Book Xiii., of Paré’s Treatise (page 753, Vol. Ii., of Malgaigne’s

edition). Furthermore, the first published account of a case of diaphragmatic hernia is that given by Paré. (Von Gurlt.)

In 1538, during a visit to Turin in the capacity of surgeon to the Mareschal de Montjean, Paré was asked by the latter to take charge of one of his pages who had been wounded by a stone which struck him on the right side of the head, causing a fracture of the parietal bone, with escape of a portion of the brain substance from the external wound. The subsequent history of this case is given by Paré in the following words:--

As soon as I fully realized the true nature of the injury and had examined the mass of tissue (about the size of a small nut) which had been expelled from the wound, I predicted that the patient would probably not recover. A young surgeon who happened to come into the room at this moment, examined the mass of tissue which had escaped from the wound and at once pronounced it to be fat. I assured him that, if he would wait until I had finished dressing the patient’s wound, I would prove to him that the mass was in reality cerebral tissue and not fat.... If this substance, I said, is fat, it will float on the water; but, if it is brain tissue, it will sink at once to the bottom of the dish. And, again, if it is fat it will promptly melt on exposure to heat, whereas brain substance will simply become desiccated. These tests were applied and it was shown that the tissue consisted, as I had declared, of brain substance.

Notwithstanding the apparently serious damage which had been inflicted upon his brain the page made a good recovery, but remained permanently deaf in the right ear.

Among Paré’s numerous reports of cases there is one which possesses, as I believe, sufficient interest--as well from the viewpoint of the pathologist as from that of the surgeon--to justify me in reproducing it, in a somewhat condensed form, in the present chapter.

Henry the Second, King of France, while tilting (June 30, 1559) with Gabriel, Count of Montgomery, an officer of that sovereign’s Scottish Lifeguard, received injuries which soon afterward proved fatal. Montgomery’s lance--so Paré’s account states--struck the King’s vizor and, breaking off at the spot where the metal tip or head is attached to the wooden shaft, carried away this part of the helmet. Then, impelled by the force which had originally been communicated to the lance, the splintered end of its shaft struck the King’s now unprotected head with great violence just above the right eyebrow, tore up the skin and underlying muscular tissue of the forehead as far as the outer angle of the left orbit, and finally destroyed the adjacent eye. Five or six of the most experienced surgeons of France were immediately summoned, and Philip the Second, King of Spain, sent Vesalius from Brussels to aid them in their efforts to save the injured King’s life. But all the measures adopted proved of no avail. Henry the Second died on the eleventh day following the injury. Although in the published account no statement is made to the effect that Paré was one of the surgeons who attended the King during his illness, Malgaigne expresses the opinion that he was probably present in the capacity of a consultant; and the interesting comments which he (Paré) makes on the nature and extent of the injury inflicted certainly justify this opinion. No evidence of fracture of the skull was discovered either before death or at the postmortem examination, and the most conspicuous symptoms appear to have been fever and a comatose condition. At the autopsy there was found, on the left side posteriorly, in the occipital region, a clot of blood lying between the pia and the dura mater. The brain substance in the immediate vicinity of the clot was of a yellowish tinge and showed evidences of having already begun to undergo decomposition. Paré’s diagnosis, in this case, was that of violent concussion of the brain with rupture of meningeal vessels by contre-coup at a point opposite to that at which the blow was originally inflicted by the lance. He did not believe that the immediate damage done to the frontal portion of the cranium and to the left eye had anything to do with the fatal issue.

FORCEPS DEVISED IN 1552 BY AMBROISE PARÉ FOR DRAWING OUT THE CUT ENDS OF ARTERIES AFTER THE AMPUTATION OF A LIMB, AND HOLDING THEM WHILE THE LIGATURE IS BEING APPLIED.

(From von Gurlt’s Geschichte der Chirurgie, Berlin, 1898.)

FIG. 23 represents the earlier; FIG. 24 the later pattern (see text.)]

One of the greatest discoveries made by Paré in the domain of surgery is his method of promptly, effectively and safely arresting the bleeding from the divided vessels of the stump after the amputation of a limb. This discovery was made between the years 1552 and 1564, before which period it had been customary to arrest the bleeding by applying the red-hot cautery iron to the exposed ends of the divided vessels. The new method consisted in tying a ligature (preferably doubled) around the free or cut end of the blood-vessel, and allowing it to remain undisturbed in situ until, as the result of a localized suppuration, it should be cast off. The accompanying cuts (Figs. 23 and 24) which have been copied from an earlier edition (1585) of Paré’s work, represent the kind of forceps which he employed in separating the free end of the artery or vein from the soft tissues in which it was imbedded--a preliminary procedure which enabled him to tie the ligature firmly around the vessel. The earlier pattern of forceps (Fig. 23) was not equipped with a spring, the purpose of which was to keep the opposing blades separated, but the later pattern (Fig. 24) has this useful addition. Another instrument which owes its origin to the inventive genius of Paré is the grooved director--an instrument that is of great value to the surgeon, particularly in operations for the relief of strangulated hernia.

Besides the two inventions to which a brief reference has just been made, Paré describes and pictures in his great treatise scores of instruments and apparatus of all sorts, many of them doubtless products of his own inventive genius. But to assign to these contrivances their true value calls for a degree of expert knowledge which I do not possess. Rather than to attempt any such appraisal, I prefer to furnish here a summary of the more important of Paré’s achievements in surgery; for such an enumeration--although it may prove to be in some measure a recapitulation of things that have already been mentioned in the preceding account--may be found useful for purposes of reference:--

The discovery of improved methods of caring for the wounded on the battle-field and of transporting them to a hospital or other refuge; the introduction of better methods of treating wounds inflicted in warfare--especially gunshot wounds; the correction of the idea, universally accepted at the beginning of the sixteenth century, that bullets are sufficiently hot, upon penetration of the skin, to affect injuriously the wounds which they inflict; the substitution of ligation of bleeding vessels (of an amputation stump) for the prevailing practice of applying to them the red-hot cautery iron; the abandonment of the practice of applying the heated cautery iron to the surface of section of a sawed bone; the performance, for the first time, of exarticulation of the elbow-joint; the demonstration of the usefulness of more frequently employing orthopaedic apparatus and prosthetic contrivances; and the introduction of improvements in the operation of trephining the skull.

It was a very common practice among the medical authors of the sixteenth century--and, indeed, among authors generally--to utilize the writings of their predecessors without giving them proper credit for their work; and Paré, it appears, was not entirely free from this fault. Von Gurlt mentions a few of the more glaring instances of such sinning, and among them the following: Paré’s two chapters on tumors are taken from the “De institutione chirurgica” of Jean Tagault (Paris, 1543), who in turn is charged with having borrowed the data from Guy de Chauliac’s treatise; in his chapter on wounds in general, Paré has also borrowed largely from the same work; and the chapter which he devotes to the subject of special wounds is taken from the writings of Hippocrates; and, finally, he has transferred almost bodily Philippe de Flesselle’s “Introduction pour parvenir à la vraie cognoissance de la chirurgie rationelle.” Before we condemn Paré for plagiarism, and although the facts as stated by von Gurlt are undeniable, we should take several things into careful consideration. It is fitting, for example, that we should make some sort of an estimate of the value of the text thus appropriated, in order that we may be able to measure the seriousness of Paré’s sinning; and, if we do this, we cannot fail to be struck with its insignificance in comparison with the admittedly valuable character of all the remaining text of these three huge volumes--text which bears every mark of being the product of Paré’s brain. Paré himself, in speaking of his borrowings from other authors, says that his acts of this nature are “as harmless as the lighting of one candle from the flame of another.” Then, again, there are several of these borrowings which are evidently the handiwork of a rather dull person, and this fact alone makes one bold to assert that Paré, who was certainly not lacking in brains or in a desire to follow the golden rule in his treatment of the property of such writers, could scarcely have been guilty of such clumsily contrived interpolations. Inasmuch, however, as many important facts bearing upon the question at issue are not within my reach, I am obliged, in my attempt to defend the memory of Paré, to fall back upon speculative reasoning. The medical profession at large has long since heard this charge of plagiarism and it refuses to attach any importance to it as affecting the personal character of Paré. It prefers to believe that he is guiltless and that somebody else--at a time, perhaps, when Paré, being well advanced in years, was too ill to revise the manuscript of the “Collection of his Writings” edited by Guillemeau--thoughtlessly yielded to the impulse to remedy, by borrowing from other sources, the trivial defects or omissions noted in the text. In any case, whatever the actual truth may be, I am, I believe, justified in maintaining that Paré is not rightly chargeable with the guilt of plagiarism.

(From von Gurlt’s reproduction of the portrait published by Le Paulmier, Paris, 1885.)]

Strange as it might appear, if history did not furnish many examples of the same character, Paré’s merits as a man and as a surgeon were not as fully appreciated as they deserved to be until after the lapse of nearly two centuries. In 1812 the Société de Médecine de Bordeaux offered a prize for the best eulogy of Ambroise Paré, and it was awarded to Vimont. Finally, in 1840, a fine bust of the distinguished surgeon was completed by the sculptor David of Angers, and set up in bronze in Laval, Paré’s birthplace. The portrait here reproduced from the engraving in von Gurlt’s work represents the bust in question (Fig. 25).

A complete collection of the writings of Paré has been prepared by J. F. Malgaigne, the distinguished French surgeon, and published in three very large volumes (Paris, 1840–1841). This collection is based on a careful comparison and collation of all the previously published editions. The contents of these volumes cover very nearly the entire range of surgery.