The history of European surgery in the 18th century: The Italian innovator Giovanni Alessandro Brambilla (1728–1800) at the Hapsburg court of Joseph II of Austria. A pioneer of medical and surgical education in the field of military medicine

The second half of the 18th century was a time of change in European surgery. Surgeons improved both their social status and their theoretical preparation, which became more closely linked to university studies and increasingly distinct from that of practitioners and barbers. In those years, which were marked by continual conflicts, surgery often acquired connotations of “war surgery”. Therefore, its history features individuals connected with the army: soldiers, in addition to healthcare professionals. A pivotal figure in Hapsburg surgery is the Italian Giovanni Alessandro Brambilla (1728–1800), who devoted much of his activity to reorganising the healthcare service of the Austrian army. This great challenge and Brambilla's long career are also recounted in an unpublished, “professional diary” written by Brambilla himself and conserved today in the Archive of Civic History in Pavia (Italy). This undiscovered manuscript constitutes a precious testimony and provides us with a detailed picture of surgeon military life. Brambilla (Fig. 1) was born in a small village near Pavia, which had been the seat of one of the most ancient universities worldwide, since 1361. In Pavia, Brambilla began his training in about 1747 and in 1752, he enlisted in the Hapsburg army as an assistant surgeon with the Hagenbach Infantry Regiment; here, he began a career that would, within a few years, take him to the highest levels of command in Vienna, where he occupied positions of power and prestige. In the manuscript the elderly surgeon reported that, in the period of peace preceding the Seven Years' War, no educated young man of good family willingly enlisted in the army, as he would be badly paid and scantly esteemed. Assistant surgeons were inexperienced, poor and short of proper instruments. Often, they neglected the sick and wounded, preferring to supplement their own meagre wages in other ways, such as by shaving the soldiers and providing medical care for payment in the cities and the countryside. Like the other soldiers, they had to pay for their own new uniforms and for the maintenance of their equipment. During military campaigns it was difficult to maintain the traditional distinction between physicians and surgeons, who treated “internal” and “external” diseases, respectively. Indeed, war overturned the established order and the separation between the profession of the physician and that of the surgeon was no longer practicable. One serious problem was that the inexperienced assistant surgeon often found himself faced with emergencies, without having any skill in internal medicine; he was therefore reduced to rapidly consulting manuals that summarised some basic notions. This was the situation in which the Seven Years' War unfolded. At the beginning of the war, regimental surgeons were provided, at the expense of the state, with three cases containing a few basic instruments, so that they would at least have the most essential surgical tools. However, these tools were of substandard quality; Brambilla complained that the blades of the saws were more suited to cutting wood than to performing amputations, and that the coarse scissors were not suitable for cutting soft tissues. The most scrupulous surgeons, including Brambilla himself, who had in the meantime been promoted to chief surgeon, bought instruments at their own expense. Moreover, bandages were in short supply and surgeons sometimes had to improvise by using their own bedlinen. In 1763, at the end of the Seven Years' War, Brambilla was first appointed “surgeon of the noble imperial guard”, and then “surgeon to Their Imperial Majesties” and, specifically, to Archduke Joseph that in 1780, became the sole sovereign (Fig. 2). During the war he had successfully treated some nobels, including General Gacomo Botta Adorno, whose arm he had managed to sava from amputation. It was also thanks to his skill that Brambilla reached the imperial court. Joseph II himself, afflicted with an anal fistula, was operated on By Brambilla with an instrument specially designed for the operation (Fig. 3). As commander-in-chief of the armed forces, Joseph zealously devoted himself to continuing the already-initiated reform of military organisation, including health care. Being a soldier himself, Brambilla realised that the monarch's plans went some way to meeting the needs of military surgery, with which he was all too familiar. In reality, Joseph's aim was to create non-specialised personnel–physicians/surgeons with only generic skills; men who were able to cope with any type of emergency and also to carry out “administrative” healthcare functions in the Hapsburg dominions. Thus, Brambilla accompanied Joseph on his journeys and in his visits to military camps and hospitals. In 1778, the Emperor appointed Brambilla Chief Surgeon of the Army, later known as Proto-surgeon of the Army. Thanks to his experience in the field, Brambilla was able to begin improving military organisation, this involved years of hard work. In 1769-70, Brambilla was involved in the reorganisation of the Gumpendorf military hospital (in a suburb of Vienna). Brambilla had an ambitious project: the foundation of a school for military surgeons. In 1781, this plan began to take shape, with the first teaching post being assigned to Gabriel von Gabriely, a doctor with great experience in surgery and military medicine. However, other “trainers” were needed. Thus, it was decided that a few promising army surgeons should be selected and sent travelling for two years, so that they could gain experience in the most advanced medical schools. Brambilla arranged for some rooms in the building to be equipped with whatever would be needed for the teaching of the students. The young men who were admitted to this school for assistant surgeons had to know Latin and to be able to maintain themselves for 4 years. In addition, they had to purchase a uniform and a instrument-bag. Accommodation was provided free of charge, while students had to pay for their own meals, which could be bought at a modest price from the innkeeper who supplied the hospital with food. The trainees attended lectures and worked in the wards, where they assisted the nurses with medications and the distribution of medicines; they also performed minor operations under the direction of higher-ranking surgeons, and practised anatomical dissections. Another innovation had been introduced in 1780: no proprietor or colonel could autonomously employ a senior surgeon; he could only nominate a candidate, who then had to be approved by the Proto-surgeon. The new organisation introduced by Brambilla was much appreciated. Nevertheless, as the Gumpendorf hospital housed a few hundred patients, it proved insufficient for the army. A new and larger facility was therefore planned. For this purpose Joseph allocated a large area, where, in 1785, a larger hospital equipped with all the necessary services and the Academy for the training of surgeons were inaugurated. The Academy housed over 200 students, in addition to some of the hospital staff. One of the storerooms contained surgical instruments, gathered in 300 leather cases. Each regiment or corps utilised 3 of these cases (one for amputations, one for trephinations and one containing a miscellany of instruments for other operations, such as lithotomy, paracentesis and herniotomy) (Fig. 4, Fig. 5). The Academy was endowed with a a precious collection of surgical instruments, displayed in various boxes which collected the instruments indicated for the operations performed at that time, from head to foot. These boxes constitute therefore a testimony on late XVIII century surgery: bloodletting, cauterizations, treatment of skull fractures, eye operations (in particular that for cataracts), operation on the nose and on the oral cavity, dental therapy, obstetric and gynaecological operations, lithotomy (removal of bladder stones), compression of aneurysms, extractions of projectiles, amputations, enemas and insufflations (Fig. 6). Brambilla payed a great importance to the study of anatomy on human corpses. Various types of dissecting instruments and large syringes for injecting wax into blood vessels for making instructive anatomical preparations were part of the collection. Various types of bandages were also on display and could be applied to a life-size model during lessons. The students could also utilise models of seats and tables for surgical operations, various physics instruments and apparatuses for use in cases of dislocation and fracture. Training was carried out on two different levels: those of trainee and master (or doctor in surgery): “trainees” were those students who followed the basic curriculum. They had to take a 6-month course, which could be repeated several times, and acquire notions of anatomy by attending operating theatres and military hospitals. Subsequently, they could enlist in the army as assistant surgeons. - After 6/8 years' service, an assistant surgeon became eligible for higher training-the so-called “great course”, which lasted two years. On completion of the course, and after passing rigorous examinations, the assistant surgeon was granted the title of “Master” or “Doctor in Surgery”. As in the case of the school previously instituted at the Gumpendorf hospital, the aspiring young students were examined by the Proto-surgeon. They were required to know Latin, as well as their native language, to be able-bodied and healthy and to have good eyesight. Applicants also had to have some basic knowledge of surgery and anatomy, and demonstrate that they were able to maintain themselves for two or three years and buy the required uniform, instruments and books. The new school supported the University in the training of more “generic” physicians/surgeons, as opposed to the more specialised and scientific training provided by the faculty of medicine. Thus, professionals were trained who were destined to become both “civilian surgeons” and “military doctors”. The uniform of the army surgeons-an essential feature in order to immediately recognise who was able to assist the wounded-was definitively regulated, and consisted of scarlet trousers and tunic and a mare sea-green long jacket. The duties of military surgeons were summarised in five points: obedience to superiors, obligation to study and improve one's knowledge, to carry out one's duties zealously, to care for patients lovingly, and to maintain good moral conduct. Brambilla also established prizes to be awarded to the most deserving students in answering scientific questions that could be useful in surgical practices. One of the questions concerned, for example, wound dressing methods that could protect against unfortunate outcomes. The problem of interpreting and resolving infections was huge at the time, and would not find a solution until the mid-19th century. However Brambilla set out to discuss the matter scientifically. The most promising solutions were the subject of publications, which were then sent to surgeons employed “in the field”.