Ambroise Pare: Barber vascular surgeon
2018; Elsevier BV; Volume: 68; Issue: 2 Linguagem: Inglês
10.1016/j.jvs.2018.04.053
ISSN1097-6809
Autores Tópico(s)Medical History and Innovations
ResumoFor his work in forensic pathology, pioneering surgical techniques, battlefield medicine and wound care, and developing new surgical instruments, Ambroise Paré is the best known of the barber surgeons and has been called the father of modern surgery (Fig 1). Although Paré was not the first to use a vascular ligature, as he is commonly credited, he promoted it more than any of his predecessors and contemporaries. He also developed what was likely the first vascular clamp. We know that the Worshipful Company of Barbers, one of the livery companies of London, has been in existence since at least 1308. Archival records in the Guildhall Library inform us that:RICHARD LE BARBOUR, dwelling opposite to the Church of Allhallows the Less, was chosen and presented by the barbers of London on Tuesday, next after the feast of Saint LUCY the Virgin, in the second year of the reign of KING EDWARD, son of KING EDWARD before NICHOLAS DE FARNDON, then Mayor of London, JOHN DE WENGRAVE, and other aldermen, to have supervision over the trade of the barbers. In 1163, Pope Alexander III issued a decree that prohibited members of religious orders from spilling blood. Because of their dexterity with scissors and razors, barbers began to aid monks in their traditional role as physicians. In addition to shaving and haircutting, barbers began performing bloodletting, which was the treatment of almost all maladies for nearly three millennia, until the late 19th century. Barbers also performed incision and drainage of abscesses and cysts, neck manipulation, tooth extraction, enemas, and fire cupping. Surgeons with little experience in shaving and haircutting also joined the barbers' company, but in 1368, surgeons formed their own guild. In 1540, Henry VIII merged the Fellowship of Surgeons with the Company of Barbers, to form the United Company of Barbers and Surgeons. The parliamentary act that led to this merger specified that surgeons could not perform grooming and barbers could not operate. Their only common procedure was tooth extraction. (Note the similarities between dental and barber chairs today.) The barber pole, with its red (for bloodletting) and white (for bandages) stripes, was used to promote the barber surgeon trade. Barbers maintained preeminence and commanded higher pay until surgeons began caring for injured seamen aboard British war ships. In 1745, King George II separated the two groups and surgeons formed the Company of Surgeons, which became the Royal College of Surgeons in 1800.1Dobson J. Walker R.M. Barbers and barber-surgeons of London: A history of the Barbers' and Barber-Surgeons Companies. Blackwell Scientific, Oxford1979Google Scholar Little is known about Paré's early life. He was born in Bourg-Hersent (now Laval), France, in 1510. Alternate possible birth years are 1516 and 1517. Various accounts suggest that Paré's older brother and brother-in-law were barber surgeons, so it is likely he did apprenticeships with them.2Ambroise Paré, "A Surgeon in the Field".in: Ross B.J. McLaughlin M.M. The Portable Renaissance Reader. Viking Penguin, New York1981Google Scholar, 3Paré A. Packard F.R. Life and times of Ambroise Paré, 1510–1590. HardPress, Lenox, MA2013Google Scholar It was vital that early practitioners of medicine and surgery obtain apprenticeships because these were the only ways to gain clinical experience and training. From 1532 to 1535, Paré studied anatomy and surgery at the Hotel Dieu in Paris. Despite the relatively recent invention of the printing press, and the scarcity of textbooks, Paré became acquainted with the work of Guy de Chauliac, a renowned barber surgeon of the previous century.3Paré A. Packard F.R. Life and times of Ambroise Paré, 1510–1590. HardPress, Lenox, MA2013Google Scholar The widespread introduction of firearms during the 16th century radically altered the landscape of conventional warfare in Europe. Extensive soft tissue damage, contamination from embedded projectiles, and the need for limb amputations increased dramatically. Paré's first experience with war and gunshot wounds came in 1536 during the French expedition to Turin. Paré joined his patron, René de Montejan, commander of the French infantry, and quickly concluded that the accepted method of cauterizing gunshot wounds with boiling oil was ineffective and inhumane:The soldiers within the castle, seeing our men come on them with great fury, did all 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 wounds made by gunshot at the first dressing. It is true I had read in John de Vigo, first book, Of Wounds in General, eighth chapter, that wounds made by firearms partake venomosity, by reason of the powder; 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 this was to bring great pain to the patient, I asked first before I applied it, what the other surgeons did for their 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.4Paré A. Ten books of surgery with the magazine of the instruments necessary for it. University of Georgia Press, Athens1969Google Scholar Paré's oil supply eventually ran out and he resorted instead to a dressing made with egg yolks, rose oil, and turpentine. That evening he slept fitfully:In the night I could not sleep in quiet, fearing some default in not cauterizing, that I should find the wounded to whom I had not used 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 those to whom I had applied my digestive medicament had but little pain, and their wounds without inflammation or swelling, having rested fairly well that night, the others, to whom the boiling oil was used, I found feverish, with great pain and swelling about the edges of their wounds. Then I resolved never more to burn thus cruelly poor men with gunshot wounds.4Paré A. Ten books of surgery with the magazine of the instruments necessary for it. University of Georgia Press, Athens1969Google Scholar Paré heard about a surgeon who had created another concoction for dressing gunshot wounds and he avidly sought him:While I was at Turin, I found a surgeon famed above all others for his treatment of gunshot wounds; into whose favour I found means to insinuate myself, to have the recipe of his balm, as he called it, wherewith he dressed gunshot wounds. And he made me pay my court to him for two years, before I could possibly draw the recipe from him. In the end, thanks to my gifts and presents, he gave it to me; which was to boil, in oil of lilies, young whelps just born, and earth-worms prepared with Venetian turpentine. Then I was joyful, and my heart made glad that I had understood his remedy, which was like that which I had obtained by chance.See how I learned to treat gunshot wounds; not by books.4Paré A. Ten books of surgery with the magazine of the instruments necessary for it. University of Georgia Press, Athens1969Google Scholar At one point, a senior surgeon was overheard to have told Montejan about Paré:Thou hast a surgeon young in age, but he is old in knowledge and experience: take good care of him, for he will do thee service and honour.5Paré A. Journeys in diverse places. Harvard University Press, Boston1910Google Scholar Upon the death of Montejan in 1539, Paré returned to Paris where he was now able to pay for licensure and gain acceptance into the French Company of Barber Surgeons. A few months later, he married Jean Mazelin, the daughter of a wine merchant, with whom he had three children. Paré also visited the famous physician, Jacques de Bois, who encouraged him to write about his experiences treating gunshot wounds. The outbreak of war with Spain, however, delayed this because Paré accompanied the Vicomte de Rohan in Perpignan, Hainaut, and Landrecies. Paré returned to Paris the following year where he published his first book, The Method of Curing Wounds Made by Arquebeques and Other Firearms, in 1545. The book provoked a strong reaction from the medical community in Paris because it represented an attempt by barber surgeons to raise their status. Physicians viewed these efforts as a threat to their prestige and power. Nevertheless, it was the barbers even more than the physicians and surgeons, who raised the bar in the study of anatomy and the practice of surgery. In that same year, a surgeon, Estienne de la Rivière, prevailed in a suit for plagiarism against Charles Estienne, a respected Professor of Medicine.6Paget S. Ambroise Paré and his times, 1510–1590 (Classic Reprint). Forgotten Books, London2017Google Scholar Paré served in many campaigns including Boulogne in 1545; Germany, Danviliers, Chateu le Comte, and Metz in 1552; Hesdin in 1553; Saint Quentin in 1557; Amiens in 1558; Bourges and Rouen in 1562; Havre de Grace in 1563; Bayonne in 1564; Saint Denis in 1567; and Montcontour and Flanders in 1569.4Paré A. Ten books of surgery with the magazine of the instruments necessary for it. University of Georgia Press, Athens1969Google Scholar It was in Metz, in 1552, that Paré began to ligate blood vessels during amputations.7Hernigou P. Ambroise Paré II: Paré's contribution to amputation and ligature.Int Orthop. 2013; 37: 769-772Crossref PubMed Scopus (18) Google Scholar Charles V had laid siege to Metz and the nobles of the city were determined to hold out at all costs. The mortality among the wounded was high and a request was sent to Henry II for Paré, along with a fresh supply of drugs. It was feared that the drug supply used for dressings in Metz was poisoned. Paré was smuggled through enemy lines by an Italian captain who was paid 1500 crowns. Paré later wrote:God guided our business so well, that we entered into the town at midnight, thanks to a signal the captain had with another captain of the company of M. de Guise; to whom I went, and found him in bed, and he received me with high favour, being right glad at my coming.My belief is that there was no poison; but the severe cutlass and arquebus wounds, and the extreme cold, were the cause why so many died.4Paré A. Ten books of surgery with the magazine of the instruments necessary for it. University of Georgia Press, Athens1969Google Scholar Paré soon got to try his new method of blood vessel ligation during an officer's leg amputation. He used the first arterial forceps or hemostat (his bec de corbin or crow's beak; Fig 2) to grasp major arteries and veins, and a threadlike wire to ligate them (Fig 3). The case went well and Paré remarked that the officer returned home gaily with a wooden leg, having gotten off cheaply, without being miserably burned to staunch the bleeding. Here is his account:Galen wrote that it is necessary to tie the vessels toward their root, which are the liver and the heart, to staunch a great influx of blood. Having used this method of closing the veins and arteries in recent wounds several times in a case of hemorrhage, I thought that it could be done also in the removal of a limb. I conferred about this with Estienne de la Riviere, King's Surgeon-in-Ordinary, and other Sworn Surgeons of Paris, and on having disclosed my opinions to them, we decided to try it on the first patient who offered himself, keeping the cautery ready for use as did everyone else, in place of a ligature. This I have practiced thus many times with very good results, even a few days ago in the care of Pirou Garbier, a Postillion of M. Brusquet, whose right leg was removed four fingers below the knee for a mortification which had developed because of a fracture.4Paré A. Ten books of surgery with the magazine of the instruments necessary for it. University of Georgia Press, Athens1969Google ScholarFig 3Paré uses a ligature during an amputation (courtesy of Wiley).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Despite Paré's continued success with his new methods, he battled his contemporaries for years to replace cautery with ligation for the treatment of bleeding. He was also resented and maligned by physicians owing to his growing fame. In 1554, Paré was admitted as surgeon to the Confraternity of Saint Cȏme although he did not know Latin. The confraternity was an academic organization of barbers and surgeons that was eventually subsumed by the University of Paris. Statutes required that a candidate for surgeon be examined in Latin, so it was remarkable that Paré was exempted from this requirement. On December 18 of that year Paré was made a master, and the Faculté of physicians remained strangely quiet. The Faculté was composed of academics and practitioners of medicine who looked down upon barbers and surgeons. Oddly enough, it was the barbers, not the surgeons, of the confraternity, who led efforts to raise the level of practice in anatomy and surgery. In 1573, Paré remarried (his first wife had died) and when Henry III succeeded Charles IX, Paré not only remained premier surgeon to the new king but advanced to the rank of valet-de-chamber and conseiller.8Hamby W.B. Amboise Paré, surgeon of the Renaissance. WH Green, St. Louis1967Google Scholar Paré eventually authored more than 10 books on anatomy and wound treatment, as well as a wartime memoir: Journeys in Diverse Places.5Paré A. Journeys in diverse places. Harvard University Press, Boston1910Google Scholar These were gathered together in 1575, in The Works of Ambroise Paré and disseminated throughout the world, despite legal attempts by members of the Faculté to stop it. This attempt was born of the intense rivalry between physicians and surgeons and had no legal basis. Paré was a military surgeon for 30 years (Fig 4) and served four successive kings of France (Henry II, Francis II, Charles IX, and Henry III). Paré saved many hundreds of lives and he personally survived a bout of plague and a viper bite. He also made contributions to obstetrics, forensics, and the design of limb and ocular prostheses. Despite the civil wars raging throughout France, Paré spent his final years quietly living in Paris. Paré died on August 29, 1590, 4 months after the siege of Henry IV was lifted. Despite harboring many of the prejudices of his time, Paré was an acute observer, highly reasonable and intelligent, and willing to break with the dogma of the past. In his own humble way, he was an early practitioner of evidence-based medicine and a product of the Renaissance more than any other surgeon. In the final paragraph of his memoir, he explained:I have published this Apologia, that all men may know on what footing I have always gone: and sure there is no man so touchy not to take in good part what I have said. For I have but told the truth: and the purport of my discourse is plain for all men to see, and the facts themselves are my guarantee against calumny.5Paré A. Journeys in diverse places. Harvard University Press, Boston1910Google Scholar
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