Advancements in Surgery

Overview

During the Renaissance, between 1450 and 1699, surgery was a mix of art, science, and myth. The art of caring for a soldier's battle wounds, the myth of blood-letting to cure or prevent disease, and the advances in scientific surgery for breast cancer, hernias, and bladder stones were all common to surgery at this time. It became a period for advancing the science of surgery as new ways to control bleeding were developed, plastic surgery was invented, complex surgeries to remove stones in the bladder were beginning to be performed, and surgeons tried their steady hands at cesarean sections with living mothers.

While significant improvements in surgical techniques and publications came from Italian, German, and French surgeons, such as Fabricius Hildanus (1560-1634) and Ambroise Paré (1510?-1590)—who dominated the field in the 1500s—British physicians such as William Harvey (1578-1657) made significant discoveries in anatomy during the 1600s that would make surgeries in the 1700s more successful.

Background

In the fifteenth century, blood letting (or phlebotomy) already had a long surgical history. The barber's red and white pole became a symbol of bleeding and bandaging and the practice of bleeding persisted well into the eighteenth century, as surgeons and barbers promoted health by periodically "thinning" the blood by bleeding. Its use proved more myth than science, however.

The turn of the sixteenth century saw the beginning of more scientific approaches to cutting to cure, however, and professional surgeons performed a wider range of services during the Renaissance. Military surgeons predominated. The advent of the use of gunpowder during the Middle Ages meant that military surgeons had to deal with gunshot wounds and wounds inflicted by canons. Cleaning combat wounds using cautery—searing remaining flesh with a hot instrument—was common practice. Amputation became the preferred method of treatment and, slowly, became more art and science than butchery.

The period from 1450 to 1699 also saw advancements in surgery for cancers, hernias, and cesarean sections, as well as the advent of plastic surgery, and new and more efficient ways to control bleeding. Thanks to the anatomists who solved many of the mysteries of the circulatory system, more surgical successes resulted. The greatest surgeons of the times studied in Italy at the University of Padua. They went on to serve the kings of Europe while uneducated but hardworking itinerant surgeons traveled from village to village in Europe cutting and healing and teaching others in their footsteps. Both groups made considerable contributions.

Impact

War provided a testing ground for Renaissance surgeons. Amputation, most often the result of wounds turned gangrenous, was the most frequent call for the military surgeon. Theoretically divided, military surgeons debated over whether or not to amputate through healthy tissue or amputate just to the limits of the gangrenous side of the limb. Questions over when and where to amputate were also tied to steps to control bleeding. Until better methods of controlling bleeding were developed, surgeons primarily amputated legs below the knee because bleeding from the major artery above the knee was very difficult to control.

Cleaning and closing wounds were major concerns for military and nonmilitary surgeons alike in this period. German surgeon Fabricius Hildanus used a red-hot knife blade to control bleeding and cauterize the wound during amputations. He and others cleaned wounds by applying boiling oil.

Ambroise Paré, a French surgeon, disapproved of both cautery and boiling oil. In 1537, Paré became an army surgeon around the age of 26. On the battlefield he became a leading authority on military wounds, finding that, contrary to current opinion, gunshot wounds were not poisonous and did not need cautery. Rather than use boiling oil, he cleaned gunshot wounds with a concoction of turpentine, rose oil, and egg yolk. One of Paré's major contributions was the ligature—a method of tying off a bleeding blood vessel—instead of cauterizing. With the ligature, he could control bleeding and amputate above the knee, where large blood vessels and arteries were previously likely to hemorrhage.

In contrast to Paré, who served monarchs, French surgeon Pierre Franco (1500-1561) occupied a professional niche somewhere between a barber-surgeon and an itinerant "cutter." It is said that his greatest contribution to surgery was to retrieve it from the quacks, bonesetters, and charlatans practicing in Europe by requiring surgical supervision from physicians. Franco specialized in hernia surgery. Whereas prior surgeons always removed the testicle to repair inguinal hernias, rather than incise at the level of the pubis, which he considered dangerous, Franco invented a low incision at the base of the scrotum to release a strangulated hernia. He performed his first successful operation using this technique in 1556.

Aurelous Philip Theophratus Bombastus von Hohenheim, who lived from about 1493-1541 and called himself "Paracelsus," was a major figure in sixteenth-century medicine. He encouraged medicine and surgery to be joined in the same art and science and dedicated his craft to wound management, traveling extensively in Europe practicing medicine, performing surgery, and teaching.

Many surgical "firsts" came in the mid and late sixteenth century. The first account of a successful tracheotomy occurred in 1546 when Italian surgeon Antonio Bravasola opened the trachea of a patient who was near death from a respiratory obstruction caused by an abscess in his windpipe. The first reported splenectomy was in Naples in 1549, performed by Zaccarelli. Georg Bartisch of Dresden performed the first eye removal for cancer in 1583. During this period British surgery lagged behind the Italian and French masters, but Englishman William Clowes was the first to perform a successful thigh amputation for gangrene in 1588. He wrote extensively on the art of surgery.

Cesarean section—the surgical removal of a baby from the mother's womb—had a long history of both fact and legend by the time of the Renaissance. Roman emperor Julius Caesar was fabled to have been delivered by the surgical technique still bearing his name. French surgeon Paré, noting that most cesarean sections on living mothers ended with the mother's death, recommended waiting until the mother died and then removing the baby as quickly as possible. However, in 1581, French surgeon François Rousset (1535-c. 1590), physician to the Duke of Savoy, published Hysterotomotokie, reporting successful cesarean sections on mothers who continued to live following their surgery.

Hieronymous Fabricius (1537-1619) was perhaps the most prominent Italian surgeon of the era. He was first a student, then a professor of anatomy at the University of Padua in Italy. He was concerned with anatomical research but also practiced surgery, improving the practice of tracheostomy by showing surgeons how to move, rather than cut muscles in the neck, to expose the trachea. In addition to his institutional contribution of building the first permanent surgical amphitheater (1594), he also improved treatment for urethral blockages and strictures.

The leading German surgeon at the end of the sixteenth century was Guilhelmus Fabricius (Fabry) Hildanus. As a young man, Fabry was too poor to receive formal medical training, so he became apprenticed in surgery at a low level. He rose in the profession, however, and traveled widely in Europe practicing surgery and publishing on surgery. He favored amputating through healthy tissue to fight gangrene and devised a tourniquet. He operated on cancers on the breast and described in his works the removal of the lymph glands. Fabry said that all the "sprouts" had to be removed with the breast tumor. He invented a device that pinched the base of the breast as a blade swept it off.

Gaspare Tagliacozzi (1545-1599) created the field of plastic surgery when he took skin from a patient and fashioned him a new nose. After removing the damaged nose, Tagliacozzi made a paper model of the nose he intended to build, used it as a pattern for cutting skin from the arm, and sutured the new nose to the face. He treated harelips by cutting away the deformity and suturing the ends back together. Tagliacozzi's fame spread until he was banned from plastic surgery by the Church, which claimed that he was undoing "God's handicraft." In Bologna, a statue was later erected of Tagliacozzi. It depicts him holding an artificial nose. His son, Antonio, advanced his work by restoring lips and ears by taking skin from the arm by a pedicled-flap.

Many surgical firsts also greeted the new seventeenth century. Gastric surgery to remove a foreign object made its debut in 1602 when barber-surgeon Florian Mattjis removed a knife from a peasant knife-swallower in Prague—during a show the patient had swallowed the knife too far, and it slid into his stomach when he drank a stein of ale. In 1635, the first reported surgery for cancer of the tongue was followed by a hemiglossectomy (partial tongue removal) in 1638. In 1664, a professor of surgery at Padua demonstrated the resectioning of ulcers and cancers of the lip.

British surgery began to catch up with its European counterparts in the early 1600s. British physician-surgeon William Harvey, who studied at Cambridge, spent several years in Europe, primarily in Italy at the University of Padua where he was influenced by Fabricius. Harvey received a medical degree in 1602 and returned to England, where he became professor of anatomy and surgery at St. Bartholomew's Hospital and Medical School. He is regarded as the father of our understanding of the circulatory system, which he wrote about in Concerning the Motion of the Heart and Blood in 1628. Detailing the contractions of the heart and how its valves operate, Harvey's discovery of the working of the circulatory system has been hailed as a landmark in medical progress that benefited, if not paved the way for, modern surgery.

British naval surgeon John Woodall, who wrote The Surgeon's Mate (1639), favored leaving healthy tissue intact during amputations and only cutting the gangrenous tissue. Woodall then recommended whittling away the remaining dead tissue little by little as the healing process progressed. Richard Wiseman (1622?-1676) of England operated on aneurysms, controlling bleeding and dissecting arteries. He published Treatise on Wounds in 1672 and Several Chirurgical Treatises in 1676.

A major advancement in surgery during the seventeenth century came with the development of a surgeon's ability to perform lithotomies—the removal of stones in the bladder. A new technique was developed during this period, which marked an improvement over running an object through the urethra to knock out a blockage. Perineal lithotomy required an incision at the base of the body, between the anus and the opening for the urinary tract. The surgeon, either with his hands or a scoop, entered the bladder and removed the stones. Jacques de Beaulieu (1651-1719), who called himself Brother Jacques, was a strolling Italian lithotomist who demonstrated the technique in Paris in 1697. While he and other lithotomists were often successful, survivors were often noted to lead sad lives of postsurgical dripping urine and fistulas. Lithotomists were considered specialists and often worked as itinerant surgeons moving from place to place to apply their skills. Many patients, however, died of the infections from the lithotomist's unclean hands and instruments.

As the seventeenth century closed, anatomists who discovered new and important information about how the human body worked greatly influenced the next century's surgeons.

RANDOLPH FILLMORE

Further Reading

Baas, J. Herman. The History of Medicine. Robert E. Krieger Publishing Co., Inc., 1971.

Cartwright, Frederick F. The Development of Modern Surgery. New York: Thomas Y. Crowell and Company, 1967.

Ingus, Brian. A History of Medicine. New York: The World Publishing Company, 1965.

Krummbhaar, E. B. A History of Medicine. New York: Alfred A. Knopf, 1947.

Meade, Richard H. An Introduction to the History of General Surgery. Philadelphia: W. B. Saunders Company, 1968.

Wangenstein, O. H. and Sarah Wangenstein. The Rise of Surgery. Minneapolis: The University of Minnesota Press, 1978.

Zimmerman, Leo M. and Ilza Veith. Great Ideas in the History of Surgery. New York: Dover Publications, 1967.

SURGICAL FIRSTS

Many surgical firsts came in the mid and late sixteenth century. The first account of a successful tracheotomy occurred in 1546 when Italian surgeon Antonio Bravascola opened the trachea of a patient who was near death from a respiratory obstruction caused by an abscess in his windpipe. The first reported splenectomy was in Naples in 1549, performed by Zaccarelli. Georg Bartisch of Dresden performed the first eye removal for cancer in 1583. During this period British surgery lagged behind the Italian and French masters, but Englishman William Clowes was the first to perform a successful thigh amputation for gangrene in 1588. He wrote extensively on the art of surgery.