The Surgeon's Handbook: general surgery in the sixteenth century

A great way to gain insight into the practices of sixteenth-century surgeons is by examining the surgical – or “chirurgical” – texts they were contemporarily reading and publishing. Sixteenth-century medical handbooks covered a wide range of topics that can be typically categorised into four subjects, surgical handbooks, recipe books or herbals, astrological guides, and anatomical textbooks, however these categories frequently overlapped and became indistinguishable in one text.

The book being explored in this post is Enchiridion chirurgicum (Surgical Handbook) by French surgeon Antoine Chaumette, first published in 1560. The text’s title outlines its subject, however apothecarial medicines and astrologically influenced treatments are interwoven throughout the surgical procedures. The Royal College of Surgeons of England Library’s edition was printed in 1570 and formatted as a pocketbook, measuring 4.5” x 6.6” (16º). Despite its small size, Enchiridion chirurgicum is packed with knowledge.

The frontispiece of Enchiridion chirurgicum.

Chaumette was a physician-surgeon, that is, more scholarly educated than a barber-surgeon, and the text appears to be directed at the same audience; those who could both afford a surgeon’s manual and read Latin. The broad nature of the handbook’s content, however, suggests that the intended user was either a student or a general surgeon, as there are no instructions for the more complex surgeries occurring in the late sixteenth century.

Enchiridion chirurgicum is divided into five books: Tumours, Wounds, Ulcers, Fractures, and Venereal disease. The specific maladies are divided into sub-chapters and further broken down into cause, prognosis, and cure, the last instructing on the necessary surgical treatment and post-operative care. In common with the works of his contemporary Ambroise Paré, Chaumette includes printed illustrations throughout the handbook of various surgical tools that are recommended or necessary for treatments, some of which were revolutionary for the period.

The first book, Tumours, constitutes almost half of the entire text. Chaumette generally defines tumours as internal diseases or abnormal growths, including cancer, dropsy (edema), and particularly “phlegmatic” maladies such as eye infections and gangrene. Like ulcers, which will be covered later, tumours were understood to be caused by an imbalance of the wet and moist humours in the body, which could either be caused by a temporary environmental change (perhaps if the patient consumed too much fish in their diet or spent too long in cold rain), or the inherent presence of water signs (Pisces, Scorpio, Cancer) in their astrological birth chart. Chaumette provides “hot and dry” recipes as well as topical ointments that can relieve the early signs of tumours, however for the more serious cases there was only one solution: bloodletting.

Bloodletting often involved the use of various surgical instruments designed to remove excess humours from the body through the blood, with the aim of restoring internal balance and improving the patient's health. It was typically performed by barber-surgeons using lancets (scalpel-like tools), however a physician-surgeon like Chaumette would have access to more specialised tools that would expedite and optimise the procedure. Beside the lancets are a set of eight glass vessels that were used for “cupping”, a method where suction cups were placed over the cut skin to create a vacuum, thus accelerating the blood loss and allowing the phlegmatic humours to escape more quickly. Chaumette also recommends the use of a “scarificator”, a small metal tool that can make multiple simultaneous cuts in the skin by turning a key that rotates multiple blades. Medical historians generally agree that the scarificator was introduced for bloodletting purposes by Ambroise Paré in Opera (1575), however Chaumette’s reference and illustration predates this by fifteen years, thus suggesting that the scarificator was used for bloodletting earlier than is believed.

A Scarificator.

Eight glass vessels used for cupping, alongside two lancets.

Like tumours, wounds also required surgical intervention if there was foreign matter, gangrene, or suppuration that needed to be removed; whole limb amputation may be necessary if the case was particularly bad. Chaumette classifies a wound as a malady caused by external trauma to the body, i.e. animal bites, bruises, and punctures to blood vessels and nerves. He directs that treatments for all wounds should follow a five-step procedure: 1. remove any foreign matter, 2. bring the wounded skin back together, 3. fix the wounded skin together (suturing), 4. provide post-operative care (protective bandages or honey balsams to prevent putrefaction) and 5. mitigate further “accidents”.

One surgical procedure that is given particular attention in Wounds is trepanning: drilling a hole into a wounded skull to either reduce the pressure of bleeding, remove fractured bone shards or foreign matter, or to check the condition of the dura mater (the brain’s protective membrane). Enchiridion chirurgicum provides numerous examples of trephines that would be useful for a surgeon to carry. These range from basic drilling tools to complex trephines with interchangeable drill heads and wooden handles, which function by twisting a wrench or rope handle to drive the serrated blades into the thick skull bone. Chaumette advises to warm the blade of the trephine to “make the pain less severe” and, surprisingly, not to suture the wound together but instead cover the head with a sheep’s skin for protection.

Examples of simple trephines.

A trephine with a wrench handle and interchangeable drill heads.

Book three covers ulcers, which in nature are similar to tumours but present more superficially, rather than internally. Examples range from skin diseases such as scabies and smallpox to abnormal growths and inflammation, like haemorrhoids. Chaumette gives most attention to ulcers caused by venereal disease, and so the treatments which are later discussed in book five will be covered in this section.

In common with tumours, ulcers are naturally phlegmatic (wet) and melancholic (cold), therefore treatment should be hot and dry, not only to combat the corrupt humours but to physically eradicate the malady. The most effective and common procedure was therefore cauterisation, the act of burning the body with hot metal irons. For more superficial ulcers the cautery iron was applied only on the skin; the treatment was extremely painful, however - by sixteenth-century terms - typically successful, as the heat both destroyed the putrid flesh while simultaneously searing the surrounding skin together, preventing any unnecessary blood loss.

For more serious ulcers that began to spread deeper through the body, cautery irons were applied until they entered the bone to ensure no trace of the affliction remained. In some cases where the cautery could not go deep enough, a small trephine was employed to create holes in the bone “until blood appeared” (a sign of reaching healthy bone), then such holes would be further cauterised by a pointed iron and flushed with water, ensuring that all traces of the ulcer were expelled from the body. Chaumette includes multiple examples of cautery irons that any good surgeon should possess, including the aforementioned pointed iron for precision, the large, flat-headed iron for large surfaces, and the knife iron for cutting through flesh. For post-operative care, Chaumette recommends applying a topical mercury paste to the cautery site, a popular contemporary “cure-all” treatment.

A selection of cautery irons.

The fourth book and final in this exploration of Enchiridion chirurgicum addresses bone maladies: fractures, dislocations and arthritis. Bloodletting is advised again throughout this chapter to be performed either away from the site of pain, to deflect the corrupt humours from fractured and dislocated bone, or directly where the pain occurs if the treatment is for arthritis or gout.

Chaumette agrees in his text that not all fractures or dislocations require surgical tools, especially if the accident occurs while on the battlefield or at sea, as the equipment is not easily portable. It is also not necessary for surgical students to possess such a tool as it was expensive to acquire and designed for a more experienced practitioner. The “glossocomium” was a contraption designed for setting broken limb bones dating from the Galenic era. It worked by strapping the limb to a pulley system of ropes that would pull either end of the limb away from each other, creating tension that would force the dislocated or fractured bone back into place. It wasn’t a simple procedure. First, the surgeon had to check for any bone protruding from the skin (if so, it would need sawing off and then the skin would be sutured) and then required the aid of two assistants to operate the pulleys whilst he set the bone. To fix the bone in place Chaumette suggests layering egg-soaked bread slices on the limb, wrapped in a thick leather or paper which will harden into a cast.

A glossocomium fixing a dislocated leg.

The surgical techniques, instruments, and medications discussed in Enchiridion chirurgicum continued to evolve over the seventeenth century, driven by the proliferation of printed books in Europe. Significant advances were made in both medicine and anatomy, however such surgical improvements were limited to university hospitals and large cities. Procedures such as bloodletting, cauterisation, and trepanation remained popular across the European continent until the eighteenth century, especially at the local level, and so texts like Chaumette’s remained in circulation until the scientific revolutions of the late eighteenth and nineteenth century.

Interested in finding out more about sixteenth-century surgery? Visit the online Heritage Collections catalogue to browse surgical handbooks and treatises spanning from the sixteenth to the twentieth century.

You can also browse the Hunterian Museum’s collection of surgical tools, including cupping sets, trephines, and cautery irons.

Georgia Wallace, Information Assistant.