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COLUMBIA LIBRARIES OFFSITE
HEALTH SCIENCES STANDARD
HX64059669 RD1 9 B49 The history and lite
RECAP
J» S* Billings
Systeia of Surgery - The History of Surgery, Pabhology, Baoteriology^ Infections, Anesthesia, fractures and Dislocations - Opera- tive Surgsry*
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COLLEGE OF
PHYSICLANS AND SURGEONS
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Digitized by the Internet Archive
in 2010 with funding from
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http://www.archive.org/details/historyliteraturOObill
SYSTEM
SURGERY
EDITED BY
FREDERIC S. DENNIS, M.D,
Professor of the Principles and Practice of Surgery, Bellevue Hospital Medical College ;
Visiting Surgeon to the Bellevue and St. Vincent Hospitals ; Consulting Surgeon to
the Harlem Hospital and the Montefiore Home, New York; President of
the American Surgical Society ; Graduate of the Royal College
OF Surgeons, London; Member of the German
Congress of Surgeons, Berlin.
ASSISTED BY
JOHN S. BILLINGS, M. D.;
LL.D. Edin. and Harv. ; D. C. L. Oxon. ; Deputy Surgeon-general U. S. A.
Vol. I,
THE HISTORY OF SURGERY-PATHOLOGY-BACTERIOLOGY- mFECTlONS -ANiESTHESI A- FRACTURES AND DISLOCATIONS-OPERATIVE SURGERY.
PROFUSELY ILLUSTRATED.
PHILADELPHIA: LEA BROTHERS & CO.
1895.
-?
L
Entered according to Act of Congress in the year 1895, by
LEA BROTHERS & CO.,
in the Office ol" the Librarian of Congress, at Washington. All rights reserved.
WESTOOTT & THOMSON, WILLIAM d. DORNAN,
ELECTROTYPERS,' PHILADA. PRINTER, PHILADA.
PREFACE.
This System of Surgery is intended to meet a growing want created by tlie great progress which Surgery has made during the past few years. It is with a view to fulfil this object that men of recognized authority in their respective branches have consented to contribute in order to present to the profession a complete review of the domain of modern Surgery — a domain which has so wonderfully enlarged its bound- aries through the achievements rendered possible by the systematic employment of antiseptic and aseptic methods of procedure. The task has been most onerous, but the labors of an eminent corps of contribu- tors have enabled the Editor to offer to the profession a concise and complete work, presenting the most advanced opinions upon the new problems involved in modern surgery, as well as the practical details which conduce to success in treatment. In accomplishing this it is gratifying to be able to announce that the whole has been the work of American surgeons, and that it may be fairly said to rejjresent the most advanced condition of American Surgery.
The Editor takes this occasion to acknowledge his obligations to the contributors, each one of whom is a teacher of Surgery or a director in some large surgical clinic or hospital, and who, for this reason, is capable of speaking with clinical authority from an experience based on the study and observation of a large number of cases. Each department is thus treated by an acknowledged master of the subject, Avho is able to present the most modern and advanced views in the most cogent and demonstrative way.
The Editor trusts that he will be found to have succeeded in the endeavor to present a work of the scope and breadth that this great subject demands, and that an appreciative reception will be accorded to the results given by the contributors, who, though busy men, have con- sented to offer the fruits of their labors for the benefit of the medical profession.
The Editor especially desires to acknowledge, with sincere thanks, the great assistance accorded to him by Dr. John S. Billings, through whose valuable services and co-operation he has been enabled to bring before the profession this work in its present comprehensive and at the same time compact form.
No. 542 Madison Avenue, New York. March, 1895.
5
CONTENTS OF VOLUME I.
PAGE
THE HISTORY AND LITERATURE OF SURGERY 17
By John S. Billings, M. D. , LL.D. , Edinburgh and Harvard ; D. C. L. Oxon. ; Deputy Surgeon-general, U. S. A.
SURGICAL PATHOLOGY, INCLUDING INFLAMMATION AND THE
REPAIR OF WOUNDS 145
By William T. Councilman, M. D., Professor of Pathology, Harvard Med- ical School, Boston.
GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS 249
By William H. Welch, M. D., Professor of Pathology, Johns Hopkins University, Baltimore.
SYMPTOMS, DIAGNOSIS, AND TREATMENT OF INFLAMMATION,
ABSCESS, ULCER, AND GANGRENE 335
By Charles B. Nancrede, A. M., M. D., Professor of Surgery and of Clinical Surgery, Medical Department of the University of Michigan, Ann Arbor.
SEPTICEMIA, PYiEMIA, AND POISONED WOUNDS 383
By William H. Carmalt, M. D., Professor of Surgery, Department of Medicine, Yale University, New Haven.
TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS 415
By J. Collins Warren, M. D., Professor of Surgery, Harvard Medical School, Boston.
RABIES ; HYDROPHOBIA ; LYSSA 433
By Hermann M. Biggs, M. D., Professor of Therapeutics and Clinical Medi- cine, formerly Professor of Pathology, Bellevue Hospital Medical College ; Visiting Physician Bellevue Hospital, New York.
GUNSHOT WOUNDS 445
By Phineas S. Conner, M. D., Professor of Surgery and of Clinical Surgery, Medical College of Ohio, Cincinnati, and also in Dartmouth Medical College, Hanover, N. H.
7
8 CONTENTS.
PAGE
FEACTUEES AND DISLOCATIONS 515
By Frederic S. Dendstis, M. D., Professor of the Principles and Practice of Surgery, Bellevue Hospital Medical College ; Surgeon to the Bellevue and St. Vincent Hospitals, New York.
ANESTHESIA ". 645
By Hokatio C. Wood, M. D., LL.D., Professor of Materia Medica, Pharmacy, and General Therapeutics, University of Pennsylvania, Philadelphia.
THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SUEGEEY 677
By Arpad G. Gerster, M. D., Professor of Surgery in the New York Polyclinic ; Surgeon to the German and Mt. Sinai Hospitals, New York.
OPEEATIVE SUEGEEY - 729
By Stephen Smith, M. D., Emeritus Professor of Clinical Surgery, University of the City of New York ; Visiting Surgeon to St. Vmcent, and Consulting Surgeon to Belleviie Hospital, New York.
THE HISTORY AND LITERATURE OF SURGERY.
By JOHN S. BILLINGS, M. D.
Iisr this sketch of the development of Surgery during the last three thousand years a brief account is given, mainly in chronological order, of the chief discoverers, improvers, and inventors in the art, and also of the principal teachers of it. The original inventor may or may not have been a lecturer or author, and the date of the first improvement in a method of treatment or in the performance of a new operation was often long prior to that general knowledge of such improvement which is necessary to constitute true development. Some account is also given of the trade, guild, or craft associations or corporations of surgeons, and of their relations to education and to legislation. A few illustrations of the state of the art at different jDeriods, in the shape of the recommenda- tions of different writers with regard to methods of treatment of certain injuries or diseases, are presented ; but no attempt is made to trace the history of the growth of knowledge with regard to each particular form of disease or operation, this being left to the writers of monographs on these particular subjects.
It requires leisure, patience, and access to a large library to make historical studies really interesting, and the most I can hope to accom- plish in this paper is to furnish to the physician who has little time, taste, or opportunity for consulting the original documents the means of ascertaining the periods and places in which the leading surgeons of the world have done their work. The printed literature of surgery is vast in quantity, and the great majority of it is obsolete and practically use- less : even for statistical purposes the records of operations performed prior to 1870 have now lost much of the value which they possessed at that date ; yet in many respects the old surgical monographs, col- lections of cases, and systems are the most definite and interesting of all ancient medical literature.
To really enjoy the history of surgery it is necessary to consult the original documents — to get the flavor of the quaint phraseology of the older writers. No discourse about the surgical knowledge of Hippoc- rates, however eloquent and eulogistic it may be, can give such an idea of his teachings as is to be obtained from a perusal of his writings.
It is not to be expected that a man who is familiar with the resources of the surgery of the present day will be able to discover in the ancient records anything of much practical utility in his daily work which will be new to him ; nevertheless, if he desires to compare his experience in a particular case or class of cases with that of his predecessors — to obtain,
Vol. I.— 2 17
18 THE HISTORY AND LITERATURE OF SURGERY.
as it were, a sort of " parallax in time " of the views which have been held on the subject which occupies him — he will often not be able to do this from the current text-books. It will be necessary that he should go back to the old masters, read, compare, and think ; and whenever he does this it is safe to say that his conclusions will be broader, wiser, established on a firmer foundation, and more interesting to those to whom he imparts them, than they will be if derived solely from his own experience.
In the history of the development in civilization of nations and peoples, surgery almost necessarily precedes internal medicine with regard to accurate observation of lesions of the human body and of their results. Speculations about humors and fluxes, black bile and medical constitu- tions, vital spirits and the doctrine of signatures, did not much occupy the minds of the men of old in their attempte to note and describe the signs of different forms of fractures and dislocations, the danger of wounds in different localities, the different varieties of tumors, or the treatment of a calculus in the bladder or of a hernia. Of the many remedies in the form of drugs, salves, embrocations, and plasters which are described at length in the ancient medical books which have come down to us, hardly more than twenty are now in ordinary use ; the ancient physiology and pathology are, for the most part, now considered as being merely curious illustrations of human error ; and it is only a portion of the anatomy and surgery of the ancients that remains as an essential part of the foundation of the art of medicine as it exists to-day.
The history of surgery is inextricably mingled with that of medicine, and the best literature on the subject is to be found in some of the larger formal treatises on the history of medicine. It has, however, been treated of as a special branch of the art in a goodly number of books and essays, the titles of a portion of which fill seven pages of volume xiii. of the Index Catalogue of the Library of the Surgeon-General's Office at Wash- ington.
The earliest records in our possession which relate to surgical opera- tions come from Egypt. It is true that human skulls have been found belonging to the Neolithic or Polished Stone Age, which have had por- tions removed — being examples of the so-called prehistoric trephining which is supposed to have been performed in cases of headache, epilepsy, etc. — and the age of these relics is unknown ; but it is not at all probable that it extends to the time of the pyramid-i)uilders in the valley of the Nile, when circumcision had been established as a religious rite and an official system of medicine was in process of construction.
The Papyrus Ebers, written 1552 b. c. — that is, at least a century before the exodus of the Israelites — is a compilation of receipts and directions for the treatment of various diseases, many of which formulfB it refers to as being then ancient. Among these is a short section on tumors near the surface of the body, in which it is said : " If this tumor goes and comes under your finger, trembling even when your hand is still, say, ' it is a fatty tumor,' and treat it with the knife, after ^vhich treat it as an open wound." From the Papyrus Ebers we learn that there were physicians in Egypt who were not priests, and the same may be inferred from the statement in Genesis (ch. 1. 2) that " Joseph com- manded his servants the physicians to embalm his father, and the phy-
THE HISTORY AND LITERATURE OF SURGERY. 19
sicians embalmed Israel." The word in this text which is translated " physicians " is rejjhalm, and it is sometimes translated as " dressers of wounds " — i. e. surgeons. The embalmers probably 4iad a little more anatomical knowledge than the physicians of the time ; but the Egypt- ians had a treatise on anatomy which, according to Manetho, was attrib- uted to Athothis, the son of Menes, who reigned 5241 b. c.
The few allusions to medicine scattered through the books^ of the Old Testament indicate that the general belief was in accord with that usually found prevailing among savage tribes — viz. that most diseases are punishments inflicted by divine power, and to be removed by sacri- fices and special ceremonies ; whence it follows that the priests were the chief medicine-men. That there were other physicians is probable from the grimly sarcastic account of King Asa, who " in his disease sought not to the Lord, but to the physicians. And Asa slept with his fathers ;" and also, perhaps, from Exodus xxi. 19 : "And if men strive together, and one smite another with a stone, or with his fist, and he die not, .... then shall he that smote him pay for the loss of his_ time, and shall cause him to be thoroughly healed ; " or, as the Septuagint has it, "and shall pay the physician's fees."
The medicine of the Bible has been the subject of several learned essays, but it does not appear that medicine was regularly studied among the Jews as a separate profession until the rise of the Alexandrian School, nor does either the science or the art of medicine owe anything to this nation until after this period. The often-quoted chapter xxxviii. of Ecclesiasticus about the physician is of late date, and was probably written under Greek influence.
Some specimens of Jewish surgery prior to 200 A. D. are to be found in the Talmud. The rabbis were acquainted with sutures for wounds, with the method of freshening the edges of an old wound to obtain reunion, with the employment of the uterine sound to learn whether the blood came from the uterus or vagina, the operation for imperforate anus, and also with ansesthetic substances with which they used to diminish the pain of a surgical operation or capital punishment.^ They understood the application to the body of artificial parts, as for supplying the loss of substance of the trachea and replacing the loss of substance of the cranial bone ; they knew artificial teeth, wooden legs, as also various forms of apparatus for the unfortunates who were deprived of the use of their lower extremities.
The first allusions to surgical subjects in Greek literature are found in the poems of Homer, which may be accepted as dating from about 1000 B. c, whatever may be thought as to the reality of the siege of Troy or the identity of Homer himself. In these poems mention is made of iEsculapius, not as a god, but as a well-known and distinguished physician, and of his sons Machaon and Podalirius as surgeons and war- riors. The works of Homer have been carefully examined and analyzed by Malgaigne and Daremberg with reference to medical and surgical matters, and their conclusions may be briefly stated as follows : ^
^ Rabbinowicz : La Medecine du Thalvmd, etc., Paris, 1880, p. xliii.
^ " Essai sur I'Histoire et I'Organisation de la Chirurgie et de la Medecine grecques avant Hippocrate," par M. Malgaigne, Jour, de Med., iv. 303, Paris, 1846 ; La Medecine dans Homere, par Ch. Daremberg, 8°, Paris, 1865.
20 THE HISTORY AXD LITEBATURE OF SURGERY.
Among the Greeks were certain surgeons whose knowledge and skill were highly esteemed ; many of the warriors knew how to dress and bandage wounds, and some of the Grecian women had the same skill, corresponding to that possessed by the wives of the nobility in AYestern Europe in feudal times. The dressings applied to the wounds appear to have been for the most part simple emollients : the eifused blood was pressed out, the surface was washed with warm water, certain crushed roots or bruised leaves were applied to check hemorrhage. Over forts- wounds in different parts of the body are described with more or less detail, and in such a way as to indicate that Homer gave the results of actual observation and experience ; and in the course of these descriptions a nomenclature is used which, anatomically, is much the same as that employed by Hippocrates. The different effects of wounds in different parts of the body are referred to, and a curious illustration of this occurs in the description of the injury of one of the horses of ISTestor by an arrow from the bow of Paris (viii. 81-86). The wound was on the top of the head, penetrating to the brain, and it is said that the injured animal was convulsed and turned round and round the pole. This, as Malgaigne points out, corresponds to the modern discovery that such movements of rotation are produced by an injury of the cerebellum.
The anatomical terms used by Homer relate mainly to the exterior of the body, and do not imply any greater knowledge of internal struc- ture than is possessed by every butcher ; but his allusions to the fatality of certain wounds embody the results of considerable experience. There is nothing of surgical interest in Greek literature betsveen the time of Homer and that of the Hippocratic Writings, unless it be the passage in Aristophanes in which the slave of Lamachus calls for hot-water com- presses, etc. with which to dress the sprained ankle of his master.
In the fifth and sixth centuries B. c. there were in Greece and Great Greece between fifty and sixty temples of ^Esculapius, all of which were probably resorted to by the sick, but those which became specially cele- brated were those of Rhodes, Gyrene, Cnidos, and Cos. Those at Cnidos and Cos gradually became the most famous, and their so-called " schools " occupy a prominent place in the history of medicine.
By the term " medical schools " as applied to Cos and Cnidos it is not meant that these were places for the public teaching of medicine, but rather that they were places where certain medical families had settled, and in each of which certain peculiar theories and methods of treatment prevailed, the phrase " school " being used much as we would now speak of the " French " or the " Munich " school in painting.
In the vicinity of these temples there seem to have collected physi- cians who were not priests, and who belonged to an association or bro- therhood, the members of which either claimed to be descendants of ^sculapius or were admitted to the guild by adoption with special cere- monies. These were known collectively as the "^Esclepiadae," and much confusion has arisen from the erroneous application of this term in later times to those who ministered in the temple. There is no doubt that the priests of the temple gave medical advice, l)ut, if we are to judge from the specimens preserved to us in the forms of inscriptions and memorial tablets, it Mas not the sort of advice of which any use is made in the medical treatises of the Hippocratic school.
THE HISTORY AND LITERATURE OF SURGERY. 21
It is probable that the real or lay physicians kept records which were handed down from father to son, and were preserved as a valuable family heritage. That medicine was thus hereditary we know from the Hip- pocratic oath, and from the genealogies which are given of many of the celebrated physicians of Greece. According to Bertrand, this custom has come down to the present time. On one of the slopes of Pindus there are still five or six villages the inhabitants of which are supposed to be born physicians and surgeons, each family having its own specialty and its inherited tradition. If a son is wanting, the child of a stranger is adopted.
There is no evidence that those who visited the temples seeking mirac- ulous cures were examined or treated by lay physicians, but there were certain attendants called zacoroi who received the patients and assigned them to places beneath the porticos ; and from the information collected by them it is possible that the priest who impersonated the god, appearing in the night-watches, may sometimes have formulated his prophecies and instructions.
The doctrines of the schools of Cos and Cnidos were committed to writing, the first work of the kind coming from the school of Cnidos, being what is known as the " Cnidian Sentences." Of this treatise there were at least two editions, and it was in existence in the time of Galen. A portion of it has been preserved to us in what are known as the Second and Third Books of Diseases, and in the Treatises on Internal Affections contained in the Hippocratic collections.
In this portion four diseases of the kidneys are described. In the first there is acute pain in the loins, groin, and the testicle of the afPected side (renal colic) ; there is frequent urination, with gradual suppression of urine and passage of sand, causing pain in the urethra. Apply Avarmtli and purge with scammony. If the pain is great, use large enemata of warm water ; if a tumor forms, make an incision over the kidney and evacuate the pus. Such incision gives a chance of recovery ; without it death will follow.
In the second form of disease of the kidney there are violent pains, as in the preceding form. The patient passes blood with his urine at the commencement of the disease, which is followed, after a time, by pus. If he preserves a strict rest, he will be cured rapidly, but if he makes eifort, the pains will become sharper. When the kidney is filled with pus it swells out near the spine ; in this case make, over the swelling, an incision, generally deep, into the kidney. If you succeed in the incision, you will cure the patient at once ; if you fail, it is to be feared that the wound will not close, and the borders of the wound will contract and the cavity of the kidney will be filled with pus ; if this passes inward and is evacuated by the rectum, there is a chance of health ; but if it affects the other kidney, death is to be feared. Evacuants are to be used, and the same regimen as for the preceding case. Very often this disease termi- nates by a renal phthisis.
The school of Cos followed with its collection of maxims, the " Prse- notiones Coacse." Its doctrines will be best considered in the work of its most illustrious disciple, Hippocrates, who was born at Cos about 460 B. c. His father, Heraclides, and his grandfather Avere physicians, and he received his early education at the school of Cos, after which he went
22 THE HISTORY AND LITERATURE OF SURGERY,
to Athens and continued his studies, receiving the best education which the Golden Age of Greek civilization could furnish.
The collection known as the " Hippocratic Writings " dates from a jDcriod about the- time of Aristotle. Only a portion of these writings are the works of Hippocrates himself ; several are probably of more ancient date — two at least appear to belong to the Cnidian School, and some are by his disciples. On the other hand, some of those which once belonged to this collection have been lost.
The books in the Hippocratic collection which treat more especially of surgical affections and operations, and which are accepted by most commentators as having been written either by Hippocrates himself or by one of his immediate pupils, are those on injuries of the head, on fractures, on the articulations (i. e. on dislocations), Mochlicus (on the bones and their injuries and displacements, and on apparatus), on wounds and ulcers, on iistulse, on hemorrhoids, and on the latrium or the Physi- cian's Establishment, or the Surgery.
The book on injuries of the head begins with a description of the sutures of the cranium and of the bones of the skull, in which it is stated that the number and position of the sutures varies with the form of the head ; that the coronal suture is wanting when there is no anterior pro- tuberance of the skull, and the lambdoid suture is wanting when there is no posterior protuberance. As this does not agree with the observa- tions of modern anatomists, the commentators have much trouble to explain it, since they are unwilling to admit that Hippocrates made a mistake in observation, or even that he generalized from insufficient data ; which last is the most probable explanation.
He divides injuries of the bones of the skull into five classes — viz. simple fissures, contusions without fracture or dejDression, fractures with depression, indentations of the outer table, and fractures at a distance from the place of injury, or fracture by contre-coup. With regard to this last he says : " There is no remedy, for when this mischief takes place there is no means of ascertaining by any examination whether or not it has occurred, or on what part of the head." He then goes on to say : " Of these modes of fracture the following require trepanning : the contusion, whether the bone be laid bare or not ; and the fissure, whether
apparent or not A bone depressed from its natural position
rarely rec^uires trepanning, and those which are most pressed and broken require trejDanning the least."
It will be seen that this is quite different from the rules of modern practice.
For wounds of the head he forbids the application of any liquors or cataplasms or tents, unless the wound is on the forehead or the part w^hich is bare of hairs or about the eyebrow and eye. The wound is to be extended by incisions for the purpose of examining the bone when- ever it is suspected that this is injured ; and it is remarked that these incisions may be practised with impunity except on the temple and the parts above it, where there is a vein that runs across the temple, in which region an incision is not to be made ; " for convulsions seize on a ])erson who has been thus treated ; and if the incision be on the left temple, the convulsions seize on the right side ; and if the incision be on the right side, the convulsions take place on the left side."
THE HISTORY AND LITERATURE OF SURGERY. 23
' The books on fractures and on the articulations, together with the book called " Mochlicus/' contain sketches of the anatomy of the bones and of the joints, and accounts of various forms of dislocations of the different joints, with detailed instructions as to reduction and as to the mode of bandaging in cases of fracture. Special attention is given to the subject of injuries aifecting the knee-, the elbow-, and the ankle-joints.
The paragraph on dislocations of the knee does not correspond to the experience of modern surgeons. It is as follows : " Luxations and sub- luxations at the knee are much milder accidents than subluxations and luxations at the- elbow ; for the knee-joint, in proportion to its size, is more compact than that of the arm, and has a more even conformation, and is rounded, while the joint of the arm is large and has many cavities
" Owing to their configuration, the bones of the knee are indeed fre- quently dislocated, but they are easily reduced, for no great inflammation
follows nor any constriction of the joint They are displaced
for, the most part to the inside, sometimes to the outside, and occasion- , ally into the ham. The reduction in all these cases is not difficult, but in the dislocations inward and outward the patient should be placed on a low seat, and the thigh should be elevated, but not much. Moderate extension for the most jpart sufficeth, extension being made at the leg and counter-extension at the thigh.
" Dislocations at the elbow are more troublesome than those at the knee, and, owing to the inflammation which comes on and the config- uration of the joint, are more difficult to reduce if the bones are not immediately replaced. For the bones at the elbow are less subject to dislocation than those of the knee, but are more difficult to reduce and keep in their position, and are more apt to become inflamed and ankylosed."
Some of the older surgeons concur with Hippocrates in speaking of dislocations of the knee as comparatively frequent, whereas at present they are very rare. Dr. Adams supposes that the wrestlers at the public games, who furnished Hippocrates with a large proportion of his cases of fractures and dislocations, may have been especially liable to this accident. Hippocrates says that he knows of but one way in which the shoulder-joint is dislocated — namely, that into the armpit ; but he does not deny that the head of the humerus might be dislocated upward, out- ward, or forward. The methods of reduction are fairly described, and are substantially those which are used at the present day.
He has much to say in various places about congenital dislocations, some of which may be reduced to their natural condition, and especially those at the ankle-joint.
In cases of compound dislocations he forbids reduction, as a general rule. For example, in speaking of dislocation at the ankle-joint com- plicated with an external wound, he says you are not to reduce the parts, but let any other physician reduce them if he choose ; " for this you should know for certain, that the patient will die if the parts are allowed to remain reduced, and that he will not survive more than a few days, for few of them pass the seventh day, being cut off by convulsions ; but
sometimes the leg and foot are seized with gangrene But if not
reduced nor any attempts first made to reduce them, most of such cases
24 THE HISTORY AND LITERATURE OF SURGERY.
recover. The leg and foot are to be arranged as the patient wishes, only they must not be put in a dependent position nor moved about."
In speaking of these compound dislocations he makes no allusion to cutting off the protruding end of the bone, but in another section he remarks that " complete resections of bones at the joints, whether the foot, the hand, the leg, the ankle, the forearm, the wrist, for the most part are not attended with danger, unless one be cut off at once by de- liquium animi or if continual fevers supervene on the fourth day."
Hippocrates knew nothing about amputation of limbs as an operation through living parts or with a view to forming a stump of a particular shape. In cases of gangrene due to the crushing of the blood-vessels, or following fractures when the bandages have been applied too tightly, he remarks that the most of such patients recover, even when a portion of the thigh comes away or of the arm, and when the forearm and leg drop ofiP the patients rapidly recover.
The surgical part of the Hippocratic collection is much more in accordance with modern views than the medical part ; but there are certain characteristics of all the books generally considered to have been written by Hippocrates himself which are worthy of special attention in connection with the high repute in which they have been held by med- ical men for over two thousand years. In the first place, it is evident that one of his special aims was to be entirely honest and truthful in his statements. He reports no marvellous cures, no specimens of extraor- dinary success in diagnosis where others had failed ; fatal cases are given as well as recoveries, and there are no hints that the former were not seen in time or that they had been improperly treated by others. He seems to have written mainly for the purpose of telling what he himself knew ; and this motive — rare among all writers — is especially rare among writers on medicine.
A second characteristic of the Hippocratic Writings is the special attention given to those symptoms which indicate the effect which the disease is producing upon the body as a whole, including such phenomena as fever, debility, delirium, restlessness, and so-called critical discharges of various kinds ; while the special diagnostic signs of particular forms of disease of particular organs are given much less attention.
The aphorism of Hippocrates concerning the efficiency of fire — namely, " that diseases which are not cured by medicines are cured by iron ; those which are not cured by iron are cured by fire ; those not cured by fire are incurable " — has been the cause of an enormous amount of suffering and of bad surgery to- nearly the present century.
Surgery of India and China.
In the literature of India the first definite hymns, invocations, and charms connected with medicine are found in the fourth (or Atharva) Veda. The oldest existing medical work is the Charaka-samhita, of which the Sanscrit text has been published in 1877, and of which an English translation is noAV in course of publication. Somewhat later, probably, is the Susruta, of which two Sanscrit editions have been })ub- lished ; also a Latin translation by Dr. F. Hcssler, published at Erlangen in 1844. English translations are in progress of publication, and a sum-
THE HISTORY AND LITERATURE OF SURGERY. 25
mary is given by Dr. Wise in his history of Indian medicine. Both Charaka and Susruta profess to be, and are commonly said to be, commen- taries on the Ayur-Veda — i. e. the Veda of Life — bnt, in fact, there is no such work as the Ayur-Veda distinct from and preceding Charaka and Susruta.
The date of composition of these works is unknown, and is variously estimated at from 1000 b. c. to 700 A. d. Recent authorities consider that the later date is the more probable one, and that the work took its present form under the influence of ideas derived from the Alexandrian School and the early Arab writers. It was certainly known in the ninth century A. D. Nevertheless, it shows little trace of a knowledge by the author of the Hippocratic Writings or of the discoveries of the Alexandrian anato- mists and surgeons, and it contains a number of things peculiar to itself and probably derived from ancient Indian traditions.
The translation of Susruta by Anna Moreshvar Kunte, of which the first numbers were published in Bombay in 1877, begins as follows :
"Salutation to Brahma, Prajapati, the twin Asvins, Indra, Dhan-
vantari, Susruta, o,nd others. " Now, hereafter, we shall narrate the chapter named the descent of knowledge (of medicine) just as it was taught to Susruta by the venerable Dhanvantari. Aupadhenava, Vaitarana, Aurabhra, Paushkalavata, Kara- virya, Gopura, Rakshita, Susruta, and his other friends in earnest addressed the venerable Dhanvantari, the respected of gods (then known by the name of Divoclasa), the descendant of Kasiraja, who was leading the life of a hermit, surrounded by a number of sages : ' Sire ! we are moved with compassion, seeing human beings, though protected (by their kings), yet quite helpless, being afllicted with numerous bodily, mental, natural, and accidental maladies. We wish to be instructed in the Science of Medicine for the sake of public good, for earning our livelihood, and for allaying the suiferings of mankind desirous of health. Earthly and heavenly bliss depends upon it. Hence, Sire, we have come to you to become your pupils.'
" To them said the venerable man : ' Ye are welcome. All of you, my lads, shall be taught and made to meditate. Ayur-Veda is an Upanga of the Atharva-Veda. The Self-born, after creating the universe, com- posed it in a thousand chapters, containing a hundred thousand verses. But, knowing the brevity of human life and the limitedness of human understanding, he reduced it to eight divisions. These are : 1. Shalyam, splinter (extraction) surgery ; 2, Shalakyam, inquiry into the disease of organs situated above the clavicles ; 3, Kayachikitsa treats of diseases afl^ecting the whole body ; 4, Bhutavida treats of diseases of mind pro- duced by demoniacal influences ; 5, Koumarabhrityam, care and treatment of children ; 6, Agadatantram, doctrine of antidotes ; 7, Rasayanatantra, doctrine of elixirs ; 8, Vajikaranatantram, rules for increasing the gen- erative powers. Which of these do you wish to be taught ?' — ' Sire,' said they, ' teach us all, but begin with surgery first.' — ' Be it so,' said he. — They again requested him, saying, ' Susruta, after consulting us all, shall ask you for explanations (in matters of doubt), and whilst he is made to understand we shall also try to do the same.' — ^ Well, then, my pupil, Susruta,' said he, ' the Science of Medicine has for its object the emancipation from disease of those who are afflicted by it, and the pres-
26 THE HISTORY AXD LITERATURE OF SURGERY.
ervation of the health of those who possess it. Avur-Veda is so called because by it health is gained or it brings health. The best portion of it I explain to you : try to follow me and judge by the four criteria of judgment — namely, inference, comparison, testimony, and perception. It is the best, because the first inflicted wound was healed (by its know- ledge), and the head of Yajna was united to his trunk. It is said that when Rudra cut of the head of Yajna the gods went to the twin Asvins and said to them, "You two are of a higher rank amongst us. We entreat you to join together Yajna's head and trunk." They complied with the request. For their sake the gods propitiated Indra and allowed them a share in his sacrifice. They forthwith joined the head and trunk together. Of all the eight parts of which the Ayur-Veda is composed, this is the best, from the speediness of its operations, from its including the use of appliances, surgical instruments, caustics, cauteries, and from its being common to the other parts (of the science). Thus it is eternal, merit-giving, divine, leading to renown, longevity, and prosperity".
" ' The great god Brahma announced (the knowledge of medicine) first ; Prajapati learnt it from him ; the twin Asvins got it from Prajapati ; from them Indra ; and from Indra have I learnt it. I am going to impart it to anybody who seeks it for the sake of public good.
" ' On the preliminary preparations (rules to be observed before, dur- ing, and after the completion) of surgical operations :
" ' Every action (to be successful) involves three stages — viz. 1, the preparatory stage ; 2, the predominant stage ; 3, the succeeding stage. We shall point out that the treatment of diseases has these three stages.
" ' In this science the use of edged instruments is considered to be predominant. Hence we shall begin our description with it and its accessories. Edged instruments are used for eight purposes — viz. 1, amputatmg ; 2, opening ; 3, scarifying ; 4, puncturing ; 5, exploring ; 6, drawing ; 7, evacuating ; and 8, sewing. A surgeon contemplating to operate in any of the above ways should first have ready the following : blunt instruments (forceps, etc.), sharp instruments, potential cauteries, virtual cauteries, catheters, horns, leeches, a dry gourd, a cauterizing needle, stuffing materials, strings, board, bandage, honey, ghee, fat, milk, oil, soothing decoctions, injections, lotions, fan, cold and warm water, a frying-pan, able, steady, and attached servants.
" ' Then on a good day, having a good lunar influence and the auspicious influence of stars, after invoking blessings from the Brah- mans and medical men, and propitiating the sacred fire Avith honey, rice, and water, let the patient be seated, who has taken very little food, offered sacrifices, and made ablutions, with his face toward the east. The surgeon should stand with his face toward him, and plunge his instrument after the proper incision until matter comes out, and with- draw it, avoiding vital parts, vessels, muscles, articulations, bones, and arteries. In the case of a large collection of matter the incision may be of the breadth of two or three fingers even.
" ' Incisions are either long, wide, even, or uneven. An incision, whether long, broad, clean, or dependent, is always to be extolled Avhen it suits (the purpose and) the occasion. Boldness, rapidity of action, sharp instruments, operation without trembling, fear, or doubt, are always
THE HISTORY AND LITERATURE OF SURGERY. 27
praiseworthy of the surgeon operating The operations for moles,
ascites, piles, calculus, fistula, and mouth diseases are to be performed on
an empty stomach The instruments should be so made that they
should be of a good finish, strong, clean in appearance, with good handles, whether they be sharp or blunt.
" ' Among these the Svastika instruments ought to be about nine inches long; their mouths should be respectively like those of a lion, tiger, wolf, hyena, bear, elephant, cat, hare, antelope, crow, heron, dog, jay, vulture, falcon, owl, kite, cock, crouch, the bee, rat, mouse, or bullock, each half being united to the other by a nail of the form of a lentil- seed, being bent inward at the handles like the elephant-driver's hook. These forceps are recommended for the extraction of splinters lodged in bones.
" ' The tubular instruments are of a variety of kinds, having various uses, open at one end or both or having several foraminae. They are used for removing obstructions from the great canals of the body, or for examination of diseases, or as suction-tubes, or for the easy application of remedies. Their lengths are always determined by the aperture of the canal whence the obstruction is to be removed or by the use to which they are to be applied.
" ' The diiferent tubular instruments which are used in fistula, hemor- rhoids, polypi, sores, urethral injections, enemas, retention of urine, ascites, inhalation for cough and dyspnoea, and obstruction of bowels, together with the bottle-gourd and the horns, shall be described hereafter in their proper places.
" ' The probe-like instruments are of various kinds and serve a variety of purposes. Their magnitudes differ according to the uses they are applied to. Among them the earthworm-like probe, the arrow probe, the serpent-hood probe, and the hook probe are each of them two in number. They have been recommended for sounding, separating, loosen- ing, and extracting (foreign bodies). Probes having lentil-seedlike ends are two. They are slightly curved inward at their extremities, and are used for the extraction of foreign bodies from the large canals. There are six probes which are capped with cotton wool, and are used for cleaning and wiping purposes. There are three which are ladle-like and mortar-like, and are used for application of caustics. Three others there are which have their ends like a jambul-seed. Three others, again, resem- bling the elephant hook. These six are used for cauterizing purposes. There is a nasal-polypus probe which resembles the kolasthi. There is the inunction probe, which at its both extremities has a knob like the pea-seed, resembling an open bud. There is the urinary catheter, which resembles the stalk of malati- {Jasminium glandifiorci\ flower, and its length varies according to purjDose
" ' The lion-mouth forceps is for foreign bodies that can be seen, while for covered ones there is the heron forceps and others' of its kind. These should be used gently, the foreign body being removed in accordance with surgical j)recepts.
" ' The heron forceps is the best of all forceps, since its use never leads to accidents. It enters easily and is very easily drawn back. It lays a firm hold on splinters and removes them easily.' "
No allusions are made to the use of the ligature, but amputations of
28 THE HISTORY AND LITERATURE OF SURGERY.
the limbs were performed, the hemorrhage being checked by the cautery, by boiling oil, and by pressure.
The operation of lithotomy is described, being that of " cutting on the gripe," the incision being made on either the left or the right side of the perineum, the breadth of a barley-corn from the central line and an inch from the anus.
The suprapubic operation was also known, rhinoplasty is described, and herniotomy is referred to. Manual skill was to be acquired by the student by making punctures and incisions on gourds and other fruits or on dead animals.
Fractures and dislocations are described with considerable detail of classification, and the bamboo splints recommended are still in use. The most original thing in the work is the part which relates to plastic sur- gery, and especially to rhinoplasty.
Of the history of surgery in China almost nothing is known. Hwa T'o, who is supposed to have lived in the third century a. d., is ordinarily considered to have been the father of surgery in China. He is said to have performed abdominal section for the local treatment of diseased viscera ; to have laid bare the scapula of a certain great military hero and scraped from it certain poison, possibly carious bone ; also to have relieved by acupuncture an affection of -the brain of another famous general of his time. It does not appear that this was entirely successful, however, for he subsequently proposed trephining for the surgical cure of this disease, on which the indignant general is stated to have declared him a traitor who was plotting his death, and to have had him beheaded.
Ch'iin Kwei in the sixth century a. d. is also said to have successfully removed certain diseased viscera by incision through the abdominal wall.
These stories rest upon no definite foundation. Acupuncture, counter- irritation, and various forms of shampooing seem to have been the only forms of surgical treatment practised in this nation, and operative surgery is now, as it probably always has been, practically unknown among the Chinese.
After the time of Hippocrates there is very little of interest from a surgical point of view recorded in Greece itself. His sons, Thessalus and Draco, and his son-in-law, Polybius, were also physicians, and are supposed to be the authors of some of the books in the Hippocratic col- lection. Aristotle gave a strong stimulus to the study of anatomy, and is said to have written two books on medicine, which have been lost. Through the influence of his pupils the famous library, museum, and schools of Alexandria were formed, and the headquarters of medical knowledge for the time being passed to Egypt. The Alexandrian School is famous for the advances in the knowledge of human anatomy which were made there as a result of the authority which was, for a sliort time, granted for the dissection of human bodies. The numerous writings of the anatomists of this school have been lost as distinct works, but prob- ably all their important discoveries and teachings have been preserved for us in the works of Celsus, Galen, and Oribasius. Herophilus (about 300 B. c.) was perhaps the most famous of these anatomists, and many of the names of parts which he gave are in use to-day, such as the choroid, the retina, the dura and pia mater, the calannis seriptorius, the duodenum, and the prostate. Erasistratus, his contemporary and rival,
THE HISTORY^ AND LITERATURE OF SURGERY. 29
was also a famous anatomist, but we know even less of his work than we do of that of Herophilus. Galen says that he invented the catheter, but it is probable that this instrument was known both in Egypt and in India long before.
The advances in surgery made by the Alexandrian School prior to the Christian era are practically summed up in the first treatise on sur- gery written in Latin which has come down to us — namely, that of Celsus, or, more properly, of Aulus Cornelius Celsus. Of the personality of this writer we know nothing positively, but he probably lived at Rome about the beginning of the Christian era, and was not a physician by profession, medicine at that time being almost exclusively practised by Greeks. He is quoted by Pliny as an author as distinguished from a physician, and his work was not referred to by any medical writer for over a thousand years after his death. His book was a sort of encyclo- paedia of the arts and sciences of his time, intended for educated men, but not specially for physicians, and the medical portion consists of eight books or sections, which, in the original, followed the five books of the treatise on agriculture — the first book of the "De re Medica" being in the oldest Vatican manuscript entitled "Auli Cornelii Celsi liber sextus, idemque medicinse primus." After the invention of printing the " De re medica " of Celsus was one of the first books that issued from the press, having been published in 1478, since which date there have been over sixty Latin editions and translations into most modern languages.
Most persons not familiar with the history of the art are accustomed to place Celsus with Hippocrates and Galen as one of the three great Fathers of Medicine ; but he was really only a compiler, although a compiler whose conciseness and clearness of style have gained for him the title of " the Medical Cicero." As Greek was the professional language of his day, he could find no Latin equivalent for many of the technical terms, and was obliged to use either a descriptive periphrasis or to give the Greek word, introduced by the phrase " the Greeks call it." He was also troubled by the fact that in writing in Latin on the subject of hernia he was compelled to use what was considered to be a very immodest and improper word, for which he duly apologizes ; and this is one of the numerous proofs that his work was not intended for physicians espe- cially, but for the educated public.
A compiler without practical experience is sure to make some mis- take ; and a good illustration of this is found in the remarks of Celsus upon dislocation of the hip, as pointed out by Broca. Dislocation of the hip-joint, prior to the discovery of anaesthetics and the introduction of Reid's method, was often very difficult to reduce ; but after it had once been reduced there was no special difficulty in keeping the head of the femur in its proper place. Celsus had probably never seen a case, but he had heard that one of the great dangers is that when reduced it may slip out again, this idea having probably arisen from confounding fracture of the neck of the femur with dislocation of its head ; so he argues as follows : " Some maintain that it always does so [^. e. slips out again], but Hippocrates, Diodes, Philotinus, Nileus, and Heraclides the Tarentine, very celebrated authors, have asserted that they have effected a perfect cure. Neither would Hippocrates, Andreas, Nileus, Nympho-
30 THE HISTORY AXD LITERATURE OF SURGERY.
dorus, ProtarchuS; Heraclides, aud also a certain mechanician have invented so manv kinds of machines for extending the femur in this
case if it had been to no purpose Therefore it must be attempted."
The logic is excellent, but the point which he supposes to be in dispute is Avholly imaginary.
Some of the details of surgical practice given by Celsus will be con- sidered in connection with those found in other writers next to be referred to. Of these the chief is Claudius Galen, who was born at Pergamus 131 A. D. He studied medicine at the schools of Smyrna, Corinth, and Alexandria, and returned to Pergamus at the age of twentj-eight, when he was appointed to the medical charge of the athletes of the gymnasium connected with the temple of JEsculapius. Four years later he went to Rome, where he soon became celebrated. He finally returned to his native country, where he died when about seventy years old. He is said to have written five hundred treatises on medicine, but a large number of these have been lost, and a number which exist in manuscript have not been printed.
The medical system of Galen is haj)pily compared by Daremberg to a tissue of which the Hippocratic AVritings are the woof and those of Aristotle the warp. His anatomy is mainly contained in his treatise " De usu partium," the purpose of which treatise is to prove that all the organs of the body are arranged in the best possible manner and show the Avisdom and care of Xature. After a few preliminar}" definitions he begins his third section as follows : " As man is the wisest of all animals, so the hands are the instruments which belong to a wise being. For man is not the wisest of animals because he has hands, so says Anaxa- goras, but he has hands because he is the wisest, as says Aristotle, who judges very judiciously. In fact, it is not by his hands, but by his reason, that man has learned the arts. The hands are an instrument, as the lyre for the musician or the pincers for the blacksmith."
Between the time of Celsus and that of Galen there were three writers whose names should be mentioned in a sketch of ancient sur- gery, although their works have for the most part been lost — namely, Soranus of Ephesus, about 79-138 A. d., and Rufus of Ephesus, and Heliodorus, about the beginning of the second century. The treatise of Soranus on the diseases of women, edited and translated into Latin by Ermerius, was published in 1869, and his "De signis fracturarum" was published by Cocchius, with a translation, in 1754. A considerable part of his medical writings form the books ordinarily attributed to Cselius Aurelianus. Such works of Rufus as have been preserved were edited and translated into French by Daremberg, and published in 1879. Heliodorus lived at Rome in the time of Trajan, about the beginning of the second century A. D., and wrote a treatise on surgery, the fragments of which, preserved for us by Oribasius, indicate that he must have been a skilful surgeon, well acquainted with anatomy and with various modes of operating which have been proclaimed as marvellous in later days, such as the torsion of arteries, a particular mode of operating for the radical cure of hernia by excision of the sac, the excision of stricture of the urethra, etc.
After Galen, probalily about the end of the third century, came a surgeon named Antyllus, who seems to have been a skilful operator and
THE HISTORY AND LITERATURE OF SURGERY. 31
an original A\'riter, but of whose works we have only fragments preserved in the writings of Oribasins, a native of Pergamus, who was the physi- cian and friend of the emperor Julian about the middle of the fourth century. Oribasius wrote a huge medical cyclopaedia, which formed seventy books, of which over two-thirds have been lost, but what remains is of much interest in an historical point of view, because he copied literally, or nearly so, the text of the authors from whom he compiled, often giving their names, and in this way has preserved frag- ments of many works of which we have no other means of knowledge.
The next in time of the great medical compilers and encyclopsedists is ^tius Amidenus, who lived in the early part of the sixth century, studied medicine in Alexandria, and practised at Constantinople, where he became famous. He wrote a work in four books, each containing four sections, which is known as the " Tetrabiblos." There are no translations into modern languages. It is an important work in the history of sur- gery, containing extracts from previous authors not found elsewhere, and it supplements, to some extent, Avhat remains to us of Oribasius, as it contains copies of some of the lost sections of that writer. He describes charms and amulets, in which he had full faith, and he has been supposed to have been a Christian, because in extracting a bone he recommends the use of the following word-charm : " Bone, as Jesus Christ caused Lazarus to come out of the grave, as Jonah came out of the whale's belly, come out ! "
Following ^tius, about the middle of the sixth century was Alex- ander of Tralles, a Lydian, who practised at Eome, and Avrote a work on medicine in twelve books, the Greek text of which was first published at Paris in 1548. He was a Christian, and made use of amulets and incan- tations, of which he gives several specimens.
Paul of ^-Egina (Paulus ^gineta), the last of the Greek writers on medicine, lived in the early part of the seventh century and studied at Alexandria. His seven books are among the most famous of medical classics, and form a compend and abridgment of the medical literature of his day carefully selected and concisely expressed. His main source "of information appears to have been the works of Oribasius. He does not pretend to any originality, as will be seen by the following extract from his preface : " It is not because the more ancient writers had omitted anything in the art that I have composed this work, but in order to give a continuous course of instruction ; for, on the contrary, everything is handled by them properly and without any omissions, whereas the moderns liave not only in the first place neglected the study of them,
but have also blamed them for prolixity To remember all the
rules of the healing art and all the particular substances connected with it is exceedingly difficult, if not altogether impossible. On this account I have compiled this brief collection from the works of the ancients, and have set down little of my own, except a few things Avhich I have seen and tried in the practice of the art." The sixth book is a system of operative surgery, the most complete of any which have come to us from before his time, and the source of most of the surgical treatises of Arabian authors. In it he neyer refers to Celsus, but often to Galen.
Having thus given a brief account of the principal Greek and Latin writers on surgery whose works are known to us, we may \\o^^' consider
32 THE HISTORY AXD LITERATURE OF SURGERY.
the progress in the art which had been made between the time of Hippoc- rates and that of Paul of ^Egina, a period of about one thousand years.
First, as to hemorrhage from recent wounds, and more especially arterial hemorrhage. Upon this subject the Hippocratic Writings contain nothing. Celsus says (lib, v. cap. xxvi.) : " If we fear th*e hemorrhage, the wound is to be filled with dry pledgets of lint, and a sponge squeezed ^ out of cold water is to be applied and compressed with the. hand. If the ' blood still issues, the lint must be changed frequently, and if dry lint does not succeed, it should be moistened with vinegar. Caustics sTFould not be used, except in urgent cases, on account of th'e'^inflammation which follows their use. If compression, cold, and vinegar fail to stop the bleeding, the vessels which pour out the blood are to be seized and tied with two ligatures, one on each side of the wounded part, after which the vessels are to be divided between the ligatures, that they may retract and still have the openings closed. If the case does not admit of this, the actual cautery may be used." Celsus makes no reference here to any distinction between arterial and venous hemorrhage. In speaking of castration he says : " The veins and arteries must be secured by a liga- ture at the groin and divided behind it." This is the first mention of the ligature of blood-vessels in .published literature : it was an invention of the Alexandrian School, and is said to have been introduced at Rome by Euelpistus, who lived a short time before Celsus.
Galen refers in several places to the use of the ligature, but treats more especially of hemorrhage in the fifth book of the Methodus Medendi. He directs that the finger be placed gently upon the mouth of the bleed- ing vessel, extending and compressing it. If the wounded vessel lies deep, the surgeon must thus learn its position and size, and then, whether it be a vein or an artery, lift it with a hook and twist it a little. Ifthis does not answer and it is a vein, styptics, such as roasted rosin, fine flour, g}^3sum, etc., are to be tried ; but if it is an artery, it must be either ligated or entirely divided. Sometimes the veins must also be ligated and divided ; but it is safer to do both — that is, to ligate the proximal end of the vessel and also to divide it beyond the ligature. Oribasius says nothing about the ligature, but advises the cautery if the bleeding cannot be checked otherwise. Paulus /Rgineta copies Galen almost literally, but says, in addition : " You may knoAV whether it is a vein or an artery that pours forth the blood from this, that the blood of an artery is brighter and thinner and is evacuated by pulsations, whereas that of the vein is blacker and without pulsation."
While it is thus evident that the use of the ligature was known from the beginning of the Christian era, it is curious that it seems never to have been employed to check hemorrhage from vessels divided in ampu- tations.
Celsus remarks that in cases of gangrene of an extremity the incision is to be made between the sound and the corrupted part, but says nothing about details. Galen's advice is the same as that of Hippocrates. Paulus says : " Leonides properly directs us not to divide all the parts at once unless they are completely mortified, but first to cut the part where not many nor very large veins or arteries are known to be situated, down to the bone quickly ; tlien to saw the bone as rapidly as possible, applying a linen rag to the parts Avhich have been cut, lest they be torn by the
THE HISTORY AND LITERATURE OF SURGERY. 33
sawing and cause pain, and then, having cut through what remains, to apply red-hot irons to the vessels, and stop the hemorrhage thereby Avith compresses of lint." The Leonides referred to here was an Alexandrian surgeon who lived about the beginning of the third century a. d. Prior to this, however, Archigenes, a celebrated physician who lived at Rome about the beginning of the second century a. d., and Heliodorus, had given more details as to methods of amputation, as appears from the fragments of their works preserved in the collection of Nicetas, published byCocchius in 1756. Archigenes appears to have commenced the opera- tion in some cases by a preliminary ligature of the blood-vessels supply- ing the parts ; the incision was a circular sweep down to the bone. The red-hot iron was used to check hemorrhage. The method of Heliodorus is substantially the same as that of Leonides.
Aneurism is not mentioned by Hippocrates or by Celsus. Galen describes it in his work "De tumoribus," saying that it may arise either from simple dilatation or from a wound of an artery, and is recognized by its pulsation. The only treatment he refers to is com- pression by means of sponge.
The following is an extract from the treatise of Antyllus on aneurism, as given by Oribasius : " There are two kinds of aneurysm. In the first the artery has undergone a local dilatation ; in the second the artery has been ruptured. The aneurysms which are due to dilatation are longer than the others. The aneurysms by rupture are more rounded. To refuse to treat any aneurysm, as the ancient surgeons advised, is unwise ; but it is also dangerous to operate upon all of them. We should refuse, therefore, to treat aneurysms which are situated in the axilla, in the groin, and in the neck, by reason of the volume of the vessels and the impossibility and danger of isolating and tying them. We should not touch an aneurysm of large volume even when it is situated in some other part of the body. We operate in the following manner upon those which are situated upon the extremities and the head : If the aneurysm be by dilatation, make a straight incision through the skin in the direction of the length of 'the vessel, and, drawing open by the aid of hooks the lips of the wound, divide with precautions the membranes which cover the artery. With blunt hooks we isolate the vein from the artery, and lay bare on all sides the dilated part of this last vessel. After having introduced beneath the artery a probe, we raise the tumor and pass along the probe a needle armed with a double thread in such a manner that this thread finds itself placed beneath the artery ; cut the threads near the extremity of the needle, so that there will be two threads having four ends ; seizing, then, the two ends of one of these threads, we bring it gently toward one of the two extremities of the aneurysm, tying it carefully ; in like manner also we bring the other thread toward the opposite extremity, and in this place tie the artery. Thus the whole aneurysm is between the two ligatures. We open then the middle of the tumor by a small incision : in this manner all which it contains will be evacuated, and there will be no danger of hemorrhage.
" To tie, as it has been advised, the artery on both sides the vein, and then to extirpate the dilated part which finds itself between, is a dan- gerous operation ; frequently, in fact, the violence and tension of the arterial pneuma push oflP the ligatures.
Vol. I.— 3
34 THE HISTORY AND LITERATVBE OF SUEGEEY.
" If the aneurysm owes its origin to the rupture of the artery, we isolate with the fingers as much of the tumor as we can, inchiding the skin, after which we pass underneath the isolated jDart the needle with the double thread and proceed as before ; after which the tumor may be opened at its summit and the superfluous portion of the skin cut away."
Upon injuries of the skull and trephining Celsus speaks at consider- able length, quoting fully from Hippocrates. To distinguish a fissure from a suture he advises the pouring of ink on the part and then scraping the bone ; if there is a fissure, the ink will mark it. He says that if blood is extravasated beneath the cranium, the overlying bone will be pale. If no dangerous symptoms come on, he would defer operating on the bone for five days. All depressed bone is to be removed, but no more is to be taken away than is necessary. Galen preferred the use of small gouges, and of an instrument called a lenticular, to that of the trephine. He says that all greatly bruised (and depressed) bone is to be removed, but that simple fissures do not require operation. Paulus copies Galen. It will be seen that the Greek and Roman methods did not differ greatly from those of the present day.
In fractures of the spine Paulus says that, " having first given warn- ing of the danger, we must, if possible, attempt to extract by an incision the compressing bone," and that the same is to be done in case of frac- ture of one of the spinous processes.
Celsus (lib. v. cap. xxviii.) describes carcinoma as usually occurring about the fiice, and in the breasts of females, but says that it may also occur in the liver or spleen. It is the seat of some lancinating pains, is tumefied, immovable, and unequal, and the veins about it are swollen and tortuous. It commences by what the Greeks call cacoethes, then proceeds to carcinoma or scirrhus mthout ulceration, then to an ulcer which becomes fungous. " Xone of these can be removed except the cacoethes ; the rest are aggravated by every method of treatment, and
the more energetic the remedies the more irritable they become
I^one were ever treated successfully with medicine ; . . . . after excision, though a cicatrix has been formecl, they have returned again and carried
oif the patient But no one can distinguish a cacoethes, which is
curable, from a carcinoma, which is incurable, except by time and exj^eriment."
Galen describes cancer at greater length, but adds nothing to the means of diagnosis : the only chance of cure lies in excision, but if this be performed the arteries must not be tied.
Paulus merely abridges Galeii's description, says nothing about an operation, and advises external applications. A hard tumor which is wholly insensible is incurable.
Cystic tumors, including atheroma, meliceris, and steatoma, are briefly but clearly described by Celsus (lib. vii. cap. vi.) ; they are to be removed by incision : in steatoma the cyst must be divided, in the others it may be removed entire. Antyllus gives a more detailed description, which is quoted by Oriliasius (lib. xlv.).
The Hippocratic oath requires that lithotomy be left to tliose who make a special business of it. The first author who describes the opera- tion is Celsus (lib. vii. cap. xxvi.). He says it should only be performed in the spring, and on children between the ages of nine and fourteen, and
THE HISTORY AND LITERATURE OF SURGERY. 35
in urgent cases when medicines have failed, although he admits that a rash operation now and then succeeds. The operation described is that which is commonly known as "cutting on the gripe," or, in modern times, as the " Celsian operation." The description given by Celsus is detailed, and in most points is very clear (lib. vii. cap. xxvi.). The essen- tial principle is to force the stone down into the neck of the bladder and hold it there by two fingers introduced into the rectum, after which a lunated incision is to be made through the skin of the perineum imme- diately over and extending to the neck of the bladder, and a second incision in the convex part of the wound, so as to open the neck of the bladder freely ; and the wound should be a little larger than the calculus, for those who dread a fistula make too small an opening, and are after- Avard reduced to the same inconvenience with still greater danger, because the calculus when forced will make a passage unless it find one ; and this is even still more injurious if the form and inequalities of surface have contributed in any way to this eifect. If the stone is so large that it cannot be extracted without lacerating the neck of the bladder, it must be split according to the method of Ammonius, who was known as Lith- otomus, the stone-cutter. It is done in this manner : A crotchet is intro- duced to the calculus, so as to hold it fast while being struck, lest it should recoil backward ; then an iron instrument of moderate thickness is to be employed, the one extremity of which is thin, but blunt, and being applied to the stone and struck at the other extremity, splits it, great care being taken that neither the instrument itself nor any frag- ment of the stone should injure any part.
There is practically nothing to add to this description by other Greek writers until we come to the time of Paulus, whose description is much the same as that of Celsus. He says that children up to the age of four- teen are the best subjects for the operation : old men are difiicult to cure, because ulcers of their body do not readily heal, and intermediate ages have an intermediate chance of recovery. The stone is to be brought down by the fingers in the rectum, as described above ; then " we take the instrument called a lithotome, and between the anus and the testicles — not, however, in the middle of the perineum, but on one side, toward the left buttock — we make an oblique incision, cutting down direct upon the stone where it protrudes, so that the external incision may be wider, but the internal not larger than just to allow the stone to fall through it. Sometimes, from the pressure of the finger or fingers at the anus, the stone starts out readily at the same time that the incision is made, with- out requiring extraction ; but if it does not start out of itself, we must extract it with the forceps called the stone-extractor," . ..." If the stone, being small, fall into the penis and cannot be voided with the urine, we may draw the prepuce strongly forward and bind it at the extremity of the glans. We must next apply another ligature round the penis behind the member, making the constriction at its extremity next the bladder, and then make an incision down upon the stone, and, bending the penis, we eject the stone, and undoing the ligatures we clear away the coagula from the wound. The posterior ligature is applied lest the calculus should retreat backward, and the anterior in order that, when untied after the extraction of the stone, the skin of the prepuce may slide back- ward and cover the incision."
36 THE HISTORY AND LITERATURE OF SURGERY.
After the capture of Alexandria by the newly-risen Mohammedan power, about 640 A. d,, the Arabians became the inheritors and preservers of the science of the Greeks. The first notions of medicine obtained by the Arabs were probably derived from Persia, if we may judge by the names of a great number of their drugs, and the medical knowledge of Persia came in part from India and in part from Greece.
The first Arab physician of note was Hareto Ben Coladoh, who lived about the middle of the sixth century, and who seems to have studied medicine under the Nestorians, a Christian sect dating from the early part of the fifth century and occupying the ancient countries of Assyria and Persia. The Nestorian physicians appear to have been very zealous in collecting and preserving all the medical works which could be found at that time, including those of the Hippocratic collection and the writers of the Alexandrian School. In the mean time, after the destruc- tion of Jerusalem, certain Jewish physicians and teachers had settled in Alexandria, and after the fall of that city we find some of these Jewish physicians taking somewhat prominent positions and being collectors and translators of the medical literature of the Greeks. The so-called " Arabic books on medicine " were largely compends and summaries of the works of Greek writers which had been translated into Syriac or into Hebrew, and thence into Arabic, or, in some few cases, directly into Arabic. There are very few of these which contain any matter of interest to the history of surgery.
The most famous of their writers was Avicenna (980-1036 a. d.), a native of Persia, who for five hundred years rivalled Galen as an authority, and, like him, was called the Prince of Physicians. The medical works of Avicenna, known as "The Canon," are a sort of encyclopaedia, in which the opinions of the Greeks and of Galen are mingled with Oriental philosophy, forming a very prolix and in many places obscure treatise upon all subjects connected with medicine. It was translated into Latin by Gerard of Cremona, and became for a time the principal guide for European physicians, its high repute being probably due in part to the difficulty of understanding it.
The most celebrated writer on surgery of the Arabian School was Albucasis, also known as Bulchasis, Abulcasis, or Alsaharavius, and properly as "Khalaf Ibn 'Abbas (Abu Al-Kasim) Al-Zahrawi." He was born at Zahra, near Cordova, and died about 1105 a. d. His great work, Al Tesrif or Tasrif — i. e. the collection or encyclopaedia — included thirty books upon all branches of medicine, but of these only a part have ever been published. The three "books of his works on surgery, forming a special treatise (book xxx, of Al Tesrif), were published in Arabic and Latin under the editorship of John Channing at Oxford in 1778, and this is the best printed edition wdiich is available, although in some respects it is obscure and unsatisfactory. A translation into French Avas made by Dr. Leclerc and published in the Gazette medicale de V Alger ie in 1858-61, and afterward issued as a reprint (Paris, 1861); and this is the most convenient edition to consult for most purposes.
The work is divided into three books. The first is devoted to the actual cautery and the use of caustics, with elaborate descriptions of the instruments which are figured. In fact, Albucasis is the first author whose works have come down to us who has given figures and good
THE HISTORY AND LITERATURE OF SURGERY. 37
descriptions of surgical instruments. The second book relates to incisions of all kinds, bloodletting, scarification, treatment of wounds, and the extraction of arrows and missiles, and the third is devoted to the treat- ment of fractures, luxations, sprains, etc.
The treatise in general is a clear and comparatively concise statement of methods of treatment. A large part of it is evidently derived from Paul of ^gina or from the original authorities from which Paul of ^gina copied, and it is hard to say how much of his work is really original ; but it was the highest authority on the subjects of which it treats during the period of the revival of letters in Western Europe, and is a very important work for the student of the history of surgery or of surgical operations. The following are some specimens of his teachings :
In speaking of the operation of arteriotomy upon the temporal arteries he directs that a portion of the A^essel be cut out, so that the two ends may separate in order to prevent hemorrhage. If the artery is large, it is necessary to tie it in two places — at two points — with a strong double thread of silk or of the cord used in instruments of music (catgut), in order that it may not alter before cicatrization takes place, which would bring on a hemorrhage. This ligature should be double, and the operator is to take away the intermediate part, either at the time or later.
In speaking of the operation on scrofulous tumors of the neck he says : " The tumor must be removed little by little, great care being taken not to cut the blood-vessels or the nerves. If a vein or an artery is injured, so that the hemorrhage is troublesome or hinders the operation, put into the wound some vitriol in powder or some kind of haemostatic powder ; bandage the wound, and leave it until the inflammation lessens and the wound tends to putrefaction. Then the hemorrhage will cease and you may go on to complete your operation."
He says : " The ancients have spoken of opening the trachea, but I have not known any one in our country who has practised this opera- tion. If the operation has been decided upon, the incision should be made below the third or fourth ring of the trachea transversely between the two rings, so as not to injure the cartilages, but only to divide the membrane between the rings. I have seen a slave who had cut his throat with a knife. On examining the wound a little blood escaped, but I found that neither the jugular vein nor the artery had been injured. The air came out by the wound ; I dressed it and he was cured, and only a little hoarseness of voice followed. I feel, therefore, authorized to say that incision of the trachea is without danger."
In speaking of aneurism he says : " A.s to the tumors Avhich result from the enlargement of the calibre of the artery, a longitudinal incision should be made over the skin. Enlarge the opening with hooks, dissect the artery, free it from the membranes which surround it, and lay it completely bare ; then introduce below it a needle with a double thread and make a double ligature of the vessel, as we have recommended for the excision of the temporal artery ; then plunge a knife into the part of the vessel included between the two ligatures, and press out all the blood which is contained therein, until the tumor has disappeared, employing after this the treatment which leads to suppuration until
38 THE HISTORY AND LITERATURE OF SURGERY.
the ligatures fall." It will be seen that this is a copy of the description of the operation of Antyllus.
In speaking of the removal of certain fungoid abdominal tumors resembling mushrooms he directs that a leaden wire be used to strangle the growths, the wire being drawn tighter and tighter from day to day, so as gradually to penetrate the root of the tumor, so that it may fall without difficulty. He says : " Refrain from attempting to excise tumors which are of a livid color, of slight sensibility, and of an irregular aspect, for these tumors are cancerous." Elsewhere he says : " If the cancer is situated in a region from which it can be entirely removed, such as the breast, the thigh, etc., and, above all, if it has had its commencement little developed, one may operate on it ; if, on the contrary, it is large and old, it is necessary to refrain. For my part, I have never been able to cure a single one. I have never seen any one who has succeeded."
His description of the operation of the removal of calculus of the bladder is substantially the same as that given by Celsus.
In the case of a vesical calculus in a woman he says that if you are obliged to treat such a case, you must find a woman with some skill in medicine, but there are very few of them. If you cannot find such, it is necessary to take a midwife, or, at all events, a Avoman who knows a little something about the matter. This woman is to perform the opera- tion under the direction of the surgeon, according to the method which he gives in detail.
While the arts and sciences were more or less prosperous and pro- gressive in the countries under Mohammedan rule, and especially in Spain, throughout the rest of Europe medicine was substantially in the condition in which it exists in barbarous tribes. AVith the rise of the monkish orders, and especially of the order of St. Benedict, the priests became the practitioners, and all progress or improvement was practi- cally at an end. Relics, exorcisms, and prayers were more and more relied upon ; the teachings of Hippocrates and Galen were for the most part forgotten. The great majority of the monks read nothing but simple formularies and receipt-books. The kings and the great nobles, including some of the bishops, resorted to Hebrew physicians, who during the tenth and eleventh centuries were almost the only persons who possessed medical learning or Avho wrote upon medical subjects. A Jewish physician in those days was a sort of contraband luxury. On account of his religion he could only be possessed by those Avho had suf- ficient power to protect him from mobs and monks ; but both Catholic and Mohammedan rulers resorted to him when anything like scientific knowledge Avas required. Rabbi Isaac Avas the medical adA'iser of Pope Boniface VIIL, and the physician of Saladin AAas Rabbi Ben-Moosa, better knoAA^n as Moses Maimonides, Avho was one of the most celebrated authors of his race and time (1136-1209 A. d.). It should be noted tliat the preference Avas for JcAvish physicians as being Jcavs. For instance, Francis I., being sick, Avrote to Charles V. for an Israelite Avho Avas an imperial physician. Accordingly, the doctor AA'as sent to Paris, but Francis, finding that he had been couA-erted to Christianity, lost all con- fidence in his skill and adAnce, and ap})lied to Solyman II., Avho sent him a true, original, hardened Jcav, following Avhose adA'ice he drank asses' milk and recovered.
THE HISTORY AND LITERATURE OF SURGERY. 39
Surgery was for the most part abandoned to barbers, bathers, and seventh sons, and fell into disrepute. These barbers and bathers were considered to be of inferior caste, and an artisan would not take an ap- prentice of a family of barbers, bath-keepers, shepherds, or butchers. The operators were often peripatetic and were subdivided into specialists. For instance, one operated for hernia, another for calculus, a third for cataract, etc., the knowledge being handed down from father to son, as among the Greeks.
There were no European writers upon, or teachers of, surgery until the time of the rise of the universities in Italy in the thirteenth century. The School of Salernum was probably in existence in the ninth century, the ancient legend being that it was founded by four men— a Jew, a Greek, an Arab, and an Italian — each of whom gave lessons in his own language.
About the year 1060 A. d. there came to this school a certain Constan- tine, generally known as " Constantinus Africanus." Constantine was a native of Carthage, and had studied in Arabia, India, and Egypt, after which he travelled extensively for over thirty years. Returning to Car- thage and bringing with him copies of all the works of the Greek and Arab writers which he had been able to obtain in his travels, he fell under the suspicion of knowing more than it was at that time considered proper for any man to know, and it was with some difficulty that he escaped the punishment then in vogue for such criminals. He fled for refuge to Salernum, where he was received with honors, which, however, he put aside, and retired to the neighboring monastery of Monte Casino, where he spent the rest of his life in translating and annotating the medical works which he had collected. These translations became the text-books of the Salernitan doctors, and in the next century the school was resorted to from all parts of Europe by those who had heard of these long-lost and forgotten treasures of learning, which at that time were far in advance of the existing knowledge of the ordinary practitioners.^
The doctrines of the school became more and more Arabic, and it had lost its importance in the fourteenth century, having been superseded by the schools of Naples, Bologna, Paris, and Montpellier.
At the beginning of the thirteenth century comes the first writer on surgery in the West — namely, Roger of Parma, whose work was first printed at Venice in 1490, and is included in several editions of the works of Guy de Chauliac. The Surgery of Roger is substantially the sixth book of Paul of ^gina. Following him came his pupil and com- mentator, Roland, who was also of Parma. His work is a copy of that of Roger, with notes and some references to Hippocrates, Galen, and Avicenna which do not appear in the work of his master.
The story of the Four Masters, as told by Quesnay, is a romantic one — i. e. that they devoted their lives to the care of the sick poor in Paris, their residence being a sort of surgical dispensary ; that they made many discoveries and improvements which they described in a book which was known to Guy de Chauliac, but has been lost ; etc. Several
* For a full and interesting discussion of the writings of Constantine and the authors copied and abridged by him, consult " Constantinus Africanus und seine Arabischen Quellen," von M. Steinschneider, Archiv f. path. Anat. (Virchow), 1866, vol. xxxvii. p. 361.
40 THE HISTORY AND LITERATURE OF SURGERY.
manuscript copies of this work are now knoAvn to exist, and in 1859 one of these was edited by Daremberg and published.
The history of surgery in Europe thus begins in Italy at Salernum, and in Bologna, where Hugo of Lucca flourished during the first half of the thirteenth century, and was followed by William of Salicet. We have no Avritings from Hugo, but the Cyrurgia of William remains to us. The first edition of the original Latin was published at Placentia in 1476, and this, with other editions, including French translations (Lyons, 1492, and Paris, 1507) and an Italian translation published at Milan in 1504, is in the Army Medical Library at Washington.
William of Salicet was the most celebrated surgeon of his century ; he was an educated physician, who gives some of his own observations and his own conclusions, hardly citing previous authors, although it is evident that he was familiar with the works of Avicenna and of Galen. It is a pity that the Cyrurgia has never been translated into English.
The next noted surgeon of this period is Lanfranc of Milan, a pupil of William of Salicet, to whom he refers as his "master of goodly memory." Lanfranc also received a university education, and was a physician as well as a surgeon. Political troubles having caused his banishment from Milan, he went first to Lyons, where he wrote an epitome of surgery, and finally in 1295 to Paris, where he gave, at the School of Medicine, a course of lectures which were probably em- bodied in his great Surgery, which he completed in 1296. He was thus the introducer of the new Italian ideas into France. His large work was first joublished at Venice in 1490 under the title Practica quce dis- citur ars completa totius Chirurgioe" In the same year a French trans- lation by Guillaume Y voire was published at Lyons, and of this there is a copy in the Bibliotheque Nationale at Paris.
After Lanfranc came Henri de Mondeville, a native of Normandy, of whose early life nothing is known except that he studied at Mont- pellier, and at Paris under Jean Pitard, who will be referred to hereafter, and that he was one of the four surgeons of the court of Philip the Fair prior to 1301. In 1306, at the request, as he says, of Bernard de Gordon, a distinguished professor of Montpellier, he began to write, and to read to his numerous pupils, a systematic treatise on surgery, which he did not complete, although he lived until about 1318. This treatise, of which several manuscripts exist, was finally edited and printed by Dr. Julius Leopold Pagel of Berlin in 1892, forming an octavo volume of 660 pages having the title of Die Chirurgie des Heinrich von Mondeville {HermondaviUe), etc., and has been-translated into French and published in 1893 by Professor Nicaise of the Faculty of Medicine of Paris. His practice is much the same as that of Lanfranc, and of his successor, Guy de Chauliac, who often quotes him. He describes the method of ligating a wounded artery, recommending a peculiar kind of slipknot, but says nothing of ligating the vessel in amputations, and refers to the use of the ansesthetic sponge described by Guy.
Here may also be mentioned the Surgery of Master Jean Yperman, a native of Flanders, who was born in the latter part of the thirteentli century and studied under Lanfranc in Paris. The manuscript of his book, dated 1351, was first described, and in part published, by Dr. Carolus in the Anncdes de la Societe de Medecine de Gand (vol. xxxii.
THE HISTORY AND LITERATURE OF SURGERY. 41
1854) ; also published separately as a reprint. He refers to Roger and Roland and the Four Masters, and frequently to Lanfranc, beyond whose teachings he seldom ventures to go, although he does give some cases of his own.
The great French surgical author of the fourteenth century was Gui (or, as it is more usually given, Guy) de Chauliac, " Guido cle Chauliaco," born about 1300 A. d. He received the university training of the cler- ical profession and studied medicine at Paris, after which he continued this study at Montpellier and Bologna, so that he had the benefit of the three greatest universities of that time — Paris being especially celebrated for its surgery after Lanfranc had reached it ; Montpellier being the centre for medicine ; and Bologna for anatomy, of which Bertrucius was then professor. After extensive travels, and practice in diiferent places, including Lyons and Montpellier, he went to Avignon and became the physician of Pope Clement VI. and of his successors, Innocent VI. and Urban V. His chief literary work was his Chirurgia, written at Avi- gnon in 1363, and first published at Lyons by Nicholas Panis in 1478.
The " Great Surgery " begins with a special introductory chapter, the chapitre singulie7\ He says: "Up to the time of Avicenna all writers were both physicians and surgeons {i. e. well-educated men), but since that time, either because of the fastidiousness or the excessive occupation of the clerics, surgery has become a separate branch and has fallen into the hands of the mechanics.
" The sects which have existed in my time among the operators of this art, besides the two general ones of the Logicians and the Empirics, have been five.
" The first was the school of Roger, Roland, and the Four Masters, who treat all wounds and abscesses alike with cataplasms and poultices, on the ground of the fifth aphorism, ' Lax things are good, and crude bad.'
" The second was the school of Bruno and Theodoric, which treated all wounds alike with wine, basing their practice exclusively upon the maxim, ' The dry is nearest to that which is sound, and the moist to that which is not sound.'
" The third sect was that of William of Salicet and of Lanfranc, who wished to pursue the middle course, covering and dressing all wounds with ointments and soft plasters, founding this practice on the fourteenth maxim of the Therapeutics — that curation has one sole method ; that the treatment should be gentle and without pain.
" The fourth sect is composed of all the military men, or German chevaliers and others following the army, who, with conjurations and potions, oil, wool, and cabbage-leaves, dress all wounds, basing their practice on the maxim that God has given his virtue to herbs and to stones.
" The fifth sect is of women and of many fools, who refer the sick of all diseases to the saints solely, saying, ' Le Seigneur me Fa donnee ainsi qu'il luy a plu ; le Seigneur me I'ostera quand il 'luy plaira ; le nom du Seigneur soit benit. Amen.' "
It will be seen that Guy is quite trenchant in his summaries and crit- icisms, which, however, appear to be on the whole fair and justifiable.
The teachings of Guy were the chief authority in surgical matters
42 THE HISTORY AND LITERATURE OF SURGERY.
for over two hundred years, and were the basis of numerous abstracts, compends, and commentaries. He contributed little that was original, although he gives some of his own observations. Follin remarks that a sort of canulated sound, the dressing of ulcers with sheet lead, and some peculiarly-shaped cauteries are his chief inventions ; but his book is one of the monuments of surgical literature.
The Sermo septimus de cyrurgia et de decoratione of Xicholas Falcu- tius, of which the Washington Library has an edition printed at Florence in 1507, is a huge folio volume compiled from the works of Arab writers, with references to Roger and Roland, but not to Guy de Chauliac, so far as I have found. His formula of words is " Dixit Haly," or " Avicen," or "Albucasis," without attempt at comment.
In the days of Lanfranc and Guy de Chauliac surgery in AYestern Europe was distinct from medicine, and was looked upon as a trade or handicraft degrading to and unworthy of physicians, who claimed to belong to the nobility. The physicians were of the priestly class and abhorred the shedding of blood, and their traditions were adhered to long after medical teaching in the universities had passed into the hands of laymen. The barbers were the ordinary surgical operators, and the reason for this is given by Dr. Gardner ^ as follows : " The monks, as all the world knows, required to have their heads regularly shaved, but it is not by any means so well known that they had to be bled at stated periods. Minutus est was the form of words descriptive of one who had undergone the operation, the meaning being that he had been minutus sanc/uine — i. e. deprived of blood. In the monastery of St. Victor at Paris there was an order which prescribed such minution five times a year : ' Prima, est Septembri ; secunda, ante Adventum ; tertia, ante Quadrigesimum ; quarta, post Pascha ; quinta, post Pentacosta.' The monks, therefore, required to have about them those who could both shave and bleed, and it was very natural that they should prefer that one and the same person should perform both these operations."
In France, however, at an early date there were a few persons whose business was the performance of surgical operations, and A\'ho were not ordinary barbers, although they may have served an apprenticeship as such. The Corporation of Barbers in the middle of the thirteenth cen- tury was divided into two classes — the ordinary or lay barbers, afterward known as " barber surgeons " or " surgeons of the short robe," and the " clerk barbers " or " surgeon barbers," " the surgeons of St. Come," or " surgeons of the long robe ; " and these last sought to be independent of the ordinary barbers, to monopolize surgical operations, and to raise their association from the position of a trade guild to that of a profes- sional organization. The Guild of the Surgeon Barbers Avas organized in 1268 by an order of the provost of Paris, selecting six surgeons Avho were to examine and license those who Avished to practise, more especially the barbers. Possibly one of these masters Avas the celebrated Jean Pitard, but if so he must have been A^ery young, for he AA-as still living in 1326. In 1311, Pitard obtained a decree from King Philip the Fair, in Avhich, after reciting that all sorts of quacks are infesting the city, it is ordered that " no male or female shall practise surgery in Paris Avho has not been
^ Gardner (John) : Sketch of the Early Histonj of the Medical Profession in Edinburgh^ Edinb., 1864, p. 6.
THE HISTORY AND LITERATURE OF SURGERY. 43
examined by our sworn surgeons of Paris named and called together for that purpose by Jean Pitard, our sworn surgeon of the Chatelet, or his successors."
It was evidently impossible to enforce this order, for it was repeated in 1352, and again in 1364, with penalties of fines on the erring barbers, half of the fines to go to the surgeons' guild, the Brotherhood of St. Come. The organization of this brotherhood was by no means pleasing to the medical faculty, the members of which desired to retain control of all branches of the art, and discredited surgery as a mere mechanical handi- craft only to be exercised under the direction of a physician, whose dig- nity forbade him to soil his hands. The statutes of the faculty in 1350 require the candidates to make oath that they will not practise surgery in the sense of performing operations or making applications by the hands, including the treatment of five classes of aifections — viz. wounds, ulcers, fractures, dislocations, and tumors.
The lay barbers were employed by the physicians, and also sometimes as assistants by the surgeons, and at last, in 1372, the barber of the king, being the master of the guild of barbers by virtue of his position, induced Charles V. to issue an edict which permitted them to treat wounds and sores and forbade the surgeons to interfere with them. The relative standing in the eyes of the public of the three kinds of practitioners — viz. the physicians, the surgeons, and the barbers — may be inferred from an order issued during an epidemic of the pest in 1383, which directed that there shall be selected to visit the sick four physicians, two sur- geons, and six barbers, and the fees of the doctors shall be three hundred livres, of the surgeons one hundred and twenty livres, and of the barbers eighty livres.
The so-called College of Surgeons of Paris was not in the least a surgical school or an association for mutual discussion and improvement : it was purely a trade guild, and the students were simply apprentices to the master surgeons, becoming, after 1370, bachelors, licentiates, and finally masters. The surgeons had a free dispensary, where they treated the poor once a week, and perhajDS the apprentices saw there something of the practice of other masters besides their own.
The medical faculty, thinking that its rights, privileges, and monopoly of treating the sick were being encroached upon by the surgeons, encouraged the barbers in their controversies, and as one means of doing this undertook to teach them anatomy. As the barbers did not understand Latin, which was the only dignified and proper language to be used in teaching in those days, a compromise was necessary, and this was eifected partly by the use of a sort of dog-Latin, of French words with Latin terminations, and partly by reading Guy de Chauliac in Latin, but with comments in French, while the assistant barber made the incisions in the cadaver and pointed out the parts as the reader named them. In 1505 the barbers came more formally under the protection and jurisdiction of the faculty, and assumed the name of the Guild of the Barber Surgeons, and a few years later the surgeons of the long robe, having opposed this movement with very little success, and having failed to become a separate faculty in the university, submitted to also receive instructions from the physicians. Almost all the medical officers attached to the French armies came from the Corporation of Barber
44 THE HISTORY AND LITERATURE OF SURGERY.
Surgeons, and finally one of them, Ambrose Pare, acquired so mucli reputation and influence as to considerably increase the respectability and standing of the guild. As a sample of surgical associations in the provinces we may take the surgeons of Bordeaux, who in 1519 formed a society composed of bejaunes (yellow beaks or young birds — i. e. aspirants) and companions. They had a password and special secrets ; instruction was given in the winter at 5 A. M. in the form of commen- taries on Guy de Chauliac, and in the course of one hundred and sixty- nine years five bodies were dissected.^
There is little of importance in the history of surgery during the next hundred years after the death of Guy de Chauliac. Peter of Argelata, lecturer on surgery at Bologna about the beginning of the fifteenth century and dying in 1423, was the principal surgeon of his time. His six books on surgery, edited by ISIoretus, first published at Venice in 1480, are largely derived from Paulus and Guy. He was an operator as well as a theoretical teacher, performed lithotomy and her- niotomy, embalmed Pope Alexander VL, practised craniotomy of the foetus in difficult labors, etc. A copy of his books was annotated on the margins by Marcellus Cumanus, a surgeon in the Venetian army in 1495, and these observations were finally published by Velschius (G. H.) in his Sylloge Curationum (Aug. Vindel., 1668). Cumanus found nothing in Argelata about the treatment of gunshot wounds, and he noted a formula for this purpose consisting of a mixture of oil of roses, galbanum, and asafoetida, to be applied hot.
Gunpowder was used in warfare at least as early as 1338 ; the English employed it at the battle of Crecy in 1346, but it was a long time before any surgeon published an account of gunshot injuries and their treatment. The first Italian surgeon to do this was John de Vigo (1460-1 52-), sur- geon of Pope Julius II. in 1503, whose Practica in Arte Chirurgica Copiosa was first published at Rome in 1514. This book had twenty- one editions in thirty years, and was translated into Italian, French, English, Spanish, Dutch, German, and Portuguese. The great success of the book was due partly to the fact that it was the first complete system of surgery issued after that of Guy de Chauliac, partly to the fact that it contained an account of gunshot wounds and a section on the new disease, syphilis, and also, probably, to a considerable degree, because it was a book which specially suited a practitioner who knew nothing of anatomy and feared or disliked to make use of the knife. It is essen- tially a surgery of plasters, ointments, and embrocations, and the name of the author is best known to-day in connection with the " emplastrum de Vigo."
The part relating to gunshot wounds is brief. He says they are con- tused and burned, and therefore need moist applications, but that they are also poisoned by the powder, and therefore need desiccation ; hence they are hard to cure. They are to be cauterized with the actual cautery or with boiling oil of elder, " for cauterization kepeth the wounde from putrefyinge."
His chapter on syphilis begins as follows (I use the English transla- tion of 1543): "In the yeare of our Lord 1494, in the moneth of December, when Charles the Frenche kynge toke hys jorney into the
^ Sous (G.) : Bordeaux medicale, 1877, p. 49.
THE HISTORY AND LITERATURE OF SURGERY. 45
partes of Ytaly to recover the kyngdome of jSTaples, there appeared a certaine dysease throughout al Ytaly of unknowen nature, which sondre nations hath called by sondry names. The French men call it the dysease of Naples, because the souldyours brought it from thence into France. The Neapolitanes call it the Frenche dysease."
Controversies as to whether syphilis existed prior to the fifteenth cen- tury have been many, and the literature on the subject is voluminous ; but no positive and convincing proofs of such existence have yet been found, although it is probable that it did occur before that time. One of the theories of its origin, advanced first by Leonard Schmaus in the preface to his little pamphlet, Lucubratiuncula de morho gallico et cura ejus noviter reperta cum ligno indico (sm. 4°, Aug. Vindel., 1518), is that it was brought from the West Indies by the sailors who returned with Columbus after his first voyage, and attempts have been made to furnish positive evidence of this from human bones showing evidence of disease, and antedating the Columbian discovery ; but none of these have been convincing to skilled pathologists. Schmaus says in his preface that he learned of its American origin from merchants and sea-captains ; but it is probable that this idea was first suggested by the use of guaiacum in this disease. Guaiacum came from America, and it was a common idea that the bane and the antidote belonged together and were to be found in the same vicinity. It is certain that the disease existed in America soon after the second voyage of Columbus.
After John de Vigo came Alexander Benedictus (145 ?-1525), who was professor of anatomy at Padua, an army surgeon, and who operated for hernia and calculus. He is the author of treatises on anatomy and on the pest, and of De omnium a vertice ad plantam morborum signis, etc. (Venice, 1535 ; Basil, 1594), which contains his surgical recom- mendations.
Jacobus Berengarius Carpensis (147?-1550), professor in Bologna, was the author of a celebrated treatise, Tractatus de fractura calvariae sen cranei (Bologna, 1518, quarto), of which a number of editions were published. This also contains a few remarks on the treatment of gun- shot wounds, which he supposed to be burned or more or less poisoned. He acquired a great fortune at Rome by his treatment of syphilis with mercurial inunctions, of which he is reported to have been the inventor.
Alfonso Ferrius (1500- ?) of Naples, the physician of Pope Paul III., wrote De Scloiietorum sive Archibusorum Vulneribus, libri tres (Rome, 1552, quarto), in which he maintains that gunshot wounds are poisoned and must be treated accordingly.
Bartholomseus Maggius (1516-62) of Bologna wrote De Vulnerum Sclopetorum et bombardorum globulis illatorum, etc. (Bologna, 1552, quarto), of which there were numerous later editions.
Leonardo Botallo (1530- ?) wrote De Curandis Vulneribus Sclope- torum (Lyons, 1580, octavo), in which he opposed the views of De Vigo and Ferrius as to the poisoned condition of gunshot wounds.
Joh. F. Rota, who lived in the middle of the sixteenth century, wrote De bellicorum tormentorum vulnerum natura et curatione ^i6er (Bologna, 1555, quarto).
One of the wisest of the Italian surgeons of this period appears to have been Michael Angelo Blondus (Biondi) (1497-15?) whose little
46 THE HISTORY AND LITERATVEE OF SURGERY.
treatise De partibus idu sectis, first published in 1542, and which is contained in the Gesner Collection and also in UiFenbach's Thesaurus, strongly urges the use of simple water and wetted lint in the dressing of wounds. Nevertheless, he was a partisan of the ancients, and two of his sayings have become historical as illustrating the university spirit of the age — viz. " It is more honorable to err with Galen and Avicenna than to acquire glory with others ;" and, " It is better to die by a regular physician than to live by a quack."- ,
One of the most celebrated Italian surgeons of the sixteenth century was Gaspar Tagliacozzi, better known as Tagliacotius (1546-99), who was professor of anatomy and surgery in the University of Bologna, and wrote the first special treatise on plastic surgery, and more particularly on the operation of rhinoplasty, with which his name is especially asso- ciated. The title of his book is De Curtonim Chirurgia per insitionem, libri duo, of which two editions were published at Venice in 1597. One of these, a large folio published by Gaspar Bindonus, is celebrated for the beauty of its plates, the quality of the paper, and its typography, being a splendid specimen of book-making ; the other edition af the same date and place, published by Eobert 3Ieiettus, is also a folio, but a much- poorer specimen of the printer's and engraver's art. Tnire is also a small octavo edition of Frankfort (1598), and one was published m Berlin so late as 1831. He does not name the person from whom he had learned his method, but it was probably from some one of the Incisors of his day who had acquired his knowledge from a pupil of one of the Sicilian Brancas, who were celebrated for operations of this kind in the middle of the fifteenth century. The elder Branca took his flaps for a new nose from the skin of the face, being the Indian method ; his son made use of the skin of the arm, and extended the method to repair of mutilated lips and ears, as we are informed by Bartholomeo Fazia.
The first notice of Tagliacozzi's method is given by H. Mercurialis in his De decorafione liber (4°, Venet., 1585, fol. 2.3). Two of his pupils describe the methods and the results obtained, and acquired repute by their performance of the operation — viz. Thomas Fienus of Antwerp, and Jo. Bapt. Cortesius, who succeeded Tagliacozzi as pro- fessor at Bologna ; but the practice fell into disuse among surgeons, and little was heard of it until the beginning of the nineteenth century. A curious use of plastic surgery is mentioned by Fortunatus Licetus — viz. the making of double monsters for show purposes by grafting two boys together by the back, nates, or arms, upon which he says : " Aver- runcet Dens e severe puniant principes tales sicophantes." Victor Hugo refers to the work of these "monster-makers" in his L' Homme qui rit.
" Marianus Sanctus Barolitanus (1490-154?), a native of Xaples and a special pupil of John de Vigo, wrote a treatise entitled Cornpendium in Chyrurc/ia Utilissimv.m YoJentibus ipsas exercere, which was first pub- lished at Rome in 1516, and subsequently appeared in connection with the works of De Vigo. It is also in the Gesner Collection of 1555. Neither Haller nor Malgaigne knew the date of the first edition, Avhich is probably rare. The copy in the AVashington Library is a small quarto of fifty leaves, unnuml^ered and unpaged, and is a fine specimen of black- letter printing. It contains three small rude figures of cauterizing irons, and the last nine pages are occupied with his Tractatus de Capite. Mari-
THE HISTORY AND LITERATURE OF SURGERY. 47
anus Sanctus is best known by his treatise De Lajpide ex vesica per incis- ionem extrahenda, in which was, for the first time, published the method of John de Romanes for lithotomy with a grooved staff, upon which an incision was made into the membranous portion of the urethra, after which instruments were introduced to dilate or rupture the prostatic portion. This is known as " the method with the great apparatus," from the num- ber of instruments required, and also as the " Marian operation," from the name of the person who first published the description. The first edition of this treatise appeared at Venice in 1535. It is contained in the Gesner Collection of 1555 and in Uffenbach's Thesaurus of 1610.
The " Gesner Collection," also known as the " Geneva Collection," is a beautifully printed folio with the title Chirurgia. De chirurgia seriptores optimi quique veteres et reoentiores, etc. (Tiguri, 1555). It was edited by Conrad Gesner, and contains the principal surgical works of Tagaultius, Hollerius, Marianus Sanctus, Bologninus, Blondus, Maggius, Ferrius, Langius, and others, forming a valuable book of reference.
The first collections of the works of different writers on surgery were published at Venice, the first being a small volume issued in 1490, and again in 1497, containing the Chirurgia parva of Guy, the Surgery of Albucasis, and the commentary of Bertapaglia on Avicenna. A much more complete collection is the Venice folio of 1498, which contains the works of Guy de Chauliac, Brunus, Theodoricus, Lanfranc, Roger, and Bertapaglia. Of this the Venice editions of 1499 and 1519 are in the Washington Library ; also the edition of 1546, which is the best and contains also the treatises of Roland and of William of Salicet. ^^
From very early times there were to be found throughout Western Europe — in France, in Italy, in Germany, and in England — a certain number of surgical practitioners known to the writers of that time as " The Cutters " or " Incisors." Those who operated for lithotomy, her- nia, etc. were of the first class. They travelled about from place to place, and maintained more or less secrecy as to their methods, which were held as a special family property, being handed down from father to son. Among these may be mentioned the two Brancas, to whom reference has been made in speaking of Tagliacozzi.
Another group of these travelling operators was known under the name of Norsini. These devoted themselves principally to operations for hernia and to lithotomy. Fabrice d'Aquapendente mentions Horace of JSTorsia as a skilled operator in hernia. Sylvaticus in 1601 complains that the operation of lithotomy was abandoned to ignorant persons, like the Norsini. In 1633, Cortesi writes that at Messina he had seen Ulysses of Norsia treat hernia by the application of caustic, followed by incision of the eschar; and still later, in 1672, Bernardino Genga says that the Norsini had some experience in the treatment of diseases of the urinary organs.
To this class of Cutters belongs probably the unknown surgeon men- tioned by Senarega, who in his history of Genoa says that there died there in 1510 a surgeon very skilled in removing calculi. He intro- duced into the penis an iron rod, which entered the body until it met the stone which he was seeking, and which he then removed by a perineal incision. It is supposed by some that this unknown Genoese taught his method to John de Romanes of Cremona, who is ordinarily credited
48 THE HISTORY AND LITERATURE OF SURGERY.
with the invention of the grooved staff for lithotomy, and who taught his method to his assistant, Marianus Sanctus.
The most famous of the Incisors was Pierre Franco, a native of Provence, born about 1500, who operated in Provence, Burgundy, and Switzerland, finally settling in Lausanne for a considerable period, and in 1561 living at Orenge. His Petit traits contenant une des parties princlpaUes de chirurgie laquelle les chirurgiens hernieres exercent was published at Lyons in 1556. In this he describes and figures the " Algalie " sound for detecting stone in the bladder ; says that the calculus is sometimes encysted so that it cannot be felt by the sound ; describes the old operation of " cutting on the gripe," which he says he formerly used ; the operation with a grooved sound and gorget, of both of which he gives figures, as also of forceps for crushing the stone if it is large ; and concludes that if the stone does not present itself when the incision is made, it is best to wait a day or two before attempting to remove it. He describes a case in a child ten years old in which, being unable to extract the stone through the perineal incision, he performed the suprapubic operation, removed the stone, which was the size of an egg, and the patient recovered. This is the first recorded case of the high operation foi* stone. He says, however, that he does not advise this in ordinary cases. In his description of amputation he does not mention the ligature, but advises the actual cautery, and gives figures of the sickle-shaped knife, the saw, and the cautery-iron. In 1561 he pub- lished at Lyons his Traite des hernies contenant une ample declaration de toutes leurs especes & autres excellentes parties de la chirurgie, assavoir de la pierre, des ccdaractes des yeux, & autres maladies, desquelles eomme la cure est perilleuse, aussi est elle de peu dliommes Men exerc^e. This is a small octavo of 16 preliminary leaves, 554 pages, and 1 leaf of errata. It contains all the matter of the preceding book, and much more, with figures of new instruments, and is really a small manual of surgery. The part relating to lithotomy remains substantially the same. Next to the works of Pare, this is the most valuable contribution of the century to surgical literature.
The history of the Colot family is curious and interesting, but is wrongly given by most of the biographers : the best is that given by Dr. E. Turner in the Gaz. Hebd. de 3Ied. et de Chir. (Paris, 1880, xvii. 2" ser. pp. 33, 49).
The story that a certain Germain Colot, a French surgeon, learned the details of the methods of some of the Incisors about 1460, and then, returning to Paris, operated on an archer who had been condemned to be hung, but whose sentence was changed by the king to be operated on by Colot, is probably without foundation. The original account, given in the Chronique scandaleuse, does not mention the name of the operator, and Malgaigne says that there is not even a presumption that there ever Avas a surgeon named Germain Colot.
There was, however, a Laurent Colot or Collot, who lived at Tresnel, near Troyes, in the middle of the sixteenth century, and who learned the method of John de Romanes — or what is called the IMarian opera- tion— from an itinerant lithotomist named Octavien da Villa. He kept the method a secret and had great success, being called to Paris in 1556, and Avas appointed lithotomist of the Hotel Dieu. The secret and the
THE HISTORY AND LITERATURE OF SURGERY. 49
office remained in the family, the grandson Philippe (1593-1656) being called to all parts of Europe to operate. His son Franjois (1630-1706) wrote an account of the method, which was published after his death under the title Traite cle V operation de la taille, etc. (Paris, 1727). In it he refers to the above-mentioned story about Germain Colot, but does not give his name, and asserts that the operation performed on the archer was a nephrotomy and not a lithotomy. That the so-called family secret could have been preserved until the beginning of the eighteenth century, after the publication of the method by Marianus Sanctus in 1535 and by Franco in 1556, illustrates the education of the surgeons of those days. We now come to an epoch-making surgeon, Ambrose Pare (1517-90), who was apprenticed to a provincial barber when he was about nine years old. In 1532 he came to Paris, where he was probably again ap- prenticed to a barber surgeon and attended the lectures of the doctor of the Faculty of Medicine of Paris, whose business it was to explain to the young barber surgeons those parts of the surgery of Guy de Chauliac . which relate to tumors, wounds, and ulcers. Very soon after his arrival at Paris he had the good fortune to obtain a position as resident appren- tice and dresser in the great hospital of the Hotel Dieu. Here he had opportunities for dissections, for making post-mortem examinations, and for the study of disease, of which he was not slow to avail himself. In his preface to the reader he says : " You must know that for the space of three years I have lived in the Hotel Dieu of Paris, where I had the means of seeing and knowing (in consequence of the great variety of diseases brought there) all which can be of alteration and disease in the human body, and to learn from an infinite number of dead all that can be said of anatomy."
At the end of this service, when he was but nineteen years old, he became body-surgeon to Mareschal Monte Jan, and went with him in the army which Francis I. opposed to that of Charles V. in the invasion of Provence in 1536. Gunshot wounds Avere supposed to be poisoned, and the recognized means of destroying the venom was that prescribed by John de Vigo — namely, cauterization by boiling oil. But in one battle the supply of oil was insufficient, and our conscientious youth could not sleep that night for thinking of the horrible fate that was in store for the poor fellows who had not been cauterized. Great was his astonishment and delight the next day on finding that those who had not been burnt were much more comfortable than those who had been treated secundum artem, and that recovery was prompter and more certain in their case. But, while Pare had the sense and the independence to refuse to give unnecessary pain, although commanded to do so by the highest surgical authority of his day, he could not free himself from the notion that some special treatment was required for gunshot wounds, nor accept the plain teaching of his own experience. He decided that the best thing to be done was to use a secret remedy which was the stock in trade of a certain surgeon in Turin, and to learn the composition of this remedy he assidu- ously courted the good graces of this surgeon for over two years and a half, and finally obtained the secret for a round price, promising not to divulge it. It was an oil of puppies, not much different from lard — a simple protecting soothing application. No sooner had Pare learned the secret than he hastened to publish it, deliberately breaking his promise
Vol. I.— 4
50 THE HISTORY AND LITERATURE OF SURGERY.
on the ground that such an important matter should not be one man's privilege.
The great improvement made by Pare in surgery was the use of the ligature to close bleeding arteries after amputation in place of searing them with red-hot irons, as had been done clown to his time.
In the edition of his works published in 1564, Dix Hvres de Chirurgie, he first describes and recommends the application of a ligature to bleed- ing vessels in amputations, and abandons the use of the cautery. His account is as follows : After alluding to the passage in Galen which states that " the vessels must be tied toward their roots, which are the liver and the heart, to staunch the great flow of blood," he says : " But having many times used this means of closing the veins and arteries in recent wounds where there was a hemorrhage, I thought it might also be done in amputating a member. Therefore, having conferred with Esti- enne de la Riviere and Fran9ois Rasse, both surgeons at Paris" [in later editions the name of Rasse is struck out and in place is read " other sworn surgeons of Paris "], " we agreed that we would make the trial upon the first patient which offered, although we would have the cau- teries all ready to use if the ligature failed." A few days afterward the ligature was applied with success in a case of amputation of the leg.
Pare was a good anatomist, by far the greatest surgeon of his time, the confidential friend of four successive kings, and is said to have been the only Protestant in Paris who was spared the massacre of St. Bar- tholomew, which was due to the direct action of the king. Malgaigne's argument against the truth of this story cannot outweigh the direct state- ments of Sully and of Brantome.
Catherine ,de Medici one day asked Par6 whether he hoped to be saved in the next world. " Yes, certes, madame," said he, " because I do what I can to be a brave man in this world, and because the merciful God understands all languages, and is as well satisfied with a French prayer as with a Latin one."
To properly appreciate the writings of Par^, they should be compared with those of other teachers of, or writers on, surgery of his day. His treatise upon gunshot wounds may be compared with several small trea- tises on surgery published in the latter half of the century, thirty or forty years after the appearance of his treatise on this subject, and written in French for the benefit of the barber surgeons. Take, for example, the TraitU des arcbusades of Joubert, published at Lyons in 1574. Laurens Joubert (1529-83) was a distinguished physician of Montpellier, pro- fessor of medicine in the university and dean of the faculty. He had served in the royal army in the campaign of 1569, where he ought to have heard something of Fare's methods of treatm-ent, but he makes no allu- sion to them, unless it be where he speaks of the oil of puppies as an anodyne. His Surgery is that of John de Vigo, written in a diifuse, pedantic style, which was probably impressive to the barbers in propor- tion to their inability to understand the meaning of his words. At one time he was called in as an umpire in an argument between a physician (Veyras) and the surgeon of the king of Navarre (Guilhemet) as to whether gunshot wounds are contused and should be treated by poultices, etc. or by desiccatives, as by washing with wine. The arguments on both sides and Joubert's decision were published in a curious little book
THE HISTORY AND LITERATURE OF SURGERY. 51
entitled TrciGiU de Chirurgie, contenant vraye methode de guerir playes d'arquebusade, etc., par M. Jacques Veyras, docteiir en Medecine, & M. Tannequin Guilhemet, Chirurgien du Roy de Navarre (Lyon, 1581, 8°). Jonbert's decision was, upon the whole, in favor of the views of the physician, as Avas to be expected. He refers to Par6 as " homme digne foy," not with reference to his treatment of wounds, but to his statement that bones may be fractured by the wind of a cannon-ball — this being precisely one of the points on which Pare was wrong.
The first teaching in French given to the barbers and surgeons was by a physician, Jean Canape of Lyons, physician of Francis I., who in the first half of the century gave public lectures to them, and for the same purpose translated into French a compend by Guy de Chauliac (Lyons, 1538, 12°; also 1563-71), some anatomical treatises of Galen (Lyons, 1541), and several other small treatises.
Pierre Tolet (1502-8?), a surgeon of Lyons, in 1540 published a translation into French of the sixth Book of Paulus ^gineta. In his prefatory letter to this, addressed to the French surgeons, he refers to Jean Canape as a man to whom surgery owes more than to any man who has written since Galen.
In 1570, Jacques Dalechamps, physician and reader in surgery at Lyons, published Chirurgie Frangoise as a manual for the barber sur- geons. It consists of the sixth book of Paul of ^gina, Hippocrates on fractures and dislocations, and extracts from Celsus, Albucasis, etc., with the annotations of Dalechamps, and a brief treatise on operations by Jean Girault, master surgeon in Paris.
In 1583, Esaie le Lievre, surgeon, published a little book entitled Offteinne et Jardin de Chirurgie militaire contenant les instrumentz et plantes tres necessaires a tous Chirurgiens, etc. The general style of this work may be seen in the following sentence : " Nous disons I'har- quebuzade ou playe faicte par harquebuze on canom ; estre une affection contre nature, portant de foy plusieurs especes d'accidens ; a scavoir extreme contusion, combustion, cliruption, dilaceratio, concution, frac- tion, fracation, puis repercution, abolitions, destructions, extinctions, ou mortifications, selon plus ou moings, des espritz tant vitaux, animaux, que naturels : de laquelle complication assemblee, selon la nature & noblesse des parties oflPensees, se forme une indisposition tendant a rendre ladite partie, consequement tout le subiect en cadaver."
The Sclopetarius of Quercetanus (Du Chesne) (Lyon, 1576) is a worthless book by a notorious charlatan. It was translated into Eng- lish and published at London in 1590 by a certain John Hester, who offered for sale the Arcana prescribed therein. Care is taken to give two sets of remedies — one for the injuries of the common soldiers, the other " to be used for the rich." For advertising purposes the same John Hester published A Short Discours of the excellent Doctour and Knight, maister Leonardo Phioravanti, Bolognese, uppon Chirurgerie (London, 1580), advertising at the end that he is prepared to furnish various salves, philosophical oils, and other preparations recommended in it. Phioravanti explains that " the reason why white of egg is to be used in mixing applications for wounds is because the white is that part which produces the flesh, the skin, and the feathers of the hen, while the yolk engendereth only the intestines. Therefore the white is like
62 THE HISTORY AND LITERATURE OF SURGERY.
unto flesh, and its special business is to produce it." He says also that the most perfect remedy for a great flux of blood from a wound is to stitch it close, and then take dry human blood-powder and lay it upon the wound. This is the same as the mummy of Paracelsus.
The reference made by Pare as to the value of the instruction which he obtained in the Hotel Dieu is perhaps the first allusion to the import- ance of hospitals as a means of furnishing instruction in surgery. Hos- pitals had existed since before the Christian era in India, and those in Persia under the Nestorians Avere really used for educational purposes in connection with their medical schools. The foundations of many European hospices and hosj^itals date from the tenth and twelfth cen- turies, such, for example, as the San Spirito at Eome and St. Bartholo- mew's and St. Thomas's in London, some of the impulse to the forming of such institutions apparently having come from the need of providing them for lepers.
ISTo surgical instruction appears to have been given in the hospitals of the Middle Ages, except that the surgeons connected with them may have employed some of their apprentices to assist them in the bandaging and in the dressing of wounds ; but what we know as " clinical surgery " was an affair of much later date.
Of the immediate pupils and followers of Pare, the most important were Pierre Pigray (1533-1613), whose published works are mainly abstracts and translations of Pare; and Jacques Guillemeau (1550-1612), surgeon of Charles IX., Henry III., and Henry IV., and surgeon of the Hotel Dieu, who acquired fame as a writer and teacher in surgery, obstetrics, and ophthalmology. His La chirurgie francoise (Paris, 1594, folio) was translated into Dutch, and thence into English, and published at Dort in 1597 under the title of The French Chirurgerye, forming a beautifully printed and illustrated folio, which was much the best work on this subject which had then appeared in English. Guillemeau was unusually well educated for a surgeon of those days, having studied under Riolan as well as under Pare, and he tried to harmonize the statements of the latter and those of his opponent, Gourmelin, by saying that Galen recommends the cautery in amputation for gangrene, and ap- proves the use of the ligature for hemorrhage when there is no corruption.
Par6 in advising the application of the ligature says it does not matter if some other tissue besides the vessel is included in it ; but Guillemeau says that a portion of such tissue is to be included : " prenant quelque portion de chair ensemble," evidently thinking that this is an important feature of the operation.
His chapter on aneurism contains an account of a case of traumatic aneurism at the bend of the elbow in which he applied a single ligature above the SM'elling with success. In this case the aneurism had ruptured, and after ligating the artery he opened it further and turned out the clots. This one ligature was placed three fingers'-breadth above the tumor. Pare's description of the operation also refers to the use of but one ligature, and not to the operation of Antyllus.
There were no surgeons of repute in Germany prior to the middle of the fifteenth century ; they were almost all barbers, who could neither read nor write. In 1868 there was for the first time pub- lished a manuscript treatise on surgery written in German about 1460
THE HISTORY AND LITERATURE OF SURGERY. 53
by Heinrich Pfolzprunclt, and entitled Bundth-Ertznei. This, the oldest German work on surgery at present known, relates mainly to the treat- ment of Avounds, but it contains a remarkable chapter on the making of a nev/ nose from the skin of the arm after the method of Branca. There is an allusion to the burning of wounds by powder, but no refer- ence is made to lithotomy or to operations for hernia. It gives a receipt for a narcotic mixture to be inhaled from a sponge similar to that men- tioned by Guy de Chauliac. The first German surgeons of repute whose Avorks have come down to us are Hieronymus BrunscliAvig, and Hans von Gersdorif, called Schylhans or Schielhans, both being surgeons at Strasburg in the last half of the fifteenth century. Brunschwig Avas born about the middle of the fifteenth century, and published at Stras- burg in 1497 a folio volume Avith the title Dis ist das buck der Cirurc/ia, Hautioirch der Wundartzny von Hyeronimo brunschwig. Of this there Avere eight other editions, the last at Augsburg (1539, quarto). The Washington Library has the folio editions of 1508 and 1513 and the quarto editions of 1533 and 1539 ; also the English translation of 1525, and a Dutch translation in folio printed at Utrecht in 1535. The Eng- lish translation is the first book on surgery in English, and its title-page is a curiosity in itself. It begins as follows :
" The noble experyence of the vertuous handyAvarke of surgeri prac- tysyd & compyled by the moost experte Mayster Jherome of Bruyns- Avyke borne in StraesboroAve in Almayne ye Avhiche hath it fyrst proA^ed and trcAvly founde by his aAvne dayly exercysynge."
This title is the Avork of the unknoAvn translator, Avho has also giA'en a short preface, in Avhich he says that " it is oftentymes sene and dayly chaunceth in small toAvnes, boroAvghs and villages that dyverse people hurt or dyseased for lacke of connynge men be taken in hande of them that be barbers or yonge maisters to Avhome this sciens Avas never dys- closed, not thynkynge on the wordes of the olde lernyd men that say, It is not Avel possible to man that he sholde brynge Avell to a good end the thynge Avhiche he ncA^er or hath but lytell seen."
Brunschwig's book Avas the first in Avhich any definite statement is made about gunshot wounds, or, as the English translation has it, " of Avoundis shot Avith a gone Avhereas the venym of the powder abydyth in." To remove the venom he advises to pass a small cord of hair through the wound and draw it back and forth, after Avhich a tent is to be placed in the AA^ound.
In amputation he adAdses either the actual cautery or boiling oil to check hemorrhage. He has nothing to say about lithotomy, herniotomy, aneurism, or tumors — the book being, in fact, a treatise on the military surgery of those days. It is illustrated Avith large quaint Avood-cuts Avhich are among the earliest specimens of the art. Haeser says there Avere two English translations — one published at London, and the other at South wark, but these are the same Avork.
Hans \^on Gersclorff Avas an army surgeon in 1476-77, and published his book, FekUbuch der Wundtarzney (in folio), at Strasburg in 1517. Of this there Avere eight later editions and translations into Latin and Dutch. The Washington Library contains the first edition, and also the Strasburg editions of 1527 and 1540 and the Frankfort edition of 1551. Gersdorff treats more fully of shot- wounds than does BrunschAvig.
54 THE HISTORY AND LITERATURE OF SURGERY.
He does not consider them to be poisonous, but gives detailed directions for finding and extracting the bullet, with figures of instruments, and advises that the powder be removed, after which warm linseed oil is to be poured into the wound. He says : " I do not know of any better or milder remedy than this, which I have learned from Master IS^icolaus, called the INIaula.rtzt, surgeon to Duke Sigmund of Austria." If ampu- tation becomes necessary, he says : " First of all advise the patient to resign himself to God,, to confess his sins, to remember the suffering of our liord with thanks, and the surgeon the same ; thus will God grant him good fortune in his work. And when you will cut him have ready by each other all your instruments and apparatus, such as scissors, knife, saw, styptics, bands (lassbendel), bandages, pads, tow, eggs, and what belongs to it, so that one follows the other in the order of the operation, since there is need of this. And when you are ready to cut let some one draw back the skin strongly and tie a band firmly around it, and place another band in front so that a space of a finger-breadth be left between the two bands that you may cut befrsveen them with the knife ; then this cut is quite sure, easily made and makes a good stump. AYhen you have made the cut take a saw and divide the bone, and then remove the band and tell some one to draw the skin over the bone and flesh and hold it tight in front ; and you should have a bandage two fingers broad and well wetted that it may lie smooth, and with it bandage the thigh down to the cut that the flesh may go in front of the bone, and leave it thus bound. And you need not fear bleeding if you have done as above described. Bind now over the styptic a good thick pad, take the bladder of a bull, OS, or hog, one which is strong, cut the neck open so that it will go over the pad and stump, and the bladder should be wet but not too soft ; draw it then over all, tie it hard with a band and you need have no care about the bleeding."
The following is the styptic referred to : " Take of unslacked lime two ounces, vitriol, alum, each, one ounce, of aloes to be calcined, gall- nuts, colophony each a quarter of an ounce ; of the residuum in the retort when you make aquafortis two and a half ounces, and the white hair of the belly of a hare or deer chopped up, and mix all together
thoroughly. When you use it mix it with white of eggs But if
an artery rages and will not be staunched then burn it with a cautery." Although he used no ligature in amputation, he does advise a double ligature on a wounded blood-vessel. He has a chapter on leprosy, but says nothing definite about syphilis. The plates in GersdorfP's book are especially interesting.
Walter Hermann Ryff was also a Strasburg surgeon of the first part of the sixteenth century, and published a number of treatises in German, his Gross Chirurgei appearing in 1545, and his Kleiner Chirurgi in 1551. This tendency to depart from scholastic methods received a strong impulse from the sayings, doings, and writings of Philippe Aureole Theophrastus Bombastes de Hohenheim, better known as Paracelsus (1493-1541), He was born in the village of Einsicdeln, near Zurich, studied medicine with his father, travelled extensively, studied chemistry and alchemy Avith Sigismund Fugger, and served as an army surgeon in campaigns in Italy and the Netherlands. Of unbounded self-assurance and having a knowledge of some ne^^• reme-
THE HISTORY AND LITERATURE OF SURGERY. 55
dies, such as antimony, arsenic, and mercury, he soon acquired a great reputation, and in 1526 was appointed professor of medicine in the University of Basle. He is characterized by Dalton as " a rampant, blatant, boasting, ignorant vagabond, with a face of brass and a tongue like a race-horse," and, if the word " ignorant " be omitted, it is a true picture. But he was also a sort of genius, in a way a poet ; and, knave and charlatan, and in his latter days drunkard, though he was, his doctrines were accepted by such men as Frobenius, Erasmus, and Van Helmont, and had a powerful influence throughout Europe for a century or more, some of his peculiar theories still surviving as the essence of modern homoeopathy. He wrote or dictated many works, of which the only one that need be mentioned here is Der grossen Wundartzney (1536-37), of which there were several editions, besides Latin and French transla- tions. The second chapter begins as follows : " It is necessary to know in the first place what is the efficient cause of the curing of wounds, because this may of itself indicate the proper treatment. Know then that the human body contains in itself its OAvn proper radical balsam, born in it, and with it, and not only the body as a whole contains it, but all its parts, such as flesh, bones and nerves, have each its own
peculiar juice competent to cure wounds It is not the surgeon
who cures wounds, it is the natural balsam (or juice) in the part itself." Hence he inveighs against what he calls " the damnable precept which teaches that it is necessary to make wounds suppurate." Elsewhere he calls this animal juice "la mumie," but he also meant by this a special preparation made from certain parts of the human body — sometliing like the animal juices and extracts which have been re- cently recommended as remedies, and which are quite Paracelsian in character.
The ideas of Paracelsus were accej)ted by Felix Wurtz (1514-74) of Basle, who studied under Ryif at jS^uremberg, and was on terms of inti- macy with Paracelsus and with Conrad Gesner, the most learned man of his time. He acquired great reputation, and published his Practica der Wundarzney in 1563. Of this about fifteen editions appeared during the next hundred years, including an English translation by Fox, pub- lished in 1656. He remarks that "skill in surgery is obtained with great painfulness, for it is not gotten with sitting on a cushion at home and by reading and writing ; .... it is not enough to be full of talk, and to say such and such and write so and so, — a patient is little the better for it if the surgeon hath no skill to dress his wounds." The work is almost entirely devoted to wounds and fractures and their consequences, and contains nothing as to the technique of surgical operations. The treatment advocated is in the main simple and sensible. Styptic powders are condemned for general use, as is also the cautery to suppress hemor- rhage, except in amputation of the thigh. No allusion is made to the ligature, and it is not probable that he had ever seen the works of Pare. He objects to the probing of wounds, declaring that it is folly to feel and grope about them, and that some surgeons use the probe merely because they have seen it used and to show that they are doing something. Cat- aplasms and poultices for fresh wounds are condemned, and the blood is not to be washed or squeezed out, " for it is a right flesh glue and hasteneth the healing." He often refers to the conservative surgeons
56 THE HISTORY AND LITERATURE OF SURGERY.
who say, " Old customs should not be abandoned," and says, " Therefore in some places the books of Theophrastus Paracelsus (to whom the best and most famous surgeons must give place) are prohibited to be read ; but in my simple judgment it is done very foolishly." He objects to drawing a cord through a gunshot wound, or to using hot oil, or to treating such injuries otherwise than as simple wounds. The third part of his book, being on the symptoms and complications of wounds, including a description of the wound-fever or pyEemia, is the most original and valuable part of the work.
The instruction of the barber surgeons' apprentices at the end of the sixteenth century appears to have been based on the views of Jerome of Brunswick, if we may judge from a little manual by Julius Holder, pub- lished at Frankfort in 1592, entitled Dialogus, ein NutzUche unci Warh- aftige Beschreibung eines rechte Wundartzts unnd seiner Meisterschaft. This is in the form of questions and answers, Latin terms being curiously intermixed with the German.
Another good specimen of the sort of instruction given to apprentices of German barber surgeons in the sixteenth century is the Wundartzney zu alien gebrechen des gantzen Leihs, etc. of Joannes Charethanus (or Charetanus), of which five editions appeared between 1530 and 1556. The edition of 1549, printed at Frankfort, is a small quarto of 20 leaves, giving directions for bloodletting and tooth-pulling, and various formulae for salves and potions. It directs that wounds should be dressed twice a day ; that he who is wounded in the head shall not walk about or move much ; that he shall avoid perspiring and talking, which inflame or disturb the brain and make him insensible ; above all, he shall avoid strong Avine, which puts him in deadly peril ; likewise the rays of the sun and light and heat and indigestible meat and the society of woman, whom he shall not even look upon.
If a large artery is cut or opened, first secure the same carefully with a silk thread to stop the bleeding ; then lay on the red powder and cover with a red plaster. Let it remain for four days and heal it like other wounds.
The Seventeenth Centuby.
The seventeenth century is more remarkable for the advances which were made in physics and in physiology than it is for improvements in surgery. It was "the age of Francis Bacon (1561-1626), of Galileo (1564- 164"2), of Ren6 Descartes (1596-1650), of Pascal (1623-62), of Sir Isaac Newton (1642-1727), and of Robert Boyle (1626-91), all pf whom had a powerful influence in developing the iatro-chemical and iatro-mechan- ical theories which prevailed about the end of the centurv. This was also the age of Borelli (1608-79), of Thomas Sydenham (1624-89), and, above all, of William Harvey (1578-1657), the pupil of Fabricius d'Aquapendente, whose celebrated work, Exercifatio Anatomka dc Jlotu Cordis et Sanguinis, appeared in 1628.
At the commencement of this century the most distinguished Italian surgeon was Hieronymus Fabricius d'Aquapendente (1537-1619), who was a pupil of Fallopius and succeeded him as professor of anatomy at Padua. He was the discoverer of the valves of the veins and the teacher of Harvey. His principal discoveries and writings relate to anatomy
THE HISTORY AND LITERATURE OF SURGERY. 57
and embryology, but he was also professor of surgery, and his Pentateu- chos ChirurgiGum (Francof., 1582) and his Opera Chirurgica (Paris, 1613, in folio, and later editions) were important works of reference during the next century. Fabricius was learned and eloquent, and made the University of Padua the most important school for anatomy and sur- gery in Europe. His surgery is mainly that of Celsus, Paul of iEgina, and Albucasis, to whom he gives full credit, carefully noting the sources of his quotations. No great advance in the art is due to him, but his works contain many accounts of cases and references to the methods of other surgeons, making them valuable historically, and they are far more interesting as a piece of literature than is the corresponding work of John de Vigo. In speaking of wounds of the intestines he refers to animal sutures and to the insertion of a piece of the trachea of an animal to preserve the lumen of the gut. He describes tracheotomy and urges its performance in certain cases, and says that he has seen one case of cancer of the breast cured by excision, but has never performed the operation himself.
Next to him came Cesare Magati (1579-1647), who became professor at Ferrara in 1612 (or 1621?), and who gained much repute by his book, De vara medicatione vulnerum, seu de vulneribus raro tractandis (libri ii., Venet., 1616, folio). In this he urged a simpler mode of treating wounds than was then fashionable, advising less frequent dressings, condemning the use of tents, and maintaining that gunshot wounds are not poisoned. His doctrines were specially urged and made prominent by Sancassini in the early part of the eighteenth century.
Marcus Aurelius Severinus (1580-1656), professor at Naples, one of the most celebrated teachers of anatomy and surgery of his time, is best known by his book De recondita abscessuum natura (Naples, 1632, quarto), of which several later editions were published.
Giovanni Battista Cortesi (1554-1636), a barber's apprentice, after- ward a pupil of Tagliacozzi, whom he succeeded as professor at Bologna, published a treatise on wounds of the head in 1632, and a manual of surgery in 1633, which are of little interest.
Gaspar Asellius, the discoverer of the lacteals, in 1623 was professor of surgery and anatomy at Pavia, but wrote nothing on surgery.
Spigelius (1578-1625), a native of Brussels, professor of anatomy and surgery at Padua in 1605, was an operator, and is said to have trephined the same patient seven times, but there is nothing surgical in his pub- lished works. Trephining was a common operation at this time, being employed in cases of insanity, of severe headache, and of chronic diseases of the eyes, as well as for injuries of the skull.
Pietro de Marchetti (1589-1673), professor of surgery at Padua, published a collection of cases under the title Observationum medico- chirurgicarum sylloge (Padua, 1664, and later editions), which is of permanent historical value. Among these cases is ' one of successful trephining following a dagger-wound of the head two or three months previous, and several cases of the same operation for headache. Here also is the celebrated case in which a pig's tail was forced into the anus of a prostitute, and was removed by slipping a tube over it. Pietro was succeeded in the chair of surgery in 1662 by his son Dominique, who acquired great fame as a teacher, and is said to have performed nephrot-
58 THE HISTORY AND LITERATURE OF SURGERY.
omy successfully without being guided by the presence of any tumefac- tion of the part.
Filippo Masiero, a surgeon of Padua, was the author of the follo^y- ing books: II chirurgo in prattka, etc. (Venet., 1688, 4to ; 5th ed, 1749, 8°), II sogno chirurgico (Parts I., II., Padua, 1697), and Ojjere chirurgische (Padua, 1707).
Carolus Musitanus, a physician of Xaples, published his Ckirurgia theoretka practka in 1698. Haller styles him " improbabilium histori- arum narrator."
In France there was little progress in surgery until near the end of the century. The medical faculty finally triumphed oyer the surgeons by obtaining a decree which united the barbers and the surgeons in one corporation, and the College of St. Come was no longer a power in the land. Among the French works on surgery of this period may be men- tioned Quelques t rentes des operations de chirurgie, by Jean Girault (Paris, 1610) ; Observations Medecinales et Chirurgicales, etc., of Gul. Loyseau (Bordeaux, 1617); Observations iatrochirurgiques of Coyillard (Lyon, 1639) and Le Chirurgien Ojj&rateur of the same author (1633 '? ; 2d ed. Lyon, 1640) ; Epnstola de laryngotoniia of Pene Moreau (Paris, 1646); La Chirurgie 3Iilitaire of Leonard Tassin (Ximwegen, 1673); Les operations de la chirurgie of J. Bienaise (Paris, 1688); and Traits des play es cV arquebusade of Scipio Abeille (Paris, 1695).
In 1696, M. de la Vauguion, a physician, published a Traite complet des opjerations de chirurgie (8°, Paris), which is the most complete man- ual in French prior to that of Dionis, and of the English translation of which at least three editions were published (1699, 1707, and 1716). He names the tourniquet and describes its application in amputation and in the operation for aneurism, and quotes frequently from Fabricius Hildanus.
Xicolas de Blegny (1652-1722), surgeon of the duke of Orleans in 1683, the founder of the first medical journal, published a treatise on yenereal diseases in 1673, and a treatise on the treatment of hernia, with description of a truss of his inyention, in 1676. He is also the author of the first city directory.
Preyious to the seyenteenth century surgery had made little progress in the Xetherlands, and there are yery few books to be noted. The work of Ypermans has already been referred to. Carolus Battus, a surgeon of Dor- drecht, published in 1590 his Handtboeck der Chirurgijen, of which there were six later editions. He also translated the works of Pare into Dutch.
In the middle of this century Holland became celebrated as a centre of anatomical and surgical teaching through the laliors of Tulp, Bar- bette, Van Meekren, Yan Home, Van Roouhuysen, Solingen, Yerduyn, and others, and the schools of Amsterdam and Leyden began to draw students from all parts of Europe.
Paul Barbette (162 ?-7?), son of a Strasburg surgeon, studied in Mont]iellier and Paris and settled in Amsterdam. He was a yoluminous writer, and his Chirurgie, first published in Dutch in 1657, passed through ten editions and translations, being a popular manual, while his Opera omnia was issued twenty-two times in yarious languages. He first described femoral hernia, suggested laparotomy in intestinal obstruc- tion, and extirpation of the spleen, which he performed on dogs.
THE HISTORY AND LITERATURE OF SURGERY. 59
Job Janszoon Van Meekren (?-1666), a native of Amsterdam and a pupil of Tulp, was a celebrated operator. His book, Heel en geneesJconstige aanmerhingen (Amst., 1668), was translated into German and Latin.
Job. van Home (1621-70), professor of anatomy and surgery in Leyden, was a distinguished teacher, but his writings relate mainly to anatomy, his Microtechne id est brevissima Chh^urgiae Methodus (1663) being merely a manual. There is an English translation of this (London, 1717).
Hendrik van Roonhuysen (1625-6?), a surgeon of Amsterdam, also well known as an obstetrician, published his Genees-en Heelkonstige aanmerhingen in 1672. He operated for wry-neck and hare-lip, advised Csesarean section, removed tumors, and seems to have been specially skilled in his art.
Cornelis Solingen (1641-87), a surgeon at the Hague, wrote Manucde Operatien der Chirurgie (Amst., 1684), which Haller says is full of original observations.
Peter A. Verduyn (162?-?), a surgeon of Amsterdam, is celebrated for his treatise on the flap method of amputation, Diss, de nova artuum decurtandorum ratione (Amst., 1696). He seems to have known nothing of the similar methods of Lowdham. (See p. 67.)
Joannes Muys of Arnhem and Leyden jjublished the first two parts of his Praxis Chirurgiae rational is in 1683, and the complete work in 1695. This contains accounts of one hundred and twenty cases, some of which are curious and interesting.
Fabricius Hildanus (1560-1624) is sometimes called the "Father of German Surgery," although this title belongs more properly to Heister. He was a Swiss by birth, and for the last twenty years of his life was the city physician of Berne. He was a surgeon's apprentice who man- aged to acquire a good classical education, and probably obtained good practical training under Griifon, a surgeon of Geneva. He travelled much, resided for some time at Cologne, and became widely known as a bold and skilful operator, and especially as a lithotomist. He was a strong opponent of Paracelsus and his friend Wurtz, and was a volu- minous writer, but his monographs are, for the most part, of little interest, the best being his Lithotomia Vesicae (Basle, 1626), translated into English and published at London in 1640. His most important publication for readers of the present day is his Observationum et Cura- tionum Ckirurgicarum Centuriae, in which he relates his experience in a large number of surgical cases of the most varied character. He advised amputation at an early stage in gangrene, and that the incision should be made in the sound and not in the decayed flesh.
He used the cautery, and not the ligature, in wounds of the arteries, and devised a number of complicated instruments, none of which are of practical interest. His chief influence on surgery was through his correspondence with German physicians and surgeons, and through his urging upon the German surgeons the necessity for the study of anat- omy. His Opera omnia, of which several editions were published, appears to have been a favorite book of reference for surgeons for many years.
John Schultes, better known as "Scultetus" (1595-1645), a pupil of
60 THE HISTORY AND LITEEATUEE OF SURGERY.
Fabricius d'Aquapenclente, became city phvsician at Ulm. His great work, tlie Anncnnentarium Chirurgicum (Ulm, 1653, folio), passed through many editions and was translated into many languages.
Joseph Schmidt (1601-?), an army surgeon, published S^jecuhirn Chirurgicum (Ulm, 1656, quarto) and Examen Chirurgicum (Francof., 1660, 16°).
The most celebrated German surgeon of the latter part of this period was Matthseus Gottfried Purmann (1649-1711 ?), who was apprenticed as a barber surgeon, became a medical officer in the Brandenburg army in 1675, and city physician at Breslau in 1685. He was a voluminous writer, and his Grosser unci gantz neu-geicundener Lorheer-Krantz, ocler Wund-Artzneij (Francof., 1692, 4to ; also 1722), his Chirurgia Curiosa (Francof., 1694, 4to ; translated into English, London, 1706, fob), and his Funfftzig sonde r- und icunderbahre Schussivunden Cur en (Francof., 1721) are valuable works in the histors' of the art. He was a strong advocate of the cure by the weapon-salve and the sympathetic powder, and tells several stories of the successful use of these remedies. He used st^'ptics and bandages to control hemorrhages after amjjutations, objecting to the cauter}', but says nothing about the ligature.
Here may also be mentioned John von Muralt (1645-1733), a dis- tinguished Swiss anatomist and surgeon, who was one of a celebrated family of physicians of Zurich. He studied at Basle, Leyden, Oxford, and Paris, and in 1761 returned to Zurich, where he soon became dis- tinguished as an anatomist and surgeon. In 1677 he announced public lessons in anatomy, with demonstrations on the bodies of criminals and of persons dying of remarkable diseases in the hospitals, and in the same year published his Vade Mecuni Ancdomicum, giving the date by the enlarged letters in the motto of the book, " LVX et faX MeDICi- nse." In the second edition of his surgical writings, published in 1711, he describes a method of amputation by flap devised by Saborian in Geneva, who first performed it in 1701, and this is by some claimed to be the first mention of that method of operation, but it had already been described by Yonge in 1679. (See p. 67.)
Other German surgeons of this period were Mathias Ludwig Glandorp (1595-1636), whose Speculum Chirurgicum appeared in 1619 ; Jessenius a Jessen (1566-1621), author of Institutiones Chirurgicae (1601); Paul Ammann (1634—91), author of Praxis vulnerum lethcdium (Francof., 1690); Joh. Agricola (1589-164?), author of Chirurgia jMrva (Sihrn- berg, 1643); and John H. Juugken (1648-1726), author of Compendium Chirurgicae Manualis ahsolufum (Francof, 1692).
The oldest English medical book which we have is perhaps the Leech- book, written about 970 a. d., and printed in 1865 as volume ii. of the Leechdoms, Wortcunning, and Starcrajt of Early England. This is mainly the receipt-book of a herbalist, giving the uses of common herbs, and among other things the composition of various " wound-salves." But it also contains matters taken from Paul of ^Egina, and directs : " If thou must carve oif or cut off an unhealthy limb off from a healthy body, tlien carve thou not it on the limit of the licalthy body, but much more cut or carve in the hole and quick body." The following is the best surgery in the book : " For hare-lip, pound mastic very small, add the white of an e^^, and mingle as thou dost vermillion ; cut with a knife the false
THE HISTORY AND LITERATURE OF SURGERY. 61
edges of the lip, sew fast with silk, then smear without and within with the salve, ere the silk rot. If it draw together, arrange it with the hand ; anoint again soon."
In the book of The Physicians of Myddvai, which dates from about the thirteenth century, there are a few references to surgical opera- tions. The author says (page 40) : " A wounded lung is the physician's third difficulty, for he cannot control it ; but he must wait for the will of God. By means of herbs a medicine may be prepared for any one who has a pulmonary abscess [empyema]. He should let out [the matter] and support [the patient] as in the case of a wounded lung, till he is recovered. But most usually he will have died within eleven years [or one year]." Page 44 : " A hard vesical calculus is thus extracted by operation : Take a staff and place it in the bend of the knee ; then fix both arms Avithin the knees, doubling them over the staff, and securing both wrists with a fillet over the nape of the neck, the patient (being placed on the back), his stomach up, with some support under both thighs, and the calculus cut for on the left side of the urethra. Let him subsequently be put in a water-bath that same day, also the day follow- ing early, and after this he should be put in the kyffeith. Then he should be removed to his bed, and laid there on his back, his womid being cleaned and dressed with flax and salt butter. He should be kept in the same temperature until it be known whether he shall escape [effects of the operation]. He should be kept without food or drink for a day and a night previous to the operation, and should have a bath."
The following is the direction for an anaesthetic (page 423) : " Take the juice of orpine, eringo, poppy, mandrake, ground-ivy, hemlock, and lettuce, of each equal parts. Let clean earth be mixed with them and a potion prepared, then without doubt the patient will sleep. When you are prepared to operate upon the patient, direct that he shall avoid sleep as long as he can, and then let some of the potion be poured into his nostrils, and he will sleep without fail.
" AVhen you wish to awake him, let a sponge be pounded in vinegar and put in his nostrils.
" If you wish that he should not wake for four days, get a penny- w^eight of the wax from a dog's ear, and the same quantity of pitch ; administer it to the patient and he will sleep.
"■ When you would that he should awake, take an onion, compounded with vinegar, and pour some into his mouth, and he will awake. Take care that you keep him quiet, and warned of the operation, lest he should be disturbed."
The first surgeon in England of whom we have any definite account, and whose writings still exist, was John of Arderne (or Arden), born about 1308, who practised in jSTewark until about 1370, when he went to London. He wrote a treatise on surgery of which several manu- script copies are in existence, but the only work of his which has been printed is A treatise of the fistula in the fundament, or other places of the body, etc., which is included with the translation of Arcaeus on wounds of the head, etc., printed in London in 1588, being a translation by John Read. His operation itself consisted either of slitting up the fistula or of passing a thread through it, which is to be drawn so as to cut through the flesh gradually.
62 THE HISTORY AND LITERATURE OF SURGERY.
His description of cancer of the rectum is a graphic one, and begins as follows :
" Bubo is an Apostume breding within the fundament in the longa- tion with great hardness, but with little paine. This before his ulcera- tion is nothing but a hid Cancer, which cannot in the beginning be knowne by sight of the eye, for it is hid within the fundament, and therefore it is called Bubo. For as an Owle hideth her self in the darke places, so this griefe lurketh within in the beginning.
" But after processe of time it is ulcerat and frettith and goeth out, and oftentimes it frettith and ulcerith all the circumference of the funda- ment, so that the excrements goeth out continuallie without retencion, and may never be staled unto the death, nor cured by the healpe of man. And it is thus knowen.
"Put your finger within the fundament of the pacient, and if ye finde within a thinge very harde, sometime on the one side, and sometime on both, which hindreth egestion, than it is Bubo.
"And the manifest signs are these. The patient cannot abstaine from stoole, for aking and priking, and that twise or thrise within an houre, and the excrementes seeme as it were mingled with watrie blond, and it stinketh very strongly, so that all the unskilfuU surgions and the patient also thinketh they have Dissenterium, when truely it is nothing so, for Dissenterium is with flux of the belly, but in Bubo there goeth foorth hard egestion and sometime they may not goe out for straightnesse of the Bubo, but are reteyned within the fundament straightly so that ye may feele them with your finger and drawe them out, and in this case glisters availeth much.
" And when they bee nigh their ende, they beginne to have lynger- ing fevers, and to loose their appetite, they forsake all, and covet wine, they eate little and covet everieday lesse and lesse, they sleepe but little and unquietly, they are heavie as well in minde as in body, and as they waxe weaker and weaker, they covet their bedde and above all thinges to drinke water, neverthelesse they can speake and move themselves to the last breath.
" From these (I say) wash your handes if you have care of your credit, unlesse it be in glisters as aforesaide to ease him."
At the beginning of the fifteenth century there was a great dearth of surgeons in England, as it appears from Rymer's Fcedera that in 1417 Henry authorized "John Morstede to press as many surgeons as he thought necessary for the French expedition, together with persons to make their instruments.^ With the army which won the day at Agin- court there had landed only one surgeon, the same John Morstede, who indeed did engage to find fifteen more for the army, three of whom were to act as archers."
Of the English surgeons of the fifteenth and sixteenth centuries, those whose names are best known are Yicary, Gale, Clowes, and Lowe. Thomas Vicary (149?-1561), the first master of the Amalgamated Bar- bers and Surgeons in 1541, and one of the first governors of St. Bar- tholomew's, published in 1548 a work on anatomy in English. No copy of this edition is known to exist, but the edition of 1577 was reprinted by the Early English Text Society in 1888. Thomas Gale (1507-86), a. ^ The Antiquary'' s Portfolio, by J. S. Forsyth, vol. i., London, 1835, p. 80.
THE HISTORY AND LITERATURE OF SURGERY. 63
native of London, served in the army of Henry VIII. in France in 1 544, and under Philip II. of Spain in 1577, succeeded Yicary as master of the Barber Surgeons Company in 1561, and in 1563 published his Insti- tution of Chirurgerie, with other treatises, one of which is Of ivounds made with Gonneshot, in which he opposes the views of Brunswick, De Vigo, and Ferrius as to the venomous nature of such wounds, and quotes Maggius approvingly. He advises styptics in amputations — says that his method is used in St. Thomas's Hospital, and gives cases to prove that bullets may be left in the body without danger.
William Clowes (1540-1624) was at first a naval surgeon, and became surgeon of St. Bartholomew's in 1581. He wrote A proved practise for all young Chirurgions concerning burnings with Gunpowder and Woundes made with Gunshot, etc. (London, 1591, 8° ; 3d ed. 1637, 4°). He refers to Pare as a man worthy of admiration, and, like Gale, comments severely on the ignorance of the so-called surgeons of his time. Peter Lowe (155?-161?), a Scotch surgeon, practised for a long time in France and Flanders and as an army surgeon. In 1596 he was in London, where he published his works on the Spanish Sickness and The WJiole Course of Chirurgerie. In 1598 he returned to Glasgow, and founded the Fac- ulty of Physicians and Surgeons of Glasgow, which was chartered by King James VI. in 1599. His book on surgery passed through four editions, and is a good manual for its time. In amputation for gangrene he used the actual cautery, but says : " In amputation without putrefac- tion I finde the ligature reasonable sure providing it be quickly done." This is perhaps the first mention in English of the ligation of arteries in amputation. In hernia he advised the pricking of the intestines with a needle to discharge the wind and lessen the bulk of the tumor.
About the middle of the sixteenth century there lived at Maidstone, Kent, a surgeon named John Halle, who published in 1565 a translation of the Chirurgia parva of Lanfranc, with some remarks of his own, entitled An Historical Expostulation also against the beastly abusers, both of Chy- rurgerie and Physicke in our tyme : With a goodly doctrine, and instruc- tions necessary to be marked and followed of all true Chirurgies.
The history of surgical corporations in England begins with the bar- bers' guild, which was at first a meeting for social and religious purposes, originating probably in the thirteenth century. These barbers soon began to call themselves barber surgeons. There were, however, sur- geons who were not barbers, some of whom had served in the army, and in 1368 these surgeons formed a separate guild, which about 1421 com- bined with the physicians.^ The barbers obtained a charter of incorpora- tion from King Edward IV. in 1462.
There is nothing in the charter about barbery — that is, shaving and hair-cutting — but a good deal about the regulation of surgery. In 1492 arms were granted to the " Guild of Surgeons," which appears to have been a small body of eight or ten men superior in social position to the
1 The details of the quarrels between the barbers and the surgeons, and of the organ- ization and progress of the guilds, will be found in The Annals of the Barber Surgeons of London, compiled by Sidney Young (a thick quarto volume published in 1890), and in The Oraft of Surgery, by J. Flint South (published in 1886). The act of Parliament passed in 1540, allowing the United Companies of Barbers and Surgeons to have yearly four bodies of criminals, was the first law in the country for promoting the study of anatomy.
64 THE HISTOBY AND LITERATURE OF SURGERY.
barbers. In 1540, under the reign of Henry VIII., the barbers and the surgeons were united and incorporated by act of Parliament as the Company of the Barber Surgeons, the first master being Thomas Vicary.
In the year 1542 an act was passed regulating the practice of surgery, stating that "the Company and Fellowship of Surgeons of London, minding their owne lucres, and nothing the profit or ease of the diseased or patient, have sued, troubled, and vexed divers honest persons, as well men as women, whom God hath endueed with the knowledge of the nature, kind and operation of certain herbs, roots and waters, and the using and ministering of them, to such as have been pained with custum- able diseases, as women's breasts being sore, a pin and the web in the eye, uncomes of the hands, scaldings, burnings, sore mouths, the stone, stran-
guary, saucelin, and morphew, and such other like diseases And
yet the said persons have not taken anything for their pains or cunning. .... In consideration whereof, and for the ease, comfort, succour, help, relief, and health of the King's poor subjects, inhabitants of this his realm, now pained or diseased. Be it ordained, etc. that at all time from henceforth it shall be lawful to every person being the King's subject, having knowledge and experience of the nature of herbs, roots and waters, etc., to use and minister according to their cunning, experience and knowledge, .... the aforesaid statute .... or any other Act notwithstanding."
The Barber Surgeons had j)ublic demonstrations of anatomy and dis- sections in their hall, but it was forbidden that any of them should make dissections or give lectures on anatomy at any place other than said hall. The reader in anatomy was for many years a physician.
In 1604 the company was presented with five hundred copies of the Tables of Surgery of Horatius Morus, a Florentine phvsician, translated by Richard CaldwelP (London, 1585, 32 pp. 8°). these books were given by Mr. Caldwell to be distributed among the surgeons who were freemen of the company.
In 1643, Edward Arris gave to the corporation the sum of two hun- dred and fifty jDounds for the purpose of having one human body pub- licly dissected and six lectures thereupon read each year.
The Gale Lectureship was founded by Dr. Gale, the order being issued in 1698. These two bequests are now combined and the lectures in con- nection wdth them are known as the Arris and Gale Lectures.
One of the lecturers before the Barber Surgeons was Alexander Bead (or Rhead), a Scotchman, who graduated in 1620 at Oxford. His Lec- tures on wounds were published in 1634, those on Surgical operations in 1637, and all his works in 1650. Read taught that a bullet may be so made that it will make a poisonous wound, quoting as authority Querce- tanus. Speaking of ligature of the arter}^, he says : " Ambrose Parrey would have this mean to be used after the amputation of a member, whom you may read ; but in my judgment his practice is but a troublesome and dangerous toy ; as he shall finde who shall go to make trial of it."
An important part of the business of the Corporation of Surgeons was
^ The Dr. Caldwell referred to was Eicliard Caldwell, a graduate of Oxford and a physician, and president of the college in 1570. Through his influence Lord Lumley founded and endowed a lectureship on surgery, which is still known as the Lumleian Bequest.
THE HISTORY AND LITERATURE OF SURGERY. 65
the examining and licensing of naval surgeons, both for the royal navy and for merchant ships. An account of such an examination is given by Smollett in his novel Roderick Random. Oliver Goldsmith also pre- sented himself for examination in 1758, and the minutes of the court of examiners read as follows : " James Bernard, mate to an hospital ; Oliver Goldsmith, found not qualified for dito."
In Scotland the University of Aberdeen was founded in 1494, and in 1505 had a professor of medicine.
King James III. is reported to have been "ane singular gude chirurgian, and there was none of that profession if he had any danger- ous cure in hand but would have craved his adwyse." His method of obtaining practice must have been effectual, although it was an unusual one. We find in the accounts of the treasurer for 1511 an entry as fol- lows : " Item to one fallow, because the King pullit forth his tootht, xnii. 5.
The first charter of the Royal College of Surgeons of Edinburgh is dated July 1, 1505. It directs that no person shall make use of the craft of surgery or of barber craft within this burgh unless he is freeman and burgess of the same, and that he must be examined by the masters of the same craft upon the following points — namely : The anatomy, nature, and complexion of every member in man's body, and all the veins of the same. Every year one executed criminal was to be given to the college for anatomical purposes. No master of the craft shall take any apprentice who cannot Avrite and read. Probably the most important provision was, that no person within the burgh shall make or sell any aqua vite except the masters, members, and freemen of the corporation.
By 1589 it had become the custom to admit barbers at a lower rate, but they had only the right to act as barbers, being specially forbidden to practise surgery, and were to have " na signe of chirurgie in their bughts or houses oppenlie or privatlie."
In the early part of the seventeenth century the leading British sur- geons were Clowes and Lowe, already referred to, and John Woodall (156?-164?), who had served as an army surgeon, and about 1612 was elected surgeon to St. Bartholomew's Hospital and likewise surgeon-gen- eral to the East India Company, which last gave him the appointing of surgeons and mates to all the company's ships. In 1617 he published a work entitled The Surgeons Mcde or Military & Domestique Surgery. Discoursing faithfully & plainly the method and order of the Surgeons chest, the uses of the instruments, the vertues and Operations of the Medicines, and the exact Cures of Wounds made by Gun-shott, etc. In 1628 he published a work entitled Viaticum, Being the Path- Way to The Surgeons Chest. Containing, Chirurgical Instructions for the yonger sort of Surgeons, imployed in the Service of his Majestic, or for the Common-Wealth upon any occasion whatsoever. Intended chiefly for the better curing of Wounds made by Gunshot.^ His
^ These works were afterwai'd published together in folio in 1639, 1653, and 1658, a separate title-page being given to each work, but the pagination being continuous. The second title-page is often transferred in place of the first one, which has been lost, lead- ing, on careless examination, to the erroneous supposition that they are two entirely dis- tinct works of the same date. Vol. I.— 5
66 THE HISTORY AND LITERATURE OF SURGERY.
works are not specially instructive^ but are in parts very good reading. In amputation he recommends tying large vessels, especially those of the thigh, if it can be done, but he seems to think that the surgeon will often fail, in which case, as well as for the smaller vessels, he recommends buttons of astringent and caustic powders.
In gangrene Woodall urged amputation in the mortified instead of the sound part — an old treatment which had then fallen into disuse. He also suggests amputating as low as the ankle for disease of the foot, instead of just below the knee, as was usually the case. He had never seen the actual cautery used in amputation.
In 1648, James Cook of Warwick published his Mellijicium Chirur- giae, or the Marroio of Surgery, a manual which seems to have been popular, the sixth edition in 1717 being "licensed by the College of Physicians and fitted for the use of all sea-surgeons." In his descrip- tion of amputation no mention is made of the ligature of arteries.
The greatest English surgeon of the seventeenth century was Richard Wiseman (1622-76), sometimes called the English Par6. He was apprenticed to a barber surgeon in 1637, served in the Dutch navy until about 1644, when he joined the army under Charles L, and was admitted to the Company of Barber Surgeons in 1651. He was a surgeon in the Spanish navy for three or four years, and in 1660 joined King Charles II. and was appointed one of his surgeons. In 1672 he published A Treatise of Wounds in an octavo of 277 pages. In 1676 this was enlarged and printed in a large folio volume under the title Sever all CkirurgiGall Treatises. There were eight of these treatises — viz. I. Of tumors ; II. Of ulcers ; III. Of the diseases of the anus ; IV. Of the King's evil ; V. Of wounds ; VI. Of gunshot wounds ; VII. Of frac- tures and luxations; VIII. Of lues venerea. In 1686 this was pub- lished in folio, having the words " the second edition " on the title-page, although it was really the third, and the so-called " third edition " (folio, 1796), with the title Eight Chirurgical Treatises, etc., was really the fourth. Other editions appeared in 1705, 1719, and 1734, and there is a spurious edition of 1692, which is really the original edition of 1676 with a new title-page.
Wiseman used the complex dressings of the period, but knew that simple measures produced equally good results. He used styptics and cauteries, and not the ligature, but he included the end of the cut vessel in one of the stitches through the lips of the wound. Being a personal friend of the king, he used his influence with him to promote the inter- ests of the Barber Surgeon's Company. His works were never trans- lated, and were very little known on the Continent, but they had a decided influence on the improvement of the art in England.
James Yonge (or Young) (1646-1721), a native of Plymouth and a naval surgeon, published in 1679 a little book of 120 pages entitled Currus Triumphalis, e Terebinths. Or an account of the many admirable Vertues of Oleum Terehinthinae. More j^articidarly , of the good effects ^produced by its application to recent Wounds." .... And. lastly, A neiv Way of Amputation, etc. He objected to Pare's method of liga- tures in amputations, saying that it is " a way always tedious, often successless ; and whatever vaunts the Author makes of it, it cannot be so secure as he pretends ; it being liable (sometimes from the slackness,
THE HISTORY AND LITEBATXJRE OF SURGERY. 67
otherwise from the too great straightness of the thred ; sometimes from its smallness, cutting through, or from its weakness, giving way) to a new flux when not so tolerable to the Patient, or so easily cured by the Artist as at first ; moreover, where two Vessels or more bleed in one Wound (which is very frequent), the one must be neglected, while the Ligature is making on the other." But he says : " The ligation of an Artery on other accounts, as in the Toothach, Epiphora, Aneurisma, &c., is not hereby impugned." On page 30 is to be found, perhaps, the first printed description of a tourniquet — " very useful in Amputations, espe- cially above the knee ; that is to say a wadd of hard linnen cloth, or the like, inside the Thigh a little below the Inguen, then passing a Towel round the member ; knit the ends of it together, and with a Battoon, a Bedstaff, or the like ; twist it, till it compress the Wadd or Boulster so very strait in the crural vessels that (the circulation being stopped in them) their bleeding when divided by the Excision, shall be scarce large enough to let him see where to apply his Restrictives." A similar tour- niquet had, however, been used by John Morell in 1674 at the siege of Besan9on. The " new way of amputation " is by a single flap, and is the first printed description of this method, which he says he learned from Mr. C. D. Lowdham of Exeter.
The Compleat Discourse of Wounds, . ... as also a Treatise on Gunshot Wounds in General, by John Brown (surgeon to the king) (London, 1678, 4to), is a pompous, diffuse, tedious book, containing nothing of any importance.
Some curious illustrations of the English surgery of the middle of the seventeenth century are to be found in the Diary of the Rev. John Ward, Vicar of Stratford-upon-Avon, extending from 164-8 to 1679, edited by Charles Severn (London, 1839, 8vo). For example: "A cancer in Mrs. Townsend's breast, of Alverston, taken off by two sur- geons First they cutt the skin cross and laid itt back, then they
workt their hands in ytt, one above and the other below, and so till
their hands mett, and so brought itt out There came out a gush
of a great quantitie of waterish substance, as much as would fill a flag- gon. They put in a glass of wine and some lint, and so let itt alone till the next day ; then they opened itt again, and injected myrrhe, aloes,
and such things, as resisted putrefaction, and so bound itt up againe
The way how and where itt should be cutt was markt with ink by one Dr. Edwards."
" Gill told mee of a woman that had an apostheme about the side, and his master intended to trepan her on one of the ribs ; whether it canne be ; — I suspected itt to be a ly."
" The mountebank that cutt wry necks, cutt three tendons in one child's neck, and hee did itt thus ; first by making a small orifice with his launcet, and lifting upp the tendon, for fear of the jugular veins, then by putting in his incision knife, and cutting them upwards ; they give a great snapp when cutt. The orifice of his wounds are small, and scarce any blood follows."
" Gill said his Mr. Day hath amputated five armes, three leggs and somewhat else since he came to Oxford, and but two of all these died, and one was a person of sixty years att least."
" John Phillips his child had a red swelling in the forehead, I sup-
68 THE HISTORY AND LITERATURE OF SURGERY.
pose a varix or naevuss and itt was taken oif by one of Coventry, by tying a hair about itt, and girding itt harder every day ; in two weeks itt fetcht itt oiF."
A curious episode in the history of surgery in the first half of the seventeenth century is the controversy on the sympathetic or magnetic cure of wounds. This was a doctrine of Paracelsus, and in 1608 one of his followers, Goclenius, professor of medicine at Marburg, called special attention to it by his work, Traotatus de Magnetica Curatione Vulneris. His doctrines were objected to by the priests on religious grounds. Van Helmont wrote in defence of the doctrine, and his pam- phlet was published without his knowledge in 1621. This created great excitement, and was translated into English by Walter Charleton, and published in 1560 under the title A ternary of Paradoxes. The cure was to anoint the bloody sword or other weapon which had inflicted the injury, or a stone or cloth dipped in the blood as it flowed from the wound, with a special ointment, and put it away carefully, applying nothing to the wound but a bit of wet lint. Goclenius thought the cure was a natural process ; the priests thought it was due to magical formula and the aid of the devil ; and Van Helmont undertook to prove that both were wrong, and that the so-called " weapon cure " was due to a certain mysterious sympathy precisely analogous to what, in later times, was called "animal magnetism."
The priests' view that weapon-salve cures are magical and sinful is given in the Hoplocrismaspongus ; or a sponge to wipe aioay the weapon- salve, by William Foster, Parson, etc. (London, 1631), which was directed mainly against the celebrated Rosicrucian Robert Fludd, who replied with Doctor Fludds ansiver unto 31. Foster, or the squesing of Parson Foster's sponge, .... wherein the sponge-bearer's immodest carriage and be- haviour towards his brethren is detected, etc. (London, 1631). Fludd's book is much better reading than that of Foster.
Sir Kenelm Digby's discourse at Montpellier, on the cure of wounds by the powder of sympathy, published in 1657, was a famous book in its day. A less-known but equally curious book, by C. de Irvine, an army surgeon, was printed at Edinburgh in 1656 under the title of Medicina Magnetica, or the rare and wonderful art of curing by sym- pathy, and several other controversial pamphlets of the period are noted in the Index Catalogue of the Washington Library under the heading "Sympathy."
After the expulsion of the Moors from Spain there is little worth noting in the history of surgery in that country until after the middle of the sixteenth century. In 1488 it was ordered that those wishing to practise surgery must be examined under the direction of the Brother- hood of St. Cosme and St. Damian at Zaragoza, to which association was granted the privilege of dissecting the bodies of persons dying in the hospital recently established in that city. The surgeons were for- bidden to order or to dispense internal remedies. At the end of the fifteenth century there were a few Spanish writers on syphilis, the best known being Villalobos.
The first celebrated Spanish surgeon was Francis Arcteus (1493- 157?), whose treatise, De recta curandorum vidnerum ratione, Avritten in his old age, was first published at Antwerp in 1574 and again at
THE HISTORY AND LITERATURE OF SURGERY. 69
Amsterdam in 1658. This was translated into English by John Read, and published at London in 1588, and a Dutch translation was published in 1667. Arcseus recommends the use of the trephine in fractures of the skull, describes with some minuteness the operation for excision of cancer of the breast and an apparatus for the treatment of club-foot, and advises mercurial inunctions on the joints for syphilis. His treat- ment of wounds is, in the main, that of John de Vigo.
Another Spanish surgeon of the sixteenth century of some repute was Bartoleme de Aguero (1531-97), professor of surgery at Seville, called by some the Spanish Pare, whose works were published in 1604 under the title Tesoro de la verdadera cirujia, and in other editions in 1624 and 1654.
Dionisio Da§a Chacon (1510-159?), a surgeon in the Spanish army, serving in many countries and in the immediate service of Charles V., Philip II., Juan of Portugal, Don Carlos, and Don John of Austria, wrote his Practica y teorica de cirujia about 1580. This was the first comprehensive work in surgery written in Spanish. He used the cautery for checking hemorrhage in amputations, did not consider gun- shot wounds poisonous, and abandoned the use of boiling oil in treating them after 1544, at the suggestion of a certain M. Bartolomeo, probably Maggius. His interesting report on the injury of the head of Don Carlos, in which he opposed Vesalius, who advised the trepan, is given with comments by J. M. Guardia in the Gazette Med. de Paris, 1863, p. 41.
Andreas Alcazar, professor at Salamanca, published in 1575, in folio, his Chirurgiae, .... libri sex, and in 1582 his Pe vulneribus capitis.
Juan Fragosa, surgeon to Philip II., published Erotemas quirurgicos (Madrid, 1570, 4to), Pe la Cirugia, etc. (Madrid, 1581, foL), Tratado de cirugia sacado de la cirugia universal, a little manual of questions and answers for students (1692), and Cirujia universal, . . . . Y mas otros tres tratados .... Una summa de proposiciones contraciertos avisos de cirugia . . . . de las declaraciones acerca de diversas heridas y muertos . . . . de los Aphorismos de Hyppocrates tocantes a cirugia (Alcala, 1592, and several later editions).
Cristobal Montemayor, surgeon of Kings Philip II. and III., wrote Medicinia y cirugia de vulneribus coptY/s (Valladolid, 1613; Saragossa, 1664).
Pedro Gago de Vadillo, a surgeon of Lima, published at Madrid, in 1632, Piscursos de verdadera cirugia y censura de ambar vias, y eleccion de la prime7'a intencion curativa, y unicion de las heridas, of which a third edition appeared in 1692.
Eighteenth Century.
At the beginning of the eighteenth century the only city in which there were any special opportunities for the study of surgery was Paris. There was no place for the barbers or the barber surgeons in the univer- sities of Europe, and they had no institutions of their own in Avhich any teaching worthy of the name could be obtained. Many of them had learned something in the camp or on the battle-field, which was the great practice school for the surgeons, as it had been for three centuries,
70 THE HISTORY AND LITERATURE OF SURGERY.
and there were but few surgeons of the time in England, France, or Germany who failed to gain experience therein. Nevertheless, this military experience contributed little to the advancement of surgery. Haeser says that the chief cause of the supremacy of French surgery in the seventeenth and eighteenth centuries was the wars undertaken by Louis XIV. and his successors, and that streams of German blood con- tributed in some degree to the foundation of the mastership of the French in the domain of surgery. There is a grain of truth in this statement, but it does not explain why the German and the English surgeons, who also saw more than enough of military surgery at this period, did not make the same progress as the French. Army service gives valuable experience to the man who has suitable preliminary training and is well grounded in anatomy, but for the barbers and barber surgeons of the eighteenth century such service increased their knowledge but little. It is true that the surgeons had learned something. They knew that shot-wounds were not poisonous and did not require cauteriz- ing, and a large number of them probably also knew that ordinary wounds not involving the bones really required very little treatment. Never- theless, they kept on prescribing and using their oils, ointments, plasters, vulnerary drinks, etc., the formulse for which fill a considerable space in the surgical treatises of the day ; and there is one special reason for this w^iich the modern surgeon and historian usually does not fully appreciate. This reason was, that the charges of the surgeons in those times were based upon these applications, and this Avas also true for the ordinary practitioners of medicine : they compounded and dispensed their own remedies; their charges were made for the remedies and not for the visits; and hence the fees were in proportion to the number of the mixtures, draughts, unguents, etc. which were ordered for a particular case. The surgeons at the beginning of the eighteenth century, as a rule, used styptic powders and compression to check hemorrhage. Those who knew anything about the use of the ligature appear to have been afraid to trust it, and to have preferred the actual cautery. It was sup- posed to be necessary, or at all events desirable, to include a portion of the surrounding tissues with the artery to be ligated, for fear that the ligature might cut through the coats, and for the same reason the cord was often tied over a small pad instead of being made directly to encircle the vessel. In the army the surgeons necessarily practised medicine, but in civil life they were, as a rule, forbidden to use or prescribe the internal remedies, that being the business of the physician, who claimed exclusive rights in this respect.
At the beginning of the eighteefath century the leading surgeons in Paris were Georges Mareschal (1658-1736), surgeon of the Charity and first sur- geon of Louis XIY. in 1703 ; Jean Mery (1645-1722), first surgeon of the Hotel Dieu and the deviser of the operation of suprapubic puncture of the bladder; and Pierre Dionis (165?-1718), Avho had commenced teach- ing anatomy at the Jardin du Roy in 1673, and in connection with his lessons gave demonstrations of surgical operations on the cadaver. He had many pupils, and his Cours cV operations de Chirunjk, first published at Paris in 1707, went through many editions and was translated into English, Dutch, and German, being a popular manual for fifty years. Headvises the ligature of arteries in amputations, but says that at the
THE HISTORY AND LITERATURE OF SURGERY. 71
Hotel Dieu the vitriol button is used instead. He advises the Marian operation in lithotomy, but says that he does not believe the high opera- tion to be so dangerous as is supposed, and that he is assured that M. Bonnet has often practised this operation at the Hotel Dieu with happy success. He tells at length the story of Frere Jacques up to that date, and apparently very fairly, showing the ignorance of the man, but saying that a surgeon who is a good anatomist may succeed by his method ; which was true prophecy.
This Frere Jacques — Jacques de Beaulieu (1651-1719) — was an ignorant peasant who for a time was a servant of an Italian Incisor named Palloni. He became a monk, or, as Dionis says, a sort of a monk, and came to Paris in 1697, as he said, to show the surgeons how to perform lithotomy in a particular way. He was successful at first, and acquired great reputation, but soon had many deaths and left Paris, going in 1704 to Holland, where he taught his method to Pan, who improved it into what is generally known as the lateral operation. Frere Jacques himself improved his methods greatly after his visit to Paris, and spent the rest of his life as a wandering lithotomist, chiefly in Austria and Italy.
There is much good reading in Dionis : he does not confine himself to a mere description of the operations, but gives anecdotes which furnish a picture of his times and surroundings.
Gabriel le Clerc, a surgeon of Lille, published at Paris in 1692 a little book called La chirurgie complete, being a sort of quiz-compend with questions and answers. This became a popular manual, passing through eighteen editions and translations. He mentions the Hotel-Dieu method of stopping bleeding arteries by vitriol buttons, and says that it is the custom of the Hotel Dieu to employ a person to keep on the dressing with the hand for twenty-four hours after the operation.
B. Saviard (1656-1702), surgeon of the Hotel Dieu, published in 1702 his Nouveau recueil cV observations chirurgicales, which was trans- lated into English and published at London in 1 740. This is a valuable collection of cases, containing a description of the tourniquet (using that name) as applied at the Hotel Dieu in 1688 in a case of successful liga- tion of the femoral for a wound of that vessel. He refers to the per- nicious atmosphere of the Hotel Dieu and its effects on wounds, gives an interesting note on Frere Jacques, describes a case of dermoid cyst of the ovary and one of congenital absence of the penis, and gives details of some remarkable cases of lithotomy. It is a book worth having.
Rene Jacques Croissant de Garengeot (1688-1759) published his Traite des operations de chirurgie in 1720 (2d ed., 3 vols., in 1731). He was one of the best anatomists and surgeons of his time, and introduced many methods in details of operations for nasal polypus, hare-lip, stran- gulated hernia, etc.
Alexis Littre (1658-1726), whose name remains connected with the form of hernia first described by him, was a surgeon who devoted him- self largely to pathological anatomy, and whose papers are contained in the Memoirs of the Academy of Surgery. He first proposed the opera- tion of colotomy in 1710.
Nicolas Andry (1658-1742), dean of the medical faculty of Paris in 1724, is known in the history of surgery by his U Orthopedie, ou Vart de
72 THE HISTORY ASD LITERATURE OF SURGERY.
prevenir et de corriger dans les enfans les difformites du corps (Paris, 1741), being the first work in which the word oithopfedia is used. It is a pop- ular treatise on the care of children, and has very little to do with ortho- p&edia as that word is now understood.
The most distinguished surgeon of the first half of the eighteenth century was Jean Louis Petit (1674-1750), who entered the armv at the age of eighteen. In 1700 he settled at Paris and commenced giving a private course of lectures in anatomy and surgery. He invented the screw tourniquet, an apj)liance of almost as much importance as the liga- tm-e to the surgeon who has to amputate with unskilled assistance, devised herniotomy without opening the sac, and made an improvement in the circular method of amputation by cutting successively the skin and the muscles, instead of dividing them at one stroke according to the old method. This was carried still further by Desault, who divided the muscles on two levels. To Petit also is due the credit of having first demonstrated the mechanism of the occlusion of arteries in wounds, showing the chief process to be the formation of a clot, a part of which surrounds the end of the vessel and a part of which is a plug occupving the cavity ; and of giving the first account of mollities ossium.
After the triumph of the medical faculty over the surgeons and bar- ber surgeons in the middle of the seventeenth century, the College of St. Come continued to give instruction, although it could not grant degrees, and in 1690 the number of the students was greater than the number of students in medicine, being over seven hundred. It was by no means poor, and in 1691 it began the construction of a new amphitheatre, which was completed in 1694.^ In it were given lessons on anatomy and sur- gical operations, and similar teaching was given by a few ambitious voung surgeons as a private enterprise. To become a member of St. Come the aspirant must have been an apprentice for at least six years before he could present himself to perform his " grand chef d'oeuvre," which, if successful, would make him a master surgeon. This "grand chef d'oeuvre " was a long process of examination. The AVashington Library- contains a manual of preparation for it, in the form of a neatly-written manuscript, bound in four volumes, 8vo, " par C. Caulay, recu chirurgien jure le 24 juillet, 1737.^'
Franyois de Lapeyronie (1678-1747) was a surgeon of Montpellier and demonstrator of anatomy in the School of Medicine. He came to Paris in 1714, soon became surgeon of the Charite, and first surgeon of the king in 1736. He was wealthy, and spent his money freely for the benefit of the Royal Academy of Sui'gery, which was organized in 1731, increasing in fame and prosperity for the next forty years, and tlirough the agency of which, to a considerable extent, Paris became the great surgical centre of the world. J. L. Petit became the first director of the academy, and Sauveur-Fran9ois Morand (1697-1773) its first secre- tary. Morand was an ingenious surgeon. He proposed amputation at the hip-joint and ovariotomy, and performed the high operation for stone, but he was an uneducated man, and was unable satisfactorily to perform the duties of secretary of the academy, which post he resigned in 1739. He was succeeded by Antoine Louis (1723-92), to whom the success of the academy and its marked influence on the progress of
^ Corlieu : La France Med., 1878, xxv. p. 481.
THE HISTORY AND LITERATURE OF SURGERY. 73
surgery are to a great extent due. He was professor of physiology, and in 1757 became surgeon of the Charite, but he was not so much an operator or inventor as he was a learned historian, editor, and critic.
An indispensable work for the student of the history of surgery in France at this period is the collection of eulogies pronounced by Louis upon deceased members of the academy, published with notes and appendices by E. F. Dubois in 1859. These so-called eloges are judi- cial, critical, historical essays which are unequalled in surgical biography. At the commencement of his eulogy on Le Cat he remarks that these memoirs will form a part of the history of the Academy to be read in years to come, and that the truth must be told ; and in this he was a true prophet. His Q^uvres diverses de ckirurgie were published in 1788.
Of the earlier members of the academy, besides those already named, the most distinguished were Le Dran and Le Cat. Henry Francois le Dran (1685-1773), the son of a surgeon, was educated in Paris, and became a master in surgery at the age of twenty-two. In 1724 he was appointed one of the four surgeons of the Charite, and established an anatomical school there, and in 1730 published his Parallele des diffe- rentes mani^re de tirer la pierre hors de la vessie, which gave him much reputation. In 1734 he was sent as chief surgeon to the army, and pub- lished the result of his observations in 1737 in his Traite .... sur les playes d' amies a feu, which went through several editions. In 1742 he published a treatise on operative surgery. Le Dran made no great con- tribution to surgery, but he was a celebrated teacher and had many pupils from Germany, through whom his method became popular in that country.
Claude Nicolas le Cat (1700-68) was a surgeon of Eouen, who became surgeon-in-chief of the Hotel Dieu of that city as the result of concours in 1729. He Avon many prizes from the Academy of Sur- gery in Paris, being specially skilled in " prize-essay writing," became professor of anatomy and surgery in the school established at Rouen in 1736, and attracted many students. He was a voluminous writer, but his papers which relate to lithotomy are the only ones of any special value. His reputation was greater abroad than it was at home.
Other surgical writers of this period are Guillaume Mauquest de la Motte (1655-1737), whose Traite complet de chirurgie (3 vols., Paris, 1722) was a very popular text-book ; Georges de la Faye (1699-1781), whose Principes de chirurgie (Paris, 1739), an elementary handbook, passed through many editions and translations ; and Elie Col de Villars (1675- 1747), whose Cours de chirurgie appeared in 1738.
Dominique Anel (1678-1725 ?), a native of Toulouse, was a pupil of J. L. Petit, a surgeon in the French and Austrian armies, and a wan- derer over Europe. In 1710 he ligated the brachial artery of a priest in Rome for traumatic aneurism, and this is claimed as a triumph of French surgery preceding the method of John Hunter, In fact, it was the operation performed and described long before by Guillemeau. In Genoa, in 1712, he devised his operation for lachrymal fistula and the syringe which still bears his name. In 1716 he was practising as an €ye surgeon in Paris.
George Arnaud de Ronsil, a French surgeon, Avent to London prior to 1748, and remained there until his death in 1774. His Dissertation
74 THE HISTORY AND LITERATURE OF SURGERY.
on Hernia (London, 1748) was a paper of much importance. His 3Iimoires de chirurgie (London, 1762, 2 vols. 4to) contains matter of permanent value, and a curious paper, " Inconveniens des Descentes par- ticuliers aux Pretres de I'figlise Romaine," with reference to Leviticus xxi. 20. In 1732 he excised the caecum and a part of the colon and ileum in a case of hernia.
Jean Baseilhac (1703-81), better known as Frere Come, was the son of a surgeon and was educated as such. In 1729 he became a monk, but continued to practise surgery among the poor, and invented the lithotome cache. He published anonymously in 1751 an account of his operation, and in 1779 published a paper on the high operation. He was a skilful surgeon, and obtained greater success with his instru- ment than any other person has been able to do.
Pierre Brasdor (1721-97) was professor of anatomy and operative surgery in the College of Surgeons of Paris, and contributed to the Memoirs of the Academy of Surgery, His name is remembered in con- nection with his suggestion to treat certain aneurisms by ligation of the artery on the distal side of the tumor ; which was first done by Wardrop.
Francis G. Levacher published in the Memoirs of the Academy of Surgery, in 1769, a paper on gunshot wounds, in which he, for the first time, showed that what were supposed to be the effects of the wind of a ball were really due to the ball itself.
Hugues Ravaton, a surgeon of the French army, published in 1750 the best treatise on gunshot wounds which had yet appeared. His Chirurgie cVarmee was issued in 1767, and his Pratique moderne de la chirurgie in 1770. He was the first to practise amputation by the double-flap method.
Jean Joseph Sue (1710-92), son of a Paris surgeon, and often men- tioned as "Sue le jeune," was a teacher of anatomy, and in 1761 one of the surgeons of the Charity. He published Elements de chirurgie (Paris, 1755), Traite des bandages (Paris, 1761), and Dictionnaire j^ositif de chirurgie (Paris, 1779).
Jean Louis Belloq (1730-1807), a professor of anatomy in Paris, devised a number of instruments, among which was the canula for plugging the posterior nares still known by his name.
In the latter part of the century the leading surgeon in Paris was Pierre Joseph Desault (1744-95), who became surgeon of the Hotel Dieu in 1788, and soon had a crowd of students following his public clinic, the like of which had never been seen before. He was a pupil of Louis and of Morand, and surgeon of the Charite in 1782. He was the first teacher of surgical anatomy in the modern sense of the term, made many improvements in the treatment of fractures, and con- tributed largely to the perfecting of surgical technique. He wrote almost nothing, but his pupil, Bichat, gave the substance of his teach- ings in the (Euvres chirurgicales (3 vols., 1798-1803). In 1792, Desault was arrested on the charge of having poisoned the Avounds of some of the revolutionists who had been brought to the Hotel Dieu. It was then but a step from the prison to the scaffold, and his pupils formed themselves into a deputation to defend him before the tribunal, their spokesman being Jean Pierre Maunoir, a young Swiss, afterward a celebrated sur- geon in Geneva, whose pleadings prevailed and Desault was released.
THE HISTORY AND LITERATURE OF SURGERY. 75
The Hotel Dieu of Paris was the " oldest, largest, richest, and worst hospital in Europe." In the latter part of the eighteenth century it con- tained over twelve hundred beds, and sometimes over three thousand patients, having four or five in one bed. The first distinct mention of surgeons in the Hotel Dieu occurs in the records of the year 1539, in which it is ordered that the surgeon Jocot la Normand shall be retained to serve as surgeon in the Hotel Dieu in place of George Barbas at a salary of about one hundred and eighty francs. By declaration of the managers in 1605 the surgeon must call a physician to see all the opera- tions of surgery which he shall make within the Hotel Dieu.
In 1654, Jacques Petit, master of surgery in Paris, was named sur- geon of the H6tel Dieu. This was an invasion, for up to that time the surgeons had been chosen from among the surgeons of the hospital. This Jacques Petit gave a course of anatomy to the pupils in the hos- pital, commenced the collection of instruments of surgery, and gave a sort of course of surgery at the bedside. This was the beginning of clinical surgery in this hospital and in France. He entered the hotel at the age of thirteen, studied surgery there, and filled the place of sur- geon-in-chief until 1705. The story was that he was more than sixty years in the house without putting his foot outside of it.
He was succeeded in 1705 by Mery, one of the most celebrated of the surgeons of this period. Mery was succeeded in 1722 by Thibault, he by Pierre Boudou, and he by Moreau, who was succeeded by Desault in 1786. Desault was succeeded by Pelletan in 1795.
The records of the Hotel Dieu which escaped the fire of 1871 have been published by the Bureau of Public Assistance under the title Col- lection de documents pour servir d, Vhistoire des hopitaux de Paris (Paris, 1881-87). In the second of these volumes, published in 1883, are given the deliberations of the governors of this hospital for the years 1768 to 1791, at the time when the hospital was badly overcrowded and com- plaints were being made by the surgeons of the management of the institution. Among other things, it contains a copy of the memoir of the Sisters in charge of the hospital, who in 1789 made a complaint against Desault to the eifect that he was bringing pupils from the out- side into the amphitheatre, which should be reserved for the pupils of the hospital alone, that the dressing of wounds was being interfered with, and that from two to three hundred strangers were admitted every day to hear his lectures. To this there is a long reply by Desault, show- ing that the complaints were in part ill founded, and urging that it is contrary to the public good to confine clinical instruction to the pupils resident in the house. The matter was investigated and the decision was given in favor of Desault. A very interesting description of the old Hotel Dieu, showing the arrangement and character of the beds and furniture, overcrowding, etc., is given by Dr. J. B. Tenon (1724-1816) in his Memoires sur les hopitaux de Pai'is (1788, 4to).
Fran9ois Chopart (1743-95) became professor in 1771, and in 1780 published, with Desault, the Traite des maladies chirurgicales et des operations, etc., which contains some of Desault's views, but which was wholly written by Chopart. His name remains connected with a form of partial amputation of the foot first described in 1792.
Raphael Bienvenu Sabatier (1732-1811) was a pupil of Petit, and
76 THE HISTORY AND LITERATURE OF SURGERY.
became professor of anatomy in the Royal College of Surgery. His princi}Dal work was his De la medecine opeyatoire (3 vols., 1798-1810).
J. Fr. Deschamps (1740-1824), a pupil of Moreau and surgeon of the Charite, brought the Hunterian operation for aneurism into notice in France, and published an interesting historical treatise on lithotomy in 1796.
Franyois Quesnay (1694-1774), secretary of the Academy of Surgery, wrote a work on the history of surgery in France which is full of errors.
Antoine Portal (1742-1832), professor of anatomy in the Royal Col- lege of France, is the author of Histoire de V anatomie et de la chirurgie, etc. (7 vols., Paris, 1770-73), which is a useful book of reference.
Jean Rene Sigault studied surgery at Paris, and was received as mas- ter in the school in 1770. In 1768 he presented a memoir to the Royal Academy of Surgery proposing to substitute the section of the symphysis of the pubis for the Caesarian section. The proposal was not approved, but he performed the operation in 1777 with success, and, as he had become a doctor of the Faculty of Medicine, his new operation was received with great enthusiasm by the members of the faculty. He published his Memoire [sur la section de la symphyse des os pubis, pratiquee sur lafemme Souchot], lu aux assemhlees du 3 et du 6 decembre, 1777 (16 pp. 4to, Paris, 1777), and Discours sur les avantages de la section de la symphyse (8vo, Paris, 1778).
Georg Fischer, in his Chirurgie vor 100 Jahren (Leipzig, 1876), has given a graphic picture of the condition of surgery and surgeons in Germany in the eighteenth century. The great mass of the people could only obtain surgical treatment from local barbers or from wander- ing charlatans. The barber's apprentice could hardly write or even read German. He learned how to ^have, and then went from house to house to serve his master's clie»ts. He was also taught how to sharpen knives, spread blisters, and make lint. He performed the most menial duties in the house, and occasionally one of the unhappy youths ran away and was duly advertised as a sort of runaway slave. The people were grossly ignorant and intensely superstitious, believing in charms and magic ; and the supply of this kind of medicine was not wanting. The cutters for stone and hernia, the cataract-operators, the bone-setters, and the travelling charlatans flourished everywhere, and the repeated edicts and ordinances issued by kings, nobles, and city authorities to remove the complaints made by the physicians and to settle the difficulties merely prove the condition of the times and seem to have had very little effect. Even the executioners competed with the sur- geons. They were supposed to have special dealings with the powers of evil, and in consequence to have special knowledge of the means of curing diseases considered to be due to witchcraft. A part of their busi- ness was to dislocate joints by the rack or to break bones upon the wheel, and hence it was supposed that they had special skill in the repair of fractures or of dislocations.
The practice of medicine was forbidden to the executioners in Prussia, but in the year 1744 Frederick the Great granted to them permission to treat fractures, wounds, and ulcers, and when tlie Berlin surgeons com- plained of this he issued an order saying tliat ho had not permitted all executioners, but only the skil