their efforts to save the injured

King’s life. But all the measures adopted proved of no avail. Henry the

Second died on the eleventh day following the injury. Although in the

published account no statement is made to the effect that Paré was one

of the surgeons who attended the King during his illness, Malgaigne

expresses the opinion that he was probably present in the capacity of

a consultant; and the interesting comments which he (Paré) makes on

the nature and extent of the injury inflicted certainly justify this

opinion. No evidence of fracture of the skull was discovered either

before death or at the postmortem examination, and the most conspicuous

symptoms appear to have been fever and a comatose condition. At

the autopsy there was found, on the left side posteriorly, in the

occipital region, a clot of blood lying between the pia and the dura

mater. The brain substance in the immediate vicinity of the clot was

of a yellowish tinge and showed evidences of having already begun to

undergo decomposition. Paré’s diagnosis, in this case, was that of

violent concussion of the brain with rupture of meningeal vessels by

_contre-coup_ at a point opposite to that at which the blow

was originally inflicted by the lance. He did not believe that the

immediate damage done to the frontal portion of the cranium and to the

left eye had anything to do with the fatal issue.

[Illustration: FIGS. 23 AND 24.

FORCEPS DEVISED IN 1552 BY AMBROISE PARÉ FOR DRAWING OUT THE CUT

ENDS OF ARTERIES AFTER THE AMPUTATION OF A LIMB, AND HOLDING

THEM WHILE THE LIGATURE IS BEING APPLIED.

(From von Gurlt’s _Geschichte der Chirurgie_, Berlin, 1898.)

FIG. 23 represents the earlier; FIG. 24 the

later pattern (see text.)]

One of the greatest discoveries made by Paré in the domain of surgery

is his method of promptly, effectively and safely arresting the

bleeding from the divided vessels of the stump after the amputation of

a limb. This discovery was made between the years 1552 and 1564, before

which period it had been customary to arrest the bleeding by applying

the red-hot cautery iron to the exposed ends of the divided vessels.

The new method consisted in tying a ligature (preferably doubled)

around the free or cut end of the blood-vessel, and allowing it to

remain undisturbed _in situ_ until, as the result of a localized

suppuration, it should be cast off. The accompanying cuts (Figs. 23 and

24) which have been copied from an earlier edition (1585) of Paré’s

work, represent the kind of forceps which he employed in separating

the free end of the artery or vein from the soft tissues in which it

was imbedded--a preliminary procedure which enabled him to tie the

ligature firmly around the vessel. The earlier pattern of forceps (Fig.

23) was not equipped with a spring, the purpose of which was to keep

the opposing blades separated, but the later pattern (Fig. 24) has

this useful addition. Another instrument which owes its origin to the

inventive genius of Paré is the grooved director--an instrument that

is of great value to the surgeon, particularly in operations for the

relief of strangulated hernia.

Besides the two inventions to which a brief reference has just been

made, Paré describes and pictures in his great treatise scores of

instruments and apparatus of all sorts, many of them doubtless products

of his own inventive genius. But to assign to these contrivances their

true value calls for a degree of expert knowledge which I do not

possess. Rather than to attempt any such appraisal, I prefer to furnish

here a summary of the more important of Paré’s achievements in surgery;

for such an enumeration--although it may prove to be in some measure

a recapitulation of things that have already been mentioned in the

preceding account--may be found useful for purposes of reference:--

The discovery of improved methods of caring for the wounded

on the battle-field and of transporting them to a hospital or

other refuge; the introduction of better methods of treating

wounds inflicted in warfare--especially gunshot wounds; the

correction of the idea, universally accepted at the beginning

of the sixteenth century, that bullets are sufficiently hot,

upon penetration of the skin, to affect injuriously the wounds

which they inflict;[93] the substitution of ligation of bleeding

vessels (of an amputation stump) for the prevailing practice of

applying to them the red-hot cautery iron; the abandonment of

the practice of applying the heated cautery iron to the surface

of section of a sawed bone; the performance, for the first

time, of exarticulation of the elbow-joint; the demonstration

of the usefulness of more frequently employing orthopaedic

apparatus and prosthetic contrivances; and the introduction of

improvements in the operation of trephining the skull.