trauma surgery in early modern europe

Trauma Surgery in Early Modern Europe

Scott Moore

For Beau Monde & Hearts through History

July 30, 2008

What to expect

Tips on researching medical history

330 years in 45min 1500 – 1830

Europe only

Trauma surgery only

NC-17 descriptionsWoundman, from Hans von Gersdorff,

Feldtbuch der Wundartzney, 1517.

Tips on Researching Medicine

Context matters – who is writing and why

PAST = medical professionals writing history for others medical professionals

=> “modern” view and jargon, bias, focus on discovery and lone genius, national pride

TODAY = Social History of Medicine=> contemporary view and language, patient view,

ignored voices, less linear view of innovation

Medical innovation was not monolithic or homogenous

16thC 17thC 18thC 19thCEngland, Scotland

Barber-surgeon guilds – limited knowledge

Harvey and circulation, but not accepted

Political instability lead to isolation

1599 – James VI granted charter for faculty of physicians and surgeons in Glasgow

London physicians and surgeons become unregulatedEducation shift from guilds to private schools and new hospitals in LondonSmall pox vaccination developedGlasgow develops as significant center of medical education

Better communication between nations leads to transnational influences in advances in anesthesia, antisepsis and cellular pathology. These advances radically change surgical possibilities.

(For example, Lister, who developed antisepsis was influenced by the French Pasteur and then carried his ideas to America.)

FranceMedical schools and hospital (Hôtel Dieu) in Paris, Ambroise Paré, innovator

Paré’s innovation not widely accepted

Intense fighting between barbers and surgeons stifles innovation

Surgeons gain political and professional status with university training mandatory before surgical apprenticeship until revolution abolishes guilds and medical societies.Paris becomes center for surgical education

ItalySome university training for surgeons in Pavia, Padua, Bologna

More medical schools open in Pisa and Naples, but surgery is generally unorganized.

Some experimentation with kidney stone surgery

Surgical training remains unorganized. Napoleonic conquest and division further stifles advances.

German speaking lands

No unified surgeon guilds 30 Years War devastates country. Prior to war, Fabry von Hilden taught in Basel and after war Johannes Scultetus published surgical works.

Formal education fails to take hold in Austria. Prussia establishes military surgery school in Berlin. Generally, suspicion, superstition, poor training, and competition with other trades stifles surgical advances.

OthersSpain: no significant contributions to European surgery

Netherlands: Leyden and Amsterdam rise as significant centers of medical education

Netherlands: Clinical teaching of medicine and advances in anatomyUSA: lack of established healers means fewer divisions between surgeons, physicians and apothecaries

Finding Credible Sources• Second source material by modern historians – overviews,

context, details on procedures, names and titles of primary sources.

• Journals of the history of medicine – sources from manuscripts, letters, court or civil docs; book lists and peer reviews.

• Primary source material in the form of surgical texts – These are the most easily obtainable through reproductions and modern translations. A caveat for in-period translations is to be aware that the translator may change text or images to reflect their point of view. If you can find modern translations of period texts, check for journal book reviews, and use them.

Misunderstandings and Myths

1785 etching by Thomas Rowlandson from Orthopedic Surgery Residency Program at The George Washington University Medical Center. http://www.gwumc.edu/edu/ortho/

Education of surgeons

Myth – Surgeons were professionals with similar education as physicians.

Reality – Surgery was a trade dealing with the physical aspects of the human body.

Myth – Surgeons were ignorant quacks who were more a danger than a help

Reality – Ignorant healers existed and flourished, but trained and licensed surgeons sought to avoid unnecessary harm and better understand the human body.

Alcohol as anesthesia

Myth – patient should be drunk before cutting begins

Reality – Perhaps a small glass of wine before and after, but not to drunkenness.

J. D. WHITBY (1980) Alcohol in anaesthesia and surgical resuscitation Anaesthesia 35 (5) , 502–505

Prohibitions against dissection

Myth – The catholic church forbade dissection of the human body and this lead to underhanded methods of obtaining bodies.

Reality – Papal bull issued at the turn of the 14thC prohibited crusaders from reducing Christians to bones for shipping home. Did not eliminate dissection, but may have had a chilling effect. Competition of 18th/19th C anatomy schools lead to shortages => grave robbing and murder.

Dissection Scene from Fasciculo di Medicina, Johanned de Ketham, 1496. Nuland, Sherwin. Medicine: the Art of Healing.

Amputations

Myth – Surgeons amputated at the drop of a hat

Reality – Before mid-19thC surgeons focused on healing the wound and used amputation as a last resort if the wound failed to heal and threatened the life of the patient or if the bones were so shattered that they would not allow a clean healing stump.

Hollywood Amputations

Myth – Saw through the whole limb

Reality – No one *ever* sawed through flesh.

How to Perform an Amputation

1. Compress the limb to slow/stop blood flow

Petit Tourniquet c1820, Bennion, Elizabeth. Antique Medical Instruments.

16th C – hands, tight wrapped linen,17th C – single band twisted with rod18th C – Petit then clamp tourniquets


2. Slice through the flesh with a knife around the limb and down to the bone

Detail of Leg Amputation, artist unknown, mid-18th C. Carmichael and Ratzan. Medicine: A Treasury of Art and Literature.


3. Retract the flesh toward the body to expose the bone

Charles Bell's Illustrations of the great operations of surgery, 1821. University of Iowa Libraries. John Martin Rare Book Roomhttp://www.lib.uiowa.edu/hardin/rbr/Imaging/albums/bellsurg/index.html


4. Saw through the bone

Amputation saw. c16thC ~24 in. Germanisches National Museum Nürnberg. http://www.bildindex.de


5. Release the retraction and staunch bleeding

6. Release compression to find missed blood vessels7. Bandage and attend to healing

Cauteries, c.1750. ~12 in. Bennion.

General wound care and recovery from surgery

The course of illness was not often dramatically altered or shortened or terminated… surgery entailed weeks of daily wound care rather than dramatic interventions that characterize modern operative surgery.

- Mary E. Fissel

Bulletin of the History of Medicine, Spring 2008 V82no1, page 14.

Treating woundsDeep wounds were often kept open to allow draining and

prevent abscesses.

If muscles or tendons cut across grain, some recommended sutures. Others recommended contracting and immobilizing muscles. If in line, no sutures.

Styptics were also used to control bleeding though sometimes misapplied.

Bleeding a blood vessel above the wound was very common.

Many styles of suturesAdhesive cloth and suture for facial cuts. Ambroise Pare. Three and Fifty Instruments of Chirurgery. 1631.

Sample sutures, ca 18thCMedizinhistorisches Museum of the University of Zurichhttp://www.mhiz.unizh.ch/Hannah Blair, Photographerhttp://www.flickr.com/photos/hannahmae/

[Various types of suture techniques and instruments] / J.M.B. sc. 1734Images from the History of Medicine at the U.S. National Library of Medicinehttp://wwwihm.nlm.nih.gov

Healing

By First Intent – Nothing introduced to wound. Bandages moistened with various liquids.

By Second Intent – salves or oils of all kinds are put in wound. Became more complicated as time progressed.

INFECTION!

“Suppuration” was the term used more often by this time than “laudable pus”. It was often induced as part of the healing process.

About the mid-18th C there were some reporting better success at healing when suppuration was avoided.

“weeks of daily wound care”

Complications seem to have been the norm.

Wounds can spontaneously reissue blood and abscesses can form once the wound can closed. These will be treated as new wounds, usually with bleeding and a change of bandage (to reintroduce styptics). Abscesses will likely be drained with a scalpel.

How to Remove Arrows and Gunshot

Many similarities so combined steps:

1. If missile can be felt under skin, cut down to it and remove it.


2. If the missile is deep, enlarge the entry wound by cutting. You may use a dilator:

Dilator Hans von GersdorffFeldtbuch der Wundartzney, 1517.

Dilators, 16thC, ~10in.Germanisches National Museum Nürnberg. http://www.bildindex.de


Special note about arrows – Yeowch!

Arrow heads for war, bodkins for armor and swallowtails for hunting.The Battle of Shrewsbury, http://www.militaryhistoryonline.com/


3. For arrows, protect the barbs, by covering or bending. For gunshot, fingers and forceps will do:

Arrow and shot forceps. 16th CGermanisches National MuseumScott Moore, Photographer


Ball screws are described throughout early modern period, but seem to have been used mainly if the gunshot was lodged against bone.

These are more finely made than the picture shows.

Bullet extractor c1520 ~12 in.Germanisches National Museum Nürnberg. http://www.bildindex.de


4. Treat the resulting wound(s) as any other wound. In the 16th/17th C, it was popular to cauterize gunshot with hot oil, caustics or cauteries.

In addition to holes, gunshot can also cause fractures.

How to Treat a Broken Limb

1. Diagnose the degree and location of the fracture.

2. If a compound fracture, treat the wounds as before. Amputation is likely if the healing does not go well.


3. Extend the limb so the bone(s) may be fitted together.


4. Bind the limb tightly.

[Fractured arm and Simple fracture] / Arnold Delineavit. 1666in Armamentarium chirurgicum by Johannes ScultetusImages from the History of Medicine at the U.S. National Library of Medicinehttp://wwwihm.nlm.nih.gov

How to Treat Dislocations1. Start before

inflammation starts, wait until is subsides, or draw blood.

2. Put the joint back in place (reduction) usually with some form of leverage device.

3. Prevent the limb from moving until healed.

Scultetus' Armamentarium chirurgicum, table 23. 1655University of Iowa Libraries. John Martin Rare Book Roomhttp://www.lib.uiowa.edu/hardin/rbr/Imaging/albums/bellsurg/index.html

How to Treat a Skull Fracture


1. Check the fracture to see if the skull depresses inward and if bits of skull seem to be free.

2. Cut the scalp either in a square with one side still attached, or as an “X” pulling back the four triangles.


3. Lift out any completely loose pieces

4. Use a saw (trepan) to cut the skull, but not so deep as to cut through the skull Charles Bell's Illustrations of the great

operations of surgery, 1821. University of Iowa Libraries. John Martin Rare Book Roomhttp://www.lib.uiowa.edu/hardin/rbr/Imaging/albums/bellsurg/index.html

Trepan or Trephine?

Bennion, Elizabeth. Antique Medical Instruments.

Trepan – any saw to cut into skull c. 1400+

Trephine – means “three ends” c.1750+

Both can be used as verbs

“Trephination” is a 20thC term


5. Use an “s” shaped lifter (elevator) to remove the pieces.

6. After 1700, a lenticular was used to scrap the rough edges of the hole.

Lenticular c1750, Bennion, Elizabeth. Antique Medical Instruments.

From Wilbur, C. KeithAntique Medical Instruments


7. After ~1750, brush the bone dust from the wound.

8. Replace the skin and treated as any cut for that time period.

Research Questions To Consider

Not just about wounds, surgery and healing

Why are you wounding your character? This can help you limit what info you need to retain.

Taking them off the stage? Meeting someone? Exposing aspect of society/knowledge? Need a sexy scar? Survive a duel? Suffering before death?

Questions?

Thank You!

Slides, updated handout, timeline, books

[email protected]

Comments, critiques, suggestions welcomed.

trauma surgery in early modern europe

Health & Medicine

thc surgeons

medical history

medical innovation

licensed surgeons

medical professionals

reality surgery

amputations myth surgeons

medical societies