10th November 2017, Volume 130 Number 1465

c

December 1917

In the dawn of history the birthplace of surgery was the battlefield. The son of Aesculapius, Machaon, he who dressed the wounds of Menelaus, was put under the special care of Nestor, for the Greeks considered a doctor to be worth in battle many soldiers.

In the Renaissance period Paré became, if not the father of modern surgery, the greatest of military surgeons. As a barber’s apprentice he left the provinces for Paris in 1529, and was employed as a dresser at the Hotel Dieu. He began practice in a modest room near the favourite duelling-ground, and after eight years’ residence in Paris became an Army surgeon, and served in the wars for nearly twenty years, first of all in the campaign of Francis I. In Italy. His experience in the field, and the use he made of it, gave him a great practice and a great name in Paris.

Let us consider first what manner of man he was. Neither birth nor education were his, but he had the advantage of freedom from the deadening influence of the University of Paris of that time. He wrote a great deal and his books are full of interesting cases, good stories of the camp and of the city, shrewd opinions, and contain much in the style of Pepys and Boswell. Paré, the Huegenot, is in striking contrast to his grand patients of the Court, the mad line of Kings, the Duke of Guise, Catherine Medici, the marquises, the courtiers, and the rest. He knew Vesalius and Mary Stuart and found a kindred spirit in Admiral Coligny. Piety permeated his life and found expression in his writings and in the oft-repeated phrase, “Je le pansay et Dieu le guarit”—I dressed him and God cured him. On the night of the Massacre of St. Bartholomew the King himself locked Paré in a room in the Louvre, swearing that it was not reasonable that a man who was worth a world of men should be murdered. One of the last and greatest scenes in the life of this noble man reveals him, burdened with the weight of eighty years, tramping the hot and noisome streets of Paris, relieving the sick and poor when the city was besieged and withstanding the fury of the League and the power of the relentless Archbishop of Lyon. The dead lay unburied in the streets and the anguish and hunger of the citizens had reached the limit of human endurance. It was Master Ambroise Paré who met the Archbishop face to face in the street and called upon him to have mercy on the citizens, as he himself hoped for divine mercy. The Archbishop said afterwards that Paré had waked him up and made him think of many things. “On Thursday, December the twentieth, died Master Ambroise Paré, the King’s surgeon, eighty years old; a learned man and the chief of all surgeons; who, even against the times, all his life talked and spoke openly for peace and for the people: which made him as much beloved by the good as he was opposed and hated by the wicked.”

But it is Paré’s work and invention as an Army doctor that appeals to us now in the days of the Great War. For some centuries in mediaeval times the surgeon had no honour, and the art was relegated to barbers, bath-keepers, sow-gelders, and mountebanks. In Prussia up to the time of Frederick the Great it was one of the duties of the Army surgeon to shave the combatant officers. But Paré had great honour. His ready sympathy endeared him to his comrades, and we read that one night he entered Metz incognito, but, being recognised, he was carried through the city by the soldiers in triumph. His reputation as an Army surgeon was built upon the sure foundation of efficiency, and his skill was a powerful aid to the Army. He seemed to exemplify the teaching of Locke, the philosopher-physician of a somewhat later period, that ideas are not innate, but that knowledge proceeds from investigation through the bodily senses. No detail was too small for his attention, and this of necessity, seeing that he had no trained nurses to depend upon. Indeed, Charles IX., dying of consumption, and the ghosts of the Massacre ever before his eyes, had no nurse save an old woman who had nursed him when he was a child, and she composed herself to sleep, as history informs us, when she was dying.

At the beginning of his career in the Army Paré’s great discovery was due mainly, as he informs us, to chance. At Suse, near Mont Cenis, in 1537,

“The enemy within the castle, seeing our men come on them with great fury, did all that they could to defend themselves, and killed and wounded many of our soldiers with pikes, arquebuses, and stones: whereby the surgeons had all their work cut out for them. Now, I was at this time a fresh-water soldier; I had not yet seen gunshot wounds at the first dressing. I had read in ‘John de Vigo,’ book one, ‘Of Wounds in General,’ chapter eight, that wounds made by firearms partake of venenosity, by reason of the gunpowder; and for their cure he bids you cauterise them with oil of elders, scalding hot, mixed with a little treacle. And to make no mistake, before I would use the said oil, knowing that it was to bring great pain to the patient, I asked first, before I applied it, what other surgeons used for a first dressing; which was to put the said oil, boiling, well into the wounds, with tents and setons: wherefore I took courage to do as they did. At last my oil ran short, and I was compelled, instead of it, to apply a digestive made of yolks of eggs, oil of roses and turpentine. In the night I could not sleep in quiet, fearing some default in the not cauterising, lest I should find those to whom I had not applied the said oil dead from the poison of their wounds; which made me rise very early to visit them: where, beyond my expectation, I found that they to whom I had applied my digestive had suffered but little pain, and their wounds without inflammation or swelling, having rested fairly well that night. The others, to whom the boiling oil was applied, I found feverish, with great pain, and swelling round the edges of their wounds. Then I resolved never more to burn thus cruelly poor men with gunshot wounds… See how I learned to treat gunshot wounds: not out of books.”

There was a surgeon at Turin, famed above all the rest for his treatment of gunshot wounds, to whom Paré paid court for two years before he would disclose his recipe, and then only after many gifts. “Then I was joyful,” writes Paré, “and my heart made glad that I had learned his remedy, which was like that which I had obtained my chance.”

His second great discovery, or rather rediscovery, for it was at one time in the practice of the ancients, was the use of ligature instead of red-hot irons to stop the bleeding of an amputation. “In 1552,” he writes, “it pleased God to teach me, without I had ever seen it done in any case, no, nor read of it.” In both of these discoveries he showed the fallacy of the orthodox practice based upon the pseudo Hippocratic aphorism that diseases not curable by iron are curable by fire.

What else do we owe to Paré? He invented many surgical instruments, popularised the use of a truss in cases of hernia, omitted castration as a routine part of the operation of herniotomy, advised massage, introduced artificial eyes made of gold or silver, and in 1536 performed the first excision of the elbow joint. He pointed to syphilis as the cause of aneurysm, and Howard Kelly gives to Paré the credit of assigning to flies a great part in the transmission of infectious diseases. By ligaturing the large arteries Paré was enabled to perform many amputations, and his treatment of wounds lessened the mortality of war, well named by Pirogoff, after his experience in the Crimea, a “traumatic epidemic.”

The great advance made in military surgery in the present day would not have been possible had it not been for the work of Simpson, Lister, Hunter, and Ambroise Paré of an army that has been dust and rust for three centuries. Some may say, Lister we know, and Hunter we know, but who is Paré? Let this short sketch whet the appetite of the reader for further knowledge of one of the most notable and most lovable pioneers in our art, who, fortunately, has revealed not only his thoughts but also his personality in his writings.