CHAPTER XXXVII. The Development of Surgery in Italy During the Renaissance

THE DEVELOPMENT OF SURGERY IN ITALY DURING THE RENAISSANCE

During the latter part of the fifteenth, all of the sixteenth and the early part of the seventeenth centuries quite a large number of Italian surgeons attained honorable distinction by the contributions which they made to the science of medicine; and even in the neighboring Latin countries of Spain and Portugal,--countries in which the force of the revival of all departments of learning had made itself felt to a much feebler degree, and in which at the same time the opposition to such revival was much more active,--several surgeons succeeded in winning creditable places for themselves in the history of their art. The names of the Italian surgeons are as follows: Giovanni da Vigo, Bartolommeo Maggi, Marianus Sanctus, Fallopius, Carcano Leone, Fabricius ab Acquapendente, Aranzi and Tagliacozzi. I will now add brief notices of the careers of all these men, in order to convey at least some idea of the grounds upon which their claim to honorable distinction rests.

Giovanni da Vigo--perhaps more frequently referred to in literature by the French form of his name, “Jean de Vigo”--was born at Rapallo, near Genoa, Italy, about the year 1460. He was the son of Bernardo di Rapallo, who was also a surgeon; and he himself was the founder of a school which sent out quite a number of practical surgeons. In 1485 he began the practice of his profession at Saluzzo, a small town about forty miles south of Turin; and ten years later he settled at Savona, which is located on the Mediterranean, a short distance to the west of Genoa. In 1503 he was chosen the personal physician of Cardinal Giuliano della Rovere, who resided at Savona, and he continued to hold this position after the cardinal was elected to the papal office under the name of Julius the Second.

Da Vigo’s great treatise on surgery (“Practica in arte chirurgica copiosa continens novem libros,” Rome, 1514) owed its celebrity, during the early part of the sixteenth century, chiefly to the fact that he was the first author to write somewhat thoroughly upon syphilis and upon gunshot wounds--two surgical disorders of great importance at that time. As to gunshot wounds, da Vigo was one of the first to maintain that they were poisoned wounds; and for a long time afterward this was the generally accepted opinion. Like all his contemporaries, da Vigo was not willing to undertake such operations as those for the cure of stone in the bladder, for the relief of cataract, and for the cure of hernia. He left these, says Haeser, to the itinerant surgeons. But he gained well-merited credit by his employment of ligatures for the arrest of bleeding in a variety of conditions--not, however, in amputations, as he appears to have avoided cutting operations. According to the same authority, the circular pattern of trephine (the kind which the surgeons of the present day prefer) was first introduced by da Vigo. The following passage copied from his “Practica” shows that he was familiar with the use of the ear speculum: “... si ad solem speculo instrumento aure ampliata.” Da Vigo died soon after 1517.

Bartolommeo Maggi, who was born at Bologna either in 1477 (Haeser) or in 1516 (von Gurlt), held the Chair of Anatomy and Surgery in the medical school of his native city, and then at a later date accepted the position of private physician to Pope Julius the Third (1550–1555). He held this position, however, only for a short time, as he found that the climate of Rome did not agree with him. His posthumous fame rests largely on the treatise which he wrote on gunshot wounds and which was published by his brother a short time after the former’s death. His treatise, says von Gurlt, is one of the best of those which were published on this subject during the sixteenth century. Henry the Second, King of France, expressed his gratitude to Maggi for the care which he took of the wounded French soldiers who fell into the hands of the papal troops at the sieges of Parma and Mirandola. Maggi maintained firmly the belief that gunshot wounds are either poisoned or burned. His death occurred in 1552. The title of his treatise on gunshot wounds is: “De vulnerum bombardarum etc.,” Bologna, 1552.

Marianus Sanctus of Barletta near Naples (born in 1489, died at some unknown date after 1550) is credited with having been the first to publish a description of the so-called “apparatus magnus”--the name given in those early days to the method of extracting a calculus from the urinary bladder through an incision in the perineum after a grooved sound or director had first been passed into this organ by way of the urethra. The title of the book in which this description is given is the following: “De lapide renum liber et de lapide ex vesica per incisionem extrahendo,” Venice, 1535. Marianus, however, does not claim to have been the inventor of this method. Some writers give the credit for this to Jean da Vigo’s father, Bernardo di Rapallo, who communicated a knowledge of the method to Giovanni de Romanis, who in turn instructed Marianus Sanctus. It is believed, furthermore, by some writers that Giovanni de Romanis was the inventor of lithontripsy--the operation of crushing a stone in the bladder or urethra. Laurent Colot, the famous French lithotomist of the eighteenth century, obtained his knowledge from a certain Octavianus de Villa, a friend of Marianus Sanctus, and then kept the matter secret for many years.

Fallopius, the famous anatomist of the early part of the sixteenth century, does not appear to have attained equal distinction in the field of surgery. So far as one may judge from the portions of the text selected from his writings by von Gurlt, Fallopius was a very conservative if not a very timid surgeon, in this respect being not unlike Fabricius ab Acquapendente. In the text to which reference has just been made, I find a brief mention of a case which passed under Fallopius’ observation and which, perhaps, is of sufficient interest to be recorded here. The patient’s--a German student’s--finger had been nearly severed by some cutting instrument, and the greater part of the member remained attached to the hand only by a narrow strip of flesh. “I stitched together the separated edges, and at the end of three or four days I was astonished to find that firm union between the separated parts had already taken place. This result seemed to me like something miraculous.”

Carcano Leone was born at Milan in 1536, his parents being people of good social standing. After receiving a thorough classical education, he began his medical studies in his native city, under the guidance of Pietro Martire, a pupil of Vesalius. He next continued his studies at the University of Pavia, but eventually went to Padua, where he enrolled himself among the pupils of Fallopius. After a residence of two years in that city, he returned to Milan and opened a medical school of his own. Upon the occasion of the death of the Cardinal and Archbishop Carlo Borromeo, whose remains now rest in the cathedral of Milan, it was Carcano Leone who was invited to make the postmortem examination. He carried on the practice of his profession during a period of about twenty-eight years, his death occurring--so far as may now be learned--in 1606.

Carcano Leone’s reputation as a surgeon rests mainly on the treatise which he wrote on the wounds of the head, and which was published at Milan in 1583. From among the numerous cases of this character which came under his observation, and of which a certain number are reported by von Gurlt, I have selected the very brief histories of three that seem to me well adapted to serve as examples of Leone’s knowledge of surgery and also of his ability to cope with problems of so serious a character. They reveal the fact that he was a surgeon of excellent judgment, most persevering, and very resourceful. Briefly told, the accounts of the three cases to which I have referred read as follows:--

Case I.--A small boy was hit on the right temple by a stone that had been thrown by one of his companions. Unconsciousness resulted and lasted for six days. On the seventh day signs of returning consciousness manifested themselves, but inability to speak persisted. By the end of another week the boy had already made some efforts to speak, but his speech was incomprehensible. After the twentieth day it was possible to understand a little of what the boy was trying to say; and from this time onward steady improvement in this respect was recognizable from day to day; but the boy’s speech did not become quite normal until after the lapse of about a year.

When Carcano Leone was called to see the patient he found that the entire temporal muscle had been crushed and that almost the entire right side of the head was occupied by a fluctuating swelling. By making a free incision in the swelling Leone gave exit to a large quantity of black coagulated blood. On the following day, when he made an examination with the probe, he found that the entire squamous portion of the temporal bone was in a fractured state, one part of it overriding the rest. By the aid of elevators he succeeded in lifting up the depressed part of the bone, but the accomplishment of this result left a large gap between the opposite edges of the fragments, and through this opening one could see the movements of the dura mater. Complete healing took place only after the lapse of twelve months.

When Leone reported the case to his former teacher, Fallopius, the latter replied that he would not have had the courage to adopt the course which his former pupil had pursued.

Case II.--In another case the patient, a full-grown man, was struck on the right temple by a highwayman with a heavy cane which broke in two in the middle under the great force which the assailant had employed. He was left lying on the roadside in a state of unconsciousness until some passers-by discovered him and carried him to his home. He remained unconscious for several days. Before the physician was summoned all sorts of measures had been resorted to for the purpose of dissipating the swelling in the temporal region, but without success. Leone, on arriving upon the scene, made a free incision which afforded escape to a large quantity of decomposing blood that appeared to be collected, not between the muscle and the skin, but between the muscle and the bone. The latter was found to be fractured transversely and depressed; and, in order to lift it back to its proper level, it became necessary first to incise the muscle transversely. At the end of three months the wound had completely healed and the patient had regained his health.

Speaking of the cases just narrated and of others of a similar nature, Leone remarks that he has never had any experience that would justify the fear expressed by Hippocrates that convulsions are likely to result from dividing the temporal muscle.

With reference to the value of trephining the skull in cases of injury to the head, Leone narrates the following experience:--

Case III.--A man was struck by a heavy stone on the upper part of the forehead close to where the hair grows, and was thrown to the ground by the force of the blow. Here he lay as if dead. When Leone was called, a short time afterward, to see the patient he found the skin unbroken except at one small spot, and from this point he made an incision of such length that he was thereby enabled to explore the surface of the skull. In this way he discovered that there was a fracture which appeared to extend through the entire thickness of the skull. He then, without further delay, trephined the cranium over the line of the fracture. This was followed by such a copious flow of blood that Leone was obliged to adopt measures for arresting any further hemorrhage. During the following fourteen days (the summer season then being at its height) large quantities of decomposed and evil-smelling blood escaped from the wound; but the dura mater gradually assumed a more natural appearance, many splinters of bone were ejected, and finally--at the end of forty days--the wound healed. (As no further details are given in the text, it is fair to assume that there were no sequelae of an unfavorable nature.)

The whole subject of injuries to the skull is treated in a most thorough manner by Leone, and the book is pronounced by Scarpa (1752–1832), the famous anatomist, the best that, up to his time, had been written on the subject. The three histories of cases which I have here reproduced and which furnish such striking proof of what surgery may accomplish when practiced by a man of good courage as well as of good judgment, certainly justify the favorable opinion expressed by Scarpa upon Leone’s work.

Fabricius ab Acquapendente, of whom I have already given some account on a previous page, was distinguished not only as an anatomist and as a physiologist, but also--which was true of his instructor, Fallopius--as a surgeon. From his published writings, however, it appears very clearly that, like Fallopius, he had a decided aversion to the use of the knife; his activities as a surgeon being restricted largely to the improvement of certain of the more bloodless operations (for example, tracheotomy and thoracentesis and operations for the relief of stricture of the urethra). He also invented several new surgical instruments and devised a number of machines for use in orthopaedic practice. He attached great value to the teachings of Celsus and Paulus Aegineta, his writings containing frequent and copious references to these authorities and relatively few data based upon his own experience. In the section which he devotes to the subject of wounds of the abdomen, Fabricius confirms the opinion very generally held by the ancients, viz., that a wound of the small intestine is invariably fatal.

Gaspare Tagliacozzi was born at Bologna in 1546. He studied medicine under Girolamo Cardano, Professor of Medicine, first at Pavia and afterward at Bologna, and received his degree (“Doctor of Philosophy and Medicine”) in 1570. Very soon afterward he began teaching surgery, and a little later he also taught anatomy and the theoretical part of medicine. In this work he was so successful that in 1576 he was made a member of the Faculty. He died on November 7, 1599, at the age of fifty-three.

The Italian method of performing plastic operations, says von Gurlt, had already flourished for about one hundred and fifty years before Tagliacozzi took up the subject in serious earnest and attained results of decided scientific value. There are some doubts, however, as to the precise degree of credit that should be awarded Tagliacozzi for his share in the development of the operation which bears his name. The facts which throw some light upon this question may be stated in the following paragraphs:--

(1.) Tagliacozzi’s Latin is not easy to understand, and he certainly does not furnish satisfactory information as to the manner in which he learned the details of the operation which we are here considering. Vesalius, Paré and other surgical authors of that period throw no light upon that question and furnish erroneous descriptions of the steps of the operation. Apparently they had never witnessed one of that character. (Von Gurlt.)

(2.) The records seem to warrant the statement that, about the middle of the fifteenth century a surgeon by the name of Branca, who lived in the city of Catania on the southeast coast of Sicily, devoted himself largely to the reconstruction of damaged or defective noses. At first he transplanted a flap from the forehead or cheek; but afterward his son sought to improve the method by utilizing a flap of skin taken from the arm. By this plan the disfiguring of the patient’s face was avoided. The son employed the same method in repairing the lips and the ears. Pupils of the latter carried a knowledge of the method to the Bojano (Vianea or Vieneo) family in Tropea, Calabria, and from them it was transmitted, about the middle of the sixteenth century, to Tagliacozzi and eventually to the medical profession in every part of the world.

(3.) In 1581 there was published at Cracow, Galicia (formerly Poland), a book which bore the title “Przymiot” and which gave a most complete account of the disease syphilis in all its manifestations and complications. This book, in its original form, is to-day one of the greatest bibliographical rarities; but a reprint of the work was published in 1881 by the Warsaw Surgical Society. In this volume Wojciech Oczko, the personal physician and secretary of the Polish kings Stephan Bathory and Sigismund the Third, discusses other surgical topics beside syphilis. He states, for example, that Aranzio (or Arantius), who was Professor of Surgery at Bologna at the time (1569) when he frequented that medical school, was successful in making a new nose by transplanting a flap of skin from the patient’s arm; and that he performed this operation without injuring the muscles of the arm, and also with perfect success as regards the creation of a straight and shapely nose. “This statement,” says von Gurlt, “coming as it does from an eye-witness who was at Bologna several years before Tagliacozzi’s time, furnishes satisfactory proof that rhinoplasty was successfully performed in that city several years before the date of publication (1586) of Tagliacozzi’s earliest comments on the subject, and that the credit for first bringing the operation to the knowledge of European surgeons is due to Aranzio rather than to Tagliacozzi.” The latter’s famous treatise on rhinoplasty (“De chirurgia curtorum per insitionem”) was published at Venice in 1597.

(From the treatise published by Tagliacozzi, Venice, 1597.)]

(4.) Fabricius of Hilden, the distinguished German surgeon of the sixteenth century, assures us that his teacher, Jean Griffon, at that time the leading surgeon of Lausanne (but, at an earlier period, of Geneva), performed the same operation in 1592. The patient was a young Genevese woman whose nose had been cut off by some soldiers belonging to the army of the Duke of Savoy who were enraged at the resistance which she offered to their familiarities; and the operation proved most successful, “the new nose eliciting the admiration of all who saw it.” Fabricius adds that during the winter seasons, up to the year 1613, the tip of this nose presented a somewhat purplish hue. The woman married in 1603.

(5.) During the short lifetime of Tagliacozzi several tablets, on which laudatory inscriptions were engraved, were erected in the high school (archiginasio) of Bologna, and after his death a bust that represented him holding a nose in his hand was erected in the same building. Corradi, the medical historian (1833–1892), writes that in his time both bust and tablets had disappeared. Tagliacozzi’s remains were temporarily lodged in the cloisters of the church of San Giovanni Battista, and the report was circulated that, a few weeks after his death, a voice was heard saying that he was among the damned. Thereupon the remains were removed to the walls of the city, and the Tagliacotian method was soon forgotten, to be revived only after the lapse of many years.

All the data which I have reproduced in the preceding paragraphs seem to point to the conclusion suggested by von Gurlt, viz., that Tagliacozzi was willing to accept for himself a credit which belonged in reality to another, and that there would be more justice in calling the famous rhinoplastic method of procedure “the Arantian operation” than the Tagliacotian; especially as our knowledge of the method adopted by the younger Branca is entirely too vague to justify us in bestowing this honor upon him.

Giulio Cesare Aranzio (or Arantius) was born at Bologna about the year 1530. He studied medicine first in his native city, under the guidance of his uncle, Bartolommeo Maggi, and then afterward went to Padua, where he may possibly have been one of Vesalius’ pupils. In 1548 he made, at Padua, his first anatomical discovery--that of the musculus levator palpebrae superioris. Before he was twenty-seven years old he was chosen Professor of Medicine, Surgery and Anatomy in the University of Bologna, and he filled the position with distinction up to the time of his death on April 7, 1589--i.e., during a period of thirty-three years.

The part taken by Aranzio in the advancement of surgery was apparently of small importance. He succeeded, it is true (see remarks on page 479), in reviving the interest of contemporary surgeons in the possibility of restoring damaged parts of the human face by means of flaps taken from the patient’s arm. But I have not been able to discover that he made any other material contributions to this department of the science of medicine. It is possible, however, that his plan of illuminating the interior of the nose and of operating upon nasal polypi may possess some measure of originality; but I do not feel competent to decide this question. As regards the procedure just referred to, it may be stated briefly that Aranzio was in the habit, when operating within the nasal cavity, of using by preference, for illuminating purposes, the direct rays of the sun, which were allowed to enter the room through a slit or hole in the wooden window blind; and, when sunlight was not available, he used as a source of light the rays emanating from a lighted wax candle. In the latter case he increased the brilliancy of the illumination by interposing between the flame of the candle and the illuminated field, a glass globe filled with water,--an idea which probably originated with the goldsmiths or the shoemakers. The employment of light reflected from a concave mirror supplanted this method somewhere about the year 1866.

In Italy, during the sixteenth century, there were several surgeons--uneducated empirics--who contributed not a little to our knowledge of the radical cure of hernia; and of this number the members of the Norsa family (from Norsa, a small town in the district of Naples) were undoubtedly the best known and most experienced operators. Horazio Norsa, for example, is reputed to have performed the radical operation (in combination with castration) no less than two hundred times. It was this same Horazio Norsa who, in the latter part of his career, complained to Fabricius ab Acquapendente that, since the wearing of trusses had become so common a custom as it then was, the number of operations for the cure of hernia had greatly diminished.