AMBROISE PARE AND THE ART OF SURGERY

12 May

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.

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