Ambroise Paré: Father of Modern Surgery (version 2)
Ambroise Paré was born in 1510 in Bourg-Hersent (now absorbed into Laval) in north-western France and lived until 1590. His elder brother and his brother-in-law were also barber-surgeons, under whom he may have served his apprenticeship. Paré went to Paris, where he soon became a barber-surgeon apprentice at the Hôtel-Dieu, France’s oldest hospital. By the time Paré entered the Hôtel Dieu, barber-surgeons were incorporated into the education system of the University of Paris. They could attend lectures on anatomy and surgery delivered by the faculté and could take the master-barber’s examination to receive professional recognition from the faculté. Paré was too poor at the time of his departure for the Italian front to pay for this examination, but would pass it following his return.
He was living in a time of war. The Italian Wars began in 1494; which was 16 years before Paré was born. But there were prelude events to the war starting as early as 1454 (56 years before Paré’s birth). The Italian Wars ended in 1559. But with the end of the Italian Wars, came the Religious Wars which started in 1562 and lasted until 1598; which was 8 years after Paré’s death. His entire life time was a series of wars and conflict.
It was Paré’s experience at the Hôtel Dieu that permitted him to serve as a surgeon to the French army. Many surgeons gained experience as a result of war, and Paré was no exception. Paré first experienced being a battle medic at Piedmont, during the campaign of Francis I when he joined the army in 1537. He served intermittently in the army for the next 30 years, during which time he also developed a flourishing private practice and gained fame through his writings and his considerate, democratic treatment of soldiers of all ranks. By 1552 he had gained such popularity that he became surgeon to the king; he served four French monarchs: Henry II, Francis II, Charles IX, and Henry III.
Before he even cared for his first wounded solider, Paré was given a lesson in compassion. He went into the stable and found there dead bodies and two wounded soldiers. They had been propped up against the wall. Both were victims of gun powder. They could not see nor hear. They were suffering great pain. Another soldier asked Paré if the soldiers could be saved. When Paré replied that they could not be saved, the solider slit their throats. It was common in that time to end the lives of gun powder victims quickly. It was seen as cruel to allow them to suffer long and slowly when there was no chance for them to survive. The soldier explained to Paré that he would want the same done for him.
In 1545 Paré began the study of anatomy at Paris, under François-Jacques Dubois (Sylvius), who encouraged him to write on his experiences with gunshot wounds. This is ironic because this encouragement started Paré on a life time of writing that helped Andreas Vesalius undermine Galen whom Sylvius was fiercely supporting and protecting.
The dogmatic quality of Galenism meant that physicians until the Renaissance — and in many ways until the 19th century — did not practice a medicine based on practical observation, experience, and empirical analysis. The treatments proscribed by Galen and the earlier Hippocratic writings were first comprehensively challenged by Paré and the anatomical writings of Paré’s contemporary, Andreas Vesalius. While the physicians, who constituted the faculté, were those most educated in diagnostic and academic medical practice, the practical tasks were left to barber-surgeons. Barber-surgeons were trained in extended apprenticeships and, sometimes, continued studies at public hospitals. Unlike modern hospitals, these were often repositories for the destitute and indigent that offered primarily palliative treatments.
In general, however, the physicians would diagnose and order the administration of certain procedures, which were carried out by the barber-surgeons who also cut hair and pulled teeth to maintain their livelihood. The crude physicality of their professions aside, the barber-surgeons were thus much more intimately aware of the means of performing surgical procedures in Renaissance France than their more highly esteemed physician counterparts.
Ambroise Paré’s numerous technical innovations and literary contributions to the art of surgery were deeply felt in the continued development of surgery following the 16th century. His use of the vernacular encouraged later surgeons to do the same and his focus on novel surgical principles established a strong foundation upon which the modern institution of surgery is built. His emphasis on techniques that minimized the damage done to the tissues of the patient has guided the development of the gentle art of surgery in the many centuries since his writings first appeared. Although his writings and techniques appeared during a time in which surgery was a separate realm from medicine proper, physicians and surgeons can now look to Paré as the founder of modern surgery, a restorative process that heals the body with minimal suffering.
Seeing the dramatic difference between the “proper” and improvised treatments, Paré resolved to only treat cases with procedures he had personally observed to be useful. This resulted in such innovations as the use of ligatures in amputations, treatments for sucking chest wounds, and a cure for chronic ulcers of the skin. Although this experimentally driven medicine did not come to define the physician’s practice until the rise of the Paris Clinic in the 19th century, these first writings established an important foundation of empiricism in European medicine.
He that would perform any great and notable work, must diligently apply himself to the knowledge of his subject. — Ambroise Paré
In a book on these new techniques, Pare also included large parts of Andreas Vesalius’s authoritative work on anatomy, translated from the original Latin into French. This information dramatically increased the barber-surgeon’s knowledge of anatomy, since the typical barber-surgeon was never taught Latin as part of his training.
Paré’s greatest accomplishment, aside from actually coming up with new surgical techniques, was to spread this information throughout the barber-surgeon community, elevating surgery’s status to a professional level and paving the way for vast improvements in surgical care. In the medical world of his times, he appeared as maverick, not knowing Latin and learning medicine from experience rather than in classical treaties. It required his royal patron’s intervention for him to obtain his medical graduation in 1554, initiating the reunion of surgery and medicine which has prevailed to our time.
Cure occasionally, relieve often, console always. — Ambroise Paré
Renowned as much for his compassion as his surgical skill. Many of the details of his surgery are no longer of scientific interest; despite his innovations, he labored under the humoral theories and superstitions common to sixteenth century surgery and was ignorant of such considerations as circulation of the blood and asepsis. Nonetheless, he saved many patients who would be the despair of a then modern surgeon, and he came to represent the ideal practitioner, both for his technical competence and for his humanitarian concern for his patients. He had a vague, reasoned anticipation of some form of transmissible infection and a crude appreciation of public health measures. Although his knowledge of pathology was at best rudimentary, he advocated and practiced (and left records of) autopsy investigations of fatal illnesses.
Like his contemporary Andreas Vesalius, Paré is now celebrated as an emblematic figure of Renaissance thinking, willing to look beyond the established authorities and instead rely on the evidence of his own experience. In the Oeuvres, for instance, he mocks the use of “mummy” a popular remedy ostensibly created from Egyptian mummies and used extensively by physicians. Such a position was particularly provocative given Paré’s identity as a surgeon, rather than a university trained physician with a formal education and knowledge of Greek and Latin.
Despite Paré’s close connections with many of its members, the Parisian Faculty of Medicine attempted to block the publication of the Oeuvres, arguing that the Faculty needed to approve all publications relating to medicine and surgery. In addition, they objected to Paré’s use of French, as he was among a small but increasing number of practitioners writing in the vernacular rather than the more scholarly Latin, making such works vastly more accessible to students of surgery operating outside the universities and the lay public.
Ambroise Paré’s publications went beyond the descriptions of procedures and his books included illustrations of the instruments he employed, another groundbreaking innovation for surgical texts. These features strengthened Paré’s arguments and gave his teachings great strength among barber-surgeons, physicians, and their clients. Paré’s clear writing and use of the vernacular, backed by decades of practical experience, ensured that his texts and techniques would become the foundation of a new surgery.
Much of Paré’s renown was based on his early work in the military context. Throughout the Oeuvres, he returns to examples of treating soldiers wounded during conflict. Perhaps the most famous vignette describes how, during his first campaign in 1536, Paré found that he had insufficient boiling oil to use in cauterizing gunshot wounds, and instead used a liniment made of egg yolk, rose oil, and turpentine. The following day, he discovered that those soldiers treated with the liniment were in a better condition than those whose wounds had been treated according to the prescribed manner. He subsequently argued for the treatment of gunshot wounds with liniments and bandaging, as well as removing affected tissue from the wound.
Gunpowder, whether projected from cannons or shot from firearms, had become a significant factor on European battlefields in the late 14th century. The use of gunpowder dramatically changed the practice of warfare. Increasingly numerous and accurate firearms contributed to the number of soldiers killed and wounded. These weapons produced new types of wounds that penetrated into the body, carrying foreign materials with them and leading to gangrene, while also deafening and blinding those near blasts.
Surgeons based their treatment of gunshot wounds on the belief that the gunpowder carried into the body by the bullets brought poison with it. This idea came from Giovanni da Vigo (1450–1525), an Italian surgeon whose 1514 Practica in arte chirurgica copiosa and 1517 Pratica in professione chirurgica were highly influential surgical texts. Rapidly translated into multiple European languages, these books include da Vigo’s suggestion to cauterize the wound with boiling oil in order to counteract the poisonous traces of gunpowder and to seal any severed arteries. This procedure became considered standard practice. Paré, after his experience with liniment rather than oil, experimented further, and recounts seeking advice from other surgeons and testing a folk remedy for onion poultices for burns suggested by an older local woman. Concluding that they were effective against blistering offered Paré another rhetorical opportunity to emphasize his commitment to observation and experimentation.
The Chirurgion must be active, industrious, and well handed, and not trust too much to books, be they French, or Latin, or Greek or Hebrew. — Ambroise Paré
While Paré was not the only surgeon to be working towards more humane and effective treatment of gunshot wounds, Paré became the most well-known and is often celebrated today as the “father” of modern surgery. This reputation rests on not only his work around gunshot wounds but his broad interests, influence, and innovation.
Paré left a powerfully reactivated surgical tradition at his death. His many publications, which were translated into both Latin and modern languages, circulated throughout Europe, and had considerable influence during his life and well into the following century. But in France itself surgeons were again under the Hippocratic yoke within two generations, and the art of surgery had reverted to about the level at which Paré had found it. Part of the blame for this must be attached to the reactionary character of French academic medicine, and to the prevailing moral and religious antipathy toward the scientific principle; the reforms for which Paré struggled did not come until both the College de Saint-Come and the once powerful and privileged Faculty of Medicine were abolished in the French Revolution.
There are five duties of surgery: to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided, and to redress the defects of nature. — Ambroise Paré
Although Ambroise Paré’s role as a founder of surgery is well acknowledged, his role as a founder of obstetrics is less well known. Human reproduction, until then the domaine réservé of midwives and surrounded with ignorance and superstition, was brought by him into the fold with medicine and science. He founded schools for midwives, elaborated on the training of wet nurses, and his book, de la génération de l’homme became the founding block of obstetrics. In this book are depicted several items of interest to pediatric neurosurgeons, such as cephalhematoma as a consequence of forceful labor, and prenatal hydrocephalus (clearly distinguished from macrocephaly) and conjoined twins as causes of dystocia. He advanced obstetrics (the study of childbirth) by reintroducing podalic version (turning a fetus in utero into a position possible for birth) and inducing premature labor in cases of uterine hemorrhage. As always, he spread knowledge of these discoveries through his writings.
During the 16th century the decision to amputate was influenced more by religious belief than by the nature of the injury, as death from a limb wound was often more readily accepted than elective mutilation of the human body. When amputation did occur it was reserved for gangrenous extremities and was performed through dead tissues to avoid blood loss. Infection following gunshot would rarely resolve until all sequestra and debris were removed; in such cases secondary amputation was the only potentially curative option. It was also common to use fire after amputations of the limbs, in order to consume and check the putrefaction which is common to gangrene. Although cauterization was also used to stem hemorrhage it also destroyed flaps of skin needed to cover the amputation site, increasing the risk of infection. Amputation was therefore often complicated by infection and hemorrhage and many patients died.
Prosthesis, artificial substitute for a missing part of the body. The artificial parts that are most commonly thought of as prostheses are those that replace lost arms and legs, but bone, artery, and heart valve replacements are common and artificial eyes and teeth are also correctly termed prostheses. The term is sometimes extended to cover such things as eyeglasses and hearing aids, which improve the functioning of a part. The medical specialty that deals with prostheses is called prosthetics. The origin of prosthetics as a science is attributed to Paré.
Work overcomes everything. — Ambroise Paré
One of the earliest written references to prosthetics is found in a book published in France in 1579 by Paré. He published his complete works, part of which described some of the artificial limbs he fitted on his amputees. As a military surgeon, Paré had removed many a soldier’s shattered arm or leg, and he eventually began designing and building artificial limbs to help the men who had been maimed. As a doctor, he was most disturbed by the reaction of some of the people whom he had saved. He found that some soldiers took their own lives rather than live without limbs, or with terrible wounds. To try to combat this problem, Paré began crafting artificial limbs.
This was not new. There is evidence for the use of prostheses from the times of the ancient Egyptians. Prostheses were developed for function, cosmetic appearance and a psycho-spiritual sense of wholeness. Amputation was often feared more than death in some cultures. It was believed that it not only affected the amputee on earth, but also in the afterlife. The amputated limbs were buried and then disinterred and reburied at the time of the amputee’s death so the amputee could be whole for eternal life. One of the earliest examples comes from the 18th dynasty of ancient Egypt in the reign of Amenhotep II in the fifteenth century B.C. A mummy in the Cairo Museum has clearly had the great toe of the right foot amputated and replaced with a prosthesis manufactured from leather and wood. The first true rehabilitation aids that could be recognized as prostheses were made during the civilizations of Greece and Rome. During this period, prostheses for battle and hiding deformity were heavy, crude devices made of available materials—wood, metal and leather. Records of ancient prosthesis can be found all over the world. Legend holds that Roman general Marcus Sergius wore an iron replacement hand during the Second Punic War. During the European medieval period, armored knights used iron prosthesis to conceal lost limbs. Some pirates actually did wear crudely fashioned hooks and peg legs.
Paré’s limbs were something different. He wanted them to be functional, not just stop-gap solutions. He was an accomplished anatomist, and so when he designed limbs, he attempted to make them work the way biological limbs worked. When he designed legs, he gave them a mechanical knee that could be locked when standing and bent at will. He drew up preliminary sketches of an arm that could be bent with a pulley that mimicked arm muscles. Paré had the idea to use the progress in robotics that occurred in his period to create prostheses that worked with the mechanical devices invented for robotic toys or clocks. In this phase the robots were replicas of the human being that made a series of simple movements. The machines began assuming tasks of aid to the man and ended up repelling their conception of the world and animated beings. The mechanics affected the study of nature, spreading to the anatomy science; of which agreed models with that conception were elaborated, such as “De Humani Corporis Fabrica” (On the workings of the human body) from Andreas Vesalius (1514–1564) who conceived the man as a complex mechanical structure.
Paré’s personal life was marked by honesty, piety, and concern for the poor and defenseless. His last recorded act is his having, at the age of eighty, stopped a religious procession in the streets of Paris so that he might plead with its leader, the archbishop of Lyons, to come to terms with Henry of Navarre (later Henry IV), who was then besieging the city. Paré hoped thus to alleviate the lot of the starving Parisians, and whether or not his unprecedented act exerted any influence, the siege was lifted about a week later. He died shortly thereafter, in the house in which he had lived throughout most of his active career. He was buried in his parish church, St. Andre-des-Artes (destroyed in 1807, in which year Paré’s bones were transferred to the catacombs).
References and Other Sources:
- Science Museum
- Britannica: Ambroise Paré
- Britannica: Prosthesis
- Ambroise Paré and the Birth of the Gentle Art of Surgery
- Ambroise Paré Biography (1510-1590)
- Ambroise Paré Facts
- Ambroise Paré on gunshot wounds
- Ambroise Paré’s accounts of new methods for treating gunshot wounds and burns.
- Compton History
- History of Surgery
- Journeys in Diverse Places
- Life and times of Ambroise Paré, 1510-1590
- Vaulted Treasures
- Ambroise Paré, surgery, and obstetrics
- Ambroise Paré IV: The early history of artificial limbs (from robotic to prostheses)
- Ambroise Paré II: Paré’s contributions to amputation and ligature
- Ambroise Paré III: Paré’s contributions to surgical instruments and surgical instruments at the time of Ambroise Paré
- Ambroise Paré’s life (1510–1590): part I
- Ambroise Pare (1510-1590): surgeon and obstetrician of the Renaissance
- AMBROISE PARE: THE BARBER-SURGEON
- Groundbreaking Scientific Experiments, Inventions, and Discoveries
- Medical Review, Volume 42
- The St. Louis Medical Review, Volume 42
- Labour, Science and Technology in France, 1500-1620
- Medieval Science, Technology, and Medicine: An Encyclopedia
- A great summary of material on Paré
- Making the Body Beautiful: A Cultural History of Aesthetic Surgery
- On Monsters and Marvels
- Anomalies and Curiosities of Medicine: Being an Encyclopedic Collection