The century of Columbus

by James J. Walsh

A very interesting incident in his experience is related by Paré in his memoirs with regard to one of these surprising cases of deep injury to the brain which seem inevitably fatal, yet the patient survives. It is, as suggested by Dr. Mumford, a replica of the well-known Harvard crowbar case, the most famous in American surgery, in which a quarry man recovered from his injury in spite of the fact that a tamping iron had passed completely through his head from beneath the chin upwards, coming out through the top of the skull. [{414}] The specimens from the case, secured long afterwards at the time of the man's death, may still be seen in the Harvard Museum. Paré's case was very similar but concerns a very important individual. Francis of Lorraine, Duke of Guise, was wounded before Boulogne, "with a thrust of a lance, which entered above the right eye, towards the nose, and passed out on the other side between the ear and the back of the neck, with so great a violence that the head of the lance, with a piece of wood, was broken and remained fast; so that it could not be drawn out save with extreme force with smith's pincers. Yet, notwithstanding the violence of the blow, which was not without fracture of bones, nerves, veins and arteries, and other parts torn and broken, my lord, by the grace of God, was healed." Without the corroboration of the possibility of this by our modern case, it is probable that there would be serious doubts as to it.

The bone surgery of the Renaissance period is particularly interesting. Fallopius declared for the preservation of the periosteum of the bone just as far as was possible whenever there was bone disease or injury. We know now that the periosteum in healthy condition will bring about regeneration of bone, and it was evidently because of clinical observation of the satisfactory improvement that occurred in cases when the periosteum was interfered with just as little as possible that brought Fallopius to this conclusion. Their treatment of fractures was excellent and they secured good results. It was during this time that the older methods of using force in the reduction of dislocations yielded to the maxim that joints should be restored along the same path through which the dislocation took place. A series of surgeons at this time, notably Massa, Ingrassias and Vigo, wrote about spinal disease, describing "penetrating corruption" of the spine, persistent suppuration and the subsequent deformity, using the term "ventositas spinae," and others that would indicate their interest in what we know as Pott's Disease. Vigo described fractures of the inner table of the skull when the outer table is unbroken, and Argelata described depression without fracture as occurring in young folks.

Considerable valuable advance was made in the treatment of fractures of the skull and injuries of the brain. Vigo [{415}] brought back the use of the crown trephine and did much to make the instrument popular. A great many surgeons invented a variety of instruments for lifting up depressed bone, or for removing fragments, and each one was sure that his particular type of instrument was the best to use. It is interesting to read Helferich's "History of Surgery" in Puschmann's "Handbuch" on these and other points, because they are arranged in the order in which the discoveries and rediscoveries and inventions and reinventions were made. The Renaissance is particularly full of interesting surgical history. The late effects of brain injury, dementia, deafness and various forms of paralyses were carefully studied by such men as Fallopius, Paré and Della Croce.

Various phases of surgery were taken up and discussed that are often supposed to be much more modern. The whole question of the transfusion of blood, for instance, attracted wide attention at this time. Magnus Pegelius of Rostock suggested that the artery of one patient should be fastened directly to the artery of another patient in order to bring about transfusion. The use of this method of treatment, after large losses of blood or in case of anaemia, is mentioned by a number of men. At least as much was hoped for from it as in our time from opotherapy. Jerome Cardan went farther than any in what he looked for from the transfusion of blood. He always saw the possibility of mystical results and his suggestion was that the transfusion of blood might bring about a change in the morals of individuals. It was even said that the use of animal's blood in the same way might bring about an endowment of the human individual with certain animal qualities of disposition. This is quite as absurd yet quite as reasonable as many of our surgical attempts at the reform of criminals by operation on their brains. In 1539 Benedictus noted the occurrence of hemophilia or bleeders' disease. This had been noticed before in the Middle Ages, but had been lost sight of.

With regard to varicose veins the Renaissance abandoned the older methods of operation and suggested the use of bandages. Savonarola, the grandfather of Savonarola the Dominican, who was burnt to death in Florence, described various forms of bandages and suggested rest in the prone position [{416}] with the feet higher than the head for the relief of discomfort. Savonarola was much interested in the correction of deformities and classifies rather carefully the different forms of gibbosity of the spine, forward, backward and to the side, and suggests their treatment with bandages that may be put on when soft and pliable, but which harden after their application. Paré at the end of the century used a corset made of very thin perforated iron plates which he insisted should be well padded. This should be changed every three months and its shape often altered so as to suit the growth of the body and the changes brought about by itself.

Some of the developments of surgical technique at this time are extremely interesting because they illustrate that accurate attention to detail and inventive ability in surgery that is usually supposed to be reserved for a much later time. Paré, for instance, invented a whole series of special apparatus for nearly every phase of corrective surgery, many of which have been mentioned. Fallopius insisted on bringing the muscles of the neck together and retaining them in position by sutures whenever they were severed, because results were nearly always excellent and function was restored. Every important surgeon of the time emphasized the sewing of severed tendons. Vidus Vidius invented a gold or silver tube to be used after tracheotomy in order to permit breathing through it, and suggested the use of this instrument also after injuries of the larynx. Monteux devised a magnet to aid in the extraction of swallowed iron objects that were caught in the throat.

All the specialties developed wonderfully at this time. The story of the Caesarean operation attests the evolution of obstetrics. In 1500 Jacob Nufer, a veterinarian, performed this operation successfully on his own wife, and a number of others followed the example until within twenty-five years after the close of our period, Rousset counts up his cases of the operation as 15. Gynaecology and obstetrics always develop together, and Weyer, the Dutch physician and surgeon, who did so much to rid the world of the witchcraft delusion and point out its connection with what we know as hysterical manifestations, wrote a text-book on gynaecology, and Caspar [{417}] Wolff laid the deep foundations of the science of gynaecology at this time. Würtz, who comes after our period, but was deeply influenced by it, and who must indeed be considered as a follower of Paracelsus, insisted very much on the simple treatment of wounds and emphatically opposed the common custom of "thrusting clouts and rags, balsam, oil and salve into them." Such teaching would have much to do with making advances in gynaecology and obstetrics possible.

Cabrol advised the removal of the breast for cancer and insisted on its complete removal and also of a part of the pectoral muscle, if that seemed to the operator to be necessary, because of actual or apparent involvement. Cabrol also declared that wounds of the heart were not necessarily fatal and gives the details of one which he himself had treated and had afterwards seen at autopsy, death having taken place from another condition. He mentions the fact that stags' hearts had been found in which there were definite indications of healed wounds so that the long-time tradition as to the fatality of heart wounds is not absolute. Della Croce taught that blood or pus or other fluid should be emptied out of the thorax by aspiration. He suggested the use of a cupping glass or a syringe, or in case of necessity even of the mouth for this purpose. He advised the placing of a metal tube in the thorax for drainage purposes. Arculanus advised the opening of empyemata by a perforation of the thorax that would permit drainage. If one had opened spontaneously and become chronic, a lower opening for better drainage should be made.

Nor were they less ingenious in their suggestions as to surgical intervention in conditions within the abdomen. Riolanus explained ileus as thoroughly as anyone has ever done it and recognized exactly what the condition was and the only way by which it could be treated. Paré advised the letting out of gas from over-distended intestines when these could not easily be returned to the abdomen. Fioravanti reported a case of splenectomy with the recovery of the patient. All sorts of bougies for strictures were invented, and many suggestions as to instrumental relief in difficult strictures made.

Savonarola suggested the extirpation of ranula, evidently [{418}] after having had the experience that the mere emptying of this cyst of the gland beneath the tongue is practically always followed by the refilling of it. He gave the technique of puncture for ascites and has some interesting details of cases, including one in which a fall led to the traumatic evacuation of the fluid with subsequent cure. He recommended the puncture of the pleural cavity for pleural effusion, and above all for empyema whenever the case was in serious condition. A little bit later, Berengar of Carpi, who is usually considered much more important in anatomy than in surgery, discussed the question of fracture of the skull by contrecoup, evidently after considerable experience. He detailed some cases of extirpatio uteri for procidentia and developed the technique of inunctions of mercury for lues. Whether he was the first to do this or not we are not sure. There is no doubt that his practice attracted wide attention. He was visited by patients from all over the world and was summoned on consultations even to great distances in order to see members of the nobility. There probably never has been a more important discovery in therapeutics than the use of mercury for specific disease, and the men of this time to whom must be attributed the development of this phase of therapeutics deserve the highest praise. It required the most careful, patient, prolonged observation, and this was successfully given.