Military surgeon Ambroise Pare and his contribution to medical science
A STORY ABOUT THE REVOLUTION IN MILITARY AFFAIRS LEADS TO A REVOLUTION IN MILITARY MEDICINE AND TO THE APPEARANCE OF MODERN SURGERY
"The gloomy face of a surgeon often satiates a patient's wounds with poison more than bullets and trills."
"Nothing is more certain than death, but nothing is less certain than its hour."
The great French military doctor and the founder of modern surgery Ambroise Pare
"Nothing is more certain than death, but nothing is less certain than its hour."
The great French military doctor and the founder of modern surgery Ambroise Pare
It is well known that a new type of weaponry, which appeared at the end of the 13th century and widely spread during the 14th century, was gunpowder weapon, led to serious changes in military affairs. As early as the 15th century, cannons became widely used by the most progressive armies of both Europe and Western Asia, and not only during the sieges of cities, but even in field battles. And in the second half of the 15th century, we owe the appearance of handguns (“handguns”, “pischals”, “arquebus”, “pistols”, etc.), which immediately began to conquer their place on the battlefields.
Thus, at the beginning of the 16th century, firearms became firmly established among the leading European armies. However, a new type of weaponry led to the emergence of a new type of wounds - deep gunshot wounds, which, despite their seeming ease for the doctors of that time, began to lead to death in the vast majority of cases. The doctors of that era could not understand for a long time why this is happening, why new bullet wounds are comparatively more deadly than previous injuries from knives and arrows.
The research resulted in the opinion that bullet wounds received from a new type of weapon have more serious consequences for two main reasons: poisoning of adjacent tissues with bullet lead and powder soot, and their inflammation from getting into the wound pieces of clothing or armor. Proceeding from this, the doctors of the end of the 15th and beginning of the 16th centuries began to recommend to neutralize the “bullet poison” as soon as possible. If it was possible, it was recommended to try to quickly remove the bullet and clean the wound from strangers who had got there materials, and then pour boiling oil mixture into the wound. If there is no such possibility or the bullet does not come out, then it was recommended to just immediately fill with a hot oil a bullet wound to neutralize the “poisonous” effect of extraneous materials that got there.
The great French military doctor and surgeon of the Renaissance Ambroise Pare in his operating room (painting by artist James Bertrand)
Yes, now it seems to us, living 500 years later, in the era of antibiotics and laser scalpels, by a crude and barbaric method, but for the beginning of the 16th century, this technique allowed us to save the lives of at least a few wounded, because if they didn’t do anything at all with bullet wounds, it almost always guaranteed the death of a soldier.
The recipes for the "bullet-proof" oil mixture were offered different, but one way or another, each tent of the military-field barber, barber-surgeon or surgeon with a diploma burned a fire on which boiled "healing" oil poured into gunshot wounds.
At that time, the main European conflict, where handguns were increasingly used, was the so-called. The Italian wars, which stretched intermittently from 1494 to 1559, and in which most of the countries of the Western Mediterranean participated. And during the so-called "Third War of Francis I with Charles V" (1536-1538), when French troops occupied Savoy, and the troops of the Hapsburg dynasty invaded Provence, there were events that gave rise to modern military field surgery.
A certain Ambroise Pare, fascinated by surgery, was a young “barber-surgeon” who voluntarily joined the French army that had invaded Piedmont, visited a number of battles and became closely acquainted with their terrible consequences when he avoided the battlefields and tried to save the wounded. For him, as a man who had an undoubted vocation for medicine, and at the same time humanistic and highly humane views, this was a turning point.
One day, during the siege of Milan in the 1536 year, as he himself later recalled this, he found several seriously injured people who were conscious, and, declaring himself a doctor, asked if he could somehow help them? However, they rejected his proposal, stating that there was supposedly no sense in treating their wounds, and asked to just finish them off. A. Pare refused such a request, but just at that time someone from their fellow soldiers approached them and after a brief conversation with the wounded killed them all. The French surgeon, shocked by what he saw, pounced with curses on “so indifferently cold-blooded to his fellow Christian villains,” but he simply replied that “if I were in their position, I would have prayed to God in the same way so that someone could do this for me ... ”After this incident, the young“ barber-surgeon ”decided to devote his life to saving the wounded, improving their care and developing medicine as such.
Ambroise Pare was born around 1517 in the town of Laval in Brittany, in northwestern France, in the family of a poor craftsman who made chests and other pieces of furniture. Once, together with his elder brother, he witnessed an amazing and successful operation when the barber-surgeon who arrived from Paris, Nikolai Kalo, removed the stones from the patient's bladder. From this point on, the young Breton began to dream not about the craft of "barber", but about the surgeon's career - to become not just a "barber" (who at that time served as not only barber, but rather "folk medical assistants", i.e. , leeches or bloodletting), but at least a barber-surgeon (i.e., sounding, tamponade, some basic operations, and sometimes very complex ones, such as stone-cutting, for example). In order to become a certified doctor with a diploma from the University of Paris, or at least a certified surgeon - master of the lancet, a poor youth from a remote province could not even dream ...
Image of the Hospital "Lord’s Shelter" (a fragment of the plan of Paris created in 1550, i.e., Ambroise Pare during his life and work in it)
For the fulfillment of this dream, Ambroise Pare and his brother went to the capital of France, where they both entered lower medical school. Soon there, the brothers established themselves as “promising” and were sent for an internship at the oldest hospital in Paris - “God's shelter”, “Hotel-Dieu”. For several years, Paray has been trained there, in parallel with operations, earning a barbarian for a living, but conducting more and more operations to the poor who needed them (and with the same razors that he shaved visitors, only occasionally washing them in water or burning them with fire, which was the generally accepted norm in that era when 200 years remained before the discovery of the world of bacteria).
And, having gained a certain qualification, he received the certificate of "barber-surgeon" and joined the emerging army with the aim of helping the wounded soldiers, which we have already mentioned. Shortly after the episode mentioned above, where he witnessed the murder “out of favor” of wounded soldiers, which, in his opinion, could have been tried to save, a second event happened that affected European medical science in the future.
After one of the battles, during the siege of the small castle of Sousse in 1537, Pare treated the injured people with traditional methods of fire: in the hole punched by a bullet, the neck of the funnel was squeezed, and boiling elder oil was poured there with the addition of other components. The wounded were writhing from the pain caused by the wound, and from the pain of the burn, and the young healer from the realization that he was hurt, but could not help otherwise.
However, this time there were a lot of wounded, and there were very few elder oil. And although A. Pare had exhausted the possibilities of treating as prescribed by the luminaries of official medicine of that period, but he decided not to leave all the wounded arriving and arriving to him without help. In the circumstances, the young French surgeon decides to try for the treatment of gunshot wounds not a boiling oil, but a cold mixture of his own production, based on egg white, rose and terpentine oils (and sometimes turpentine). The recipe for this mixture, as he said later for greater seriousness, allegedly read in one late antique book, but given the fact that he did not know the Latin language, it is very difficult to believe, and most likely he himself invented it.
By the evening, having treated all the remaining wounded with his “balm”, the “barber-surgeon” went to bed, however, he recalled, at night he was tormented by a nightmare where the wounded who did not have the oil mixture died in agony. At dawn, he rushed to examine his patients in the infirmary tent, but the result surprised him greatly. Many of those who received treatment for boiling elderberry oil were in agony; in the same way as those who were brought too late, when he, having completely exhausted both his strength and medicines, went to sleep. And almost all of his patients who received treatment with the cold “balm” of his own making, had relatively good condition and quiet wounds.
Of course, over the past decades, since the wide spread of firearms, no doubt many simple barber-surgeons, surgeons with a diploma of the lancelet guild, and even scientists of the “doctors” with university diplomas (medicum purum) ended up in field conditions stocks of their oil mixture and they tried alternative treatments. But it was Ambroise Pare, the first and only one, who turned the seemingly simple case into a multiple repetition and analysis of the consequences, i.e. scientifically proven, observation.
After that, the young French “barber” used boiling elder oil for the treatment of gunshot wounds less and less, and more and more often he applied his “balm”, which made the result better and better. And with this practice, he proved that boiling “antidote” is more likely to cause harm than good, and there is less traumatic and more effective treatment.
At the same time, Ambroise Pare proposed a new way to stop bleeding, which turned out to be a way out of the impasse in which surgery had come to that time in this practical matter, and which modern surgeons still use in many ways. The fact is that prior to the discovery of A. Pare, what the surgeons knew and used to stop the bleeding caused additional suffering to the wounded and did not guarantee the preservation of their lives.
At that time, if a large vessel was damaged during injury or amputation, cauterization of the wound with a hot iron was used to stop the blood. If (in the case of very abundant damage or an extensive excision field during amputation) this did not help, then for a brief moment the stump was dipped into a pot of boiling resin. Bleeding, even from the main arteries, stopped, and a kind of sealing of the wound occurred, but sometimes the burned bones and tissues under the resin began to rot, and the patient died from blood or gangrene infection.
Ambroise Pare during the operation (modern image)
What Pare proposed was as simple and humane as gauze dressings with balsam instead of hot oil - he suggested dressing the blood vessels with an ordinary strong thread. The great Breton surgeon suggested pulling a cut artery out of a wound with tweezers or small tweezers and not burning it, but just firmly tie it up. During amputations, he recommended to warn the bleeding in advance: in his opinion, it was necessary to first expose the artery above the amputation site, firmly tie it up, and then amputate the limb; it was possible to cope with small vessels in the wound itself.
Truly, all ingenious is simple! With this decision, Pare led the way out of the impasse. Since then, for more than 500 years, ligation of vessels has been the main method of dealing with bleeding during operations. Despite the fact that in our century operations are performed on the brain, heart operations are done, and eye microsurgery has reached unprecedented heights, the Pare thread still remains among the basic tools of the surgeon (true, in some medicine of the 21st century) to medieval standards, but with the use of the latest technological advances - so the ligation of the vessels is now increasingly inferior to its position of electro-plasma coagulation, that is, the same cauterization).
However, he proposed a new method of treatment using not hot oil, but a cool balm for a long time did not receive recognition even from the doctors who practiced with him in the French army operating in Piedmont, and who saw radically different results with his own eyes. And only over the years “the power of medical tradition” began to give way before the onslaught of scientific discovery ...
At the end of the war in 1539, the army in which he served was disbanded and A. Pare, thus demobilized, began to heal people in Paris again. At the same time, the funds accumulated in the military service and the huge military field practice allow him to abandon the craft of the barber himself and begin a genuinely scientific and broad journalistic work. Immediately upon returning to 1539, he successfully passes the qualifying exam and finally receives the diploma of a professional surgeon, becoming no longer a simple barber doctor (then something like a modern medical assistant or paramedic), but a barber surgeon (roughly equivalent to a modern high school student). medical school) and returns to surgical practice in the well-known to him in Paris, "God's shelter."
But soon, after a short break, the Italian wars resumed with a new force - the next Franco-Habsburg war of 1542-1546 began, and Pare again voluntarily joined the French army, deciding that there would be a huge number of people on the front who needed it. in his help. Again, his share of endless campaigns, many sieges and battles, again hundreds and thousands of wounded, whom he operates, more and more perfecting his art, inventing new methods of extracting bullets, carrying out amputations, etc.
But most importantly, he, unlike many of his colleagues, keeps records, analyzes the effects of the use of various surgical and restorative techniques, and works on books that will soon be released from his pen. And the second war was not over, in which he personally participated, as in 1545, he sends his first capital work to a publisher friend, which is called “Methods of treating gunshot wounds, as well as wounds caused by arrows, spears and other weapons ".
Title page of one of the many works of Ambroise Pare
This book, in which Ambroise Pare summarized his 5 years experience of a military field surgeon and many years of experience as a medical practitioner at a Paris hospital, was written in a very good language, in French (as he did not know Latin), and became the first European textbook on field surgery, while generally accessible to all doctors, and not just to the elite of the medical community. The first edition of this work came out immediately, in 1545, and gained wide popularity, which neither the author nor the publisher expected from this book. This book was so wildly successful that in the next few years a number of reissues were made.
It can be said that, thanks to this textbook as well, by the end of the 16th century, the French school of surgeons took leading positions in Western Europe and remained there for about 200 years, giving up its leadership only in the 18th and 19th centuries to British and German surgical schools (Russian The military surgical school was one of the world leaders in the 2 half of the XIX century).
So, it was the simple, but original methods of treatment of various wounds proposed by Pare that played a significant role in transforming both surgery in general and military field surgery in particular, from a relatively little-respected “craft” into one of the most important areas of scientific medicine. And how many of these methods were implemented by him! Pare was the first to describe and propose a treatment for a hip fracture. The first was to carry out resection of the elbow joint. The first of the European surgeons of the Renaissance era described the operations of stone-cutting and cataract removal. It is to him that the improvement of the craniotomy technique and the introduction of a new type of trephine — the instrument for this operation — belongs. In addition, Paray was an outstanding orthopedist - he perfected several types of prostheses, and also proposed a new method for the treatment of fractures, in particular, a double fracture of the leg.
Surgical instruments invented by A.Pare and recommended by him to his followers in the book.
During the Second French-Habsburg War, in 1542, Ambroise Pare took part in the siege of the fortress city of Perpignan on the French-Spanish border, where the following incident happened to him, which contributed to his future career. One of the main commanders of the French army is the incredibly brave and very charismatic Charles de Cosse, Count Brissac (1505-1563), better known as "Marshal de Brissac", led the French army, carrying out this siege, in parallel with the still inexperienced in military affairs dauphin ( the future king Henry II).
And once, in a small skirmish at the walls of the city, Marshal de Brissac received a heavy wound from the arquebus. By order of the dauphin, an urgent consultation of the best doctors of the army was held, but the general decision was to admit that the wound was fatal - the bullet went very deep into the chest, and a number of attempts to at least find it, not to pull it out, broke off (recall that before X-ray 400 years remained , and before the advent of computed tomography 500 years). And only A.Pare, the youngest, both by rank and age, of the attending doctors (who was called to a consultation almost by chance, just remembering his vast practical experience), after sounding the wound, stated that the injury was not fatal. He explained to those present that miraculously vital organs were critically undamaged, and that he would take a bullet, but he asked Nicol Laverno, the personal surgeon of the king, to assist him in this. The life surgeon tried to get the bullet, but he could not, and only by direct order the dauphin again agreed to help in a seemingly hopeless operation.
Properly assessing the situation, Ambroise Pare decided not to operate on a bed patient, but he decided to put him in the same position that the Marshal had at the time of a gunshot wound. Thanks to this, Nicola Laverno, as a leading surgeon, still managed to pull a bullet deep from under the Marshal's shoulder blade (which it was almost impossible to find and extract, having only the tools of the XVI century at hand,), and the young Breton assumed responsibility for wound closure and postoperative care. And, oddly enough, it was for all those who were present at this operation, but after such a severe injury, even for XX century medicine, the celebrated marshal fully recovered and after some time continued command of the troops.
This incident made Pare famous not only among the poor of Paris or ordinary soldiers, but among the highest French aristocracy, and he introduced them to people personally familiar to the king. After this incident, the fame of the young Breton surgeon only increased, and with the growth of his medical professionalism. So, for the first time in stories European surgery, A.Pare made and began practicing the isolation of the elbow joint to persons whose arms were split or chopped up with splinters or blade arms, and also developed several different, qualitatively new surgical techniques.
And, we recall, he carried out his operations more than 500 years ago, in the war, in the field conditions of the tent camp. Without medical anesthesia, which was then not even in projects, and which was invented only through 300 years by the American dentist William Morton and introduced into the surgical practice by the Russian doctor Nikolai Pirogov. Without antiseptics, which was also discovered through 300 for years and introduced into everyday practice by the British surgeon Joseph Lister, not to mention aspetic. Without sulfonamides and antibiotics, which respectively were discovered and implemented only after 400 years by German and British scientists and doctors.
Death of King Henry II, modern event engraving 1559 / 1560
And Ambroise Pare already in the XVI century did complex operations, having at his disposal only what was in his time, and did his operations in most cases successfully. Of course, he also had failures, the most famous of which was an attempt to save a mortally wounded face in the 1559 year in the tournament of King Henry II Valois. However, “only the one who does nothing is not mistaken,” and in this case, a priori, everyone was convinced of the deadly nature of the wound, and Pare only offered to try to save the King of France ...
Returning to Paris at the end of his second, but far from the last in his fate of the war, an outstanding young Breton surgeon continued his traditional practice at the Hotel-Dieu hospital. At the same time, he received the diploma of “professional surgeon”, “master of the lancet”, and was admitted to the guild fraternity named after the holy healers Kosma and Damian - the main and oldest professional association of Parisian surgeons.
But the recognition of his merits and the huge popularity of patients - from commoners to higher aristocrats - caused an extremely hostile attitude on the part of "colleagues in the shop." Soon, the medical faculty of the University of Paris even filed a petition addressed to the king in order to deprive Pare of the title of "certified surgeon" and withdraw his book from sale. Fortunately for European surgery, the royal administration did not support the protest. Moreover, in a few years Pare becomes the head of the surgical department of his beloved Paris hospital “God’s Shelter”, and after some time, in the 1552 year, he is even appointed to the forensic physician of the French King Henry II Valois.
And it was during this period, in the middle - 2 of the 16th century, that the name Pare became known far beyond the borders of France. Thanks to his research, which was widely distributed in print media at that time (and, interestingly, equally in both Catholic and Protestant countries), from Madrid to Warsaw, and from Naples to Stockholm, strong basic foundations of modern military field surgery.
Ambroise Pare in old age (image in his life in the book of the 16th century)
Unfortunately, Russia at this time was still aloof from the progress of European medical science. Only in the reign of Boris Godunov, the famous “Westerner,” did the Russian government talk about the need to invite “foreign doctors”, and then only for the needs of the troops of the Moscow kingdom; the question of the development of national health care was not even raised then. However, a good project to create a prototype of the military medical service remained only on paper - the Godunov dynasty fell, Smoot began, and the question of the development of domestic military field surgery and providing the troops of the Moscow kingdom with medical personnel was further developed only under Tsar Alexei Mikhailovich. At the same time, unfortunately, more or less serious military-medical support of the Russian troops began only with the rule of Peter I, in parallel with the creation of a regular army in the Western European style.
But back to Ambroise Pare. Despite the failure to save the life of King Henry II, in another, very similar case of injury - a penetrating head injury to the Duke de Guise (the one who will be the leader of the Catholic party in France and one of the inspirers of the St. Bartholomew's night) mastery.
During the siege of Boulogne, the Duke de Guise was wounded in the eye with a thin and sharp fragment of a spear that had penetrated the helmet's viewing slot. A piece of wood entered the inner corner of the orbit and came out behind the auricle, and moreover, when the duke fell from his horse, both ends of the chips that were sticking out of his head broke off. Even by modern standards such a wound is very serious. Several doctors have already tried to remove a spear shard, but unsuccessfully, and most of the urgently assembled doctors recognized the injury as incurable and fatal.
When Pare arrived, after inspecting the wound and getting acquainted with the failed attempts, he went to the camp forge and asked the master to show him all the available types of ticks. Having selected some of them, he ordered them to be urgently finalized and, having thus obtained a new surgical instrument, he returned to the wounded duke and pulled a piece of wood from his head. Despite the fact that from the skull, de Guise poured a huge flow of blood, Pare was able to stop the bleeding, and then he processed and sealed the wound.
And, surprisingly enough even to modern doctors, but a man with such a monstrous penetrating head wound recovered after this operation, carried out with primitive tools, without the use of antiseptics and asepsis, without the use of antibiotics, not to mention the lack of X-rays and a computer tomograph. Moreover, the Duke de Guise, despite the wound through the skull, retained all his mental and physical activity, and in a few weeks he was able to ride his horse again!
So, thanks to the skill of an outstanding surgeon, the duke seemingly doomed to death unexpectedly resurrected, and the name of Pare became a legend and became famous not only throughout France, but throughout Western Europe.
And this glory served him once a great service. In the course of the next war, in which the founder of modern military surgery is directly involved, he is still captured. When the opponents from the troops of the Habsburg dynasty found out who had fallen into their hands, they immediately brought him to their commander, the Duke of Savoy, who offered Pare to enter his service. However, despite the promise of a huge salary and high position, the French surgeon, although he was a Breton by birth, was a staunch French patriot and therefore refused. Then the duke, enraged by the refusal, ordered him to enter his service already forcibly, practically without salary, and on pain of death. But Pare again refused, and then he was announced that he would be executed at sunrise the next day.
It would seem that the life of the great surgeon came to an end, but the soldiers and officers from the Habsburg army decided to do everything to save such an outstanding personality, and although they did not dare to contradict the direct order of their commander to execute, they ensured the successful escape of the head surgeon of the French army to the coming night my own Pare’s absolutely unexpected return to the camp of the French troops was greeted with triumph, and the glory of the staunch patriot of France was added to his glory as a great surgeon.
It should be noted that it was at the suggestion of Ambroise Pare, as well as the army surgeons and officers of several armies who had supported him, that in Western European countries already in the 16th century the question was raised about the manifestation of philanthropy on the battlefield to fallen enemies. So, it was Pare who became an active propagandist of the idea that a wounded adversary is no longer an enemy, but only a suffering, demanding healing, and having the same rights as a warrior of his army. Until that time, there was widespread practice in which most of the wounded soldiers of the defeated army who remained on the battlefield were killed by the victors, and often even the heavily wounded soldiers of the victorious party would have the same fate.
The statue of Ambroise Paré in Angers (France). Auth. - David D'Ange, 1839)
Faced with similar in the years of his youth, A. Pare, after several decades, was able to achieve a pan-European recognition of the idea that all wounded, without exception, have the right to life and medical assistance, and wounded soldiers of the enemy’s army have the same right to treatment and the soldiers of the winning army.
Killing not only prisoners or wounded on the battlefield as winners, but even “killing out of grace” their seriously wounded, who still had chances for a cure, though not immediately, several decades after Pare’s death, but was recognized as an international crime in most countries Western Europe. And not just became a private rule, but was enshrined in a number of international agreements, including those that ended the Thirty Years War in 1648.
This is how the skills and ideas of one simple but ingenious person influenced the course of European history and laid the practical and ethical foundations of modern field surgery for the next centuries.
Remarkable facts
1. Ambroise Pare did not learn Latin until the end of his life and wrote all his fundamental works in French, and therefore any educated Frenchman, and not just medical aristocracy, could read his works. But since it was Latin that was (and partly remains) the language of international communication in the medical environment, to disseminate his knowledge outside France, Pare asked several of his colleagues, who were fluent in Latin, but not so brilliant surgeons, to translate his books for publication in other countries Of Europe. And it was the Latin versions of his books that hit the territory of the Moscow kingdom in the luggage of a German doctor at the end of the 17th century, thereby having some influence on the beginning of the formation of the Russian military surgical school.
2. The Parisian hospital "L'Hotel-Dieu de Paris" ("Orphanage of the Lord"), within the walls of which Ambroise Pare lived and worked, is the oldest hospital on our planet. This institution was created back in 651 as a Christian shelter for the poor thanks to the activities of the Bishop Landre of Paris, Chancellor of King Clovis II, and with short interruptions for reconstruction it has been functioning for almost 1400 years.
3. In honor of Ambroise Pare, a hospital established in the colonial period is named after the French in the city of Conakry, the capital of the Republic of Guinea (former French Guinea, West Africa), which is still the best clinic in the country.
List of used literature
1. Borodulin F.R. Lectures on the history of medicine. - M .: Medgiz, 1955.
2. Mirsky M.B. History of medicine and surgery. - M .: GEOTAR-Media, 2010.
3. Shoyfet M.S. “One Hundred Great Doctors” - M .: Veche, 2010.
4. Yanovskaya M.I. A very long way (from the history of surgery). - M .: Knowledge, 1977.
5. Jean-Pierre Poirier. Ambroise Pare. Un urgentiste au XVI siècle. - Paris: Pygmalion, 2005.
6. The Parisian Barber, or the Glorious Deeds of the Great Surgeon Ambroise Pare // “Pharmacist Practitioner”, September 2015.
7. Surgeons emerged from the barbers // AiF. Health. No. 32 from 08 / 08 / 2002.
8. Berger E.E. Ideas about poison in the medical literature of the XVI century / / Middle Ages. 2008. No.69 (2), p.155-173.
9. Berger E.E. Features of surgical education in medieval Europe // History of medicine. 2014. No.3, s.112-118.
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