CHAPTER XLII. Reforms Instituted by the Italian Surgeon Magati in the

REFORMS INSTITUTED BY THE ITALIAN SURGEON MAGATI IN THE TREATMENT OF WOUNDS.--FINAL ENDING OF THE FEUD BETWEEN THE SURGEONS AND THE PHYSICIANS OF PARIS.--REVIVAL OF INTEREST IN THE SCIENCE OF OBSTETRICS

Reforms Instituted by Magati.--Cesare Magati, who was born in 1579 at Scandiano, in the Duchy of Règgio, studied medicine at the University of Bologna and received the degree of Doctor of Medicine from that institution in 1597. Immediately afterward he went to Rome and devoted himself particularly to the study of anatomy and surgery. Then, upon his return to his native land, he quickly acquired so great a reputation as a surgeon that the Duke of Bentivoglio, who was a man of enlightened views and ambitious to promote in every possible way the best interests of the University of Ferrara, offered Magati the Chair of Surgery in that institution. The offer was accepted in 1612, and Magati continued to hold the position for several years, his services being highly appreciated both by the authorities of the university and by the students. But, when his health began to break down,--he was affected with stone in the bladder,--he decided that his best course was to resign his professorship, retire from active practice, and become a Capuchin monk. When he took this step he obtained permission from the head of the Chapter to which he belonged, to resume in a limited measure the surgical work which he was so well fitted to do. But in the year 1647 his sufferings became so acute that he was obliged to visit Bologna in the hope of obtaining relief through operative interference. The operation, however, did not prove successful, and death occurred shortly afterward.

Magati effected, in a quiet and unostentatious manner, a number of desirable reforms in surgical procedures. Thus, for example, he pointed out how undesirable it is, in most cases, to change the dressings of a wound so frequently as was, at that period, the common practice. The process of cicatrization, he insisted, is not effected by the efforts of the surgeon, but is fundamentally the work of Nature. Then, in addition, he protested against the practice of introducing wicks and pledgets of lint into wounds. These criticisms and this advice, says von Gurlt, had been given many times before by different ancient authors, but they undoubtedly had to be repeated from time to time.

The treatise in which Magati has written these things bears the following title: “De rara medicatione vulnerum, seu de vulneribus raro tractandis, libri duo,” Venice, 1616 and 1676; also Nuremberg, 1733.

Final Extinguishment of the Long-standing Feud between the Surgeons and the Physicians in Paris.--At several points in the course of this sketch of the history of medicine, I have called attention to the fact that, during the centuries preceding those which are reckoned by certain authors as belonging to modern times, surgeons as a class were generally looked upon, especially in the larger cities of France, as decidedly inferior to physicians. The first attempt at something like systematic instruction in surgery was made by the Brotherhood of Saint Cosmas and Saint Damian at Paris. This organization, which was founded by Jean Pitard about the middle of the thirteenth century, was composed of a group of barbers who felt a strong desire to secure for themselves a better training than was obtainable by the generality of barbers in those days. The latter were known as “surgeons of the short gown,” while the more ambitious men, who belonged to the group mentioned above, were known as “surgeons of the long gown.” With the progress of time this smaller group of barbers really succeeded in making better surgeons of themselves, but in accomplishing this they intensified at the same time the jealousy which the physicians as a class felt toward them, a jealousy which repeatedly manifested itself in the form of downright persecution. The data for a complete account of this persecution, that persisted through centuries, are lacking, and even if I possessed them I should not care to devote the time that would be required for a proper presentation of the subject. It is pleasant, however, to be able to record the fact that these plucky barbers never entirely lost courage, but fought on, year after year, until they eventually succeeded--with the help of a strongly sympathetic public--in making the St. Côme Medical School the nursery of some of the best surgeons in France during the sixteenth and seventeenth centuries. It was here, for example, that Paré, Guillemeau, Thierry de Héry and other men of distinction obtained their early training, and it was doubtless through their influence that some of the wealthy patients whom they had treated successfully, were induced to contribute liberally to the support of the school. The final event in the history of this institution was the complete overthrow of the opposing physicians and the merging of the two surgical schools--that of the regular Faculty and the St. Côme School--into one, under the direction of de Lapeyronie, of whom I shall now furnish a brief sketch.

François de Lapeyronie.--François de Lapeyronie was born at Montpellier on January 15, 1678, and he enjoyed the privilege of receiving a most careful preliminary education. He was only seventeen years of age when the academic degree which corresponds to our Master of Arts was bestowed upon him. As the next step he visited Paris for the purpose of perfecting his knowledge of surgery, the branch of science in which he was specially interested; and upon his return to Montpellier he began giving instruction in anatomy and surgery. In a short time he was chosen Surgeon-in-Chief of the Montpellier Hôtel-Dieu. In 1714 he was called to Paris to take charge of the Duc de Chaulnes, whose malady had not yielded to the treatment adopted by the surgeons of that city; and in this case the measures which he employed proved so efficacious that de Lapeyronie decided to settle permanently in the metropolis. He taught anatomy in the Collège de Saint-Côme, and in a short time was chosen Head Surgeon of the Charité, one of the largest hospitals of Paris. In 1731 he became one of the founders of the Royal Academy of Surgery, and he took a most prominent part in the struggle which was then actively going on between the physicians and surgeons of Paris,--one of the last and most serious of the attempts made by the former to render the surgeons subordinate to the physicians. The surgeons won the battle (April 23, 1743), and Dezeimeris says that the part taken by de Lapeyronie in this struggle may be looked upon as one of the most honorable achievements recorded in the history of medicine. De Lapeyronie died on April 25, 1747, after a long and painful illness. In his will he made most liberal provision for the promotion of medical science; establishing funds for the giving of annual prizes, for the founding of a medical library, for the building of an anatomical amphitheatre, etc. In his treatise on anatomy Hyrtl, the distinguished professor at the University of Vienna, makes the following brief statement with reference to a certain dissecting room in Paris, but he does not state in what part of the city the room in question is located, nor does he mention any other facts that might enable his readers to fix its location. In the absence of more precise information concerning this matter, I shall take the liberty of suggesting that Hyrtl’s discovery was made in the Anatomical Institute which de Lapeyronie founded. Hyrtl’s statement reads as follows:--

Over the entrance doorway of a dissecting room in Paris I read this inscription: Hic locus est ubi mors gaudet succurrere vitae. [Here is the spot where Death rejoices to render assistance to Life.] No more beautiful or fitting words could be employed for inspiring the student, upon his first entrance into the room, with respect for the work in which he is about to engage.

And yet, a few pages beyond that on which the above statement is printed, Hyrtl quotes Vicq d’Azyr as saying: “Among all the sciences anatomy is perhaps the one the usefulness of which has been most highly lauded, but at the same time the one for which the least has been done to favor its advancement.”

The Revival of Interest in Obstetrics.--With Soranus, the early Greek writer on obstetrics, this science seemed to come to a standstill, and during all the intervening centuries, up to the sixteenth, not a single work of any special value was published on this subject; for it is safe to say that nobody would claim for the one or two obstetrical treatises that were written by teachers in the Medical School of Salerno during the ninth or tenth century, that they contributed materially to advance our knowledge in regard to this branch of medicine. It therefore seems fitting, as suggested by Haeser, that during the century which gave birth to such immortal works as those of Vesalius and Paré, there should appear somebody who possessed the inclination to stir once more into life the dying embers of the science of midwifery; and such a man was found in the person of Eucharius Roesslin, the elder, more commonly known--says Dezeimeris--by the Greek name of “Rhodion.” He lived during the first half of the sixteenth century, his death occurring about the year 1526, and his was the first modern treatise especially devoted to obstetrics. He began the practice of medicine in the city of Worms, in the central part of Germany, and then moved to Frankfort-on-the-Main, where he filled the salaried office of City Physician. Midwifery, at that time, was left entirely in the hands of ignorant old women; and it was only in response to the wishes of Catherine, the Duchess of Brunswick and Lüneberg, that Rhodion undertook to prepare a manual from which these ignorant and careless women might learn to conduct their midwifery work in a more efficient, safe and acceptable manner. This little treatise, which was first published at Worms in 1513, passed through a number of editions and was translated into Latin, French, Dutch and English. Von Siebold says that Rhodion compiled its text from various ancient sources, and added practically nothing from his own experience. The woodcuts, which are supposed to represent the different positions of the foetus in the uterus, are not at all in accordance with the truth, and show the most marvelous products of the artist’s fancy. Von Siebold states, however, that the prejudices which at that time existed in the minds of the people against the slightest participation of males in the operations of midwifery were so strong that Rhodion would not have been permitted to do anything toward learning the truth by the employment of direct observation and careful examination--the only possible way in which the actual facts might have been learned.

Rhodion’s book, notwithstanding the defects to which I have just referred, accomplished much good. It also restored the operation of podalic version to the position which it deserved, and it improved the service of the midwives,--which was what the Duchess chiefly desired,--and it undoubtedly emphasized the fact that the time had arrived when obstetrics should receive the same degree of scientific study that was being bestowed on all the other departments of medicine.

The title of Rhodion’s (or Roesslin’s) little book reveals the fact that he possessed no small degree of humor. It reads: “Garden of Roses for Pregnant Women and for Midwives,” Worms, 1513.

The Operation Known as Caesarian Section.--The following statements relating to the operation known as “Caesarian section” have been compiled from Haeser’s Geschichte der Medizin:--This operation, which owes its name to the erroneous idea that Caesar was brought into the world by its aid, is commonly believed to have been practiced on different occasions throughout antiquity, but there has not yet been found in the records of history any account which shows clearly that the operation was performed upon a living woman, and also that the incision extended not merely through the abdominal integuments, but also through the actual uterine wall. At Siegershausen, in Switzerland,--according to the report of Caspar Bauhin in the treatise (“Gynaecia”) which he published at Basel in 1586,--a man named Jacob Nufer performed (about 1500) what was believed to be a Caesarian section on his own wife, and delivered a living child. Both mother and child did well; the child growing up to the age of seventy-seven and the mother giving birth to living children, per vias naturales, several times afterward. In this instance it is generally believed that the case was one of abdominal pregnancy and that the wall of the uterus had not been incised.

The first separate treatise on Caesarian section was written by François Rousset, and in it are reported several cases in which the operation was said to have been performed successfully. But both von Siebold and Kurt Sprengel do not seem willing to accept these reports as genuine, and we are therefore compelled to assume that the first trustworthy account of a Caesarian section successfully performed by a Dr. Trautmann of Wittenberg (in 1610) is that given by Sennert in a communication which was printed early in the seventeenth century.

Invention of the Obstetrical Forceps.--After the publication of Roesslin’s “Garden of Roses,” the book of which I gave a brief sketch on a previous page, nothing worthy of special note was done for a period of several years to advance the existing knowledge of midwifery or even to systematize that which had already accumulated. Then there began to appear evidences of an awakening among those physicians who recognized the importance of this department of medical science, and as a result there were soon placed upon record accounts of two or three advances of real and permanent value. One of the first of these gains, for example, was the revival and general acceptance of the practice of podalic version, or version by internal manipulations,--that is, the operation of changing the faulty position of the foetus in utero in such a manner that the feet shall be the parts which protrude into the vagina. Podalic version--as it appears from the account given by von Siebold--was known to the ancients, both Celsus and Aëtius having described it in their treatises, but it was afterward forgotten or neglected until Ambroise Paré, in 1550, again recommended it in one of his writings. At the same time Paré states, at the very beginning of his monograph on this subject, that his colleagues, Thierry de Héry and Nicole Lambert, had both of them already carried out the method in certain cases. This fact, however, does not detract from the credit due Paré for having been the first, after the lapse of several centuries, to bring the operation to the knowledge of the medical profession; and from that day to the present it has held a fixed place in the science of obstetrics. As will be readily understood, this is not the proper place in which to furnish details with regard to the operation itself. When Paré was asked whether it would be permissible for the midwives to undertake this operation of podalic version, he replied that it would be, provided the individual who assumed this responsibility felt convinced that she possessed the requisite degree of skill and experience in work of this nature, and provided also that--as soon as she began to suspect her inability to finish the operation successfully--she would promptly call to her aid a skilful surgeon, one who had acquired considerable experience in obstetrical operations. Paré’s favorite pupil, Jacques Guillemeau (1550–1630), a native of Orleans, France, made several important additions to our knowledge of the operation of podalic version, and he was also in other respects an important promoter of the science of operative obstetrics. His treatise on this branch of practical medicine, which was originally written in French and published at Paris in 1609, was soon translated into English (“Childbirth, the Happy Deliverance of Women,” London, 1612). In the opinion of von Siebold, podalic version may justly be considered the most important contribution that was made to obstetrical science during the sixteenth century.

One of the French midwives of this period, Louise Bourgeois (or Boursier), attained considerable celebrity by the excellence of the treatise which she wrote on obstetrics. She was born at Paris about the year 1564. In 1588 she began to fit herself for the career of midwife, and in the course of a few years, after passing successfully the required examinations, she was admitted by the authorities as a “sworn midwife” of the city of Paris. She gained steadily in experience and public favor, and the record states that already as early as 1601 she had the good fortune to officiate at the delivery of Henry the Fourth’s wife (Marie de Medicis) of a son--the Dauphin (later, Louis the Thirteenth). Her royal patrons were much pleased with the services which she rendered on this occasion, and, as a further evidence of the confidence which she inspired, they asked her--as each of these occasions approached--to preside at the births of five other children.

One of the meritorious features of the treatise which Louise Bourgeois wrote, says von Siebold, is to be found in the fact that she championed most earnestly podalic version. The book was translated into both German (1644) and Dutch (1658).

François Mauriceau (1637–1709), who was indisputably the most distinguished writer on obstetrics of the seventeenth century, was born in Paris. During the early part of his career he was simply a general surgeon, but, after the lapse of a few years, he gave up all his other work and confined himself strictly to midwifery. For quite a long period he held the position of Chief Obstetrician at Hôtel-Dieu, and at the same time he conducted an extensive private practice in cases of confinement. Worn out by the excessive amount of work which he performed during the most active period of his career, he was finally obliged to retire from practice several years before his death.

Mauriceau did not invent any remarkable obstetric instruments or procedures, but he was the first to set forth in clear and precise terms the principles of this science and art and to expound the rules required for putting them into practice. The titles of his two most celebrated treatises are the following: “Traité des maladies des femmes grosses,” Paris, 1668; and “Observations sur la grossesse et l’accouchement,” Paris, 1695. In 1706, three years before his death, he also published “Dernières observations sur les maladies des femmes grosses.”

The first of the three books mentioned passed through five editions during Mauriceau’s lifetime, and there were two reprintings after his death. A noticeable feature of the work, says von Siebold, is the care which the author takes to preface all his lectures with a detailed exposition of the anatomical relations of the region concerning which he is about to speak; and this custom, which he was the first to introduce, has since then been followed by the great majority of those who have written on the subject of midwifery.

In the book which hears the title “Observations sur la grossesse, etc.,” Mauriceau gives an account of his first and only interview with the English obstetrician, Hugh Chamberlen, to whom is commonly accorded the credit of having invented the first pattern of the obstetric forceps. From this account it appears that on August 19, 1670, Mauriceau was called to see a primiparous woman, thirty-eight years old, who had already been in labor for several days, but who had not yet been able, owing to the extreme narrowness of her pelvis, to give birth to her child. (The case was one of head presentation.) As Mauriceau was not at all willing to perform a Caesarian section,--which alone, as he believed, promised a way out of the difficulty,--Chamberlen, who happened to be in Paris at that moment, was asked to see the patient. He came at once, made a hasty examination, and declared that he needed only six or seven minutes for effecting, by means of the method which he had invented, the delivery. The patient was placed under his charge and he proceeded to apply his method. Instead of a few minutes, he spent three hours in the attempt to accomplish this purpose, but without success; and then admitted that it was impossible, in this particular case, to effect delivery. At the end of twenty-four hours the woman was dead. A postmortem examination revealed the fact that the uterus was torn in several places and perforated at one spot, all of which lesions had evidently been produced by the instrument or instruments employed by Chamberlen. “To complete this story,” adds Mauriceau, “it should be remembered that, six months before the occurrence of the events just narrated, this physician had come to Paris from England, and boasted that he possessed a secret method by means of which he could, even in the most desperate cases of labor, promptly effect the delivery of the child, and had told the King’s Physician-in-Ordinary that he would sell the knowledge of this secret for the sum of 10,000 Thalers (about $7500).”

One naturally hesitates about giving any measure of credit to a physician whose professional conduct, as revealed in his relations to Mauriceau’s patient, is clearly that of a charlatan. At the same time we are obliged to bear in mind that in 1670 it was still possible for a physician or surgeon to own a secret method of treatment and yet not forfeit all consideration on the part of his professional brethren. But at no time in the history of medicine has such conduct as that attributed to Hugh Chamberlen (apart from the question of ownership of a secret process) been considered otherwise than reprehensible. However, as there does not appear to have been an earlier claimant for the honor of having invented the obstetric forceps,--crude as it must have been in its first form,--it seems only fair that Chamberlen should be granted undisputed possession of this honor. During the eighteenth century--a period with which the present volume has no concern--the obstetric forceps underwent many alterations, and finally was given, by Levret and Baudelocque in France, by Smellie in England, and possibly also by Palfyn in Holland, practically the form which it possesses to-day.

Before I finally dismiss the allied topics of obstetrics and gynaecology, it seems desirable that I should add a few remarks concerning two French surgeons who attained considerable eminence in this special field, viz., Portal and Dionis.

Paul Portal.--Paul Portal, a native of Montpellier, France, was a contemporary of Mauriceau and an excellent obstetrician. He received his training under the best teachers at Paris, and more particularly under the guidance of René Moreau, Dean of the Paris Faculty of Medicine (1630 and 1631) and Royal Professor of Medicine and Surgery. He died in 1703. In the treatise which he published at Paris in 1685 (“La pratique des accouchements, etc.”) he lays down very strongly the maxim that the surgeon or the midwife who has charge of a case of labor should make no attempt to accelerate the efforts of Nature until it becomes plainly evident that artificial assistance is absolutely necessary. Portal cultivated the art of digital exploration to a very high degree of excellence. In Chapter VI., according to von Siebold, he expounds with great clearness the dangers which result from a prolapse of the umbilical cord. When this condition is discovered, no time should be lost in delivering the child. “In narrating some of his most remarkable cases Portal uses very simple and clear language, and he puts on record many things which in later years have been published as entirely new discoveries. But, unfortunately, his immediate successors were not disposed to profit from Portal’s admirable teachings.” (Von Siebold.) The only translations of his treatise into foreign languages that have been published are one in Dutch (1690) and another in Swedish by Van Hoorn (1723).

Pierre Dionis.--Pierre Dionis, who was born at Paris in the early part of the seventeenth century, was in some degree related to Mauriceau, the famous Parisian accoucheur. In 1673 he was appointed Royal Demonstrator of Anatomy and Surgery at the institution known as the “Jardin-du-Roi,” and from this date onward, up to the year 1680, he gave instruction regularly in these branches of medical knowledge to large classes of students. He was particularly distinguished for the clear and methodical manner in which he handled the subjects upon which he lectured. In the year last mentioned he was called to Vienna to fill the position of Physician-in-Ordinary to Maria Theresa, Empress of Austria, but von Siebold, who is my authority for the present sketch, does not say for what length of time he continued to hold this position. His death occurred in 1718.

The earliest work published by Dionis bears the title: “Histoire anatomique d’une matrice extraordinaire,” Paris, 1685. (Description of a case of extra-uterine pregnancy.) Five years later he published the treatise on human anatomy (“L’anatomie de l’homme, etc.,” Paris, 1690) upon which his celebrity largely rests. This book passed through numerous editions and was translated into Latin, Dutch and English (1723), and also Chinese; this last piece of work being done by the Jesuit missionary, Father Parrenin, at the request of Cam-Hi, Emperor of China, who died in 1723. Another treatise, which perhaps contributed, even more than did his Anatomy, to render Dionis celebrated, is that which bears the title: “Cours d’opérations de chirurgie démontrées au Jardin-du-Roi,” Paris, 1707; and later translations into German, Dutch and English. This book covers the entire field of operative surgery, and its subject-matter is most methodically arranged. It contains a large number of precepts which are as sound to-day as they were two hundred years ago. From the frequent mention which Dionis makes of the diseases to which the teeth are liable, and from his descriptions of the operations that may be performed for the cure or relief of these disorders, one is justified in drawing the conclusion that, at that early period, this branch of surgery was not, as many suppose, abandoned entirely to charlatans.