CHAPTER XL. The Development of Surgery in France (continued).--Ambroise Paré

THE DEVELOPMENT OF SURGERY IN FRANCE (Continued).--AMBROISE PARÉ

Ambroise Paré was born, about the year 1517, at Laval, a small town in the Department of Mayenne, France. His father was probably the valet and barber of the Count of Laval. He went to Paris in early manhood and spent three years, at this period, in fitting himself for the career of a surgeon. He attended lectures on anatomy and surgery, did a certain amount of dissecting, served for over two years as a surgeon’s assistant in the great hospital of Hôtel-Dieu, made notes of some of the cases which he saw, and was occasionally permitted to prescribe for patients and even to perform some minor operations. From 1536 onward, nearly up to the time of his death, he was almost continuously engaged, in the capacity of a surgeon, in accompanying different French armies on their military expeditions. His professional title at first was that of “barber,” but he doubtless very soon discovered that, if he wished to advance, it would be absolutely necessary for him to secure a higher title. Accordingly, in 1541, he and his friend Thierry de Héry presented themselves for, and passed successfully, the required examination and were accepted as “master-barbers.” It is an interesting fact that, during his long professional career, Paré was Chief Surgeon to four Kings of France in succession--first to Henry the Second (1547–1559), next to Francis the Second (1559–1560), then to Charles the Ninth (1560–1574), and finally to Henry the Third (1574–1589). The last-named King bestowed upon him the additional honor of “Councilor to his Majesty.” He also served, during a certain period of his career, as an attending surgeon at Hôtel-Dieu. The three large volumes of Paré’s writings (Malgaigne’s edition) are filled with the rich experience which this great surgeon gained in the course of a large private practice and in the field expeditions and sieges conducted during the reigns of these Kings. Interspersed among the reports of cases and descriptions of operations are to be found not a few comments of a more general character and some biographic details which add greatly to the charm of the work as a whole, and which at the same time make it possible to form a general idea of Paré’s traits of character. On almost every page one finds statements which reveal the fact that he weighed almost all the duties of his daily life in a profoundly religious manner. He showed himself warmly sympathetic for all those whose ailments he was called upon to treat, and he was always as ready to bestow his best services upon the Roman Catholics as upon the Huguenots--to which latter denomination (if we may so call it) he himself is commonly reported to have belonged. It seems to me more probable, however, that he was a liberal-minded Roman Catholic rather than a Protestant, for there is trustworthy evidence showing that all his ten children were baptized in that faith and that he himself, nineteen years before the night of Saint Bartholomew (August 24, 1572), held the office of “Pathe” in the church of the parish in which he lived. Another prominent trait of Paré’s character was the modest estimate which he placed upon his own professional achievements. One of his sayings, which occurs a number of times in his writings and which has since become famous, is this:--

Je le pansay, et Dieu le guarist. [I dressed his wound and God caused it to heal.]

Some of the other sayings attributed to his pen and printed under the heading “Surgical Canons and Rules,” at the end of Book XXVI., are characterized by a homely type of wisdom which seems to have secured for them a permanent place in French literature. I give here in the form of English translations six or seven of the more striking specimens:--

Mere knowledge without experience does not give the surgeon much self-confidence.

Small will be the influence exerted by him who chooses surgery as a career simply for what he may make out of it.

The frequent changing of physicians is not likely to bring comfort to the patient.

The facts already discovered are few in comparison with those which are yet to be brought to light. We must not allow ourselves to lie down or fall asleep under the impression that the ancients knew all or have divulged all that is worth knowing. What they have accomplished should be utilized by us as a sort of scaffolding from which a more extensive view may be obtained.

In another place Paré expresses the same sentiment in a somewhat different form, as follows:--

My professional brethren must not expect to find any new and startling facts [Paré is speaking here of his treatise on surgery], but simply here and there some little addition to our previous stock of knowledge; for the good Guy de Chauliac has taught us that we are like the child who sits astride the giant’s neck; that is, we can see all that he sees and just a little more--or, in other words, we are able, through the aid afforded by the writings of our predecessors, to learn all that they have learned, and may at the same time acquire a little further knowledge through our own observations.

A remedy that has been thoroughly tested is better than one recently invented.

An injury which opens a large blood-vessel is likely to lead the victim of such a wound to the tomb.

It is always wise to hold out hope to the patient, even if the symptoms point strongly to a fatal issue.

All through his professional career, but more especially during the later years, Paré was repeatedly annoyed by the efforts which the Medical Faculty made to bring him into disrepute. These men were bitterly jealous of him on account of the great favor which he enjoyed at Court, and so they adopted every possible means to injure his reputation. When the complete collection of his writings was published in 1575, they petitioned the authorities not to allow these “works of a very impudent and ignorant man” to be sold until they should have received the official sanction of the Faculty. One of Paré’s chief offenses, as it appears, was that of not writing his treatises in Latin, and among the twenty-nine specifications of his shortcomings was that of plagiarism. (See remarks on this subject further on.)

In his efforts to extend his knowledge of the science of medicine, and in particular to learn what the ancients had written on the subject, Paré soon discovered that many obstacles stood in his way. He did not allow himself, however, to be discouraged by this fact, but set to work, without delay and in his usual resolute fashion, to remove them. He found, in the first place, that all the available treatises of the ancient medical authors were written in Latin, a language of which he possessed scarcely any knowledge. So he was obliged to hire men to translate for his own use large portions of these books. Then, at a later date, after he had begun to accumulate notes for the treatises in which he proposed to publish his own experiences and his own views about the surgical topics in which he was interested, he saw clearly that suitable pictorial illustrations would add materially to the value of the written text, and he therefore did not hesitate to spend a considerable sum of money--Malgaigne says three thousand livres--in having the needed drawings made. Paré was also in no small degree a public benefactor, for he purchased the formulae of some of the more valuable of the remedies employed by the leading charlatans, in order that he might print them and so place them within the reach of everybody.

Paré gives the following picturesque account of his first experiences as an army surgeon in actual warfare:--

In 1536, he says, I accompanied the large army sent to Turin by Francis the First, King of France, to retake certain castles and fortifications which were held at that time by the troops of the Emperor Charles the Fifth. My official position was that of surgeon to the foot soldiers; and when our men took possession of Susa, after the enemy had been defeated, I was among the first to enter the city. Our horses rode rough-shod over the dead bodies lying on the roadway, and over the bodies of many who were simply wounded. It excited my compassion strongly to hear the cries of those who were thus subjected to great additional suffering, and I could not help wishing that I had never left Paris. Once actually in the city, I began to look around for a stable in which the horses of myself and my orderly might find shelter. The one I entered contained the corpses of four soldiers who had presumably died there, and three badly wounded men who were still alive, but whose faces were greatly disfigured by the wounds which they had received, and who--as we soon learned--were unable to see, hear or speak. An old soldier who entered the stable at that moment, and whose pity was excited by what he saw, asked me if it would be possible to save the lives of the men who were so badly injured. I replied “No.” He thereupon proceeded, without the least excitement and with due gentleness, to cut the throats of all three. At the sight of this act, of what seemed to me to be great cruelty, I exclaimed, “You are a wicked man!” His reply was: “I pray God that, if it should ever be my fate to be situated as these three men were when I entered the stable, there may be somebody at hand who will do to me what I have just done to these men, and will save me from a lingering and painful death.”

When the fighting was entirely over, we surgeons had much work to do. I had not yet had any personal experience with the treatment of gunshot wounds, but I had read in Giovanni da Vigo’s work that such injuries should be considered poisoned wounds, by reason of their contact with gunpowder, and that the correct way of treating such wounds was to cauterize them with oil of sambucus (elder flowers) that was actually boiling and to which a little theriaca had been added. At first I hesitated somewhat about carrying out this practice, but after watching the other surgeons, in order to learn exactly how they applied the boiling oil, I plucked up my courage and did exactly what they did. My supply of oil, however, soon gave out, and I then decided to use as a substitute a healing preparation composed of yolk of egg, oil of roses, and turpentine. I slept badly that night, as I greatly feared that, when I came to examine the wounded on the following morning, I should find that those whose wounds I had failed to treat with boiling oil had died from poisoning. I arose at a very early hour, and was much surprised to discover that the wounds to which I had applied the egg and turpentine mixture were doing well; they were quite free from swelling and from all evidence of inflammatory action; and the patients themselves, who showed no signs of feverishness, said that they had experienced little or no pain and had slept quite well.

On the other hand the men to whose wounds I had applied the boiling oil said that they had experienced during the night, and were still suffering from, much pain at the seat of the injury; and I found that they were feverish and that their wounds were inflamed and swollen. After thinking the matter over carefully, I made up my mind that thenceforward I should abstain wholly from the painful practice of treating gunshot wounds with boiling oil.

In 1545, when he was about twenty-eight years of age, Paré was sent as a military surgeon to Boulogne-sur-Mer, which at that moment was being besieged by the French. In 1544 the city had been captured by the army of Henry the Eighth of England, and fighting of a desultory character was in progress between the besiegers and the besieged at the time of Paré’s arrival. He had not been there a long time when he was asked to see professionally Francis of Lorraine, Duke of Guise, who had been seriously wounded by a lance in a recent encounter with the enemy. The metal head of the weapon, under the impulse of a glancing blow, had penetrated the skin just above the right eye, had then traveled toward the left side and in a slightly downward direction, along the surface of the skull, and had finally come to rest at a point behind and below the left ear, near the nape of the neck. When the lance had penetrated thus far the wooden shaft broke in two, leaving the metal head in its entirety and a part of the shaft so firmly lodged in the wound that great force had to be employed before it was found possible, with the aid of strong pincers, to extract it from its bed. An examination of the injured parts then showed that there had been some fracturing of the bony structures and extensive laceration of the arteries, veins, nerves, etc., but that the left eye had apparently not been seriously damaged. The onlookers were naturally impressed with the belief that the Duke could not possibly recover from such a slashing of the face and head; and Paré himself was careful at first not to commit himself to a prognosis of too favorable a nature. However, he treated the wound with the greatest care and in the course of a few weeks had the satisfaction of seeing his patient restored to perfect health, but with a deeply scarred face.

As can readily be imagined, this experience proved a splendid triumph for Paré, and speedily brought him into great favor at Court and among the nobility throughout France.

For several years subsequent to these events, Paré continued to serve actively as a surgeon in the frequent wars which took place between the royal troops of France and the armies of other European monarchs. In 1552, when he was thirty-five years of age, his rank in the army was raised to that of “Surgeon to the King,” the entire medical staff of that period consisting of twelve surgeons of this rank. In 1554 he was admitted to the Collège de Saint Côme in Paris, the highest professional honor to which a barber-surgeon might aspire; and in 1563, after the siege of Rouen, he received the appointment of “First Surgeon to Charles the Ninth.” After the latter’s death, Henry the Third also appointed Paré to the same position in his Court. Thus, from almost the very beginning of his professional career to the time of his death, Paré was honored in every possible way by four successive Kings of France. It was Charles the Ninth, however, who appears to have taken a greater interest in Paré’s prosperity than did either of the other three Kings. It was at Charles the Ninth’s request, for example, that the brother-in-law of the Duke of Ascot, the Marquis of Auret, sent for Paré to undertake the treatment of a wound which he had received from a harquebus ball seven months previously. Paré gives the following account of this interesting case which foreshadows--for example, in the changing of the patient’s bed and linen and keeping him entertained during convalescence--the best modern hospital nursing:--

On arriving at the Chateau of Auret, writes Paré, which is located not far from Mons in Belgium, I learned that the harquebus ball had entered the thigh near the knee, had done considerable damage to the soft parts, and had fractured the femur. When I was ushered into his bedchamber, I found the Marquis very much emaciated, his eyes deeply sunken in their sockets, his skin hot and of a yellowish hue, and his voice feeble like that of man very near to death.... The leg was drawn up against the wall of the abdomen, and two large bedsores were visible posteriorly--one near the root of the spine and the other somewhat higher up. Thus it was impossible for the patient to assume any posture in which he would be free from suffering.... All things considered, it did not seem to me that the Marquis could possibly recover from such a combination of bodily ills. Nevertheless, to give him some encouragement,--for he was very low in spirits,--I told him that, with the aid of God and the assistance of his regular medical attendants, I would soon have him on his feet again....

After dinner, in the presence of the Duke of Ascot, a few friends of the family, and the assembled physicians and surgeons, I expressed considerable surprise that free openings had not been made in the Marquis’s wounded thigh, in which bone caries and decomposition of the resulting discharge were already well established. The medical attendants replied that the patient was unwilling to submit to any such measures, and that he had even forbidden them to substitute clean linen bedclothes for those which were soiled and which had not been changed during the previous two months....

When the consultation had come to an end and the local medical attendants had given their full approval of the different measures which I recommended, ... I proceeded to carry them out without further delay.

Two or three hours after the completion of this operative work I instructed the house servants who were in immediate attendance upon the Marquis to place alongside his bed a second one equipped with a soft mattress, over which a fresh linen sheet, etc., had been spread. The transfer from one bed to the other was easily effected by a strong attendant, and when the change had been made the Marquis manifested great contentment. Two feather pillows were so placed under his back and loins that no pressure whatever would be made upon his bedsores. A refreshing sleep of four hours’ duration followed the adoption of these different measures, and there was much rejoicing in the entire household.

After a course of treatment lasting several weeks, Paré says:--

Under this treatment the fever steadily diminished, the pain grew less and less, and the patient’s strength increased. When the proper moment arrived, I advised the Marquis to engage the services of some musicians (players on stringed instruments) and one or two comedians, in order that his spirits might be cheered by occasional entertainments of this character. Already at the end of one month we found it practicable to carry him in a chair into the garden and as far as the entrance gate, where he could watch the passers-by. When it became known among the peasants that he was in the habit of sitting close to the highway, they came from far and near to sing and dance in groups for his entertainment. He was greatly loved by both the common people and the nobility.

At the end of six weeks the Marquis was able to get about on crutches, and two weeks later still I bade him good bye and returned to Paris. Before I left he presented me with a gift of great value, and the Duchess of Ascot insisted on my accepting a beautiful diamond ring as a mark of her appreciation of the services which I had rendered her brother.

Among the varied experiences which fell to the lot of Paré during his association with Charles the Ninth, there is one which throws a little additional light upon the man’s manner of promptly dealing with an event which, without such promptness of action, might have led to serious consequences.

He was passing through Montpellier one day in company with the King, when he stopped for a few minutes at the shop of an apothecary for the purpose of ascertaining how he preserved alive the vipers which he used in compounding the remedy which is called “theriaca,” and which has been used from time immemorial as an antidote to the poison of venomous serpents. The apothecary placed before him a glass jar in which were kept a number of these reptiles; and, when Paré took one of them up in his fingers in order to obtain a better view of his fangs, the reptile bit him near the tip of his index finger, between the nail and the flesh. The pain which immediately followed was severe, partly, as Paré explains, because the tip of the finger is a very sensitive part, and probably also on account of the irritating effect of the venom. Then, to quote Paré’s own words, “after making firm pressure upon the soft parts above the wound, to prevent the poison from traveling upward, I crowded the skin downward in the hope of forcing as much of the venom as possible out of the finger. While doing these things I instructed the apothecary’s assistant to mix some old theriaca with brandy, and then to apply a pledget of cotton, saturated with the mixture, over the wound. In the course of a few days, and with no other treatment, all effects of the bite disappeared.”

In 1536, two years after his first experience with actual warfare in the vicinity of Susa, Italy, and while he was still very young to assume so great a responsibility, Paré--as we learn from the text of