The century of Columbus

by James J. Walsh

While gunshot wounds were becoming so frequent as to claim much attention, wounds from swords and other sharp instruments causing ugly disfigurements were rather common. Cosmetic surgery attracted attention. It might be thought that owing to their ignorance of aseptic surgery there would be no possibility of any great development of plastic surgery at this time. As a matter of fact, however, not a little was done that was of great significance for the correction of disfigurements due to injury and unsightly congenital defects or scars after disease. A number of procedures for the correction of harelip and of cleft palate have already been noted. Just at the beginning of Columbus' Century the technique of the Brancas, father and son, for the restoration of noses that had been lost by injury or disease attracted wide attention. Their method was to make the new nose from the skin of the arm, [{419}] lifting a flap from the inner portion of the upper arm, fastening it to the forehead and bandaging the hand firmly on top of the head so as to keep the flap in place, fed by the circulation of the arm until it had obtained a firm hold, when the attachment to the arm was cut and the nose fashioned from the living tissue thus obtained. Vianeo and Aranzi both described methods of forming the nose, and it was suggested that a portion of the skin of the forehead might be used for that purpose. Defects of the lips and eyelids were cured by slipping tissues over and by freshening the edges and bringing them together.

An extremely interesting surgical writer of the beginning of the sixteenth century is Michele Angelo Biondo, sometimes known by his Latin name of Blondus. There are some passages in his writings with regard to the use of warm water as the only proper dressing for wounds that are rather startling. He tells of some physicians of his time who, in place of liniments and all the various applications that are made by the "wax-dealers," simply wash off their wounds with warm water. He adds that these physicians insist that a great many surgical patients are not killed by their disease so much as by the custom of allowing them only small amounts of food and the unfortunate effect produced on them by the applications to their wounds. He adds further that these men are not wont to treat patients suffering from fevers by keeping them on a light diet, but on the contrary they give them wine and nourishing food instead of slops (ptisans). His comment is that this sensible method of supporting treatment unfortunately does not make much headway in the profession. Apparently it was too simple and natural to appeal to the physician of the time. He adds with fine irony, "It is said to be preferable to die methodically than to live empirically."

Gurlt in his "Geschichte der Chirurgie" (Berlin, 1898), to whom I owe most of what is here said of the work of these old surgeons, gives some further details of Biondo's treatment of wounds. After the staunching of the bleeding, the wound was to be cleansed and then covered with oleum abjetinum, very probably oil of turpentine, one part to two parts of oil of roses. With regard to the use of water in the treatment of [{420}] wounds, Biondo said: "The most experienced of the older physicians held water in such dread that they would scarcely use it in removing dirt from the neighborhood of wounds. I myself, however, having seen the wonderful effect of water in wounded parts, cannot help but be amazed at its super-celestial virtue." In spite of this strong declaration, Biondo in his book gives chapters on all the old methods of treating wounds and the various applications that were supposed to work wonders in bringing about healing. The consequence was that the water doctrine was pushed into the background and probably attracted very little attention. Here was the germ of a great discovery, the use of boiled water, evidently with some experience behind it, and yet it was to remain untried, its true value unappreciated until four centuries later.

Paracelsus, who brought about the revolution in medicine at this time, worked almost as great a change with regard to surgery. At least the principles that he laid down were as startlingly different from much of those accepted in his time and strikingly like those we have come to accept in our time. He insisted that to as great an extent as possible wounds should be left to nature, for there was a definite tendency to cure. He inveighed strongly against meddlesome surgery and declared that not a little of the subsequent complications in wounds were due to misdirected efforts at cure of them. He talked about pestilence due to wounds, and declared that he had seen it spread epidemically from one patient to another in hospital wards. He discussed pyaemia as Wundsucht, that is, an infectious disease produced from a wound. Paracelsus described gangrene and proclaimed its epidemic character. He is the first from whom we have a careful study of the effects of lightning and almost the first who believed that it was possible for a man to be struck by lightning and yet not be killed or even fatally injured.

In general, the ideas of this time were not nearly so distant from our own as some of the intermediate periods have been. Fallopius described union by first intention as resembling that which occurred between two waxed surfaces when they were brought together in parallel lines and adhered. [{421}] Würtz described a wound fever, evidently erysipelas, and warned about the possibility of its becoming epidemic.

Arceo, known also by his Latin name of Francisco Arceus, a Spanish surgeon, born near the end of the fifteenth century, illustrates the vitality of surgery in Spain at this time. He has a number of interesting surgical suggestions and has this to say with regard to club foot. The foot should be soaked thoroughly for thirty days in warm water in which some cereal has been cooked. Then the surgeon, taking the lame foot, should exert all his force to put it back into its due position and the form that he desires. This can usually be accomplished without difficulty or delay, partly because of the preceding softening of the tissues, but above all because of the tender age and soft tissues of the child. Then a bandage should be used to maintain the foot in this position until the correction becomes permanent. Ambroise Paré, as I have said, accomplished similar results, but he also used a number of forms of apparatus for the cure of club foot and for the prevention of contractures in the joints as a consequence of paralysis. He is the first surgeon whom we know to have interested himself in artificial hands, arms and legs for those deprived by amputation of members and the first to employ artificial eyes. Fabricius of Aquapendente, born in Columbus' period, but doing his work afterwards, recommends massage and bandaging for pes varus and an iron shoe with side pieces for pes valgus. He made the correction gradual. He said, "I talk from experience, as I have had much to do with crooked legs, feet and backs and have made them straight and proper."

That Germany was not without the distinctive spirit of the time by thoughtful work in surgery is made clear through the writings of Hugo von Pfolspeundt, which were found only a few years ago. In what relates to the mechanics of surgery he made many practical suggestions and inventions. For harelip he suggested that stitches should be placed on the mucous surface as well as on the skin surface, after the edges of the cleft had been freshened in order to be brought closely together and held in coaptation. He also suggested the use of a permanent weight extension for fractures and for certain [{422}] injuries of the joints. Perhaps his most interesting surgical development for us is a description of a silver tube with flanges to be inserted in the intestines when there were large wounds, or when the intestines had been severed, the ends being brought together carefully over the tube which was allowed to remain in situ. Pfolspeundt said that he had often seen these tubes used and the patient live for many years afterwards. This is an early form of what is known as the Murphy button in our time, though it was not the first suggestion of a mechanical device to aid the repair of intestinal injuries. One of the latest mediaeval surgeons had employed the trachea of an animal as the tube over which the wounded intestines were brought together. This became disintegrated after a while in the secretions, but remained intact until after thorough agglutination of the intestines had occurred.

Pfolspeundt was not an educated man and did not even write his own German tongue with correctness, not to say elegance. He was just a practical devotee of surgery, probably not even a regularly practising physician, and yet his writings show how much there was that he knew of technical details, extremely important for surgical practice, that are usually supposed to be of much later origin. After all, some of our own distinguished surgeons have not been educated men in any sense of the word, and there has sometimes been the feeling that a surplus of information of what had been accomplished just before his time, sometimes deterred the physician, as well as the surgeon, from thinking independently about problems connected with practice and reaching valuable practical conclusions.

Besides Pfolspeundt there are at least two other German surgeons of this time whose writings have come down to us that deserve a place in a history of distinguished accomplishment in Columbus' Century. One of these is Jerome of Brunschwig, whose name is spelled in many different ways, and the other is Hans von Gerssdorff. Brunschwig, or Braunschweig, used to be considered the oldest writer on surgery in German until the comparatively recent discovery of Hugo von Pfolspeundt's manuscript. He published his surgery in 1497, and it went through nine editions in a few years. It [{423}] contains a number of woodcuts, and these probably helped to give it its popularity.

Brunschwig was very proud of his calling as a surgeon, and quotes what Galen, Rhazes, Abulcassis, Lanfranc and Guy de Chauliac had declared should be the qualities possessed by a surgeon and insisted particularly that he "should have deep knowledge and trained observation of anatomy, so that whenever it may be necessary to cut or cauterize, he shall know exactly in what regions to do it, so as to do just as little damage as possible and that he shall be capable of diagnosing joint conditions and know what important organs may be injured by bullet or other wounds with weapons and be able to judge of the danger of cutting down for their removal." He recommends above all that the young surgeon should invariably call an older and more experienced colleague, or even two, in consultation, if the case is very difficult, and he has doubts about it.