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Ambroise Paré, the uncommon surgeon
R. Merrell (Chirurgia, 104 (2): 123-126)
Born in 1510, died in 1590, surgeon to four French kings, greatest surgeon of the 16th century, prolific author who changed surgical practice as no one had since Galen, Pare was a common man in a time of empowerment of the common, a time to celebrate accurate observation, a time to abandon harmful and false tradition, a time to give new ideas a chance, a time to beware of radical ideas yet celebrate innovation, a time of the renaissance of learning and inquiry.
So what were the fabulous opportunities that allowed the humble youngster from the Province of Maine to become the loudest voice for surgical innovation in his time? Wedged between Normandy and Brittany in the Northwest of modern France in the town of Laval in Maine little in the way of education was possible; so Pare was sent to board with a chaplain. He never learned Latin and undertook a decidedly undistinguished apprenticeship with a barber. For the son of a cabinetmaker this was not much more than could be expected in order to learn an attainable trade. Pare was part of the growing middle class, not bound to the land, chattel, distinguished professions, academics, holy orders, or a title of aristocracy. One could say the middle class was lacking a perch to rest upon. One could also say the only option was to fly. There was certainly nothing auspicious or predictive of greatness about his beginnings. Recall that in that time barber and surgeon were synonymous. The barbers had sharp things to lance and cut.
 
They had cloth dressings to bind. In fact the colorful red and white poles that identify a barber salon today are derived from poles in front of such shops in the middle ages where the barber was drying clean and partially cleaned bloody dressings, wrapped in stripes around a pole. When the distinguished physicians of the age recommended bleeding or lancing as a treatment, no one expected the erudite faculty of the University of Paris to actually do the dirty work themselves. Indeed they sent an instruction to the local barber/surgeon to carry out the undignified intervention. However, a young man needed a career and Pare followed his apprenticeship with a move to Paris in 1536 as a comapagnon chirugien at the Hotel Dieu. When Pare arrived the hospital was already 900 years old and was housed in Gothic buildings to the right of Notre Dame Cathedral. In fact the buildings were not replaced until the end of the 18th century and the facility has continued to care for the people of Paris for some 1400 years. After four years of dressing wounds Pare was prepared to practice his skill. He had certainly no medical degree and could not even afford to take the basic examination let alone the examinations for the College of St Come, the fellowship of barber surgeons who took on trappings like the elite physicians and segregated themselves from the lowly barbers.
However, he was ready for life in the strongest dose the 16th century could offer. Today we worry about the economy, international development, stability of governments, conflicts of faith, epidemics, poverty, war, and the burden of an aging population. The only one of that litany of grief not to trouble the young person of 1536 was an aging population. Death was just too prevalent. There were many more poor than prosperous in that year in France and poverty had little relief. Suleiman the Magnificent ruled the Ottoman Empire including the suzerainty of Moldavia and Wallachia. International development was a matter of commerce with the Sultanship of Aceh in Indonesia declaring for the Ottomans and the forces of Phillip II establishing the Spanish Empire in the Americas. Development was a far cry from the Millennium Development Goals of the United Nations rather favoring colonization and commerce. Globalization was not yet defined. Bucharest was a young city first mentioned in 1459 and the ancient Black Sea port of Constanta had been part of the Ottoman sphere of influence since 1419. The fleets of Spain and the Ottoman Empire were developing the Indies and Africa where abundant slaves were part of trade equations between Europe, Africa and the colonies. In contrast with the Millennium Development of Goals history relates a highly competitive, querulous international development very much a part of the times of Pare.
Government was not very stable. France had not been completely defined. Disastrous wars with England in the previous century needed Joan of Arc to declare the nationhood of France in terms other than those of property and fief. Francis I, a Valois, was king from 1515 to 1547 and ruled without challenge from his Chateau, Ambroise. He had been engaged in several Italian Wars to end the rule of the Sforzas in Milan. The serial wars lasted from 1495 to 1559. Did they not get tired of the conflict by then? How long can one perpetuate such lack of resolution and loss of human life? Oh, that does sound modern does it not? Francis moved Leonardo da Vinci to a house near Ambroise where he spent to the remainder of his Renaissance life away from the need for war machines, giant statues, defense walls and court intrigue. Leonardo moved the Mona Lisa with him and followed Italian wars and politics from a distance before dying in 1519. If Francis looked to be a founder of stability look ahead in the life of Pare and the instability is striking. He was indeed affiliated with four kings AFTER Francis I. Henry II married Catherine de Medici of Florence. The king died in a jousting match celebrating the marriage of daughter Elizabeth to Philip II to end some conflict with Spain over Italy. Philip also married Mary, Queen of England and was king of that land until Mary was indisposed by execution. Henry’s beloved wife, an expert in poisons, guided the reign of her son Charles IX during his regency and short life to the succession of his brother Francis II. The latter was kidnapped by religious opponents and was married to Mary Queen of Scots also later removed from this transitory life by execution. Then followed another brother, Henry III, who was killed to make room for another dynasty, the Bourbons. Of course there were no elections but live political coverage could have been very interesting. However, there were no journalists either. In the time of Francis l France was allied with Suleiman the Magnificent against the Habsburgs. It was an era of unlikely alliances when people, cities, and cultures were traded among the power centers with as impersonal a tone as casual philatelists.
Faith was in a time of personal and geopolitical frenzy. Protestantism with the Huguenots of France was hotly contested. It is thought Pare may have been a Huguenot but discretion and a sense of self preservation kept him from ever making matters clear. He always served catholic armies and kings. In fact the term Huguenot was not even in common use in his use in his early life and the great religious wars of France, eight in all, came in the decades after his death. However, the conflict with Islam was intense. Of course the Iberian Peninsula was not part of the Ottoman Empire but all of the Balkans, Hungary, Wallachia, and Transylvania were held by Suleiman the Magnificent (1520-1566). His predecessor had won two sea battles at Lepanto off Greece and ruled the Mediterranean driving the Europeans into Atlantic trade. We in the West better remember the battle of Lepanto of 1571 which the western countries finally won. When Pare was beginning his studies in barber surgery, Vienna was under siege and Suleiman was almost into Western Europe. Vienna stood firm but was repeatedly attacked by Ottoman armies up until the final battle in 1683. After Lepanto the Ottoman Empire began to decline in many ways. However, the conflict with Islam was cruel, protracted and never marked by true tolerance on either side. Religion served politics and commerce in terrible ways. We have much to learn and remedy in that regard today.
Epidemic disease is not strongly identified with the 16th century. Europe was much occupied in exporting smallpox, measles, etc to America where an immunologically naïve population was devastated, dying by the millions.
There was always a war in the 16th century nearby or coming soon. In some ways it was like an epidemic of new diseases. The use of firearms grew dramatically in this century and the wounds they produced were poorly understood and managed by doctrinaire and perhaps unthinking practitioners. War wounds were certainly managed by the barbers and in 1536 the young Pare went off to seek his fortune and practice his craft with Marshal de Montejan. At the siege of Turin the next year he had a sort of epiphany that changed his life and greatly accelerated progress in surgery.
The well trained dresser believed the common teaching that these new injuries caused by firearms represented a poisoning of the tissues by gunpowder and that to treat them one must apply oil of the elder tree, scalding hot, mixed with a little treacle ( a dark brown sugar syrup). The young dresser ran out of the proper oil in the thick of battle and in his words“…was constrained instead thereof to apply a digestive of eggs, oil of roses and turpentine. In the night I could not sleep in quiet, fearing some default in no cauterizing that I should find those to whom I had not used the burning oil dead empoisoned; which made me rise very early to visit then, where beyond my expectation I found those to whom I had applied my digestive medicine to feel little pain and their wounds without inflammation or tumor, having rested reasonable well in the night: the others to whom was used the said boiling oil I fond them feverish, with great pain and swelling about the edges of their wounds. And then resolved with myself never cruelly to burn poor men wounded with gunshot.”
This account is stunning. He had a control group. He established a protocol. He observed the results and from that observation based upon compassion for patients he resolved never to use the prescribed technique again. Note his sleepless night, worried about the outcome of a treatment he thought might be decidedly inferior. The patients slept better than he and I believe all surgeons can identify with that sleepless night before the benefit of our work has been clear and while our patients either do not quite know enough to worry or have the benefit of narcotics. Note that when he could not get the caustic oil recommended he resorted to a soothing preparation. He knew from experience that gentle handling of tissues was the best and that there could be soothing applications that avoided excessive rubor, calor, dolor, tumor, a phrase that had identified inflammation since first used by Celsus in the first century.
Although Pare was not classically trained, he actually knew a great deal about the traditions of medicine. It seems he readily accepted there were immutable truths in the lessons and teaching of the previous icons of medicine. However, as a young surgeon in the Renaissance he also knew the world was changing and that there were new answers for the new problems and almost certainly better answers for the old ones. It was thematic of the Renaissance to reawaken observation and assert new truths with confidence based upon sound observation and thought. When he returned to Paris he began a practice and private life. He had enough money to take his basic examinations and he began to acquire property building prosperity that he enjoyed the rest of his life. His family never produced a surgical heir although he had a total of nine children by two wives. His reputation as surgeon grew and his stature as well as that of surgery in general grew with recognition by the military and civilian sectors that the contribution by surgeons to direct care and caring was noble and highly informed.
Pare was able to reach a much larger group when convinced by the famous Sylvius, professor at the Faculte de Medicine, teacher and later harsh critic of Vesalius, that he should write about his experience in wound care. In 1545 he published “The Method of Treating Wounds Made by Arquebuses…” He apparently detested the guns that defined modern warfare thereafter. Of the introduction of firearms he wrote “Wherefore we all of us rightfully curse the author of so pernicious an engine.” He described in vivid detail the pain, tissue destruction, infection, necrosis, amputation and despair of such injuries. He wished his readers good will and offered no pedantic intimidation in his writing. He wrote with humility but with the unembellished force of fact. He often said in his writing that “I dressed him, God healed him.” In his books he invited those who read them to try to elucidate the truth better and then abandon his poor work. Much as any modern observer he had no thought that in medicine he was likely to find a truly immutable truth that could never be challenged. Medicine is not physics or a dead language! Medicine changes with new discoveries. He went on to write about the advantage of ligating vessel in amputation rather than cauterizing them. He made important observation in obstetrics and prosthetics. He even developed a prosthetic eye. He taught not only through his books but in direct tutelage. His most famous student was Paracelsus.
Pare always seemed to be interested in the patient and often recommended measures to increase patient comfort. He even described the use of falling water to simulate rain to soothe the patient and encourage sleep. At the time of his writing the importance of the individual was just coming to currency. Rather than medieval ciphers, nameless serfs or titled icons, the individual was increasingly recognized for the importance of independent thought and action. What followed Pare was a long series of fabulous observations always pertinent to the care and nurturing of the individual. In current science the fragmentation to molecular and nanophysical forces makes it difficult at times to step back and see the whole patient. As Sherwin Nuland points in “Doctors” that problem did not exist for the renaissance and Pare, its foremost physician. Then the whole person was something new. Now it seems a very old concept awaiting rediscovery in order to better serve patients and community.
Pare published extensively on anatomy and issued his books in multiple editions, always in French. When surgeons in other countries wanted to know what he had to say his works were translated into Latin or the vernacular of German, English, etc. The very notion that some great truth could first appear in the vernacular to later be translated into Latin foretold the end of classical language for sophisticated communication. Pare was challenged about not publishing in Latin and he pointed out that Hippocrates had published in his native idiom of Greek and never Latin. However, in 1554 the members of St Come, the middle group between barbers and physicians, waived the Latin requirement and acceded to admitting the acknowledged master of European surgery, friend and surgeon to kings, to their exalted ranks. The Romanian language is first recorded in a letter of 1512. This was indeed a time of the vernacular and a rising sense of national identity.
Pare cold be just as barbed as the next writer in responding to critics. When a professor attacked his work Pare referred to him as “my little master” and as a “young lad of Brittany with plump buttocks”. Pare noted that the lack of practice by his learned critics reminded him that “the laborer doth little profit by talking of the seasons, or discussing of the manner of tilling the soil or showing what seeds are proper to each soil… if he does not put his hand to the plough and couple the oxen together.”
Of course while Pare represents the Renaissance in surgery, surgery did not define the Renaissance. Pare was working at a time when there were regular discoveries in science, new trends in art, new accomplishments in engineering, great public works and bold new ideas in philosophy and the humanities. It is our good fortune that when these great advances were being made in knowledge in general a person of the gentle intellect, careful eye, great compassion and superb communication skill like Pare was present to move surgery forward.
So here we are five hundred years later. Our heroes are often disgraced, the world is moving too fast, religion is so contentious, international development can be cynical, the truths of our elders are not so reliable, wars are horrible, life is uncertain, privilege seems to prevail and young people lack recognition, governments do not seem to stay and new ways of getting ill like blood borne viruses and Alzheimer’s and environmental exposures confront and confound us regularly. The density of population and limitation of resources guarantee suffering on a monumental scale from illness and aging. Why read about some old surgeon who just figured out how to cut off legs? We must understand Pare to respond to our times. Such study invites us to look at this new world with questioning eyes. We are prompted to look again at the whole patient with exuberant compassion. We are likely to cultivate a disdain for engines and implements and influences that harm people and deny them their nobility. We must conclude that times have never been better to find new solutions and discard frayed old truths. There is no guarantor for an aspiring medical career or future absent individual initiative but that is ample resource no matter family circumstances. There is no obvious benefit waiting for the times to improve either. However, there is change about and new tools are coming at a rapid pace. There are innovations and they are not all wicked. Look around. Find the problems and do the right thing. This is again a perfect time to put our hand to the plow and couple the oxen together.

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