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The illnesses of politicians and military leaders are interesting from a historical point of view not only because they impinge on government business and the conduct of war: since they are usually well documented, they can also provide useful insights into medical practice and belief in the past. In the case of Giuseppe Garibaldi (1807-1882), the leading force in the unification of Italy, there was controversy over the treatment of the bullet wound he had received during his abortive march on Rome in the summer of 1862—the detection of the bullet being particularly difficult at a time before X-rays were available. Furthermore, delicate questions of medical etiquette arose against the backdrop of nationalistic interests, as clinicians from four countries, including Britain and France, became involved. Finally, the dispute was settled thanks to a new surgical instrument, ‘Nélaton's probe’, named after the French surgeon who invented it. These circumstances and Garibaldi's enormous popularity meant that the case received extensive coverage in the British medical press, providing a minutely detailed account of a surgical dilemma of the nineteenth century.
The popular appeal of Giuseppe Garibaldi in the second half of the nineteenth century was extraordinary. His military exploits in South America, where he had fought for the indepence of Uruguay, and his brave but ultimately disastrous attempt in 1848 to free Rome from Papal rule, had made him world-famous by the age of 43. After his remarkable conquest of Sicily and the capture of the kingdom of Francis II in 1860, popular support for Garibaldi in Europe and the Americas reached near-hysterical proportions. Streets and squares, blouses and biscuits were named after him; ladies of fashion begged for his autograph or a lock of his hair; adoring fellow Italians dubbed him ‘our second Jesus Christ’. Even Queen Victoria could not help remarking that Garabaldi was ‘honest, disinterested and brave’1.
Flattery and public adulation, however, never deflected Garabaldi from his chief objective, which was to free Italy from foreign oppression and bring about its unification. These aims were only partly fulfilled in 1860 with the annexation of southern Italy to the Kingdom of Piedmont and the creation of the Kingdom of Italy, since Venice and, most importantly, Rome and the papal states did not form part of the new political entity. Garibaldi was determined that Rome, the symbol of united Italy, should be at the heart of the Kingdom of Italy, but the Italian government was reluctant to launch a military campaign against the Pope. Angry and resentful, Garibaldi resolved to take matters into his own hands. At the beginning of August 1862 he crossed the Strait of Messina and headed for Rome with three thousand volunteers in open defiance of the King of Italy to whom he had previously pledged loyalty.
Fearing international complications, the Italian government hastily dispatched troops to stop his advance. The two armies came face to face on the mountain of Aspromonte in Calabria on 29 August 1862. When the regular troops opened fire, Garibaldi could not bring himself to shoot at fellow Italians and ordered a cease-fire. In the ensuing confusion he received three gunshot wounds, only one of which gave cause for concern. A bullet had penetrated the right ankle a little above and in front of the medial malleolus and, despite the efforts of the attending surgeon, Enrico Albanese, it could not be found.
Garibaldi was taken down the mountainside to Scilla on a stretcher; his foot was swollen and the pain was agonizing. He was then put on board the steamer Duc de Gêne and conveyed to Varignano near Spezia, where he was imprisoned on a charge of treason. Two days later he was examined by Professor Porta of Pavia in the presence of Professors Rizzoli (Bologna) and Zanetti (Florence) and the surgeons Prandina (Chiavari), Negri (Genoa) and Ripari (Turin). With one exception, all were of the opinion that the ball was no longer lodged in the ankle.
As the news of the injury spread, a wave of sympathy for Garibaldi's plight swept across Europe. Letters, books and gifts were heaped beside his bed; Lady Palmerston, appalled by the Irish who ran through the streets of London shouting ‘No Garibaldi! The Pope for ever!’, sent him an invalid bed2.
Two weeks after the incident, the medical bulletins emanating from Varignano were giving little cause for cheer. Reversing their previous opinion, Garibaldi's surgeons now appeared to believe that the ball was lodged in the ankle-bone; however, they could not make up their mind as to the proper course of treatment3. Meanwhile a Viennese surgeon was reported as saying that the wound was very serious and amputation might be inevitable4.
These developments caused consternation in Protestant England, where support for the champion of Italian liberty had always been enthusiastic. Sympathizers quickly formed the opinion that Garibaldi was not receiving the best possible medical care in his native country and might benefit from the advice of a British surgeon. The Garibaldi Italian Unity Committee, which had been largely responsible for financing Garibaldi's 1860 expedition to Sicily, immediately launched a public appeal to raise the money for the consultation. In a short time a sum in excess of one thousand guineas was collected, and Richard Partridge (1805-1873), professor of surgery at King's College Hospital, London, was appointed to travel to Italy and give a second opinion5.
Why Partridge was selected we shall probably never know: he was regarded as a painstaking but not brilliant surgeon, ‘minute in detail and hesitating in execution’6. What was more worrying, though, was that he had no experience of gunshot wounds—a point that was not lost on the editor of The Lancet7. This, however, was not the chief reason why the British medical press had profound misgivings about the mission. Partridge's intervention smacked of patient-stealing, a practice that the watchdogs of the profession were eager to stamp out. At a time of fierce competition amongst practitioners, patient-stealing was frowned upon not simply because it posed a threat to medical incomes. Poaching patients undermined group solidarity and put medical men in the same category as shopkeepers and businessmen, thus thwarting the profession's aspirations to gentlemanly status. Commenting on the Garibaldi case, The Lancet wrote: ‘The usefulness not less than the dignity of a profession which is linked by such close and manifold relations to all the great branches of human knowledge, demands that the harmony which has long ruled amongst us shall not be wantonly broken’8. By agreeing to travel to Italy without the express invitation of Garibaldi's medical attendants, Partridge had broken one of the cardinal rules of medical etiquette.
Harping on the dangers of this ‘new manifestation of the proverbial insular pride which is ever insisting upon the immense superiority of everything British’ fulfilled another purpose: it served to highlight the reasons why the lay public should not be allowed to meddle in matters pertaining to the regulation of the profession. As The Lancet argued, laymen's disregard for the niceties of professional intercourse, so amply demonstrated by the Garibaldi case, made self-regulation a necessity. This principle had only just been established with the creation of the General Medical Council (1858), and The Lancet now took the opportunity to remind medical men that they must not look to the public for ‘any nice respect’ for professional honour: ‘we are the only true judges in questions affecting our own conduct and dignity’9.
Despite these fears, Partridge was able to complete his mission without raising opposition. Arriving at Varignano on 16 September 1862, he was cordially received by Garibaldi's surgeons and allowed to examine the patient. He was subsequently able to report back to the Committee that the general's health was good, although he was much emaciated; his appetite was ‘tolerable’; the pulse ‘quiet’; the tongue ‘clean and moist’. Partridge's conclusion after examining the wound was unequivocal: ‘the bullet did not enter the joint nor effect a lodgement elsewhere’. This opinion was based primarily on the unswollen state of the ankle, and on ‘other circumstances’ that were not explained in the report. Partridge was confident that the wound would heal with time, provided that the limb was kept at rest and that Garibaldi received good nursing care10.
Meanwhile the wildest rumours were circulating about the nature of Partridge's mission: it was claimed that he was the bearer of political letters, messages and money for Garibaldi. The fund-raising activities of the Committee, which had continued after the cost of the consultation (£680) had been met, only served to reinforce this opinion11. At the same time, the bulletins issued by Garibaldi's medical advisers intimated dissent from the opinion ventured by the English surgeon. ‘There are, it would seem, certain Italian practitioners who still maintain that the bullet is in Garibald's foot’, observed the British Medical Journal. ‘We suspect their opinion will not be accepted in this country, at least, after the very clear diagnosis given by Mr Partridge’11.
Despite Partridge's optimism, Garibaldi's wound did not improve. By the end of October sepsis had set in and the dreaded necessity of amputation appeared increasingly likely. Garibaldi's supporters, however, did not give up hope that the limb might be saved. This time the initiative came from Maurice Hereczeghy, a doctor in Hungary who had been a member of Garibaldi's entourage. Hereczeghy managed to persuade his former professor of clinical surgery in Paris, Auguste Nélaton (1807-1873), to provide a further opinion.
The son of an army officer killed at Waterloo, Nélaton had been a pupil of the famous surgeon Dupuytren. Although he was not noted for academic achievement, he had gained recognition in his own country as a skilful and innovative clinician13. Nélaton popularized the use of electrolysis in surgery and he devised a new operative technique for the extraction of stones in the bladder. He was a pioneer of ovariotomy in France at a time when this controversial operation was roundly condemned by the surgical establishment as ‘belly-ripping’13. For his first ovariotomy Nélaton designed his own trocar, and a clamp which the English surgeon Spencer Wells was later to describe with admiration as the best one he had ever seen. This talent for designing innovative surgical tools was to be brilliantly applied to the solution of Garibaldi's case.
Nélaton arrived at Spezia on 28 October 1862 at 2 o'clock in the morning. On leaving Paris he had already declared that amputation would not be necessary, and he reiterated this opinion when, later that day, he finally had a chance to examine the patient.
Nélaton used an ordinary probe to explore the wound. When the instrument reached the depth of one inch, it was arrested by a hard substance. Was it bone or was it metal? In Nélaton's view, the ‘peculiar sensation and dull sound’ that had been produced as the probe struck the obstacle was very different from the sharp noise resulting from contact with necrosed bone. As well as the quality of the sound, other circumstances pointed to the presence of the bullet in the joint—namely, the direction of the shot; the shape of the ball; the perforation of the boot and sock in which the ball had not been found; and the shreds of leather extracted at different intervals from the wound. The French surgeon recommended extraction by the ball forceps. He suggested that, to facilitate the ejection of the bullet, the wound should be enlarged, first by means of small cylinders of gentian root, and subsequently by the insertion of sponges. Amputation would not be necessary, and Garibaldi would recover, he said, although stiffness in the joint was inevitable14. Garibaldi, who had endured all the medical examinations without the benefit of analgesia, was immensely relieved15.
Nélaton returned to Paris in the expectation that one of the Italian surgeons would carry out the operation. However, it soon became apparent that Garibaldi's medical attendants were hesitating. Porta, who had examined the wound with the finger, claimed that the bullet was not lodged in the bone. Zanetti, the senior consultant, summed up the situation as he saw it: ‘the ball will remain, or be cast off in time; the recovery, though certain, will be tedious’, he said vaguely. Meanwhile rumours of a difference of opinion between Nélaton and Partridge were beginning to fly around Europe. Shortly after Nélaton's departure, Partridge returned to Spezia accompanied by the Russian surgeon Nicolai Pirogov (1810-1881)17. After this second examination he became convinced that the bullet was still in the ankle, but unfortunately the battle-lines were already drawn: French and English surgery were now locked in a contest that was bound to be deeply wounding for one of the parties18.
As concern mounted over the expectant turn the treatment appeared to have taken, Nélaton realized that the doubters would not be persuaded without some form of physical evidence of the metal. His approach to the problem was to create a new exploratory instrument which harnessed the techniques of chemistry to the cause of surgery. In much the same vein, Professor Favre of Marseilles had suggested that electricity might provide a means of detecting the bullet. He had devised an electrical apparatus consisting of electrodes attached to probes, so as to provide electrical evidence of the bullet by galvanometer deflection. The apparatus had been used in Garibaldi's case, but by some mishap the electrodes had not been brought into contact with the bullet, and no indication of its presence had been obtained19.
Nélaton had better luck with his instrument. At first he had thought of a steel probe ending with a kind of file which could take off a few particles of metal. While the probe was being made, however, he began to toy with the idea of a chemical reagent. He asked the chemist M E Rousseau to provide him with some simple means of determining the presence of lead in a wound by chemical analysis. Rousseau suggested the introduction of a body capable of bringing away an impression of the metal, such as rough porcelain (biscuit)19. Thus an unglazed porcelain-tipped probe was made and forwarded from Paris to Professor Zanetti for testing20.
With this instrument (Figure 1) Zanetti became so certain of the presence of the ball that on 23 November he finally resolved to make an attempt at extraction. The event was described by Jessie White Mario, an English nurse who had gone out to Italy to tend to Garibaldi's wounded, and had married one of his officers:
‘At last Professor Zanetti, the great Tuscan surgeon, enlarging the orifice of the wound by inserting cotton-wool steeped in gum, felt prepared to make an attempt to extract the ball. Garibaldi held my hand during the whole of the operation, and as soon the forceps entered the aperture he exclaimed “Per Dio! c'e!” A few seconds later Zanetti produced the sharpshooter's bullet, which, striking first against a boulder thence rebounding into the ankle, had assumed the perfect form of the cap of liberty. It was a supreme moment of emotion when Zanetti held it up to view. Garibaldi embraced the surgeon, then all of us: the news spread—spread like magic and rejoicing was universal’ (see Ref.2, pp. 337-8).
Sheets and bandages stained with the blood of the ‘martyr of Aspromonte’ were eagerly sought for, and they were torn to ribbons for distribution. An Englishman offered to purchase the bullet for a fabulous sum; Garibaldi's son Menotti refused to part with it (see Ref. 2, p. 337).
In Paris the liberal press erupted in unanimous celebration of Nélaton's clinical skill: as a memento, Nélaton was presented with a gold tobacco box decorated with the effigy of his famous patient. In London the President of the Royal College of Surgeons, Luther Holden (1815-1905), enthused about the benefits the sciences could bring to surgery (although he mistakenly attributed Nélaton's success to the use of Favre's electrical apparatus). ‘Is not this a beautiful instance of the co-relation of the sciences?’, he wrote to Thomas Madden Stone, librarian to the College. ‘Here is a branch of knowledge, apparently very distantly related to our noble art of surgery, which throws a flood of light on a surgical point, and does the signal service of solving a question which for weeks was involved in obscurity’21.
Holden's remarks drew their meaning from a debate that had preoccupied surgical authors since the eighteenth century. What was the proper balance between the manual and the theoretical aspects of surgery, between the ‘art’ and the ‘science’? Almost without exception, ‘art’ was given inferior connotations, a point of view implicit in Holden's letter. This was hardly surprising in the light of the wider professional contest which occupied surgeons for much of the eighteenth and nineteenth centuries. In their efforts to achieve equal status with physicians, surgeons saw the manual and instrumental aspects of surgery as a distinct disadvantage. On both sides of the Channel, attempts were made to distance surgery from the empiricism of craft practice. Condemnations of operation were commonplace: ‘The art of operating... is only a single point in the cure of disease’, wrote the French surgeon François Quesnay (1694-1774) in 174322. In England John Hunter (1728-1793) condemned operations as a ‘tacit acknowledgement of the insufficiency of surgery’, and after the International Exhibition of 1862, James Syme (1799-1870) wrote of his outrage at the increase in the number of surgical instruments submitted for approval. ‘I sometimes think of taking down a bagful to laugh at’, he said23.
The trend noted by Syme was no passing fad: the invention of the probe, and indeed Nélaton's entire career, reflected an interventionist outlook that would soon come to dominate the practice of surgery. During the second half of the nineteenth century, a rising generation of surgeons rediscovered with pride the manual traditions of the surgical craft. Bold, confident and innovative, these men had no anxieties about excessive instrumentation (Nélaton developed a special relationship with Charrière, the Parisian instrument manufacturers). Gradually but surely, they devised increasingly radical operations which came to be seen, paradoxically, as the ultimate in conservative surgery. By the early twentieth century, the ‘belly-ripping’ surgeons of fifty years earlier were hailed as pioneers of abdominal surgery, and obsolete instruments were proudly displayed as evidence of surgery's noble heritage. The Royal College of Surgeons of England established a formal historical instrument collection in the early 1870s; by 1910, 806 items had been collected24. Once the social status of surgeons had been assured, instruments could fulfil a new function as symbols of skill and achievement.
Garibaldi gradually recovered the use of his limb, but the wound continued to trouble him, intermittently causing great pain and stiffness in the joint. Partridge's reputation never recovered from the blow it had suffered: his professional credibility in shreds, he died a poor man in 1873. By contrast, Nélaton gained world-wide recognition as Garibaldi's saviour, although he had not personally extracted the bullet. He received many honours, including the Légion d'Honneur, and by the time of his death he had amassed a fortune valued at twelve million gold francs.
The French satirical press took a jaundiced view of Nélaton's meteoric rise, depicting the famous probe as nothing more than a cynical publicity stunt25. Nevertheless, porcelain-tipped probes were made in great numbers after Nélaton's success, and well into the twentieth century they were considered an essential part of the equipment of military and naval surgeons. Probably they were not extensively used in practice, since the porcelain tip was difficult to clean after it had been stained by the lead.
Humbled by the French, the British medical profession was finally forced to admit that the whole nation had been wrong about the skill of Italian surgeons: ‘We think that these gentlemen have received very scant justice from all quarters’, observed the British Medical Journal on 29 November 1862. ‘We verily believe, from what we know of their skill, that if neither English, nor French, nor Russian surgeons had visited the general, the same result—the extraction of the ball—would have been obtained. Indeed, we may say that, to a certain extent, the foreign led the native surgeon off the true scent’26.
I thank the History Group, London School of Hygiene and Tropical Medicine, for comments on the paper.