CHAPTER XLI

SURGERY IN GREAT BRITAIN DURING THE SIXTEENTH AND SEVENTEENTH CENTURIES

In Great Britain the cultivation of the science of medicine began at a much later date than it did on the continent of Europe, and, so far as may be judged from the facts within our reach, there were, in the early part of the sixteenth century, very few Englishmen who could justly lay claim to the possession of more than the rudiments of the art of surgery. Two centuries earlier, as I have already stated in a previous chapter, there were three men in England who gained considerable fame in this department of medicine. They were Gilbert “the Englishman” (1210), John of Gaddesden (1320), the author of the famous book entitled “Rosa Anglica,” and John of Ardern (circa 1350); but afterward, for a period of nearly two hundred years, the records fail to reveal to us a single surgeon of any note. Then during the sixteenth century the only English surgeons whose names deserve to be perpetuated are Gale, Clowes and Woodall, of whom I shall presently give brief accounts. They were all at one time or another, as in the case of the leading continental surgeons of that period, officially connected with the army. Some idea of the unsatisfactory state of the medical service in the English army of that period may be gathered from the statements made by Gale regarding this matter. From his account it appears that in 1544 the army was accompanied by a miscellaneous crowd of men who were supposed to be in some measure physicians, but who in reality were uneducated quacks, vendors of all sorts of dressings and washes for wounds, of infallible cures for gunshot injuries, etc. The mortality in the English camp was, as might readily be expected, very heavy. The same state of things existed, at a somewhat later date, in the fleet sent against the Spanish Armada. It is not to be wondered at, therefore, that very few of the educated surgeons were willing to accept service in the English army or the English fleet, especially as the pay which they received was no greater than that of the drummers and trumpeters. Toward the end of the century much greater attention was paid to the care of the wounded and crippled, and, in corroboration of this, it may be stated that Henry the Fourth, King of France,--who, it may safely be assumed, was influenced to take this step by the enlightened advice of Ambroise Paré,--ordered the establishment of military hospitals for the use of the army which was at that time besieging Amiens. And again, at a later date (1603), there was established at Paris a retreat for old and infirm or mutilated officers and soldiers.

It is an interesting fact that during the year 1544, while Henry the Eighth of England, in alliance with the German Emperor Charles the Fifth, was carrying on the war against Francis the First, King of France, there were present, on the soil of the latter country, all the leading European surgeons of that period--viz., Ambroise Paré, with the French army which was laying siege to Boulogne-sur-Mer (captured a few months earlier by the English troops); Thomas Gale, the most famous surgeon of that day in England, with the army of the besieged; and Vesalius and Daza Chacon with the troops of Charles the Fifth at Landrecy (near the Belgian boundary, south of Brussels) and at St. Didier (in the northeastern part of France). I have already, in preceding chapters, given brief accounts of the lives and professional accomplishments of all these surgeons with the exception of Gale, and it only remains now to supply such information as may be obtainable concerning the latter and also concerning his contemporaries, the English surgeons Clowes and Woodall.

Thomas Gale.--Thomas Gale was born in London in 1507, practiced medicine for some years in that city, and then, in the capacity of a surgeon, entered the service of the army under Henry the Eighth. At a later date he joined the army of Philip the Second of Spain. In 1544 he was present at the battle of Montreuil in France, and he was also present at the siege of St. Quentin, in 1557. Two years later he returned to London and became a member of the Barber-Surgeons’ Company. His death occurred in 1587.

Gale was the author of several books on surgical subjects, the most important of these works being that which deals with gunshot wounds. His views regarding wounds of this nature agree in the main with the teachings of Ambroise Paré; and yet, according to von Gurlt, he appears to have formed his opinions independently, for he does not once mention that surgeon’s name. He was not only a skilful surgeon, but also a man of scientific and literary tastes, as shown by his translations of some of Galen’s writings and of Giovanni da Vigo’s treatise on surgery, and also by his own published works. His book on gunshot wounds, to which reference has already been made, is the one which reflects the greatest credit upon the author. One of its chief merits is to be found in the fact that it enabled the physicians of England to keep in some measure abreast of their brethren on the continent, at least in the matter of treatment by surgical means. In one part of the work he makes reference to the belief, which was held at that time by many surgeons, that the bullet not only scorched the flesh of the wound which it inflicted but also introduced into it a poisonous element. I quote here one or two extracts from the comments to which I have just referred:--

The usuall Gonnepouder is not venemous, nother the shotte of such hoteness as is able to warme the fleshe, much lesse to make an ascar.... Hange a bagge ful of Gonnepouder on a place convenient: and then stand so far of as your peece wil shote leavell, and shote at the same, and you shall see the Gonnepouder to bee no more set on fyer with the heat of the stone [used as a bullet] than if you caste a cold stone at it.

An English translation of Paré’s book, says von Haller, was not published until 1577. It is therefore not strange that Gale, whose book was printed fourteen years earlier (i.e., in 1563), should have made no mention of that author’s method of applying ligatures to the bleeding vessels of an amputation stump. The first reference (in English) to this plan of preventing hemorrhage from the divided blood-vessels in an amputation stump occurs--so far as I have been able to discover--in the treatise published in London by William Clowes, in 1588, under the title “A prooved practise for all young chirurgians etc.” Clowes, however, erroneously gives the credit for this important procedure to Guillemeau, one of Paré’s pupils.

In one of his writings Gale states, after witnessing the surgical practice at the Royal hospitals of St. Bartholomew and St. Thomas in 1562, “that it was saide that Carpinters, women, weuvers, coblers and tinkers did cure more people than the chirurgians.” (South.)

William Clowes.--William Clowes was born, about the year 1540, at Kingsbury, in Warwickshire, and received his early training in surgery under George Keble of London. In 1563 he accepted the position of surgeon in the army which was under the command of Earl Ambrose of Warwick and was stationed at that time in France. Six years later he settled in London, and was made a member of the Barber-Surgeons’ Company. In 1575 he received an appointment on the Surgical Staff of St. Bartholomew’s Hospital and six years later still he was promoted to the rank of full surgeon, a position which he already held in Christ’s Hospital. In 1585 he resigned his appointment at St. Bartholomew’s and accepted an invitation to serve in the Earl of Leicester’s army, which was at that time in the Netherlands. During this war Clowes acquired a rich and varied experience in the treatment of wounds. Soon after his return to London in 1588 he joined the fleet which vanquished the Spanish Armada. Later, he was given the appointment of Surgeon to the Queen. His death took place at Plaistow, County of Essex, in August, 1604. Von Gurlt does not hesitate to qualify him as one of the most distinguished English surgeons of his day.

Of the four surgical treatises which were written by Clowes, and of which several editions were published between the years 1575 and 1637, there is only one to which I shall refer in this brief account, viz., that which, in the edition of 1637, bears the title: “A profitable and necessarie Book of Observations, for all those that are burned with the flame of Gun-Powder.” This book is full of brief histories of cases which came under the author’s personal observation, and it therefore furnishes an excellent and truthful picture of the kind of wounds which the highwaymen and soldiers of that day inflicted, and of the treatment which was employed by the best English surgeons. The following may serve as sufficient examples:--

(1) A clothier, who had been assailed by robbers, received a dangerous wound in the left thigh. It was about four inches long and of such a depth that “the rotula or round bone of the knee did hang downe very much.” Clowes first removed a clot of blood from the wound and then, “with a sharp and square-pointed needle, armed with a strong, even and smooth silke thred, well waxed, introduced five stitches, one good inch distant betweene every stitch, leaving a decent place for the wound to purge at.” He then applied a suitable bandage. The patient’s friends were not at all pleased that Clowes, having pronounced the wound dangerous, should not have been willing to state how much time would elapse before it would be healed. So they called in a charlatan, who on the following day removed the dressings and cut through all the stitches. Seven days later, Clowes was once more asked to see the case. He found the wound gaping widely and in a bad state. After adopting such measures as were most urgently required, he brought the edges of the wound together by the application of three strips of sticking-plaster. In due time healing took place, “but the motion perished: for the patient had the imperfection of a stiff knee, which constrained him to use a leather strap, fastened unto the toe of his shooe, and again made fast unto his body; and so he remaineth unto this day.”

(2) The history of the second case may be given here in the following brief outlines. The patient, a ship’s gunner, was wounded in the lower part of the abdomen by what was probably a partially spent ball. The wound made by the missile was of such a nature that it permitted a large portion of the “zirbus” (omentum), together with some of the intestinal canal, to protrude from the opening. After making a careful examination of the parts, Clowes was satisfied that the intestine was still uninjured.

Then with a strong double thread I did tie fast the zirbus as close unto the wound as possible wel I might, and within a finger bredth or thereabouts I did cut off that part of the zirb that hanged out of the wound, and so I cauterized it with a hot iron almost to the knot; all this being done, I put again into the body that part of the zirb which I had fast tied, and I left the peece of thred hanging out of the wound: which, within four or five days after, nature cast forth, the thred as I say being fast tied; then presently I did take a needle with a double strong silke thred waxed, wherewith I did thrust thorow both mirach [skin, adipose layer and muscular tissue] and ziphach [peritoneum] on the right side of the wound, but on the left side of the wound I did put the needle but thorow mirach only, and so tied these three fast together with a very strong knot, and presently I did cut of the thred.... All which is according to Weckers and other learned men’s opinions and practices, who also say that the stitches of the one side must be higher than on the other side. [The usual dressings were afterward applied and were renewed three days later. At the end of twenty-one days the wound was found to be completely healed.]

In chapter 27 of the same work there is given a list of the medicaments and instruments with which a field-or ship’s-surgeon should be equipped before he engages in active service. From this list I select the following items as showing--at least in some measure—--in what respect the tools employed by surgeons four hundred years ago differ from the modern ones of a similar character: “Small and long waxe candles to search the hollownesse or depth of a wound.” “Small buttons or cauterizing irons meete to stay the flux of an artery or veine.” “A trepan.” “Needles two or three, some eight inches, some ten or twelve inches in length, having a decent eye in it guttered like a Spanish needle, and point or end blunt or round, that it offend not in the going in of it, made fit to draw a Flammula, or a pece of fine lawne or linnen cloth through the body or member that is wounded.” “As for stitching quils and other instruments, that a Surgeon ought always to carry about him, I leave unspoken of.”

In praise of one of the plasters enumerated in the list, Clowes narrates the following incident which occurred near Arnheim in the Netherlands: “A horseman was wounded with a pike neere the middle of his right thigh; the weapon so passing upwards that by good fortune it rested upon the os pubis, otherwise he had been slaine.” As the first step in the treatment, the copious bleeding was arrested; after which warm oleum hyperici [oil of St. John’s wort] was injected into the wound, then a short tent was introduced, and the sticking plaster was applied on the outside. “Thus he was cured in fourteene days, and so was ready to serve in the field again.”

John Woodall.--John Woodall or Woodhall was born in England about 1569, and was sent as a military surgeon to France by Queen Elizabeth with the troops which Her Majesty placed at the disposal of the French King, Henry the Fourth. After his return to England, Woodall was made a surgeon of St. Bartholomew’s Hospital and also Surgeon-General of the East India Company. He was already at that time a member of the Company of Barber-Surgeons of London. Woodall must have had a very extensive experience in the practice of surgery, for he states that he had performed the operation of amputation of a limb more than one hundred times. The date of his death is not known.

Von Gurlt calls attention to the fact that the first notice printed in English of Ambroise Paré’s method of ligating blood-vessels after an amputation is to be found in the treatise written by John Woodall and published in London in 1639, under the title: “The Surgeon’s Mate, or Military and Domestic Surgery.” As the first edition of this book, which was published in 1617, says nothing about Paré’s method, it seems permissible to infer that the news of this improvement, one of the most important made in surgery (1552), reached England from France only after the lapse of eighty-seven years! There can be scarcely any doubt, however, that individual English surgeons had already learned about Paré’s improved method at a much earlier date.

State of Surgery in England During the Seventeenth Century.--Before I pass on to the consideration of the state of surgery in England during the seventeenth century it seems desirable that I should say a few words with regard to the relative standing of the two branches of the medical profession--the physicians and the surgeons--in the esteem of their fellow Englishmen at this period of history. In France, it will be remembered, a surgeon was looked upon, even as recently as during the first half of the sixteenth century, as a man of inferior social standing, perhaps a shade better than an apothecary, but certainly far below his more highly educated associate--the physician. The favors extended by French Royalty to Ambroise Paré and the very high esteem in which he was held by French society in general effected a great change in the relative status of the two classes of practitioners in France; and, as a result of this change in public opinion, medical practitioners, subsequent to 1560 or 1570, were led to realize that a surgeon, if sufficiently educated, if earnestly devoted to his professional work, and if intent upon helping his fellow men rather than upon accumulating a fortune, might confidently aspire to a position of equality with the best physicians of the community in which he lived. In England a similar change of opinion in regard to the honorableness of the career of surgeon took place about this time, probably in consequence of the great reputation gained by Gale, Clowes and Woodall. In both countries the change occurred slowly, and in France what was gained during Paré’s lifetime seemed afterward to be lost for a period of several years. But eventually the prevailing opinion again became favorable to the surgeons, and from that time to the present they have enjoyed an ever-increasing esteem in public opinion. But there was a brief period, early in the seventeenth century, when it must have been very galling to the pride of an honorable and experienced surgeon to be placed as it were under the tutelage of the physicians who were his official associates in certain hospitals--as, for example, in St. Bartholomew’s, London. The following extracts from the “Orders” or “Articles” of that institution (1633) explain more precisely what is meant by the use of the word “tutelage”:--

9. That no surgeon or his man do trepan the head, pierce the body, dismember or do any great operation on the body of any but with the approbation and by the direction of the Doctor (when conveniently it may be had) and the surgeons shall think it needful to require.

13. That every surgeon shall follow the directions of the Doctor in outward operations for inward causes, for recovery of every patient under their several cures, and to this end shall once in the week attend the Doctor, at the set hour he sitteth to give directions for the poor.

(From St. Bartholomew’s Hospital Reports, Vol. XXII., 1886.)

Among the English surgeons of the seventeenth century there appears to have been only one who attained some degree of eminence, viz., Richard Wiseman, who is often spoken of as the Ambroise Paré of England. Haeser mentions 1625 as the date of his birth, and at the same time states that he was in the service of the Stuart Kings from Charles the First to James the Second. It seems to me highly probable that this statement regarding the date of Wiseman’s birth is erroneous; for if it be accepted as correct, then he (Wiseman) must have been only fifteen years of age when he first started out with the prince (in 1640) on the latter’s wanderings through France and the Low Countries. On the other hand, if Wiseman was really born in 1625, then we shall be justified in assuming that he traveled with the prince at first simply as his companion and not in a professional capacity; and we shall be further justified in assuming that he acquired his medical and surgical training during his residence on the continent.

In 1650 Wiseman returned with the prince to Scotland. At the battle of Worcester he was taken prisoner by the Parliamentary army under Cromwell and did not regain his liberty until 1652, at which time he settled permanently in London. After the Restoration in 1660, his practice increased very greatly and, so far as one may judge from the large number of cases which he reports in his work on surgery that was first published in 1676, it must have been very extensive and of a most varied character. I have read many of these reports of cases that occurred in Wiseman’s practice, and have been much impressed with the thoroughly practical character of the treatment which he adopted in the majority of instances, and also with the very clear and concise manner in which he narrates the attendant circumstances--the nature of the malady or of the injuries received, the treatment which he adopted, and the final results attained. In the belief that they may furnish corroborative evidence of the statements which I have just made, I now take the liberty of reproducing here two of these reports of cases:--

(1) Whilst I was a prisoner at Chester (1651), after the battel of Worcester, I was carried by Colonel Duckinfield’s order to a man that out of much zeal to the Cause, pursuing our scattered forces, was shot through the joint of the elbow; the bullet entering in at the external part of the os humeri, and passing out between the ulna and radius. He had been afflicted with great pain the space of six weeks. I found the wound undigested, and full of a loose, soft, white flesh, the bones fractured, and not likely to unite, many shivers lying included within the joints, and incapable of being drawn out. The lower part of the arm was oedematous to the fingers’ ends as full as the skin could well contain, and the upper part was inflamed; also about the os humeri and axilla a perfect phlegmon was formed. The patient thus tired with pain, desired to be cured or have his arm cut off. To which purpose he had procured the Governor’s leave for my staying with him. But, while that phlegmon was upon the upper parts, there was no hope of a prosperous amputation, nor of cure while those shivers of bone lay pricking the nervous parts within the joint. The phlegmon was too forward for repercussion, and yet not likely to suppurate in less than a week’s time. Wherefore I endeavored by emollients and some discutients to succour the grieved shoulder and parts thereabout by hindering the increase of the phlegmon, and to give some perspiration to the part. Then with good fomentations I corroborated the weak and oedematous member below; in which end I also raised his hand nearer to his breast. Also by detergents and bandage I disposed the wounds and fractured part to a better condition, made way for discharge of matter, and endeavored to extract the shivers of bones; then applied medicaments to remove the caries. After some days the abscess suppurated in the upper part of the shoulder and in the armpit; and while the matter discharged from thence, the tumour discussed, and that upper orifice cured soon after. But the continual pain in the fractured joint kept that opening in the axilla from healing. The patient growing weaker, and without hopes of cure, I was necessitated to proceed to amputation. To which purpose I sent to Chester to Mr. Murry, a knowing chirurgeon (since Mayor of that city), to come with instruments and other necessaries, whereby I might the better do the work. He accordingly came, and we prepared dressings ready; which were stupes or pledgits of fine short tow well worked, some like splenia [bandages], others were round, and bigger or less. We wetted them all in oxycrate [water and vinegar], and dried them; et cetera....

The apparatus thus made, and the patient some while before refreshed with a good draught of caudle [a hot drink made of spiced and sugared wine], his friends took him out of his bed, and placed him in a chair toward the light. One of his servants held his arm; another of his friends held his other hand. Then Mr. Murry drew up the skin and museulous flesh of the arm towards the shoulder, whilst I made a strong bandage, some three or four fingers’ breadth, above the affected part. Then with a good knife I cut off the flesh by a quick turn of my hand, Mr. M. pulling up the flesh, whilst I bared the bones. After which, with as few motions of my saw [as possible], I separated the bone, the patient not so much as whimpering the while. After this Mr. Murry thrusting his hands downwards with the museulous flesh and skin which he had drawn upwards, I passed a strong needle and thread through the middle of the flesh and skin on both sides, within half an inch of the edges, and brought the lips close within a narrow compass; and having tied that ligature fast, and cut off the string, I passed the needle again through the two contrary sides, which I tied as close; then loosened the ligature above, and applied the little round stupes of tow spread with a quantity of Galen’s powder mixed with egg albumen. The long pledgits were applied from the middle of the stump each way upwards along the arm, over which I put on a bladder and a cross cloth, then rowled up the stump, and made the bandage under his other arm and over his neck.... He being thus dressed up, we put him into his bed. The third day we took off his dressings, and found the stump well digested, and at least two spoonfuls of matter discharged.... During which the bone exfoliated, and the stump soon after cicatrized. Then having procured a pass to come to London, I hastened away.

(2) A lady coming to town with a swelling in her left breast, consulted some of our Profession, and at last me. She said she had some years since kernels in her breast, which were judged the “King’s Evil”; upon consideration of which she was presented to His Majesty, and touched. In progress of time they swelled, and her breast being extremely painful, she desired my judgment of it. The swelling was large and round, and greatly inflamed, under which it was soft and seemed to have matter in it. The parts more distant were hard, and several tubercles lying under the skin made it unequal; yet the breast was not fixed. She urged me instantly to deliver my thoughts of it; which to decline I turned from her, and told her friend it was a cancer, and that I saw no hopes to save her life but by cutting it off. He wished me to consider how I delivered such judgment of it, two chirurgeons having lately assured her the contrary, they taking it for a phlegmon. But I, not being used to guide my judgment by what others delivered, confirmed to him what I had before said by a sad prediction, which befel her in few weeks after. And indeed there was no way then to deal with it but by cutting off her breast.

One is not a little startled, after reading a number of case-histories like the two which I have just reproduced, to discover other portions of text (Vol. I., pp. 384 and 385) which show clearly that Wiseman, although a surgeon of the most practical character and a man equipped with excellent reasoning powers when he was placed in the presence of most of the problems which are constantly being submitted to physicians for solution, was nevertheless the victim of a belief that supernatural powers may reside in certain human beings. Speaking of the cure of the “King’s Evil”--also called by him “struma” and “scrofula”--Wiseman, in the chapter which he devotes to this subject, makes the following statement:--

But when upon trial he (the chirurgeon) shall find the contumaciousness of the disease, which frequently deluded his best care and industry, he will find reason of acknowledging the goodness of God; who hath dealt so bountifully with this Nation in giving the Kings of it, at least from Edward the Confessor downwards (if not for a longer time), an extraordinary power in the miraculous cure thereof.... I myself have been a frequent eye-witness of many hundreds of cures performed by his Majesty’s touch alone, without any assistance of chirurgery; and those, many of them, such as had tired out the endeavors of able chirurgeons before they came thither.

Some years before his death, which occurred in 1686, Wiseman was given the title of Serjeant-Chirurgeon to King Charles the Second.