Kitabı oku: «The Greatest Benefit to Mankind», sayfa 19

SURGERY

Surgery saw fewer significant changes, and still played second fiddle to physic, being relatively unaffected by the new anatomy. Restricted largely to the body’s surface, surgeons dealt with the many accidents of life. They set fractures, treated burns, contusions, knife wounds and the increasingly common gunshot wounds, tumours and swellings, ulcers and various skin diseases; syphilis was usually handled as a surgical condition. Surgery was seen as a skilled craft: ‘A chirurgien should have three divers properties in his person,’ judged John Halle (1529–68), ‘that is to say, a heart as the heart of a lion, his eye like the eyes of an hawk, and his hands as the hands of a woman.’

Through most of Europe, surgery continued to be taught by apprenticeship and organized in guilds. In London a master surgeons’ guild had been founded in 1368; the Mystery or Guild of the Barbers of London received its charter from Edward IV in 1462; and in 1540, by Act of Parliament, the Guild of Surgeons merged with the Barbers to form the Barber-Surgeons Company, its first master being Thomas Vicary (c. 1490–1561); Holbein painted Henry VIII chartering the company, which continued until 1745. An active member was William Clowes (1544–1603), who worked as a naval surgeon before setting up in practice in London and being appointed surgeon at St Bartholomew’s Hospital in 1575. Military operations in the Low Countries (1586) gave him ample experience, and in 1588 he was appointed surgeon to the fleet. Clowes’s treatises on wounds, venereal disease and scrofula were written in racy vernacular, with young surgeons in mind, presenting personal case histories.

Clowes was one of a line of able common-or-garden surgeons: John Woodall’s (1556–1643) The Surgeon’s Mate (1617) served as a manual of naval surgery, attacking the bad habits of ‘blaspheming the name of the Almighty’ and the ‘dedication to the pot and Tobacco-pipe’ which were all too common among apprentices; Richard Wiseman (1621–76) was honoured as the ‘father of English surgery’. His Several Chirurgical Treatises (1676) dwelt on military and naval problems, while his Treatise of Wounds (16 j 2), jocularly known as Wiseman’s Book of Martyrs, advertised itself as specially for ships’ doctors ‘who seldom burden their cabin with many books’. He picked up much of his experience during the English Civil War, and his account of military surgery reveals its horrors: cannonballs and gunshot caused horrifying wounds, and amputation and trepanation were often the only remedies, conducted on the battlefield or on a storm-tossed vessel.

Fabricius left a graphic description of a sixteenth-century amputation:

I was about to cut off the thigh of a man of forty yeares of age, and ready to use the saw, and Cauteries. For the sick man no sooner began to roare out, but all ranne away, except only my eldest Sonne, who was then but little, and to whom I had committed the holding of his thigh, for forme only; and but that my wife then great with child, came running out of the next chamber, and clapt hold of the Patient’s Thorax, both he and myselfe had been in extreme danger.

This may not have been an uncommon scene before anaesthesia was available.

‘He who wishes to be a surgeon should go to war,’ Hippocrates had advised, and the battlefield became accepted as the school of surgery. Growing use of gunpowder had worsened the injuries confronting field-surgeons, because cannonballs and lead shot destroyed far more tissue than arrows or swords and left gaping wounds prone to infection. Many of the most popular vernacular handbooks, such as the Buch der Wund-Artzney (1497) [Book of Wound Dressing] of Hieronymus Brunschwig (1450–1533) and the Feldbuch der Wundartzney (1517) [Fieldbook of Wound Dressing] of Hans von Gersdorff (c. 1455–1529), were based on field experience. Brunschwig’s work contains the earliest printed illustrations of surgical instruments, and endorsed the view that shot wounds were poisoned by gunpowder and so required cautery. Gersdorff explained how to extract bullets with special instruments and dress wounds with hot oil. Amputated stumps were to be enclosed in an animal bladder, after controlling haemorrhage by pressure and styptics. Thomas Gale (1507–87) published An Excellent Treatise of Wounds made with Gonneshot (1563) – the first English work on the subject.

The most acclaimed Renaissance surgeon, Ambroise Paré (1510–90), also learned his craft through war. In 1533 he served as aide-chirurgien to the chief Paris hospital, the Hôtel Dieu; and from 1537, for almost thirty years, he divided his time between tending the Paris sick and following the army. Enrolled in 1554 into the confraternity of St Côme, the surgeons’ college, five years later Paré attempted in vain to save the life of Henri II after he had been wounded in a jousting tournament.

Paré gave a conventional account of the ‘five duties’ of his art: ‘to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided and to redress the defects of nature’. His prime innovation lay in rejection of the standard treatments for gunshot wounds: the use of cautery (the burning iron) or scalding oil (‘potential cautery’) to destroy poison and forestall putrefaction before beginning restorative therapy. In his La methode de traicter leys playes faictes par hacquebutes et aultres bastons à feu (1545) [Treatise on Gunshot Wounds], he described how, as a greenhorn on campaign in Italy in 1537, he had been forced to innovate. Initially, as taught, he had used boiling oil on what were considered to be poisonous gunpowder wounds:

But my oil ran out and I had to apply a healing salve made of egg-white, rose-oil and turpentine. The next night I slept badly, plagued by the thought that I would find the men dead whose wounds I had failed to burn, so I got up early to visit them. To my great surprise, those treated with salve felt little pain, showed no inflammation or swelling, and had passed the night rather calmly – while the ones on which seething oil had been used lay in high fever with aches, swelling and inflammation around the wound.

At this, I resolved never again cruelly to burn poor people who had suffered shot wounds.

Thenceforth he relied on restorative methods, using a digestive (wound-dressing) made of egg, oil of roses and turpentine, justifying this on the supposition that the gunpowder and shot were not, after all, poisonous. Piously, he always said that he had dressed the wound but God had healed the patient: Je le pansay; Dieu le guarit.

Another innovation mentioned in his Dix livres de la chirurgie (1564) [Ten Books of Surgery] was the use of ligatures in conducting amputations. Other writers had recommended tying off the veins and arteries so as to stop the blood, but Paré worked out the practical details. This made successful thigh amputations possible – William Clowes reported performing one in 1588, as did Fabricius a little later. There was, however, one drawback. No fewer than fifty-three ligatures were necessary in a thigh amputation, and this required trained assistance. Consequently, ligatures could come into general use only after a method had been found to control blood flow until the surgeon could tie the blood vessels, something accomplished in eighteenth-century France when J. L. Petit invented the first effective tourniquet.

Paré’s Cinq livres de chirurgie (1572) [Five Books of Surgery] dealt at length with fractures and dislocations, while in the Deux livres de chirurgie (1572) [Two Books of Surgery] he addressed the study of obstetrics, showing the art of podalic version (turning a baby in the womb, to facilitate feet-first delivery, as earlier described by Soranus) – and also seeking to explain monstrous births. His successes, however, did not go unchallenged. In 1575, the Paris faculty condemned him for publishing on ‘medical’ topics – an affront reflecting the tetchiness of physicians towards surgeons’ encroachments on their turf.

The practice of early modern surgeons challenges the myth that before anaesthesia and antisepsis their craft was crude and often lethal. The case notes of the London surgeon Joseph Binns (d. 1664) present a different picture. In a career stretching from 1633 to 1663 he recorded 616 cases. Of these no fewer than 196 related to gonorrhoea or syphilis; 77 were of swellings and 61 were more properly medical – including ague, stomach-ache, headache, insomnia, diarrhoea and epilepsy. Fifteen individuals suffered battle wounds, 14 were hurt at work, 19 suffered from falls from horses and 41 were injured in fights. Of the 402 outcomes recorded, 265 were cured and 62 improved; 22 showed no improvement and 53 died.

As Binns’s cases show, surgeons’ work remained mainly routine, small-scale and fairly safe – if often agonizing. Next to dressing wounds, drawing teeth, dealing with venereal sores and chancres, treating skin abrasions and so forth, the most common surgical procedure (indeed the profession’s badge) was blood-letting, often performed at the patient’s request. Galenic medicine had warned about the dangers posed by a ‘plethora’, believing that fevers, apoplexy and headache followed from excessive build-up of blood. Venesection was the obvious corrective. The normal method for phlebotomy was to tie a bandage around the arm to make the forearm veins swell up, and then open the exposed vein with a lancet: this was popularly called ‘breathing a vein’. Cupping with scarification was another procedure for drawing blood.

A few surgeons came up with ambitious new operations. In Italy Gaspare Tagliacozzi (1545–99) described in his De curtorum chirurgia per insitionem (1597) [On the Surgery of the Mutilated by Grafting] the procedure of rhinoplasty or nose reconstruction, which was obviously attractive in the era of syphilis. Rhinoplasty had been known in India since ancient times; in southern Italy the operation was apparently practised by empirics. Tagliacozzi was thus far from the technique’s inventor, but he published and claimed to have perfected it. In his rhinoplastic procedure, a skin flap was partially detached from the flesh of the upper arm, and allowed to establish itself as a viable tissue. Then the flap, still attached to the arm, was shaped and sewn to the remains of the nose. The patient remained with his arm thus attached to his nose for fourteen days, before the flap was severed from its original site. After a further period, the process began of reshaping the flap to form the new nose. The whole business took from three to five months.

Overall, however, with its deep-seated craft basis, surgery remained rather traditional. Paré concluded:

A Chirurgion must have a strong, stable and intrepide hand, and a minde resolute and mercilesse, so that to heale him he taketh in hand, he be not moved to make more haste than the thing requires; or to cut lesse than is needfull; but which doth all things as if he were nothing affected with their cries; not giving heed to the judgement of the common people, who speake ill of Chirurgions because of their ignorance.

Whether surgeons were ignorant or not, there remained severe limits upon what they could achieve.

PHARMACY

Pharmacy underwent significant change as the range of remedies was extended, thanks to the retrieval of classical drugs, the discovery of new vegetable products from America and the Indies, and the increasing use of chemical substances. Herbs – understood in the widest sense as the leaves, seeds or fruits, bark and roots of plants, shrubs and trees – had always been the prime ingredients of medical remedies. If used individually, apothecaries called them ‘simples’; combined into a compound drug, perhaps with animal and mineral ingredients, they would be called ‘Galenicals’. Herb gathering (simpling) and preparation of remedies were domestic skills practised in the family, but there was also a commercial side to herbal medicine.

With the Greek revival, physicians became concerned that the remedies then in use were inferior, and sought to recover the original materia medica used by the ancients. This required the reform of botany, since there was no uniform nomenclature, leaving plant identification chancy. Botany enjoyed its own humanist renaissance: medieval authors were denounced for their barbaric language and for corrupting ancient texts, and there was a call for pure editions of classical botanical works. The great scourge of the pharmacists was the Paris humanist Symphorien Champier. About 1513 he issued his Myroel des Apothecaires, whose subtitle reveals his position: The Mirror of the Apothecaries and Druggists in Which is Demonstrated How the Apothecaries Commonly Make Mistakes in Several Medicines Contrary to the Intention of the Greeks … on the Basis of the Wicked and Faulty Teachings of the Arabs.

Around the mid fifteenth century manuscripts of Theophrastus’ Historia plantarum [The History of Plants] and De causis plantarum [On the Causes of Plants] were brought from Constantinople and translated into Latin by Theodore Gaza. Galen’s De simplicium medicamentorum facultatibus [On the Powers of Simple Remedies] had been used in the medieval universities, but in 1530 a new Latin translation was published, corrected by reference to ‘old manuscripts’. More important, however, as a vehicle for medical botany was the De materia medica of Dioscorides (fl. AD 50–70), which galvanized the botanical revival. The work had been known in Latin to the Middle Ages, but humanists collected Greek manuscripts, and the Aldine Press published a Greek edition in 1499.

With the Dioscorides revival, herbals themselves changed. The earliest printed ones were compiled from medieval sources, but later works by William Turner (c. 1510–68), Leonhart Fuchs (1501–66) and others became more naturalistic, both verbally and pictorially, mirroring the Renaissance anatomy atlases. The first to abandon the old stylized pictures was the Herbarum vivae eicones (1530) [Living Images of Plants] of Otto Brunfels (d. 1534), town physician of Bern. The artist Hans Weiditz (d. c. 1536) (school of Durer) gave this herbal its innovative look. When his plants did not tally with Dioscorides’, Brunfels tried to force identifications.

He described 258 different plants; ninety-seven years later, Caspar Bauhin’s (1560–1624) Pinax theatri botanici (1627) [A Catalogue of Botanical Theatre] included around 6,000 specimens. This stupendous increase was achieved through individual and collaborative efforts. The first chair in botany was established in Padua in 1533; botanical gardens were created in Pisa and Padua in 1544–5, with other universities following: Bologna, Leiden, Leipzig, Basel and Montpellier. Plants, however, were not always available and altered with the seasons; this made the artificial or dry garden (hortus siccus) an invaluable invention, allowing rare plants to be preserved or exchanged, and providing teaching material and draughtsmen’s models.

A great boost was provided by Pier Andrea Mattioli (1500–77), who in 1542 became physician to the province of Gorizia, where he worked on a commentary of Dioscorides. Published in 1544, his edition of De materia medica became the spur for botanical and pharmacological research, earning its author European celebrity. Like Linnaeus later, Mattioli had a gift for inspiring collaborators to travel, collect and send him specimens. Expanding with each edition, the work culminated in the version of 1565, a lavishly illustrated Latin folio running to nearly 1500 pages, bejewelled with full-page illustrations.

As the entrepôt of the Mediterranean, enjoying close links with the Middle East and the overland spice trade from the Indies, Venice was the natural centre for the humanist goal of recovering classical medicaments. Not least, the Venetian Republic controlled Crete and Cyprus, the herb gardens of the ancients. Drugs unknown to the latin West – balsam and myrrh for instance – were rediscovered. Famous for its purging powers, rhubarb had entered Europe through the overland trade routes from the East; by the early seventeenth century, seeds from Bulgaria allowed one medically valuable type of rhubarb (Rhaponticum, from the Pontus or Black Sea) to be grown in Europe, while search continued for the ‘true’ rhubarb which Marco Polo had reported in 1295 as deriving from China. Theriac, that panacea of the ancients, composed of up to a hundred herbal, animal and mineral ingredients, seemed in the 1540s quite impossible to compound; many of its ingredients were unknown and more than twenty substitutes were needed. But by 1566 the Veronese botanist-pharmacist Francesco Calzolari (1522–1609) was using only three proxies. Physicians grew confident that the remedies of the ancients had been recovered.

Thanks to Iberian voyages of discovery, new drugs filtered in, together with foodstuffs like potatoes. Cocoa came back with Cortés in 1529, becoming a favourite drink, a specific for ‘wasting diseases’, a stimulant, and even the basis of cocoa-butter suppositories. Meanwhile the Portuguese had rounded the Cape of Good Hope in 1487–8 and reached India in 1499. By 1512–13 they landed in the legendary Spice Islands, the Moluccas, whose spices had traditionally arrived in Europe via the overland route.

Remedies from distant parts entered into scholarship, particularly through the writings of Nicolas Monardes (c. 1493–1588) and Garcia d’Orta (1501–68). Educated at Seville, Monardes commented that New World drugs were inferior to those of Spain (pharmaceutical chauvinism was strong), but he later changed his mind, enthusiastically praising their powers in his Dos Libros (1565–74). The book followed a standard format, giving for each plant its place of origin, appearance, colour, properties and uses. New World plants posed problems, for their virtues were uncertain. This led him to concentrate on the distinguishing marks of the new plants and to describe how they were processed by the American Indians. Together with coca, jalap, sarsaparilla and sassafras (these latter famed for blood-cleansing), one of his best-known descriptions was that of tobacco, which he praised for curing head pains, toothaches, bad breath, chilblains, worms, joint pains, swellings, poisoned wounds, kidney stones, carbuncles and fatigue. Its efficacy derived from its heating and drying qualities. Despite King James I’s strictures against ‘this filthy custom’, tobacco enjoyed a high medicinal reputation in the seventeenth century.

In the face of the terrifying syphilis epidemic, imported plant remedies might appear godsends, for treatment with mercury was almost worse than the disease. In the Caribbean the Spaniards saw syphilis (more probably yaws) treated by decoctions made from guaiac wood (Guaiacum officinalis); by 1508 this was being imported into Spain and its use became widespread. Also known as ‘holy wood’, guaiac was obtained from evergreens indigenous to the West Indies and South America. The folk belief that God planted cures where diseases arose reinforced the conjectural New World origin for syphilis. Shiploads of guaiac were imported into Europe, organized by the Fuggers of Augsburg, the mercantile and banking family who monopolized the trade and profited mightily. The German humanist and soldier Ulrich von Hutten (1488–1523) experienced the horrors of the mercury treatment; he went through eleven mercury cures in nine years, then he heard of guaiac, and after repeated infusions believed he was cured. Von Hutten’s De guaiaci medicina et morbo gallico (1519) [On the Guaiac Remedy and the French Disease] was translated into German and French, but by the time Monardes wrote in 1565 guaiac was losing support.

One key remedy from the East was opium, largely imported from Turkey. It had been in use in Egypt in the second millennium BC, and Avicenna called it ‘the most powerful of stupefacients’. Ever the queen of drugs, it was profusely used in western medicine from the sixteenth century, and Thomas Sydenham (1624–89) later proclaimed that ‘among the remedies which it has pleased the Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.’ It seemed the wonder drug; not just a pain-deadener, it also stopped dysentery and relieved respiratory disorders.

India supplied new remedies. In 1563 Garcia D’Orta published Coloquios dos simples, e drogas he cousas mediçinais da India [Dialogues on Simples and Drugs and Medical Matters from India] which described such eastern products as aloes, camphor, sandalwood, ginger, asafoetida and betel, and new fruits such as mangoes. Like the Italian humanist botanists, he had to confront identification problems. (Was modern cinnamon the ‘canella’, ‘cinnamon’ or ‘cassia’ of the ancients?) Other eastern drugs filtered to the West later, including Chinese rhubarb and ginseng, introduced in the eighteenth century by the Jesuits.

Thanks in part to the labours of the botanists and the importation of new drugs, the apothecary’s trade boomed, though for many (witness Romeo’s remarks) the apothecary remained a wretch vending poisons:

I do remember an apothecary

And hereabouts he dwells – whom late I noted

In tatter’d weeds, with overwhelming brows,

Culling of simples; meagre were his looks,

Sharp misery had worn him to the bones;

And in his needy shop a tortoise hung,

An alligator stuff’d and other skins,

Of ill-shap’d fishes …

Like other branches of medicine, apothecaries organized themselves. In England, James I recognized them as a special body in the Grocers’ Company in 1607, and ten years later they gained their independence, organizing as the Masters, Wardens, and Society of the Art and Mystery of the Apothecaries of the City of London.