CHAPTER XXXIX

THE DEVELOPMENT OF SURGERY IN FRANCE DURING THE RENAISSANCE.--PIERRE FRANCO

Von Gurlt speaks of Pierre Franco as “one of the most skilful surgeons and at the same time one of the most original medical writers of the sixteenth century.” He and his contemporary, Ambroise Paré, were of French birth, and to France therefore belongs the conspicuous distinction of having contributed to medical science during the Renaissance two of its most illuminating and efficient laborers. These men, who were the leading operative surgeons in France during the first half of the sixteenth century, did not owe their education as physicians to the official training provided by the Medical Faculty, but partly to the men who were classed as barbers and surgeons, or barber-surgeons (Collège de St. Côme), and still more to their own efforts. They gathered practical knowledge wherever they might--largely from their official connection with armies during the progress of different wars. Further details with regard to their personal characters and the principal events of their professional careers will be furnished in the following brief sketches.

Pierre Franco.--Pierre Franco was born in the village of Turriers, in Provence (now the Department of Basses-Alpes), about the year 1500. He received his instruction in surgery from itinerant lithotomists, operators for cataract, hernia-healers and men of that class; and it is quite likely that, in the early days of his professional career in Provence, he was himself a practitioner of this humble type. At a somewhat later date he left the southern part of France and took up his residence in Switzerland, first at Berne and then at Lausanne. He probably left Provence because, in the early part of the sixteenth century, the Protestants of that region were being subjected to every form of persecution; and it is almost certain that Franco belonged then to the Reformed Church, for he accepted the salaried office of City Surgeon at Berne, the authorities of which city were bitterly opposed to everybody and everything connected with the Roman Catholic Church. Franco held the office named during a period of ten years, the first part of the time at Berne, and afterward at Lausanne, which latter city was then under the control of the Bernese Government. He was a very close observer, a most enthusiastic student of his art, and a man of intensely religious nature. Malgaigne, the distinguished editor of the modern edition of Paré’s writings, speaks thus of Franco: “I have no intention of writing here the history of this man who was endowed with such a fine surgical genius; I may say, however, that his was a life devoted entirely to the advancement of surgery as a science.”

As an operative surgeon, says Edouard Nicaise, Franco ranked higher than any of his contemporaries. Strange as it may appear, Ambroise Paré frequently refused to take charge of cases in which an operation for stone in the bladder, for hernia, or for cataract was required, whereas Franco owed much of his reputation to the success which he had in operating upon these three classes of cases. The latter, furthermore, did most of his work on patients who belonged to the middle class, and consequently his operations were characterized by very little of the éclat which marked a large part of the work done by Paré, who from the very beginning was befriended by Royalty and the Court circle. At the same time, says Nicaise, Franco did more than any other man of that period to enrich surgery with new discoveries.

Franco has written only two treatises. The first one, which was published in Lyons, France, in 1556, bears the title: “A Small Treatise on the Operative Treatment of Hernia”--one of the most important departments of surgery (a book of 144 pages, 8vo). The second work, which was issued in 1561, also at Lyons but by a different publisher, bears the title: “Traité des hernies contenant une ample déclaration de toutes leurs espèces, etc.” (a book of 554 pages, 8vo). This work goes very thoroughly into the subject of hernia in all its bearings, and also deals with several other important surgical topics, such as genito-urinary diseases (in both the male and the female), affections of the eyes, hare-lip, tumors, wounds in general, dislocations, fractures, amputations, etc.; in short, it is a fairly complete and decidedly original treatise on general surgery. When Franco wrote the smaller work (that of 1556), he was settled at Lausanne; but in 1561 he was living in Orange, which at that time was the capital of a Principality that belonged to the House of Nassau. A few brief citations from the larger of the two treatises will suffice to give our readers some idea of the manner in which Franco deals with the subject-matter of the book.

Franco, says von Gurlt, was one of the first surgeons--perhaps the very first--to perform the operation required for the relief of strangulated hernia and at the same time to furnish a description of the manner in which it should be performed. After mentioning the fact that the strangulation of a portion of the intestine is attended with considerable danger to the patient’s life, Franco proceeds to consider the subject in greater detail:--

Owing to the large amount of the fecal matter and gas contained within the portion of the intestine that is imprisoned in the scrotum, and also owing to the inflamed condition of the parts, it is frequently not possible to push the bowel back through the narrow aperture in the peritoneum; and this condition of things is apt to be aggravated by the constipation or by the efforts at vomiting that frequently accompany such strangulation. The vomiting, it is true, may in certain cases facilitate the desired reduction, but in others it does harm, especially by forcing more fecal matter into the scrotum. If the conditions described are permitted to continue unrelieved, death may certainly be expected to result. In a few cases the timely administration of medicine internally may overcome the difficulty, but, if this measure fail to produce the desired result, recourse must be had to surgery--not, however, if already the scrotum and neighboring genital parts have changed their color to a black, livid, bluish or some other unnatural hue, or if the hernial tumor manifest a round rather than an elongated shape, for all these signs are harbingers of death; and, as further unfavorable signs, should be reckoned a livid or black mucous membrane of the patient’s mouth, contracted nostrils, and an appreciably sunken condition of the eyes. But if, on the other hand, the scrotum possess a natural color and if it have not a spherical form but rather an oval shape, then it is proper, after a failure to secure the desired reduction by the internal use of medicine, to resort to a surgical operation.

For the proper performance of this operation the surgeon should be provided with a nicely rounded metal staff, flat on one side, and a little larger than a goose’s quill. [Paré’s grooved sound or director, says von Gurlt, had not yet at that time been invented, and this staff was intended to serve, in a crude fashion, the same purpose.] The first step is to make an incision in the upper part of the scrotum, the direction in which it is to be carried being toward the symphysis pubis. When the hernial sac is reached the staff is introduced into the slit and pushed upward between the wall of the sac and the fleshy part of the penis, the flat side of the instrument being kept uppermost, as it is upon this surface that the cutting with the scalpel or the razor is to be done. After the end of the staff has been pushed well upward the flesh of the scrotum is to be divided upon the flat surface of this instrument; all danger of injuring the intestine being thus avoided. Then the attempt should cautiously be made to reduce or replace the intestinal folds. But if these efforts fail,--owing to the excessive distension of the bowel or because the constricting band has not yet been sufficiently relaxed,--then the following steps should be taken:--Grasp the spermatic cord (“didymis”), lift up its enveloping membranes one by one with hooks, and divide each one of them completely upon one’s finger nail, up to the point where the intestine is encountered. Then, having established, between the intestinal wall and the membranous coverings of the cord, an aperture large enough to admit the end of the metal staff, push the instrument onward and upward while at the same time it is held as it were balanced in the air, so that early warning may be communicated to the holding fingers in case the instrument, as it travels onward, should become caught in the folds of the intestine--an accident, however, which the slippery nature of the outer surface of the intestine renders improbable, but which nevertheless may occur if at any point there happen to be a break in the continuity of the tissues. As the next step in the operation the cord should be completely divided high up (the incision being made upon the staff) close to the opening in the peritoneum through which the folds of the intestine forced their way, in the first instance, into the scrotum; but the surgeon must, without fear of doing harm, and remembering that he is dealing with conditions of a desperate nature, see to it that the opening made in the peritoneum is amply large. Finally, with the aid of a soft piece of linen he should return the folds of the intestine to the peritoneal cavity, etc. [The remaining portions of the description are of minor importance and may well be omitted here.]

Franco, speaking of those cases in which a portion of the omentum is found projecting into the hernial sac, lays great stress upon the importance of “not doing what many a surgeon has done in the past and what not a few are still doing in our time, viz., simply cutting off the imprisoned distal portion of this membrane and returning the remainder to the peritoneal cavity without first ligating the divided blood-vessels and then cauterizing the cut surface; the danger being that a failure to take these steps frequently leads to a fatal hemorrhage into the peritoneal cavity--an occurrence which actually happened to one of our most experienced surgeons in a case of enterepiplocele.”

There were certain operative procedures in which Franco took a greater interest than in others. Thus, for example, he was particularly fond of operating for the relief of cataract, and the results which he obtained were exceptionally favorable (180 cures out of a total of 200 cases subjected to operation). Von Gurlt quotes him as saying:--

If I had to choose between operations for the cure of cataract and abandoning all the rest of my surgical practice, I should prefer to adopt the latter course, so highly do I estimate the amount of good which I can do in this line of work, so very important does it appear to me, and so small is the amount of labor and worry which it entails.

Franco was also greatly interested in the cure of stone in the bladder, and it was while treating cases of this character that he invented the very important surgical procedure known in France as the “Franconian operation for stone in the bladder” (hypogastric cystotomy, suprapubic lithotomy). Here is the account which he gives of the circumstances under which he was led to devise this method of removing a stone from the bladder:--

I will mention here an experience which I had on one occasion when I tried to remove a calculus from the bladder of a boy about ten years of age. The stone was about as large as a hen’s egg and resisted all my efforts to extract it by way of the incision made in the perinaeum. Being in a quandary as to how I should proceed next, and the parents and friends being greatly demoralized by the suffering to which I was unavoidably subjecting their child,--they maintained, I should add, that they would rather have him die than be subjected to such awful suffering;--and being influenced also by the thought that I could not afford to have it charged against me that I was not able to extract the calculus, I deliberately decided that I would make an opening above the pubic bone, and would remove the stone in this manner. Accordingly I incised the skin above the pubes, a little to one side of the base of the penis, and carried the knife through the soft tissues down to the calculus, which I had simultaneously pushed upward by pressing the fingers of my left hand against the perinaeum, while at the same time my assistant made counter-pressure against the stone by firmly compressing the abdominal wall above the object. This method of extraction proved successful.

In due time the wounds healed firmly and the patient was relieved of his trouble, but only after a long and most serious illness.

Franco does not appear to have performed the suprapubic operation for the extraction of a cystic calculus more than once (the case just narrated), and he carefully refrains from recommending it to other physicians. Most surgical authors, says Edouard Nicaise, blame Franco very strongly for not having dared to recommend his suprapubic operation. “But I do not agree with this judgment; Franco should rather be praised for his prudence in not immediately announcing to the world his invention of an important surgical operation.”

The subsequent history of suprapubic lithotomy shows that Franco was laboring under an exaggerated idea of the dangers attending this operation. The comments of Pascal Baseilhac--a nephew of “Brother Cosmas” (the famous French lithotomist of the early part of the eighteenth century) and himself a skilled lithotomist--are worthy of being repeated here. He says (p. 318 of his “Traité sur la lithotomie,” Paris, 1804): “Franco based his unwillingness to recommend the operation of suprapubic lithotomy on the belief which was then widely prevalent, and which still persists even in our time (middle of the eighteenth century), that the making of an incision into the main body of the urinary bladder is sure to prove fatal, a belief which experience and observation have now shown to be unwarranted.”

The Franconian operation, the great value of which was not sufficiently appreciated by its inventor nor by contemporary surgeons, was revived in 1719 by an Englishman, John Douglas, the distinguished surgeon of Westminster Hospital, London, and the brother of James Douglas--the anatomist who in 1730 described so minutely the relations of the peritonaeum to the bladder (Douglas’ cul-de-sac).

In the case the history of which has just been narrated, the circumstances attending the invention of the operation known to-day as suprapubic cystotomy or “suprapubic lithotomy,” were certainly of such an unfavorable character as to call for the display of an unusual degree of courage, wisdom, patience and manual skill on the part of the surgeon in charge; and it was through a careful consideration of these facts that Edouard Nicaise was led to award such high praise to Franco for the work which he had done. Scarcely less remarkable is the talent which the latter displayed in the invention of a forceps (Fig. 22) strong enough to crush all but the hardest calculi and yet so cleverly planned that it is practicable, while the crushing end of the instrument is lying inside the bladder, to separate the blades sufficiently far apart to render possible the grasping of the stone between the jaws of the instrument without at the same moment injuriously crushing the soft parts in the narrow channel of the wound or opening.

(From Edouard Nicaise’s Pierre Franco, Paris, 1895.)

a, closed; b, open.]

In Franco’s day the belief was widely prevalent that there were remedies which possessed the power of dissolving a cystic calculus. His own opinion in regard to this matter is expressed in the following words: “I am astonished that there should be many men who do not hesitate to undertake the disintegration and pulverization of a stone in the bladder by the employment of remedies which are either to be administered by the mouth or to be injected per urethram into that organ.” He adds that a remedy strong enough to dissolve even the softer stones would become so changed and weakened in passing through the various organs which it must traverse on its journey from the mouth to the bladder that it could not possibly produce the desired effect; nor could a chemical solution strong enough to dissolve such a calculus be injected into the bladder by way of the urethra without either causing inflammation and ulceration of the walls of that organ or promptly exciting muscular contraction that would effectively expel the solution.

This seems to be an appropriate place in which to state that lithotrity was practiced at an earlier date by Antonio Beniveni (1440–1502), a Florentine physician whose writings reveal him to have been a man of a very practical and unprejudiced type of mind, a very clear writer, and a practitioner of wide experience. He also deserves credit for having been the first surgeon to revive the operation of tracheotomy, a procedure which was carried out by Antyllus fourteen centuries earlier, but which appears to have been forgotten during this long interval. He saved a patient’s life by means of the operation.

The date of Franco’s death is not known.