SURGERY

Ordinarily it is assumed that surgery has received almost its only and its greatest development in our time. Probably no development of knowledge that has come to us in the recent revival of interest in the history of medicine has been more surprising than the finding that surgery had several periods of great progress before our time. One of these and the most important came during the thirteenth and fourteenth centuries. Another great phase of surgical advance, after a period of decline such as seems inevitable in all human affairs, occurred during the Renaissance. It had its origin in or at least was greatly influenced by the publication of the chapters on surgery in the Latin and Greek classics, though strange as that may sound to modern ears even more was probably accomplished for surgical development by the printing of the text-books of the later mediaeval surgeons. The new impetus thus given affected nearly every phase of surgery and accomplished ever so much more than we would be likely to think possible, only that the republication of old surgical text-books in recent years has proved such a revelation to us.

As I have said in preceding chapters, one of the greatest debts of the modern time to the Renaissance is due for the printing of old books in the early days of printing. Scholars were willing to give liberally of their time and to devote patient labor to secure a good text for the printers, and somehow or other great printers succeeded in bringing out usually in magnificent editions, though of small size as regards the number of copies, not only the ancient but what we have now come to recognize as the mediaeval classics of medicine and surgery. The chapters on surgery in such writers as Aetius, Alexander of Tralles and the Arab writers like Abulcassis are among the most important contributions to the medicine of their time. The text-books on surgery of such men as Theodoric, Hugo of Lucca, the Four Masters, William of Salicet and Guy de Chauliac are landmarks in the history of a great surgical era. All of these were reprinted usually in magnificent editions during Columbus’ Century. Without such reprinting at a cost of time and money that we can scarcely understand, many of these precious treasures of the history of medicine and surgery would almost surely have been lost. Certainly very few of them would have remained in the manuscript forms in which they then existed and at most, only in seriously mutilated conditions. There have been several centuries since when they would have been utterly neglected, for almost no hint of their value survived and there was an impression prevalent that no one knew anything either about medicine or surgery during the Middle Ages at all worthy of preservation. This publication of the old text-books gave an impetus to the surgeons of the time that brought about a great new era in surgery, though there were other important factors at work in producing this. Above all the development of anatomy made for a corresponding development in surgery and by increasing men’s knowledge of the tissues through which operations had to be made, added to their confidence and decreased the mortality of surgical intervention. The magnificent hospitals of the time are of themselves the best possible evidence of proper care for patients, not alone in a medical, but also surgical way. It cannot be too often repeated that whenever hospitals are well built, properly cared for and suitably maintained, there is sure to be good medical practice and a fine development of surgery; whenever hospitals are neglected, medical and surgical practice both sink to a very low standard. Hospital construction reached a very high plane during the Renaissance period, only to sink afterwards, as did every other constructive effort for humanitarian purposes, to what Jacobsohn, the German historian of hospitals and care for the ailing, calls an indescribable level of degradation. Literally, the worst hospitals in the world’s history were erected at the end of the eighteenth and the beginning of the nineteenth century. Hospital organization and maintenance inevitably sank in the same way. A corresponding decadence in medical and surgical practice could not help but occur, fortunately to be followed by the progress of our own time. There are many, however, who seem to think that because the twentieth century is so far ahead of the early nineteenth it must be correspondingly in advance of preceding centuries. This assumption constitutes the most important reason for the very common failure in our time to understand properly the history of medicine and surgery as well, indeed, as that of every phase of science.

This was the period when gunpowder began to be used extensively in the operations of war and it is not surprising that a great deal of attention was given to gunshot surgery. We have four books, treatises in their way on gunshot wounds, that were written at this time by men of large experience. They made mistakes of course, there is no period in the world’s history, even our own, when men have not made mistakes, but the surgeons of Columbus’ Century accumulated an immense number of observations and gradually worked out a rather valuable set of suggestions with regard to the treatment of various kinds of wounds. At the beginning of the century they made the mistake of thinking that bullets caused both poisoned and burned wounds, and they were over-anxious to treat these imaginary consequences rather than the mechanical effects produced in their passage. They gradually worked out their problems however, even using experiment in order to show the effects of wounds. Braunschweig, Felix Wuertz, De Vigo and Ferri are the classics of the time on gunshot wounds and their books have probably been more read in our generation than in any other since the end of the sixteenth century. Nothing is indeed more surprising than the recognition of the value of the observations made by these old-time surgeons which has come in the last twenty years.

The greatest of the surgeons of Columbus’ Century is the Frenchman, Ambroise Pare, who has come to be spoken of as the Father of Modern Surgery. He well deserves the title if we restrict it definitely to the modern time and do not conclude, as so many do, that there had been no surgery since the classical period, for, of course, there was a very great era of surgery during the thirteenth and fourteenth centuries, but as is the way with humanity a period of decadence occurred, followed by another upward phase in the curve of history of which in his time Pare is the apex.

It is to him that we owe the treatment of gunshot wounds by simple water dressings, or at most by aromatics. When he began his work they were treating gunshot wounds as if they were poisoned and burned wounds by pouring boiling oil along the track of the bullet. Pare ran out of oil on an historical occasion but found that the wounded left untreated recovered with less pain and complications than those subjected to the heroic remedy. He recognized the mistake and had the genius to correct it properly. He reinvented the ligature, though, of course, it had been in use a number of times before and had gone out because of the tendency to produce sepsis involved in it, and because so often secondary hemorrhage occurred from the coming away of the ligature in the suppuration which ensued. He deserves, as do several others, the credit of real invention in its use. Pare himself speaks of this discovery, which he made just at the close of Columbus’ Century, as an inspiration which came to him through Divine Grace.

In nearly every department of surgery Pare left his mark. He was a thoroughly practical surgeon. He suggested, as did also Maggi, the Italian surgeon at this time, exarticulation as an important mode of amputation. This consisted of the removal of an injured limb or a gangrenous member at the joint just above, because in this way there was less danger of complications and a better stump could be obtained for subsequent use. In order to demonstrate that gunshots did not make a burned wound he demonstrated that when balls are fired even into a bag of gunpowder it does not explode. Maggi independently made this same observation but went further and showed also that shot do not melt when they strike a hard surface and that balls of wax that are fired do not spread out as if the wax were melted. This series of experiments made to demonstrate certain valuable points in gunshot surgery is quite worthy of the most modern time and indicates well the thoroughly scientific spirit that was abroad at this period. Pare also suggested that cut tendons should be sewed, the ends being carefully brought together and that no portion of the tongue should be removed after injury, but the parts should be brought together, for there was great power of healing in this organ. He advised the cutting of the uvula with a ligature gradually made tighter and he, as well as Franco, devised an apparatus to fill up the cleft in the bone of a defective palate and other similar mechanical appliances.

Indeed from the mechanical side of surgery Pare is the most interesting. Orthopedics, that is the treatment mechanical and surgical of deformed children, in order to bring about their cure or at least the lessening of their deformity, is generally supposed to be new, but there are many suggestions for it in the Renaissance period. Helferich in his "Geschichte der Chirurgie" in Puschmann’s "Handbuch" says, for instance, that Pare’s orthopedic armamentarium was rather extensive. He used various apparatus and specially designed shoes with bandages in order to bring on the over-correction of club foot. He treated flat foot in various ways and particularly by the use of special shoes. He invented a corset with holes in it for ventilation to be worn for various torsions of the spine and other spinal deformities. He and Fallopius taught the value of résections for joint troubles of various kinds and even for deformities. Pare declared that genu valgum, that is knock-knees, were due to similar causes as those which produced club foot, or at least that the affections were related.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Some of his details of technique are very interesting as showing how carefully he thought out even minor problems connected with the practice of surgery. For instance, he says as to wounds of the face, that as “the beauty of the countenance is what above every other thing makes men beautiful, the surgeon must take the greatest care that no ill-looking or ugly union should take place in it, and just as far as possible the parts should be brought together and kept in apposition, with as delicate means as possible, until healing has taken place.”

On the other hand he does not hesitate to discuss even fractures of the breast-bone, and says that if the patient expectorates blood it is a bad sign, for almost surely some of the arteries lying under the bone have been ruptured. He suggests position to help in the correction of deformity and displacement of the bone, and mentions that some of the older surgeons sought to raise it up by means of large dry cups. In fractures of the ribs similar recommendations were made, but Brunschwig was of the opinion that they did more harm than good. He recommended bandages, thickened with albumen, or leather moulded to the part, and he covered the thorax with a large binder.

There is no doubt at all that he knew very well the books of his predecessors and that he had thoughtfully adapted them in the way that had been taught him by his forty years of experience. He begins his book with a dedication to the praise of God and His Mother, not forgetting the honorable magistrates of the city of Strassburg. He says in the preface that he is tempted to write his book because there are many young, inexpert masters of surgery in the care of wounds who do not understand it and consequently inflict much harm on mankind. He hopes to be able to instruct them and also others who, living in the smaller towns and villages, have not had the opportunity to see the practice of surgery and yet must be able to help the ailing and injured. The picture of the position of the surgeon of the time is rather interesting.

The next of the German surgeons of this period was Hans von Gerssdorff, who practised in Strassburg. His well-known work is the “Field Book of Surgery,” in which he gives some of the experiences of long years as a military and municipal physician. The book was issued with a series of woodcuts, some of them anatomical but most of them surgical in interest, which are very well executed. His illustration of an amputation is the first one of this subject ever made, and there are many pictures of his instruments. We have only room to note some of his discussions of subjects usually not supposed to be thought of in his time. He discusses wounds of the liver, especially such as occur from large wounds of the abdomen, and says that if the liver substance itself has been wounded the issue will surely be fatal. If the liver is not wounded, yet appears in the wound, it should be replaced and the external wounds sewed. His discussions of wounds of the deep organs are all in about this same conservative strain.

Gerssdorff has much to say with regard to contractures and anchyloses. When these deformities are to be corrected, the tissues around the joints should be softened by means of embrocations and the rubbing in of old oil, and the contractures gradually overcome by manipulation or by instrumental means. He invented a number of apparatus for stretching such contractures, and four of the large pictures reproduce them. They are partly in the shape of armor or splints so arranged that they can be bent or made straight by means of a screw. There is also a screw arrangement for bringing about extension in various directions. He did not believe very much in going too slowly about the correction, for he declares that most of the contractures and anchyloses can be overcome in a few hours.

In discussing amputations he mentions the use of anaesthetics by the older surgeons, and quotes from Guy de Chauliac the method of anæsthesia employed by him, but he thinks that better results are obtained without the use of such material. He had never employed anaesthetics himself, though he had performed over 100 amputations. Perhaps his Teutonic people were able to stand pain better than the patients of the Latin countries. The refusal to use anaesthetics is very interesting at this time, for the practice gradually disappeared and was forgotten. Gerssdorff warns particularly against the use of opium alone as a means of preventing pain, and Chauliac had done the same thing earlier.

The spirit that the surgeons of the time were expected to have is very well illustrated by a passage from John Hall, written shortly after the close of Columbus’ Century in his “Historian Expostulation,” which is referred to more at length in the chapter on Medicine. He said, “I would therefore that all Chirurgiens should be learned, so would I have no man think himself learned otherwise than chiefly by experience, for learning in Chirurgery consisteth not in speculation only, nor in practice only, but in speculation well practised by experience.”

Dr. Hall made a series of rhyming verses which were meant to be helpful to the young surgeon to enable him to recall his duties readily. He urged him above all never to treat a case unless he understood it, when in doubt to call in a consultant and advises him after consultation to console the patient, but to talk seriously to some of the patient’s friends. Above all not to disturb the patient’s feelings. Among other excellent bits of good advice he insists very much on the knowledge of anatomy, and two of his rhyming stanzas regarding it seem worth while quoting to show the spirit in which he wrote:

“He is no true chirurgien
That cannot show by arte
The nature of every member
Each from other apart.

For in that noble handy work
There doth nothing excell
The knowledge of anatomy
If it be learned well.”

In a chapter of this kind, almost needless to say, it is impossible to give any formal account of the surgery of the time. All that I have been able to do is to point out that in every country in Europe surgeons were thinking for themselves and facing most of our modern surgical problems and finding not inept solutions. There is scarcely a phase of our modern surgery from antisepsis and anæsthesia to technical details of various kinds, through plastic surgery, the use of apparatus, manipulation and many forms of instruments, which cannot be found in the surgical text-books of this time. Gurlt in his great “History of Surgery” has taken some 400 pages of a large octavo volume, with the excerpts in rather small type, to tell the story of the surgery of Columbus’ Century. Helferich occupies several hundred pages of Puschmann’s “Handbook of the History of Medicine” with the details of what was done by the period’s surgeons. The specialties developed, and in all of them important contributions were made. The great independent, seeking temper of the era is as noteworthy in surgery as it is in every other department of intellectual effort at this time.