SYMHC Classics: Ambroise Paré

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Speaker 1: Happy Saturday. In our episode on Goods of the Iron Hand, we talked about the state of surgery in fifteen oh four when he was injured in battle and had to have his hand amputated. We mentioned that when this happened, Ambras Pire's work advancing the field of surgery in Europe was still decades away, and in our episode on Mpoise Perree, which originally came out on May seventeenth, twenty twenty one, we talked about how so many other advances happened hundreds of years after Pire's groundbreaking work. Our episode on him is Today's Saturday Classic, So enjoy. Welcome to Stuff you missed in History Class, a production of iHeartRadio. Hello, and welcome to the podcast. I'm Holly Frye and I'm Tracy V. Wilson. Oh, it's more medical history. So exciting. I've been doing so much over the pandemic and we've just had lots of medical things come up. But this time we're going to talk about early surgery, and I mean very early surgery. We're going to talk about Amboise Parrey, who has been called everything from the gentle surgeon to the father of modern surgery, and he really really did advance the field of medicine significantly during his fifty plus years in practice, and just for a level set, so you get a sense of how ahead of other things we've talked about he is. When we recently talked about Jean Baptiste Denis in our two parter about the development of blood transfusions, those events took place more than one hundred years after what we're talking about today. And when we talked about, for example, Scottish surgeon Robert Liston, who was famed for his speedy amputations, that was three hundred years after Paree. And so first though, to set the stage, we have to talk a little bit about barber surgeons and some of the other stuff that was going on in Europe regarding the trade leading up to the sixteenth century, which is when Parrey was doing his work, and then we will get into Amboise Parrey's story. Yeah, when you sent me, when I asked what you were working on this week and you told me, I googled it and saw the word surgeon and then saw the year and kind of went woe. We've talked about some very early surgical history before, but this was one that jumped out at me so yes, glad you picked it. Yay. So before we get into Pare's story, as Holly just said, we need to have a little overview of barber surgeons and where they were at when he was working in this field. We have mentioned barber surgeons before, I don't think we've really talked about the origins of barber surgeons and how exactly we got to a point that you would hire the same person to shave your face as you would to extract a tooth or amputate a limb, so wide range of job responsibilities. It seems like such a strange grouping today, but for a long time it was totally normal. Yeah, and we know that specialists in grooming go all the way back to ancient Egypt. But there's this question of like, when did the cosmetic occupation take on all of these other duties. So the answer to that lies in the Hippocratic oath. We won't read the whole thing. It is quite long. It includes a lot of language about holding your teacher in the same regard as your parents, and administering healthy diets and all kinds of other things. But the section of it that's germane to today's topic is this quote, I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. So we should note two things here, because you also may have heard or read a different version of the Hippocratic Oath. First, the oath was originally written in Greek, so obviously there are translations. Second, there is a modern version that is quite different, and you may have heard that one. That one, though, was not written until nineteen sixty four, so long long after Envois papail time. It was written by Tuft's university academic dean of the School of Medicine, Louis Lasagne. That phrase, though, about not using the knife on patients, meant that if somebody did need surgery, there has to be a different profession who could handle it. Physicians could take care of their patients in every way that didn't require surgery, but then if things reached a point where a knife was involved, then the patient needed to be handed off to someone else, so a surgeon, or very often a barber surgeon. So from their beginnings which had the religious significance of being in charge of things like tonsuring clergy barbers, over time adopted additional duties as standard for the barber trade. Needs like bleeding or tooth extraction were handled by barbers for the simple reason that in eleven sixty three, monks, who up to that point had been providing services like bloodletting, were then forbidden to do so by a papal decree issued by Pope Alexander the Third. So at this point Pocrates has said that physicians can't do it, and the papal decrea said that none of the monks could do anything like this. So additionally, actual trained surgeons were pretty thin on the ground. So the role of the barber continued to expand to include more and more complex procedures, until barber surgeon had emerged as a career. Yeah. Basically, basically, somebody in Europe's got to do it, yeah, And that's where we landed. In London. The Worshipful Company of Barbers, which was founded in the early thirteen hundreds and still exists, was a guild for the barber profession, and it supported this expanding role. But there were also surgeons who were just surgeons. They had made their careers specializing in that field. So naturally this led to some tension barber surgeons felt that they were filling a really vital need for their clientele, and they were, But surgeons felt that barbers were beneath them, and they didn't have the same skill level because they hadn't learned Latin or gone to university, and that these combination shops that handled the tasks of multiple professions should really just be relegated to the country, where professionals in general were a lot more sparse. But most surgeons were employed by royal or high ranking households exclusively, so even in the city there was still a lot of need for somebody who could do all of this stuff. To compound matters, a lot of doctors thought that some of the tasks that a barber surgeon could perform, like bloodletting, was really beneath them. In a nineteen sixty two paper, RS. Roberts wrote quote, despite the pretensions of the physicians, it was impossible to keep medicine, surgery and pharmacy as separate activities, and a more general form of practice which combined all that was necessary did develop in London just as quickly as the provinces. There was so much strife in London over all of this that Henry the Eighth, surgeon Thomas Liinaker used his influence with the king to ask that some sort of supervisory guidelines be put in place for surgeons. Similar requests for medical regulation came from other scholars who had the king's ear, and for just about the entirety of Henry the Yighth's reign there was this sort of constant effort and struggle to get London on par with other cities in terms of medical licensing and education. In fifteen forty the Company of Barber Surgeons was formed and that combined the two professions, although surgeons and barber surgeons were still separate things, but under this larger group medical care was regulated. In France, the two had joined under one guild eighty years earlier, in thirteen eighty three, during the reign of Charles the sixth of France, the king's first barber and valet was made head of that guild. But then Paris had its own complexities and conflicts in the medical field. Barber surgeons were sometimes called doctors of the short robe, with doctors of the long rowe being used to refer to members of the Confraternity of Sant Kame. These were theoretically surgeons, although they often had sort of a snooty attitude it seems, about performing surgery themselves. These doctors of the long robe had a lot of friction with the university trained physicians and with the barber surgeons. This made Paris a very contentious place to practice medicine at all. It's so all of the posturing that goes on in the hierarchy of these medical fields is very fascinating to me. There was reform to this very problematic system just before Envoise Perier was born. The Faculty de Midcent decided on a course of action to try to alleviate the tension by making barber surgeon a legitimate licensed title. That meant the barber surgeons could attend classes at the university and they had to take two exams after completing their training in order to be licensed. As part of this reformation, the existing surgeons could move up in title to doctor's region at the faculty. So this ended up consolidating these three factions into two, and it elevated both barber surgeons and surgeons. And while this did not by any means eliminate all of these problems and posturing, it definitely did improve things, and m wois Pai was working in the medical field right in the middle of this unique and sometimes tense culture. We will talk about his life and career in just a moment, but first we will pause for a quick sponsor break. Amboise Parre was born in fifteen oh nine or fifteen ten in Burgerson in western France, and his path in medicine was actually set fairly early on. Both he and his brother were set on educational tracks to become surgeons by their father, who was not in the medical field but did well for himself as a master carpenter. One of the key pieces of education that a surgeon needed was Latin, and a working knowledge of Latin was considered vital for that career, but and was never quite mastered it. That was even though he had been sent to a boarding school that was run by a chaplain who could focus on that language. Yeah, and there was a lot of very dedicated educational effort to getting him to learn Latin, but that was just not happening. When he was in his early twenties, Parey traveled to Paris to pursue a position as an apprentice. Despite his Latin still lacking he did get an apprenticeship with a master barber surgeon, so that at that point was the only possible path because that Latin requirement was not quite as vital for a barber surgeon. He didn't really get a whole lot of time with the surgeon part of the job, though. He mostly tidied up in the shop by sweeping hair, and he was occasionally allowed to give beard trims. This was not, we should say, because his mentor was particularly cruel. The shop just had to be maintained during business hours, so most apprentices faced kind of similarly challenging schedules. There just wasn't really a way to attend medical lectures because of this, unless they were lectures that were given unusually early in the morning or late in the evening, so study of the surgery side of the job was usually done via late night reading, although there were some procedures like leeching that were taught their hands on in the shop. Paray accepted this sometimes ruling schedule, and he applied himself to get to his goal of being accredited as a barber surgeon. But the diploma from the master barber was really just the first step. The next phase of his education was pretty similar to the way a modern medical doctor goes through a residency training period. For Pahy, this meant a surgeon trainee position at Houtel du de Paills starting in fifteen thirty two as an assign. The Houteldieux may one day be its own episode. It is the oldest operating hostelspital in the world, it still operates, and it has its roots reaching back at least eleven hundred years. But for the purposes of Mboise Paris story, the key here is that the Hotel Dieux had started as a home for the poor of Paris that eventually added medical care for the residence to its mission, and it had actually become essentially a teaching hospital by Parrei's time. There was also sort of a weird setup for surgical training because the hospital was run by the Church, and the Church looked upon cutting a human body as anathema. This meant that any kind of actual surgery that mbois Pire was able to perform had to be on deceased patients. The hospital was packed, though it was often really overcrowded with patients having to share beds, so he had plenty to do over the course of four years, he provided care to thousands of residents, including through a cholera outbreak, and he studied surgery in books and by doing autopsies. But even though he had done all this hands on training and work to qualify for a surgical license, stories go that this lack of Latin continued to hold him back. He was not able to obtain a license. But really most accounts indicate that it wasn't so much the Latin issue. It was that he was too poor to take the required certification exam. Yeah, the Latin hold back is like a nice story, but it really seems more to have been a financial issue. Regardless though, of which of those factors was the one holding him back, he ended up on another path, and that was one that would enable him to practice medicine even if he did not have a license, and that was as a member of the French military, Parrey was able to get a position as the surgeon attending the General Martial de Monjan and the impact this role had on the way Parrey practiced medicine and consequently a lot of other people kind of reminds me a little bit of the episode we did about famed chef Augusta Scoffier, because if you heard that one and recall it Ascofier had learned to improvise really impressive meals for the true that he cooked for with minimal supplies during his time in the military, and on bois Perree, in kind of a similar move, improvised treatment of wounds when his medical supplies ran low. Pahia described a key moment in his military career during the fifteen thirty seven Siege of Turin, when he ran out of the oil that they normally boiled to cauterize amputation and gunshot wounds. So the treatment that he had always felt was often really damaging and risky to the soldiers. So it is very easy to the modern ear to immediately hear that whole boiling oil thing and think, WHOA, what were they thinking? They're so foolish. Keep in mind, though, this is really still pretty early in the use of gunpowder artillery in war. There are references to artillery on battlefields as early as the mid fourteenth century, but in the years between then and when Parey was deployed, the use of such weapons had grown pretty slowly, and the Italian Wars, which Parey found himself part of As France and Spain battled over control of Italian territories, were marked by a significant uptick in the amount and variety of firearms used, and there was still a commonly held belief that there was poison in gunpowder, so the oil was thought to somehow counter that. Parree listed the weapons of war in his writing as quote all sorts of minds, countermines, pots of fire, trains, fiery arrows, lances, crossbows, barrels, balls of fire, and all such fiery engines and inventions. They are certainly a most miserable and pernicious kind of invention by which we often see a thousand unsuspecting men blown up with a mine by the force of gunpowder. For these modern inventions are such as easily exceed all the best appointed and cruel engines, which can be mentioned or thought upon in the shape, cruelty, and appearance of their operations. Yeah, as many physicians, he had very strong opinions about firearms, but his improvisation in this moment and its results changed the way he looked at medicine forever, and he wrote about it. This is translated, obviously, at last, my oil ran short, and I was forced instead thereof to apply a digestive made of the yolks of eggs, oil of roses, and turpentine. In the night I could not sleep in quiet, fearing some default in not cauterizing that I should find the sounded to whom I had not used the set 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 medica mint 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. Clear, this was hugely risky. If these soldiers had died because of Pire's experimental treatment, not only would he have felt responsible, he also probably would have been kicked out of the military. Additionally, it would have also likely ended any hope he had of being a barber surgeon beyond the battlefield. So it's really no surprise that he couldn't sleep, and this discovery that an alternate approach to treating wounds, one that did not involve pouring boiling oil on already suffering patients, was successful, gave Parey a new degree of confidence. He started to extol the virtues of observing patients and treating based on assessment of the individual, rather than only going by what appeared in books as the prescribed method for a particular type of injury. He had also decided from that moment that he would only use treatments that he truly believed to be useful. So in a way, he was making a conscious decision to trust his instincts because he had always suspected that scalding oil was not the best idea, but now he had experiential proof that another approach created a far better outcome. Up to the time that he became a military medic, Plaret's knowledge about surgery was like most medical professionals of the time, based on the writings of Galen. Galen moved medical practice forward in a lot of ways. He clarified understanding of anatomy, particularly the circulatory system and the workings of respiration, and he also did a lot of surgeries. He cared for gladiators and accompanied Marcus Aurelius into battle to care for the troops, so he had plenty of injuries to treat and to learn from. But Galen lived in the first century, so a lot of his ideas were outdated by the time Parry was working, even though he was still a really key part of standard medical education. His writing, for example, was based on the idea of bodily humors that Hippocrates had developed. Most of the early sixteenth century medical profession still had an almost dogmatic devotion to following Galen's writings to the letter, even though Galen himself wrote about the importance of personal observation. Parray continued to elevate the care of wounded soldiers as a field medic insurgeon over the course of several military tours, and that dedication paid off, although he was encouraged to stay in the military because of his usefulness. In fifteen forty one he returned to Paris and he was able to take the necessary examinations that he needed, and he was given the title of Master barber surgeon. He also got married after he went home to Paris, and he basically set himself up with a house and a shop in what is modern day Place de Michele. Pire went back to the military in fifteen forty two when he was selected by the Grand Lord of Brittany to be his surgeon on campaigns. It was during this phase of military touring that Piree developed a new technique for dislodging bullets from wounds by having the wounded person placed their body in the position they had been in when they were shot, so that he could more easily track the book its trajectory. It seems like such a cool and interesting thing, rather than people digging around in wounds, going how exactly were you standing? I see it entered here, It probably went here. It seems so obvious and yet was not standard at all. And one of the reasons that we know about amboise Pari's experiences and his refinement of surgical techniques is because he wrote numerous books on those subjects. And we're going to talk about the beginning of his work as an author after we hear from some of the sponsors that keep stuff you missed in history class going. After he returned to Paris again and on the advice of one of the physicians at the Faculty de med Saint Amboise started writing about his work, and this is where not having learned Latin actually helped make him even more well known. He wrote in French that was unusual for medical texts, and as a consequence, it made them accessible to a far away, wider audience. Whereas the use of Latin in the medical field had always been a separator between the well educated and the masses, Pire's work disregarded that divide, and to some degree it democratized medical knowledge. Barber surgeons were no longer left out of the conversation. They were reading the exact same text as master surgeons. When it came to Paray's work. The use of French for his writing also meant that translations of his works went into circulation really quickly. Soon there were printings of Parre's writings in English, German and Dutch, and they spread quickly throughout all of Europe. And because of this, his ideas created a true watershed moment in medical history where practitioners started re examining some pretty long held truths. His first book was published in fifteen forty five and it was titled The Method of Treating Wounds made by arquebuses and other firearms, darts and such. Also combustion made especially by cannon powder. So just as quick aside, an arcbus was a long gun, sort of a precursor to the musket. And the preface to that book really evidences Parre's religious devotion. It is dedicated quote to young surgeons of goodwill, and after a few opening lines about how he was asked to share his knowledge of treating wounds, it reads quote, not presuming in my present capacity being able to teach you, for which more instruction would be necessary, but to satisfy your desire in part, and also stimulate some higher spirit by writing in this way, so we can all give it greater attention. Now I ask you humbly to take this little book kindly, which, if I know you are agreeable, will cause me to do something more such as my small mind can undertake. For such, I pray the creator, brothers and friends to happily support our work by his grace, always increasing our good affections, so that something fruitful and useful can come of it, to the support of the infirmity of human life, and to the honor of the one in whom are hidden all the treasures of science. Who is the eternal God. This religious reference is also reflected in a phrase that's often associated with pay, which is je la pinsaille du de gerrie, which is I bandaged him, God cured him parey with a lot of course study in his early years, You'll remember he did a lot of book learning combined with his situational experience on the battlefield. Wrote about the various changes to treatments that he had developed while in military service, and this of course included his opinion that hot oil led to pain that could be avoided in amputation situations, and that the oil could actually damage the tissue and slow healing. He continually worked to be objective about reconsidering old methods of doing things as compared to his new ideas. He never presumed that his way was better, and he always offered reasoned explanations in situations where he felt that surgeons should perhaps update their practice to include new techniques. In all of his writings, they're really pervasive aspect of it is that he speaks of compassion and kindness and remembering that saving lives is worth the effort. This isn't necessarily common in medical texts at this time, so it was very unusual, and all of this led to his nickname in history as the Gentle Surgeon. In fifteen fifty he published his second book, which was Brief Collection for the Conduct of Anatomy, and once that was out, he started editing and updating his first book for release as a second edition. Right after that second edition project, he was once again attending to soldiers on the battlefield with the medics under Vicon de Rohan and Parey is said to have gone to great efforts to save a soldier who everyone believed was going to die. They had actually already dug a grave for him, and that his dedication to saving even the lowest ranking of the troops gained him great admiration and loyalty among the men. During this deployment, pay started to use ligatures to tie off vessels during amputations, abandoning the use of hot iron cauterization. When the city of Metz was overwhelmed by the forces of Emperor Charles the fifth and Bois Parree was snuck past the occupation forces so that he could treat trapped soldiers there. Because of this and his extraordinary service throughout his military assignments. King Henry the Second of France appointed him to be one of the king's surgeons. This honor came with some strings, though, because after the battles in Ruren, Parray had returned home to his practice in Paris in fifteen fifty three, only to have the King order him almost immediately to another battlefield in Dain, where the situation was quite dire and paree were day and night to try to treat the overwhelming number of wounded. Things grew even more precarious when Parray was taken prisoner along with the rest of the French garrison. He disguised himself at this point as a low ranking soldier so that his identity would not be revealed. At this point, remember, his stuff had started to be translated and spread throughout Europe, so people knew who he was, and he knew that like that could potentially endanger him or cause his captors to ask for a very high ransom. But he did continue to treat people medically during this time, and he actually managed to secure his freedom by treating an enemy officer I believe it was for an ulcer on his leg, and he returned to King Henry the Second and gave his report before once again at least attempting to return to his civilian life. In fifteen fifty four, his career took another step forward. He was granted the title of Master Surgeon, in part because the surgeons of the city knew it would make them look good. He became the surgeon attending King Francis the Second. Yeah, this is actually pretty pivotal, where somebody who came up as a barber surgeon suddenly all of the snowdier levels of the medical establishment were like, no, no, no, you're one of us. You're famous and stuff. He was sent on two more military campaigns, at San Quentin and Durlain, and when Charles the ninth became King of France, Parrey was once again in that monarch service. As the French Wars of Religion began, they dominated Parrey's professional life just as other conflicts had, because he was ordered to treat soldiers at the request of the crown. Although he was sent away from Paris less and less often, likely because at this point he was getting a bit older. Pirai continued to write, and in fifteen sixty four he released a highly illustrated project titled Ten Books of surgery with the magazine of the instruments necessary for it. He also developed a specialized clamp called a beche de crobat, which is a crow's beak and that would help hold a vessel closed to keep patients from bleeding out. This was used in cases where a wound had severed the vessel and the surgeon could quickly stem the bleeding with the clamp to improve survival rates. He also invented a number of other clamps with similarly charming names. The beche de grue in English as the crane's beak and another called a duck's beak that's a bech decan. We're both developed for bullet extraction. These were long and thin, so they could reach deep into the tissue to get to a bullet without having to widen the entry wound too much. That was an ongoing problem. Again, Parray's focus on preserving the tissue and treating the patient as gently as possible is driving his innovation. Gentle handling of patients and their tissue was just a really important part of Pare's writing and work. It was accepted and also expected that patients would have incredible pain during surgery. If you recall our episode on Scottish surgeon Robert Liston, which was in the eighteen hundreds. You may remember that he became famous for his speed at surgical procedures and was deemed to be a showboater because of it, but his real goal with that was to keep the patient's pain as brief as possible. Similarly, and was Parrey several centuries before that was also trying to be as brief as possible with the scalpel and to be as gentle as he possibly could in the hopes of minimizing suffering. Long before it was customary, and vois Parrey was encouraging the medical profession to embrace the idea of pain management for patients as well as more comprehensive follow up care on the part of the surgeon. So he, like a lot of people, dispensed opium for postop recovery. Although this wasn't just like a blanket thing to knock people out. He was trying to really like carefully determine how much they needed to help them with their pain. And at a time when surgeons typically kind of performed a procedure and then left any after care to physicians and nurses, he believed in remaining part of the recovery team for the patient after that surgery was completed. When Charles the Ninth died in fifteen seventy four, Pare remained the king's surgeon. Under the new regent that was Charles's brother, Henry the Third, he was also elevated to the position of Valle de Chambre. Pare served Henry the Third until the king's assassination in fifteen eighty nine. In fifteen seventy five, Parrei published his complete Works of Envoise Parier Councilor and Premier Surgeon of the King. This volume gathered together all of his writings on surgery and medicine into one and it was edited and revised as needed, and it was so popular that it had multiple edition runs over the course of the following century. In sixteen thirty four it was translated into English for publication in London. In fifteen eighty five, his last book, Apology and Treatise, was released, and this became his most famous work. It was part medical discussion, part autobiography. It covered his medical career during the fifty years from fifteen thirty five until its publication. At its heart it was a drama because it was a response to criticism from his contemporary, Etienne Gourmalin, who was dean of the Faculty to Medicine. Gourmalin's own writing on surgery had never been as popular as Parees, and it definitely led to some tension. In fifteen eighty one, Gourmalin wrote a book about surgical techniques in which he criticized pai is amputation ligatures. Yeah, I think it probably ground his gears a little bit, that he was a more of a trained and educated surgeon and yet no one was listening to him when a barber surgeon had gotten famous written books and everyone wanted to read them. Apology and Treatise takes on these criticisms of Gourmalin's and outlines the many ways in which Parey shifted thinking in the medical community throughout his career. Basically, he's establishing his street cred and then he kind of addresses the actual criticism, and the whole thing is also written with the usual careful analysis and logic that he became famous for, including detailed case histories that supported his work. And this whole thing was a huge humiliation for Gourmelin. Just like Gormala shouldn't have been a jerk. Then he allegedly wrote a response to it that was written anonymously, and it's kind of this like weak, well, you don't know of paper that he I can't remember if it was written anonymously or if he had one of his students publish it under their name. But Gormalin did not really get over it, but he was shamed. That sadly brings us to the end of m Bois Parey's life. He died at home and bed on December twentieth, fifteen ninety, at the age of eighty. Yeah. I literally had this moment where I was doing the math on the length of his career and I was like, wait, he couldn't have been practicing myself fifty years. Yes, yeah, fifty years at a time when I wonder how many people even had any career for fifty years, particularly one that changed the way that people practiced medicine. And he undoubtedly, I mean, he saved a lot of lives directly himself, but there's no real way to measure how many lives were made better or saved because other doctors were like, I think he's onto something blas Parrey. Thank you for suggesting being gentle. Thanks so much for joining us on this Saturday. Since this episode is out of the archive, if you heard an email address or a Facebook RL or something similar over the course of the show, that could be obsolete now. Our current email address is History Podcast at iHeartRadio dot com. 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