Of course, the education, training, status, and legal standing of surgeons and physicians varied considerably throughout Europe. But almost everywhere, warfare provided golden opportunities for enterprising sur- geons; the battleﬁeld has always been known as the ultimate medical school. In such an environment, it was possible for Ambroise Pare´ (1510–1590), an ‘‘unlettered’’ barber-surgeon, to think his own thoughts, learn by experience, and bring pride and dignity to the art of surgery. To Pare´ surgery was a divine calling, despite the lowly status of its practitioners. Described by his contemporaries as independent, gentle, impetuous, and ambitious, Pare´ was honest enough to admit that his major contributions to surgery were simple and not necessarily original. Nevertheless, his willingness to break with tradition and cou- rageously follow methods suggested by his own observations pointed the way towards a general renaissance in surgery. Unlike previous gen- erations of innovative craftsmen, Pare´ and his peers could emerge from obscurity because the printing press allowed them to publish popular texts in the vernacular. Pare´’s writings were collected and reprinted many times during his lifetime and translated into Latin, German, English, Dutch, and Japanese. Always willing to learn from ancient authorities, contemporary physicians and surgeons, or even quacks with a promising remedy, Pare´ was a deeply religious man, who acknowl- edged only one ﬁnal authority.
Little is known about Pare´’s background and early life. Even the date of his birth and his religion are uncertain. Pare´ rarely discussed his training and apprenticeship, other than the fact that he had lived in Paris for three years during the nine or ten years he had studied sur- gery. Although apprenticeship was ostensibly a time for learning, pupils were all too often exploited by cruel masters who neglected their obli- gation to teach. To obtain more practical experience, Pare´ worked at the Hoˆ tel Dieu, a hospital that provided examples of a great variety of disorders, as well as opportunities to participate in autopsies and ana- tomical demonstrations. Conditions at the hospital were so miserable that during one winter, four patients had the tips of their noses frozen and Pare´ had to amputate them.
Pare´’s surgical texts provide vivid and moving accounts of the horrors of war, as well as accounts of the kinds of wounds caused by weapons unknown to Hippocrates and Galen. After a battle, the stench of rotting corpses seemed to poison the air; wounds became putrid, corrupt, and full of worms. All too often, injured soldiers died from lack of food and attention, or from the economy measures used to treat them. For example, surgeons believed that mild contusions were best treated with bed rest, bleeding, wet cupping, and sweat-inducing drugs. Such gentle and time-consuming treatments were ﬁne for ofﬁcers and nobles, but a common soldier was more likely to be wrapped in a cloth, covered with a little hay, and buried in manure up to his neck to encourage sweating.
Gunpowder weapons were, as Francis Bacon noted, among the world-shaking inventions unknown to the ancients. Although gun- powder was referred to in Europe as early as the thirteenth century, it was not until the fourteenth century that pictures of primitive cannons appeared. Thus, to rationalize the treatment of gunpowder wounds, physicians had to argue from analogies. John of Vigo (1460–1525), one of the ﬁrst to write speciﬁcally on the surgical problems of the new warfare, argued that wounds made by ﬁrearms were poisoned. Tra- ditionally, poisoned wounds, such as snakebites, were neutralized by cauterization. To assure that deep, penetrating gunpowder wounds were thoroughly cauterized, Vigo recommended the use of boiling oil. When Pare´ began his career in military surgery, he followed Vigo’s methods until his supply of oil was exhausted and he was forced to treat the rest of his patients with a wound dressing made of eggs, oil of roses, and tur- pentine. In comparing the outcome of these treatments, Pare´ discovered that the patients who had received the mild dressing healed better than those cauterized with boiling oil. Based on these observations, Pare´ promised himself that he would never again rely on books when he could learn from experience. In his writings, Pare´ urged other surgeons to follow his example.
When cauterization was necessary, Pare´ preferred the ‘‘actual cau-tery’’ (red hot irons) to the ‘‘potential cautery’’ (strong acids or bases, boiling oil). To aid the healing of burned ﬂesh, Pare´ recommended a dressing of raw onions and salt. An elderly female healer taught Pare´ about the use of raw chopped onion in the treatment of burns. After conducting his own tests, Pare´ determined that the remedy was effective. In the 1950s, scientists reported that onions contain a mild antimicro- bial agent. Thus, in the absence of modern antibiotics, onion might be valuable in preventing bacterial superinfection of burns. In some cases, however, Pare´ recommended the use of his famous puppy oil balm. He had procured the secret recipe for puppy oil at great trouble and expense, but he openly published it for the beneﬁt of all surgeons and patients. To prepare puppy oil dressing, the surgeon began by cook- ing two newborn puppies in oil of lilies until the bones dissolved. The oil was mixed with turpentine and a pound of earthworms, and then cooked over a slow ﬁre. Pare´ was convinced that puppy oil soothed pain and promoted healing.
When the Faculty of Physicians challenged Pare´ to explain why so many men died of minor gunpowder wounds, Pare´ examined the com- ponents of gunpowder to see whether the ingredients contained a special venom or ﬁre. He concluded that there was neither ﬁre nor venom in gunpowder. Indeed, soldiers, blessedly ignorant of medical theory, drank gunpowder in wine to stimulate healing, or applied gunpowder to wounds as a drying agent. Quoting Hippocrates’ On Airs, Places, and Waters, Pare´ argued that the noxious air of the battleﬁeld corrupted the blood and humors so that after a battle even small wounds became putrid and deadly. Finally, Pare´ suggested that many of these deaths were due to the will of God. If it seems unfair for Pare´ to blame wound infection on God, it should be remembered that when a patient recov- ered, Pare´ invariably said that he dressed the wound, but God healed the patient.
Battleﬁeld surgery often included the amputation of arms or legs, an operation that could lead to death from hemorrhage. Many patients died after amputations because cauterization destroyed the ﬂaps of skin needed to cover the amputation site and increased the danger of infection. The use of the ligature for the repair of torn blood vessels was an old but neglected technique when Pare´ brought it to the attention of his contemporaries and demonstrated its value in amputations. If the surgeon had performed his task with skill, wealthy patients could be ﬁtted with ingenious and beautifully ornamented prosthetic devices that allowed for various degrees of movement. Pare´ also devised wooden legs suitable for the poor.
When Pare´ suffered a compound fracture of the leg, he was fortu- nate to avoid the usual treatment, which was amputation. (In a simple fracture, there is no external wound. Compound fractures involve a break in the skin; the existence of this external wound often leads to complications.) In 1561, Pare´ was kicked by his horse; two bones in his left leg were broken. Afraid of being kicked again, he stepped back and fell to the ground, causing the fractured bones to break through ﬂesh, hose, and boot. The only medicaments that could be found in the village—egg whites, wheat ﬂour, oven soot, and melted butter— did nothing to assuage the excruciating pain, which Pare´ suffered with quiet dignity. Knowing the usual course of such injuries, Pare´ feared that he must lose his leg to save his life, but the fracture was reduced, the wound was bandaged, the leg was splinted, and rose ointment was applied until the abscess drained.
Despite Pare´’s reputation for kindness, he had a consuming curi-osity that made him willing to use human beings as experimental sub- jects. When Charles IX praised the virtues of a bezoar stone (a hard indigestible mass found in the stomach or intestinal tract of animals) he had received as a gift, Pare´ argued that such stones were not really effective antidotes to poisons. To settle the argument, one of the king’s cooks, who was about to be hanged for stealing two silver plates, was allowed to participate in Pare´’s experiment. The condemned man was given the bezoar stone and a poison provided by the court apothecary. Unfortunately for the cook, Pare´ was correct about the uselessness of bezoar stones, as well as many other widely prescribed and fearfully expensive remedies and antidotes, such as unicorn horn and mummy powder. Noblemen drank from vessels made of unicorn horn and car- ried unicorn horn with them when traveling in order to ward off illness, much as modern tourists rely on quinine, Dramamine, and Kaopectate. True unicorn horn was very expensive because the bashful creature could only be captured by a beautiful virgin, but the major sources of unicorn horns were the rhinoceros and the narwhale.
Expressing skepticism about the existence of the unicorn, Pare´ conducted a series of experiments on alleged unicorn horns, such as examining the effect of unicorn preparations on the behavior and survival of venomous spiders, toads, scorpions, and poisoned pigeons. In no case did unicorn horn demonstrate any medicinal virtues. Despite Pare´’s work and the questions raised by other skeptics, apothecaries vigorously defended the virtues of ‘‘true’’ (high quality, high price) unicorn horn. On aesthetic and medical grounds, Pare´ rejected the use of mummy powder; he said it was shameful for Christians to consume remedies al- legedly derived from the dead bodies of pagans. Ever skeptical, Pare´ revealed that expensive preparations sold as the mummies of ancient Egyptians were actually fabricated in France from bodies that had been dried in a furnace and dipped in pitch. But some physicians recommended mummy in the treatment of bruises and contusions, because of its alleged power to prevent blood from coagulating in the body. Advocates of mummy as a medicine urged physicians to select high quality, shiny black preparations, because inferior products that were full of bone and dirt, and gave off an offensive odor, were not effective. Well into the seventeenth century, physicians were still prescribing a variety of disgusting remedies, including mummy preparations, bezoar, powdered vipers, dried animal parts, human placentas, the entrails of moles, and ﬁlings or moss from an unburied human skull. Such remedies were also found in various editions of the London Pharmacopoeia.
Opposing the use of established remedies required courage and independence. When Pare´ published his studies of poisons and anti- dotes, physicians and apothecaries attacked him for trespassing on their territory. One critic claimed that one must believe in the medical virtues of unicorn horn because all the authorities had proclaimed its efﬁcacy. Pare´ replied that he would rather be right, even if that required standing all alone, than join with others in their errors. Ideas that had been accepted for long periods of time were not necessarily true, he argued, because they were often founded upon opinions rather than facts.
Although Ambroise Pare´ was the exemplar of sixteenth-century French medicine, thanks to Louis XIV’s (1638–1715) ﬁstula-in-ano, Charles-Franc¸ois Fe´lix (1635?–1703) had a rare opportunity to demon- strate the efﬁcacy of the art of the surgery. For many months, physi- cians had subjected the king to emetics, purges, leeches, bleedings, and other futile and dangerous remedies. The king’s distress was caused by a seed or fecalith that had lodged itself in the royal rectum, causing inﬂammation, abscesses, and a ﬁstula. On November 18, 1686, the desperate king turned from medicine to surgery. According to Fe´lix’s enemies, the surgeon had been practicing for the operation in a Parisian hospital. Some of his human guinea pigs did not survive, but their deaths were attributed to poisoning and the corpses were disposed of secretly. In any case, the operation on the king was entirely successful. A much relieved and grateful monarch granted royal rewards and favors to the surgeons, much to the displeasure of the physicians.