Management of injuries on the 16th-century battlefield: Ambroise Paré’s contributions to neurosurgery and functional recovery

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  • 1 The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
  • | 2 Creighton University School of Medicine, Omaha, Nebraska
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During the 1536 siege of Turin in northern Italy, a young French barber-surgeon abandoned the conventional treatment of battle-inflicted wounds, launching a revolution in military medicine and surgical techniques. Ambroise Paré (1510–1590) was born into a working-class Huguenot family in Laval, France, during an era when surgery was not considered a respectable profession. He rose from humble origins as a barber-surgeon, a low-ranked occupation in the French medical hierarchy, to become a royal surgeon (chirurgien ordinaire du Roi) serving 4 consecutive French monarchs. His innovative ideas and surgical practice were a response to the environment created by new military technology on 16th-century European battlefields. Gunpowder weapons caused unfamiliar, complicated injuries that challenged Paré to develop new techniques and surgical instruments. Although Paré’s contributions to the treatment of wounds and functional prosthetics are documented, a deeper appreciation of his role in military neurosurgery is needed. This paper examines archives, primary texts, and written accounts by Paré that reveal specific patient cases highlighting his innovative contributions to neurotrauma and neurosurgery during demanding and harrowing circumstances, on and off the battlefield, in 16th-century France. Notably, trepanation indications increased because of battlefield head injuries, and Paré frequently described this technique and improved the design of the trepan tool. His contribution to neurologically related topics is extensive; there are more chapters devoted to the nervous system than to any other organ system in his compendium, Oeuvres. Regarding anatomical knowledge as fundamentally important and admiring the contemporary contributions of Andreas Vesalius, Paré reproduced many images from Vesalius’ works at his own great expense. The manner in which Paré’s participation in military expeditions enabled collaboration with multidisciplinary artisans on devices, including surgical tools and prosthetics, to restore neurologically associated functionality is also discussed. Deeply religious, in a life filled with adventure, and serving in often horrendous conditions during a time when Galenic dogma still dominated medical practice, Paré developed a reputation for logic, empiricism, technology, and careful treatment. "I have [had] the opportunity to praise God, for what he called me to do in medical operation, which is commonly called surgery, which could not be bought with gold or silver, but by only virtue and great experimentation."

During the 1536 siege of Turin in northern Italy, a young French barber-surgeon abandoned the conventional treatment of battle-inflicted wounds, launching a revolution in military medicine and surgical techniques. Ambroise Paré (1510–1590) was born into a working-class Huguenot family in Laval, France, during an era when surgery was not considered a respectable profession. He rose from humble origins as a barber-surgeon, a low-ranked occupation in the French medical hierarchy, to become a royal surgeon (chirurgien ordinaire du Roi) serving 4 consecutive French monarchs. His innovative ideas and surgical practice were a response to the environment created by new military technology on 16th-century European battlefields. Gunpowder weapons caused unfamiliar, complicated injuries that challenged Paré to develop new techniques and surgical instruments. Although Paré’s contributions to the treatment of wounds and functional prosthetics are documented, a deeper appreciation of his role in military neurosurgery is needed. This paper examines archives, primary texts, and written accounts by Paré that reveal specific patient cases highlighting his innovative contributions to neurotrauma and neurosurgery during demanding and harrowing circumstances, on and off the battlefield, in 16th-century France. Notably, trepanation indications increased because of battlefield head injuries, and Paré frequently described this technique and improved the design of the trepan tool. His contribution to neurologically related topics is extensive; there are more chapters devoted to the nervous system than to any other organ system in his compendium, Oeuvres. Regarding anatomical knowledge as fundamentally important and admiring the contemporary contributions of Andreas Vesalius, Paré reproduced many images from Vesalius’ works at his own great expense. The manner in which Paré’s participation in military expeditions enabled collaboration with multidisciplinary artisans on devices, including surgical tools and prosthetics, to restore neurologically associated functionality is also discussed. Deeply religious, in a life filled with adventure, and serving in often horrendous conditions during a time when Galenic dogma still dominated medical practice, Paré developed a reputation for logic, empiricism, technology, and careful treatment. "I have [had] the opportunity to praise God, for what he called me to do in medical operation, which is commonly called surgery, which could not be bought with gold or silver, but by only virtue and great experimentation."

Thou hast a young Chirurgion of age, but he is old in knowledg and experience, preserve him well; for he will doe thee service, and honor.

— Physician to Milan to the Lord Marshall of Montejan after observing Ambroise Paré treating wounded soldiers, Turin 15371

During the 1536 siege of Turin, Italy, a young French barber-surgeon abandoned the conventional treatment of battle-inflicted wounds, launching a revolution in military medicine and surgical techniques. Ambroise Paré (1510–1590) was born into a working-class Huguenot family in the village of Bourg-Hersent, near Laval, France, during an era when surgery was considered a low-status occupation. His modest yet brilliant approach, innovative and compassionate, began to shape surgery into being evidence based, respectable, and patient centered (Fig. 1).

FIG. 1.
FIG. 1.
A: An image of Paré at 45 years of age, as he was achieving notoriety, from a copper engraving in his Anatomie universelle.26 This image is from the copy of Anatomie universelle bequeathed by William Osler to the Faculte de Medicine, Paris. Osler made the bequest because he was concerned that no good copy of the book existed in Paris. Public domain. B: An image originally from Paré’s 1585 Oeuvres27 (published in 1641 Oeuvres28) shows him at 75 years of age. During the siege of Paris in 1590, an intimate and revealing assessment of Paré, who was only months away from his death, was recorded by a journalist who described a meeting between Paré and the Archbishop of Lyons during those turbulent days:

I remember that about eight or ten days at most before raising of the siege, [the Archbishop] found himself besieged by a crowd of mean people, dying of hunger, who cried to him, demanding bread or death, and he not knowing how to dispatch them, encountered Master Ambroise Paré, who said loudly to him, ‘Monsiegneur, these poor people whom you see here about you are dying of the cruel rage of hunger, and demand pity of you. For God’s sake, Monsieur, give it to them, if you would have God countenance you, and think a little of the dignity in which God has placed you, and that the cries of these poor people which mount to Heaven, are a warning that God sends you […] for which you are responsible to Him. Therefore, according to this, and by the power which we all know that you have, procure us peace, and give us wherewith to live, because the poor people can no longer do so.’ [The] Archbishop […] contrary to his custom he was patient to hear [Paré] out without interruption, and he said afterwards that this good man had altogether astonished him; and again that this was a different sort of politics than his own, but that he had awakened him and made him think of many things.25

Public domain. C: Dramatic lithograph by Mouilleron after Robert-Fleury of Paré, who is shown writing at his desk with his hand on a skull. A bone saw hangs behind him, a trepan is on the table, and medicinal materials and what appear to be unique anatomical specimens that Paré is known to have kept are in jars on shelves in the background. Two somewhat ragged, leather-covered books are on the floor, touching the butt of a heavy musket, perhaps representing Paré’s personal records or diaries of his battlefield medical encounters. A helmet, connoting his military experiences, is placed at the center, on the table. Ambroise Paré. Lithograph by Mouilleron after Robert-Fleury. Wellcome Collection. Public domain.

Dominated by the Wars of Religion (1562–1598), 16th-century France witnessed the emerging use of firearms, which increased the number of dead soldiers and introduced unfamiliar, often brutal injuries. Paré’s hands-on surgical education, intuition, and commonsense approach to the evolving battlefield technology paved the way toward new surgical practices and away from traditional and theoretical teachings.

We examined original sources to discuss cases and developments that demonstrated Paré’s contributions to surgery of the nervous system and the neurologically associated restoration of functionality, focusing on the social context and battlefield environment, which were conducive to his revolutionary ideas.24

Surgical Institutions

The age of the Hundred Years’ War (1337–1453) and Italian Wars (1494–1559) contributed to the expansion of surgery and introduction of surgical training communities.5 A formal surgical curriculum did not exist until the early 16th century. In France, there were 3 hierarchical classes of medical professionals. The physicians, usually members of the Paris Faculty of Medicine, were academics who were well versed in medical philosophy and treated the wealthy, especially for internal diseases that did not require hands-on intervention.6 A second class was an elite guild of master surgeons from the College of Saint-Côme in Paris. These "surgical aristocrats" were chirurgiens de la longue robe and could attend lectures delivered by the faculty.7 Barber-surgeons, the third class, were generally despised by the former 2 classes but were the most experienced in surgery, conducted procedures that physicians were unwilling to do, and successfully competed against the Saint-Côme surgeons.2 Unlike physicians, who studied Galenic and Hippocratic texts at universities, barber-surgeons were trained by practice and apprenticeship, often forming surgery-training craft guilds.8

At age 13, Paré began a long apprenticeship as a barber-surgeon, achieving barber-surgeon apprentice at the Hôtel-Dieu in Paris at age 23.1,2 One of his brothers became a barber-surgeon, and his 2 sisters married barber-surgeons in Paris.3 There is little information on Paré’s education, and he did not comment on his teachers in his texts, "no doubt wishing to give no extra handle to those who taunted him with his lack of letters."3 However, Paré attributed and quoted freely from contemporary surgeons and physicians in his works. His base of education was his own inquisitiveness and intuition. Paré seized opportunities to try new methods and even tried medical advice from an old woman in a town. Paré must have been a distinguished and energetic student, being appointed as a resident prosector of the Hôtel-Dieu, which likely provided him with significant academic and professional associations.

He accompanied different French armies as a battlefield surgeon beginning in 1536 and served the army intermittently over the next 30 years. Because of their practical surgical skills, mainly barber-surgeons accompanied the army. Some became wealthy as a result of the reputations that they earned and connections that they formed while serving royalty and aristocrats. By 1552, Paré had gained such recognition that he became surgeon to the king, eventually serving 4 French monarchs (Henri II, François II, Charles IX, and Henri III).2,3

New Injuries on the Battlefield

A growing interest in distant warfare engagement fed the acceptance of gunpowder weaponry in the 15th and 16th centuries.9 Changing military strategies and advancement in weapons resulted in new common battlefield injuries. Gunpowder was used to fire canister shots and grapeshot from often poorly and hurriedly constructed metal cylinders packed with various materials, such as nails, glass shards, lead scraps, rocks, and iron balls. More directed gunpowder weapons and cannons were used to fire lead and iron balls that produced dreadful injuries, shattering bones. Previously, many weapons powered by human force did not produce enough impact energy to shatter a bone in multiple places; rather, bone injuries were mostly fractures in one area and easily treated with splints. With the advancement of gunpowder weapons, compound fractures, considered to be fatal and previously rare, became more prevalent. Such injuries resulted from the projectile’s low speed and deformation upon contact. Musket and pistol balls, usually lead or iron of various weights, were dynamically unstable, changed shape after exiting an unrifled barrel, and spread flat upon entering the body. This combination of dynamics and materials resulted in an increased incidence of complicated fractures.10

Pistols, rifles, long-barreled large-bore muskets, arquebuses, and other gunpowder weapons produced a variety of complicated wounds that easily became infected. Piercing armor and driving in pieces of cloth and leather, the unjacketed bullets perforated soldiers’ skin at low speed. Probing for fragments with unclean fingers or contaminated tools contributed to the many wound infections.10 Soldiers firing weapons were often burned by explosions from unstable powder, improper barrel swabbing, and metal casting defects in cannon and artillery. As soldiers quickly reloaded their weapons, they often added inaccurate amounts of powder into the flash pan of their muskets, causing explosions that burned the face and sometimes led to blindness.9

Paré’s first publication was a revolutionary 1545 treatise on gunshot wounds (Fig. 2A).11 He detailed the mechanisms of gunpowder weapons and communicated his skill in effectively managing cases that would be regarded as challenging even today (Fig. 2B).12,13 Paré developed diagnostic and surgical algorithms and encouraged the writing of detailed reports about the patient and procedures.14 In addition to his work on penetrating head injuries, Paré discussed the causes, diagnosis, and treatment of the relatively recently recognized phenomenon of "concussion." His insight into the association between new military technology and its medical effects was prescient: "I have thought good here to premise my opinion of the originall, increase, and hurt of fiery Engines […]. For thus it shall bee knowne to all whence Guns had their originall, and how many habits and shapes they have acquired from poore and obscure beginnings, and lastly how hurtfull to mankind the use of them is."1 Many soldiers possessed reliable firearms, became accomplished marksmen, and would aim for the head or other bodily regions that would kill or create significant injuries.

FIG. 2.
FIG. 2.

A: The title page from the 1617 English translation (The Method of Curing Wounds Made by Gunshot. Also by Arrowes and Darts, with their Accidents29) of Paré’s first book, on the treatment of gunshot wounds.11 The translator, Walter Hamond, had been trained in the tradition of the barber-surgeon, was an explorer and ship’s surgeon, and was a student of the English surgeon Arthur Doughton, who became the warden of the Company of Barbers of London in 1632. The "wound man" shows injuries caused by not only cutting and piercing weapons but also round projectiles from gunpowder weapons. Courtesy of the Medical Historical Library, Harvey Cushing/John Hay Whitney Medical Library, Yale University. Public domain. B: Title page from the first (1634) English edition of Paré’s Workes.13 By the advent of this compendium, Paré had been deceased for 44 years, yet his influence was obvious. Important elements of his career and contributions were represented on the title page. The upper left shows Paré trepanning the skull of a patient, supported by what appears to be a young trainee. In the same scene, the heritage of the barber-surgeon is represented by a man who is having his hair cut or being examined within the barber-surgeon’s room. Paré’s novel surgical instruments are depicted in the background. The portrait shows Paré at age 75 (see Fig. 1B). On the top right, Paré records his experiences, while behind him are jars of what are likely elements to make drugs or other medical pharmaceutical applications. The title in the center middle is flanked by anatomical illustrations hearkening to Vesalius. The bottom left shows the distillation and heat studies of Paré. In the bottom middle are various surgical instruments, including suture material, and on the bottom right are images of Paré’s text describing "monsters" (i.e., human abnormalities). Public domain.

Paré treated patients in a rapidly changing environment and recorded the trials and errors involved in treating these new types of injuries. His fame as a battlefield surgeon quickly grew because of his logical and considerate approach to his patients. In his 1552 Voyage d’Allemagne,1,3,13 Paré recorded the instance of a wounded soldier, destined to be cast aside into a ditch to die or be murdered by peasants: "I was moved with pity […] that he might yet be cured if he were well drest […] and after I clothed him he was but put into a cart upon a bed well covered. I did the office of Physician, Apothecary, Chirurgion, and Cooke. I drest him even to the end of his Cure and God Cured him."13 So moved after witnessing this benevolence, every man-at-arms and archer gave a coinage gift to Paré. Paré referred to himself as a "Souldier" in his writings several times.

Paré’s First Military Expedition

Paré’s field campaigns began in 1536, when French troops marched into the northern Italian Cisalpine plain.1 The accepted authority on gunshot infection rates was Giovanni di Vigo, an Italian surgeon to Pope Julius II.15 According to Vigo, gunshot wounds were inherently poisonous due to the effects of gunpowder; therefore, the treatment of such injuries required cauterization of wounds with boiling oil.1,13 Under Marshal de Montejan, Paré’s first military expedition was at the siege of Turin, where he treated cases of gunshot wounds.1,13 Initially following Vigo’s method of cauterization, Paré ran out of oil. Instead, he gathered resources and applied a digestive medication consisting of egg yolk, rose oil, and turpentine to the remaining wounded soldiers. The next morning, he was surprised to find that the soldiers who had been treated with the ointment felt "little pain in their wounds, without inflammation and swelling," in contrast to the soldiers who had been treated with cauterization by heated irons or "burning oyle."13

Noting the effectiveness of the balm, Paré "resolved to never again to so cruelly burn the poor wounded by gunshot."13 At Danvilliers, a man whose leg Paré had amputated returned "to his house merry with a woodden Leg, and was content, saying that he scaped good cheape, not to have beene miserably burnt."13 At the siege of Hesdin, France, Paré wrote that soldiers "would have slain [a surgeon] like a Calfe for this cruelty."13 Pain relief was limited; survival often required quick, painful procedures.16 Paré recorded that traditional theories, for example, that pain was essential for treatment, were not always correct. Experiences in northern Italy catalyzed Paré’s belief that surgical practice should promote gentleness and healing.

Head Wounds and Conditions

Between 1560 and 1590, Paré published 12 volumes and, at his death, was preparing the fifth edition of his Oeuvres, published posthumously in 1598. His Workes devotes more space to head wounds and associated conditions than to any other single organ system or anatomical location (Table 1).17 In a collection of case and autopsy records by Paré, 35 of 223 reports concern neurosurgical situations or brain and head anatomy, with the majority of reports concerning the treatment of head injuries.14

TABLE 1.

Chapters from Paré’s The Workes of That Famous Chirurgion Ambrose Parey pertaining to neurological topics

BookChapter (no. of pages)
III. Treating of the Anatomy of Mans Body.Of the distribution of the Nerves to the natural parts (1)
IV. Treating of the Vital parts contained in the Chest.Of the distribution of the nerves or sinews of the sixth conjugation (1)
V. Of the Animal parts contained in the Head.A general description of the Head (1)
Of the musculous skin of the Head (commonly called the Hairy Scalp) and of the Pericranium (2)
Of the Sutures (1)
Of the Cranium or Skull (2)
Of the Meninges, that is, the two membranes called Dura Mater and Pia Mater (1)
Of the Brain (2)
Of the Ventricles and Mammillary Processes of the Brain (3)
Of the seven conjugations of the Nerves of the Brain, so called, because they always shew the Nerves conjugated and doubled, that is, on each side one (3)
Of the Rete Mirabile, or wonderful Net, and of the Wedge-bone (2)
Of the holes of the inner basis of the skull (1)
Of the perforations of the external basis of the Brain (2)
Of the Spinal Marrow or Pith of the Back (1)
VI. Treating of the Muscles, and Bones, and the other extreme parts of the Body.Of the neck and parts thereof (3)
Of the muscles of the Neck (7)
Of the Nerves of the Neck, Back, and Arm (2)
Of the Nerves of the Loins, Holy-bone and Thigh (2)
VIII. Of the particular Tumors against Nature.Of an Hydrocephalos, or watery tumor which commonly affects the heads of Infants (2)
IX. Of Wounds in general.Of Convulsion by reason of a Wound (2)
The Cure of a Convulsion (1)
Of the cure of a Convulsion by sympathy and pain (2)
Of the Palsie (1)
Of the Cure of the Palsie (2)
X. Of the green and bloudy Wounds of each part.Of the kinds and differences of a broken skull (2)
Of the causes and signs of a broken skull (1)
Of the signs of a broken skull, which are manifest to our sense (2)
Of a Fissure being the first kind of a broken skull (2)
Of a Contusion which is the second sort of Fracture (2)
Of an effracture, depression of the bone, being the third kind of a Fracture (2)
Of a seat, being the fourth kind of a broken skull (1)
Of a Resonitus, or Counterfissure, being the fifth kind of Fracture (1)
Of the moving, or concussion of the Brain (2)
Of prognosticks to be made in Fractures of the skull (2)
Why when the Brain is hurt by a wound of the head there may follow a convulsion of the opposite part (2)
A conclusion of the deadly signs in wounds of the head (1)
Of salutary signs in wounds of the head (1)
Of the general cure of a broken skull, and of the symptoms usually happening thereupon (3)
Of the particular cure of wounds of the Head, and of the musculous skin (2)
Of the particular cure of a fracture or broken skull (2)
Why we use trepaning in the fractures of the skull (1)
A description of Trepans (3)
Of the places of the skull whereto you may not apply a Trepan (2)
Of the corruption and Caries, or rottenness of the bones of the Head (2)
Of the discommodities which happen to the Craffa Meninx by fractures of the skull (2)
Of the cure of the Brain, being shaken or moved (2)
Of the Wounds of the Nerves and nervous parts (1)
Of the cure of Wounds of the nervous parts (2)
XI. Of Wounds made by Gunshot, other fiery Engines, and all sorts of Weapons.A division of wounds drawn from the variety of the wounded parts, and the bullets which wound (1)
Of the signs of Wounds made by Gunshot (1)
How these wounds must be ordered at the first dressing (2)
A description of fit Instruments to draw forth bullets, and other strange bodies (2)
What dressing must first be used, after the strange bodies are pluck’d or drawn out of the wound (2)
How you shall order it at the second dressing (2)
By what means strange bodies left in at the first dressing, may be drawn forth (1)
Of Indications to be observed in this kind of wounds (2)
What remains for the surgeon to do in this kind of wounds (2)
Of Bullets which remain in the body for a long time after the wound is healed up (1)
An Apology concerning Wounds made by Gunshot (3)
Another Apology against those who have laboured with new reasons, to prove that wounds made by Gunshot are poisoned (1)
How wounds made by Arrows differ from those made by Gunshot (1)
XV. Of Fractures.Of the Fracture of the Vertebræ or Rack-bones of the Back, and of their Processes (1)
XVI. Of Dislocations or Luxations.Of the luxation of the Spine, or Back-bone (1)
Of the dislocation of the Head (1)
Of the dislocation of the Vertebræ or rack-bones of the neck (1)
Of the dislocated Vertebræ of the Back (1)
How to restore the Spine outwardly dislocated (1)
A more particular enquiry of the dislocation of the Vertebræ, proceeding from an internal cause (2)
Prognosticks of the dislocated Vertebræ of the back (1)

Chapters on brain, head wounds, spine, and other neurologically related topics from the 1678 Workes, which is the first to show a clearly readable and well-organized table of contents.17 Public domain. There are more chapters devoted to neurologically related surgery, diagnosis, anatomy, applications, and treatments than to any other organ system.

Jousting was less widespread than in previous eras, but the 16th century still witnessed tournaments during which traumatic military-like injuries, although not the result of gunpowder-based weaponry, were commonplace. Significantly, Henri II, "he himself running in the Tilt-yard," was mortally wounded by a lance during the joust held to celebrate his daughter’s wedding to Philip II of Spain on June 30, 1559 (Fig. 3). As the king’s surgeon and the most distinguished surgeon in France, Paré led the early management of the case. However, the Duke of Savoy, Emmanuel Philibert, an ally of Philip II who was also present when Henri was injured, immediately summoned Andreas Vesalius. Vesalius was dispatched to take charge of Phillip II’s father-in-law and arrived in Paris on July 3. Vesalius’ reputation as the leading physician in Europe was reinforced by his attendance to Henri.

FIG. 3.
FIG. 3.
Lithograph showing Henri II on horseback struck by a lance, with persons running to his aid. Paré described the situation, including the autopsy and contrecoup manifestations of Henri’s injury:

[W]ith the famous and noble exercise of Tilting [jousting] … with a blunt lance [Henri] received so great a stroak upon his brest, that with the violence of the blow, the vizour of his Helmet flew up, and the truncheon of the broken Lance hit him above the left Eye-brow, and the musculous skin of the Fore-head was torn even to the lesser corner of the left Eye, many splinters of the same Trunchion being struck into the substance of the [left] Eye, the Bones being not touched or broken, but the Brain was so moved and shaken, that he died the eleventh day after the hurt. His Skull being opened after his death, there was a great deal of blood found between the Dura and Pia Mater, poured forth in the part opposite the blow, at the middle of the suture of the hind-part of the head; and there appeared signs, by the native colour turned yellow, that the substance of the Brain was corrupted […].13

Paré was grieved by the loss of Henri, who had treated him well. Paré immediately again became chirurgien ordinaire du Roi to François II, who reigned only 18 months and whose short term contributed to the demise of his young wife, Mary Queen of Scots. Apparently, Paré was friendly to the young queen and frequently conversed with her. Ironically, Gabriel de Lorges, Comte de Montgomery, captain of the King’s Scottish Guard, did not want to joust against Henri, who had already had several successful contests during the day. Montgomery did not fare well. He escaped to England, converted to Protestantism, was captured in France, and returned to Paris. There, in 1574, Catherine de Medici, blaming Montgomery for the death of her husband Henri, took satisfaction in watching him beheaded.2 The jousting match at the Hôtel des Tournelles in Paris in 1559, in which Henri II of France loses his life. Etching by J. Perrissin, ca. 1570. Wellcome Collection. Public domain.

Paré recorded the injury in a chapter entitled "Of the moving, or concussion of the Brain."13 "Besides the mentioned kinds of Fractures by which the Brain also suffers, there is another kind of affect besides Nature, which also assails it by the violent incursion of a cause in like manner external; they call it the commotion or shaking of the Brain, whence Symptoms like those of a broken skull ensue. Falling from aloft upon a solid and hard body, dull and heavy blows, as with Stones, Clubs, Staves, the report of a piece of Ordnance, or crack of Thunder, and also a blow with ones hand."13 The surgeons experimented, using the heads of 4 criminals who had recently been hanged, to determine the probable mechanism and location of the brain injury by driving in the butt of Henri’s lance.2,3 Both Paré and Vesalius recorded the autopsy findings of Henri, who died on July 10. There were minor discrepancies between the 2 accounts, but neither surgeon mentioned the other; it is surmised that Vesalius led the autopsy.

In Turin, Paré treated a case of skull base osteomyelitis after a servant experienced a sword injury to the left parietal bone without penetration to the inner table.14 Although the wound initially appeared to be healing, after several days, the servant suddenly developed fever and lost his speech and understanding. The patient’s face swelled and his eyes, red and inflamed, bulged out of his head. Relatively inexperienced with treating battlefield injuries at the time, Paré consulted other physicians and surgeons and followed their advice by bloodletting, massaging extremities, and administering clysters and medications. A few days later, the wound area swelled and drained pus when opened. Subsequently, the scalp and pericranium became depressed, "attaching to the edges of the bone which was exposed for about four inches."14 Both the inner and outer tables of the skull became black, rotten, and porous. In an attempt to control and separate the decayed part, Paré cauterized the damaged bone. About a month after the sword injury, Paré found 3 cavities on the dura mater that were filled with crawling worms. He removed the rotten bone, a piece about the size of the palm of a hand, and marveled that removing part of the skull did not lead to the patient’s death. After the wound healed, Paré noted that the scar was depressed, and he constructed a helmet of molded leather for the servant to wear to prevent further injury.14

In 1538, a young page of the late Marshal de Montejan was struck on the right parietal area by a stone while playing quoits; the blow resulted in a skull fracture and small loss of cortex. Seeing the brain tissue, Paré initially declared the wound fatal, at which "a young physician came up and argued vigorously against [Paré] saying this was not a piece of brain substance but a piece of fat." After dressing the page’s wound, Paré explained that, in his experience with dissections of dead bodies, he had never found fat in the skull. Rejecting Paré’s ideas, the physician agreed to Paré’s suggestion of a series of experiments with the tissue. If it was fat, it should float in water and melt in a hot pan. Contrarily, if it was brain tissue, it would sink in water and desiccate to the consistency of dry parchment before burning in a hot pan. Paré recorded that the experiments were performed and proved his argument. The patient recovered, although he was deaf after the accident. This case also delineates Paré’s evidence-based diagnostic method and demonstrates the experiential differences in medical education between physicians and barber-surgeons, especially with regard to practical anatomy. Paré meticulously depicted the brain and nerves of the head in his texts (Fig. 4).

FIG. 4.
FIG. 4.

Images of brain anatomy as depicted in Instrumenta chyrurgiae et icons anathomicae.30 Many anatomical images used by Paré, including these brain depictions, were adapted from Vesalius and are featured in his 1561 Anatomie universelle.26 After his first military employer and commander, Marshal de Montejan, died during the 1537 Turin campaign, Paré declined to stay with the army and returned to Paris to resume practice as a barber-surgeon. He also continued his anatomical studies, working with Sylvius (Jacques Dubois), the famed anatomist and lettered academician, who encouraged and promoted Paré’s work to the Faculty of Medicine. Paré became Sylvius’ prosector, performed public anatomical dissections, and taught at the Faculty of Medicine.3 A: Illustration of the brain with the dura mater intact. B: Illustration of the brain with the dura mater peeled. C: Illustration of a side view of the brain, cranial nerves, and spinal cord. D and E: Depictions of axial hemispheric exposures through the lateral ventricles. F: Illustration of the undersurface of the brain showing the brainstem, cerebellum, and cranial nerves. These are large-format colored images, whereas in earlier French editions of Oeuvres from 1585 and 162812,27 the brain images are smaller and uncolored. In the 1634 English edition of Workes, the translator, Thomas Johnson, stated that he substituted anatomical images of "Bauline" (possibly French-Swiss anatomist Gaspard Bauhin [1560–1624]): "The figures in the Anatomy are not the same used by my Author [Paré] (whose were according to those of Vesalius) but according to those of Bauline, which were used in the work of Dr. Crook; and these indeed are the better and more compleat."13 However, close examination reveals that the French brain illustrations are more similar to those of Vesalius and more accurate. Anatomy was central to Paré’s interests, and although he did not have an intimate knowledge of Latin, he knew Vesalius and his work, and Vesalius allowed Paré to use his 1543 Fabrica31 illustrations. Paré acknowledged the progressive anatomical contribution of Vesalius in his 1561 Anatomie universelle,26 but he better described the importance of Vesalius and anatomy in the earlier Oeuvres: "[T]he figures of Anatomy: most of which I have borrowed from Andre Vesal, a rare man, & the first of his time in this era of Medicine: which, for the reader’s convenience, [I have had] reduced to small plates, which with excessive expense, which I would consider well employed […]. Even so, I see, that among all things compared to the other parts of medicine, Anatomy is that which is more necessary, as well for Medicines [Physicians], as for Surgeons […]."27 All images: Instrumenta chyrurgiae et icones anathomicae/[Ambroise Paré]. Wellcome Collection. Public domain.

Paré was particularly concerned with traumatic brain injuries that required use of trepans (Fig. 5).13 Although not new, the use and indications of trepanning for in-driven cranial bone increased with the use of gunpowder weapons. Paré added a protective bar to his trepan, Chaperon, that was intended to reduce the potential harm caused by surgeons who lacked the skill and practice to use the trepan safely.12,13 Paré also frequently used the trepan for exploration when no fracture was obvious.13

FIG. 5.
FIG. 5.
At least 324 instruments, nearly 20% (63/324) related to surgery of the head and brain, were illustrated in Paré’s 1634 edition of Workes.13 Although not all the instruments were his original designs, Paré developed many and made improvements to instruments that already existed. The 1634 Workes chapter "A Description of Trepans" details the trepan and its application, and the chapters "Why we use Trepaning in the Fractures of the Skull" and "Of the places of the Skull whereto you may not apply a Trepan" include indications when to use and not use the technique.12,13 Recognizing that improper trepan technique could be disastrous, Paré developed his own trepan with a plunging guard, "piece de fer appellée Chaperon,"12 essentially an iron sleeve guard fitting over the circular cutter that could be depth adjusted:

But seeing there are many sorts of Trepans invented and expressed by many men, yet, if you weigh and rightly consider them all, you shall find none more safe, than that I invented and have here delineated. For it cannot pierce one jot further into the skull, than he pleases that uses it, and therefore it cannot hurt either the Meninges or the Brain. An iron head or cover, stays it as a bar, that it can penetrate no further than you shall think it requisite […] the Trepan [will] not go a hairs bredth beyond your intended depth. So that henceforwards there shall be no Chirurgeon, however ignorant in the performance of his Art, which by the benefit of such a Trepan may not perform this operation without any danger, or fear of danger, of touching the Dura Mater, the hurting whereof, puts life in jeopardy.13

Panels A and B show disassembled and assembled trepans from the 1628 edition of Oeuvres,12 with the Chaperon labeled B in panel A and D in panel B. Malgaigne32 showed clear illustrations of disassembled and assembled trepans, with the Chaperon labeled B in panel C (with close-up [labeled E and F] of the in-place Chaperon) and D in panel D (with close-up [labeled H at the top and G at the bottom] of the in-place Chaperon). These illustrations also demonstrate the variations in illustrations in later editions of Paré’s Workes and Oeuvres. Public domain.

Paré used the trepanning technique many times on the battlefield with great success. In the winter of 1552–1553, he was sent to Metz, in northeastern France, to treat French army soldiers who were defending the city from Spanish troops led by Charles V (Fig. 6). Paré’s access to Metz through hostile lines was facilitated by bribery and secrecy. Henri II specially requested Paré, and several French marshals paid an Italian captain 1500 crowns to get Paré safely into Metz.1,2,13 The town seigneurs asked Paré to provide special care to Monsieur de Pienne, who had been wounded in the temple by a stone cannonball that had caused a depressed skull fracture. As the seigneurs explained, the patient had bled from the mouth, nose, and ears; had developed spasmodic tremors; and had lost the ability to speak or reason for 2 weeks. The patient was successfully trepanned over the frontal bone and survived.1,18

FIG. 6.
FIG. 6.

A photogravure of the siege of Metz, France, by Théobald Chartran (1889), incorporating significant symbolism. Within the battlements and next to the cathedral in Metz, Paré stems the flow from a bleeding artery while performing an amputation during the siege of the winter of 1552–1553. In a logical place for surgery—partially under a portico, but with light and near a water source—Paré, with rolled up sleeves, has 3 assistants: to his right, a man intently watches, probably handing him surgical instruments; a hooded man comforts and steadies the soldier; and another young man kneels at a bowl on the ground, rinsing out bloody cloths with water from the fountain, to be used again. A priest performs last rites as dark, ghastly hooded figures, expecting a death, stand behind the cross held high. Wounded soldiers treated by Paré, including a recent left leg amputee, look on in the foreground. A soldier brings straw for the wounded soldiers to lie on, while the battle rages in the background. A lion with a shield watches atop the fountain, perhaps symbolic of the king, as if to lend Paré his full authority. Paré records that the reason for so many injured dying at Metz was at first believed to be poisoned drugs, "for they [the princes and king] beleeved theirs were poysoned, seeing that of their hurt people few escaped. I doe not beleeve there was any poyson, but the great stroakes of the Cutlasses, Musket shot, and the extremity of cold were the cause."13 One can only imagine this horrific scene played out repeatedly as Paré faithfully and determinably attended to the injured. Ambroise Paré using a ligature on an artery of an amputated leg of a soldier, during the Siege of Metz, 1553. Photogravure after T. Chartran, 1889. Wellcome Collection. Public domain.

At Rouen in 1562, Paré recorded that in a single day "I Trepaned eight or nine, who were hurt at the breach with the stroakes of stones."13 The management and surgery of each of these cases probably lasted at least an hour, likely much longer, and Paré was surely busy managing other injury cases as well as supervising assistants. His discourse that surgery is defined by "the quicke motion of an intrepide hand joined with experience" lends insightful perspective.13

Functional Recovery

Paré interacted with a wide range of artisans, including locksmiths, clockmakers, blacksmiths, and gunsmiths who typically accompanied a 16th-century army. Exchanging knowledge and skills, Paré collaborated with them to design mechanized prostheses.19 Ironically, the same community of artisans who produced finely articulated weaponry also made surgical instruments to heal injuries caused by such weaponry.20 This network of metalwork, injuries, and healing led to frequent developmental interactions among surgeons and artisans.21

Paré’s experience and anatomical knowledge led to improved functionality of prostheses: "Necessity oftentimes constrains us to find out the means whereby we may help and imitate Nature, and supply the defect of members that are perished and lost. And hereof it cometh that we may perform the functions of going, standing and handling with Arms and Hands made by Art, and undergo our necessary flexions and extensions with bothe of them" (Fig. 7).13 His design for a mechanical hand included a button that activated multiple catches and springs, allowing fingers to flex and extend (Fig. 7A).11,22 For artificial legs, Paré designed the movements of standing and bending with a mechanical knee that could be locked (Fig. 7B). Such movements could be seen on the battlefield when soldiers knelt on one knee to support the weight of firing a heavy musket. The prosthetics that Paré designed were often laced and strapped to armor (Fig. 7C).22

FIG. 7.
FIG. 7.

During the brutal winters of the Italian Wars, especially during the siege of Metz, Paré reported that many frozen limbs, most of which had also been injured, had to be amputated. Paré noted that there were many injuries that, although they did not require amputation, produced limbs or hands that were nonfunctional because of injuries to nerves and tendons. Some of his designs of prosthetics consisted of gears and triggers, imitating locking joints and bending limbs. Only once did Paré mention the name of an artisan, who collaborated in the design of a prosthetic hand: "I have gotten the forms of all those members made so by Art, and the proper names of all the Engines and Instruments whereby those artificially made are called, to my great cost and charges, of a most ingenious and excellent Smith dwelling at Paris, who is called of those that know him, and also of strangers, by no other name than the Little Lorain […]."13 He appears to have financed many of these developments himself, or they may have been compensated through royal funding. A and B: The 1628 edition of Oeuvres12 describes the components and operation of the hand (A) and leg (B) prosthetics illustrated here. In the subsequent English editions of Paré’s Workes, translator Thomas Johnson incorporated commentary and text that deviated from the original French versions, including eliminating illustration legends, such as those shown with the prosthetics in these illustrations. So many inaccuracies crept into Paré’s texts that the French surgeon, medical historian, and promoter of accurate analysis in medicine Joseph-François Malgaigne returned to Paré’s records and original manuscripts to publish, in 1840, what is regarded as the most accurate re-edition, with clear illustrations of Paré’s collected works.32 C: Recognizing that cosmesis is important to people with physical abnormalities, who were regarded as inferior, Paré wrote: "[Prosthetics] are not onely profitable for the necessity of the body, but also for the decency and comeliness thereof."13 Note also that Paré’s prosthetics were designed so that they were available in different versions according to economic status: "Figure d’une iambe [jambe] de bois pour le pauvres [Figure of a leg made of wood for the poor]."12 Public domain.

Paré believed there might be suitable alternative solutions to amputation. A "General of the French Horseman" came to him who had received a crippling cutlass injury to the wrist and hand tendon that resulted in loss of his dominant thumb function. "Wherefore he consulted me about the cutting away of his Thumb, which did hinder his griping, which I refused to do, and told him that I conceived a means how it might be remedied without cutting away."13 Paré had a simple yet highly effective tin sleeve with lanyards created for the hand and thumb that allowed holding and control of a weapon or horse reins.

Phantom limb pain was described by Paré during his work with amputees.13,23 In 1551, Paré wrote, "Verily it is a thing wondrous strange and prodigious, and which will scarce be credited, unless by such as have seen with their eyes, and heard with their ears the Patients who have many months after the cutting away of the Leg, grievously complained that they yet felt exceedingly great pain of that leg cut off."13 He believed that this phantom sensation occurred in the brain and was not attributable to remnants of the limb.

To correct spinal deformities, such as scoliosis, Paré, likely in collaboration with armorers, designed an iron torso brace, "full of holes […] whereby they may be lighter to wear."13 He wrote that the spinal brace should be "lined with bombaste [cotton or soft cloth] that they may hurt not place of the body."13 The cotton doublet was worn underneath armor as padding to secure the fitting of the armor and prevent chafing. Although doublets were uncomfortable for soldiers because they retained heat, they allowed the soldier to be more comfortable when wearing the brace.

Conclusions

On December 20, 1590, Paré died at age 80 years at his home in Paris and was buried in his church, St. André-des-Arts.14,24 He was remembered as a "[S]urgeon to the king […] a learned man and the chief of his art; who, in spite of his times, had always talked and talked freely for peace and for the good of the people…."25

Ambroise Paré, a contemporary of Vesalius, Paracelsus, Luther, Erasmus, Knox, Calvin, Titian, and Raphael, was born into a revolutionary period that included evolving battlefield technology. In a life filled with adventure, serving in what were often horrendous situations and during a time when Galenic dogma still dominated medical practice, he developed a reputation for logic, empiricism, technological innovation, and thoughtful treatment. He ingeniously contributed to the development of many surgical specialties, importantly including the management of neurological trauma and the restoration of functionality. His texts reveal that he taught others his techniques and that they were readily adopted. A deeply religious man, Paré’s heartfelt admonition concerning being a surgeon remains relevant:

[F]or all days encourage the young students in surgery, to which [my] written messages are addressed. And none the less, [in spite of] all the pains that I have taken here before, I have the opportunity to praise God, for what he called me to do in medical operation, which is commonly called surgery, which could not be bought with gold or silver, but by only virtue and great experimentation. And all the time this is the same in all countries: unless the laws of the Faculty of Medicine are not subject to those of the Kings, & other Lords, nor has prescribed time, as taking its origins from God, who begs him to embrace this undertaking of mine, so that he will be eternally glorified. So be it.12

Acknowledgments

M.T.P. is currently a medical student at Creighton University School of Medicine, Phoenix, Arizona. The authors thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

Disclosures

This study was supported by funds from the Newsome Chair of Neurosurgery Research held by Dr. Preul from the Barrow Neurological Foundation.

Author Contributions

Conception and design: Preul, Park. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: Park, Houlihan. Critically revising the article: Preul. Reviewed submitted version of manuscript: Preul, Park. Study supervision: Preul.

Supplemental Information

Videos

Video Abstract. https://vimeo.com/737902736.

References

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    Doe J. A Bibliography of the Works of Ambroise Paré:. Premier Chirurgien & Conseiller Du Roy (No. 4). University of Chicago Press; 1937.

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    Paré A. La methode de traicter les playes faictes par hacqvebvtes et avltres bastons à feu: et de celles qui sont faictes par fleches, dardz, et semblables: aussy des combustions specialement faictes par la pouldre à canon,. Composée par Ambroyse Paré maistre Barbier, Chirurgien à Paris. Vivant Gaulterot; 1545.

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Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

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    A: An image of Paré at 45 years of age, as he was achieving notoriety, from a copper engraving in his Anatomie universelle.26 This image is from the copy of Anatomie universelle bequeathed by William Osler to the Faculte de Medicine, Paris. Osler made the bequest because he was concerned that no good copy of the book existed in Paris. Public domain. B: An image originally from Paré’s 1585 Oeuvres27 (published in 1641 Oeuvres28) shows him at 75 years of age. During the siege of Paris in 1590, an intimate and revealing assessment of Paré, who was only months away from his death, was recorded by a journalist who described a meeting between Paré and the Archbishop of Lyons during those turbulent days:

    I remember that about eight or ten days at most before raising of the siege, [the Archbishop] found himself besieged by a crowd of mean people, dying of hunger, who cried to him, demanding bread or death, and he not knowing how to dispatch them, encountered Master Ambroise Paré, who said loudly to him, ‘Monsiegneur, these poor people whom you see here about you are dying of the cruel rage of hunger, and demand pity of you. For God’s sake, Monsieur, give it to them, if you would have God countenance you, and think a little of the dignity in which God has placed you, and that the cries of these poor people which mount to Heaven, are a warning that God sends you […] for which you are responsible to Him. Therefore, according to this, and by the power which we all know that you have, procure us peace, and give us wherewith to live, because the poor people can no longer do so.’ [The] Archbishop […] contrary to his custom he was patient to hear [Paré] out without interruption, and he said afterwards that this good man had altogether astonished him; and again that this was a different sort of politics than his own, but that he had awakened him and made him think of many things.25

    Public domain. C: Dramatic lithograph by Mouilleron after Robert-Fleury of Paré, who is shown writing at his desk with his hand on a skull. A bone saw hangs behind him, a trepan is on the table, and medicinal materials and what appear to be unique anatomical specimens that Paré is known to have kept are in jars on shelves in the background. Two somewhat ragged, leather-covered books are on the floor, touching the butt of a heavy musket, perhaps representing Paré’s personal records or diaries of his battlefield medical encounters. A helmet, connoting his military experiences, is placed at the center, on the table. Ambroise Paré. Lithograph by Mouilleron after Robert-Fleury. Wellcome Collection. Public domain.
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    A: The title page from the 1617 English translation (The Method of Curing Wounds Made by Gunshot. Also by Arrowes and Darts, with their Accidents29) of Paré’s first book, on the treatment of gunshot wounds.11 The translator, Walter Hamond, had been trained in the tradition of the barber-surgeon, was an explorer and ship’s surgeon, and was a student of the English surgeon Arthur Doughton, who became the warden of the Company of Barbers of London in 1632. The "wound man" shows injuries caused by not only cutting and piercing weapons but also round projectiles from gunpowder weapons. Courtesy of the Medical Historical Library, Harvey Cushing/John Hay Whitney Medical Library, Yale University. Public domain. B: Title page from the first (1634) English edition of Paré’s Workes.13 By the advent of this compendium, Paré had been deceased for 44 years, yet his influence was obvious. Important elements of his career and contributions were represented on the title page. The upper left shows Paré trepanning the skull of a patient, supported by what appears to be a young trainee. In the same scene, the heritage of the barber-surgeon is represented by a man who is having his hair cut or being examined within the barber-surgeon’s room. Paré’s novel surgical instruments are depicted in the background. The portrait shows Paré at age 75 (see Fig. 1B). On the top right, Paré records his experiences, while behind him are jars of what are likely elements to make drugs or other medical pharmaceutical applications. The title in the center middle is flanked by anatomical illustrations hearkening to Vesalius. The bottom left shows the distillation and heat studies of Paré. In the bottom middle are various surgical instruments, including suture material, and on the bottom right are images of Paré’s text describing "monsters" (i.e., human abnormalities). Public domain.

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    Lithograph showing Henri II on horseback struck by a lance, with persons running to his aid. Paré described the situation, including the autopsy and contrecoup manifestations of Henri’s injury:

    [W]ith the famous and noble exercise of Tilting [jousting] … with a blunt lance [Henri] received so great a stroak upon his brest, that with the violence of the blow, the vizour of his Helmet flew up, and the truncheon of the broken Lance hit him above the left Eye-brow, and the musculous skin of the Fore-head was torn even to the lesser corner of the left Eye, many splinters of the same Trunchion being struck into the substance of the [left] Eye, the Bones being not touched or broken, but the Brain was so moved and shaken, that he died the eleventh day after the hurt. His Skull being opened after his death, there was a great deal of blood found between the Dura and Pia Mater, poured forth in the part opposite the blow, at the middle of the suture of the hind-part of the head; and there appeared signs, by the native colour turned yellow, that the substance of the Brain was corrupted […].13

    Paré was grieved by the loss of Henri, who had treated him well. Paré immediately again became chirurgien ordinaire du Roi to François II, who reigned only 18 months and whose short term contributed to the demise of his young wife, Mary Queen of Scots. Apparently, Paré was friendly to the young queen and frequently conversed with her. Ironically, Gabriel de Lorges, Comte de Montgomery, captain of the King’s Scottish Guard, did not want to joust against Henri, who had already had several successful contests during the day. Montgomery did not fare well. He escaped to England, converted to Protestantism, was captured in France, and returned to Paris. There, in 1574, Catherine de Medici, blaming Montgomery for the death of her husband Henri, took satisfaction in watching him beheaded.2 The jousting match at the Hôtel des Tournelles in Paris in 1559, in which Henri II of France loses his life. Etching by J. Perrissin, ca. 1570. Wellcome Collection. Public domain.
  • View in gallery

    Images of brain anatomy as depicted in Instrumenta chyrurgiae et icons anathomicae.30 Many anatomical images used by Paré, including these brain depictions, were adapted from Vesalius and are featured in his 1561 Anatomie universelle.26 After his first military employer and commander, Marshal de Montejan, died during the 1537 Turin campaign, Paré declined to stay with the army and returned to Paris to resume practice as a barber-surgeon. He also continued his anatomical studies, working with Sylvius (Jacques Dubois), the famed anatomist and lettered academician, who encouraged and promoted Paré’s work to the Faculty of Medicine. Paré became Sylvius’ prosector, performed public anatomical dissections, and taught at the Faculty of Medicine.3 A: Illustration of the brain with the dura mater intact. B: Illustration of the brain with the dura mater peeled. C: Illustration of a side view of the brain, cranial nerves, and spinal cord. D and E: Depictions of axial hemispheric exposures through the lateral ventricles. F: Illustration of the undersurface of the brain showing the brainstem, cerebellum, and cranial nerves. These are large-format colored images, whereas in earlier French editions of Oeuvres from 1585 and 162812,27 the brain images are smaller and uncolored. In the 1634 English edition of Workes, the translator, Thomas Johnson, stated that he substituted anatomical images of "Bauline" (possibly French-Swiss anatomist Gaspard Bauhin [1560–1624]): "The figures in the Anatomy are not the same used by my Author [Paré] (whose were according to those of Vesalius) but according to those of Bauline, which were used in the work of Dr. Crook; and these indeed are the better and more compleat."13 However, close examination reveals that the French brain illustrations are more similar to those of Vesalius and more accurate. Anatomy was central to Paré’s interests, and although he did not have an intimate knowledge of Latin, he knew Vesalius and his work, and Vesalius allowed Paré to use his 1543 Fabrica31 illustrations. Paré acknowledged the progressive anatomical contribution of Vesalius in his 1561 Anatomie universelle,26 but he better described the importance of Vesalius and anatomy in the earlier Oeuvres: "[T]he figures of Anatomy: most of which I have borrowed from Andre Vesal, a rare man, & the first of his time in this era of Medicine: which, for the reader’s convenience, [I have had] reduced to small plates, which with excessive expense, which I would consider well employed […]. Even so, I see, that among all things compared to the other parts of medicine, Anatomy is that which is more necessary, as well for Medicines [Physicians], as for Surgeons […]."27 All images: Instrumenta chyrurgiae et icones anathomicae/[Ambroise Paré]. Wellcome Collection. Public domain.

  • View in gallery
    At least 324 instruments, nearly 20% (63/324) related to surgery of the head and brain, were illustrated in Paré’s 1634 edition of Workes.13 Although not all the instruments were his original designs, Paré developed many and made improvements to instruments that already existed. The 1634 Workes chapter "A Description of Trepans" details the trepan and its application, and the chapters "Why we use Trepaning in the Fractures of the Skull" and "Of the places of the Skull whereto you may not apply a Trepan" include indications when to use and not use the technique.12,13 Recognizing that improper trepan technique could be disastrous, Paré developed his own trepan with a plunging guard, "piece de fer appellée Chaperon,"12 essentially an iron sleeve guard fitting over the circular cutter that could be depth adjusted:

    But seeing there are many sorts of Trepans invented and expressed by many men, yet, if you weigh and rightly consider them all, you shall find none more safe, than that I invented and have here delineated. For it cannot pierce one jot further into the skull, than he pleases that uses it, and therefore it cannot hurt either the Meninges or the Brain. An iron head or cover, stays it as a bar, that it can penetrate no further than you shall think it requisite […] the Trepan [will] not go a hairs bredth beyond your intended depth. So that henceforwards there shall be no Chirurgeon, however ignorant in the performance of his Art, which by the benefit of such a Trepan may not perform this operation without any danger, or fear of danger, of touching the Dura Mater, the hurting whereof, puts life in jeopardy.13

    Panels A and B show disassembled and assembled trepans from the 1628 edition of Oeuvres,12 with the Chaperon labeled B in panel A and D in panel B. Malgaigne32 showed clear illustrations of disassembled and assembled trepans, with the Chaperon labeled B in panel C (with close-up [labeled E and F] of the in-place Chaperon) and D in panel D (with close-up [labeled H at the top and G at the bottom] of the in-place Chaperon). These illustrations also demonstrate the variations in illustrations in later editions of Paré’s Workes and Oeuvres. Public domain.

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    A photogravure of the siege of Metz, France, by Théobald Chartran (1889), incorporating significant symbolism. Within the battlements and next to the cathedral in Metz, Paré stems the flow from a bleeding artery while performing an amputation during the siege of the winter of 1552–1553. In a logical place for surgery—partially under a portico, but with light and near a water source—Paré, with rolled up sleeves, has 3 assistants: to his right, a man intently watches, probably handing him surgical instruments; a hooded man comforts and steadies the soldier; and another young man kneels at a bowl on the ground, rinsing out bloody cloths with water from the fountain, to be used again. A priest performs last rites as dark, ghastly hooded figures, expecting a death, stand behind the cross held high. Wounded soldiers treated by Paré, including a recent left leg amputee, look on in the foreground. A soldier brings straw for the wounded soldiers to lie on, while the battle rages in the background. A lion with a shield watches atop the fountain, perhaps symbolic of the king, as if to lend Paré his full authority. Paré records that the reason for so many injured dying at Metz was at first believed to be poisoned drugs, "for they [the princes and king] beleeved theirs were poysoned, seeing that of their hurt people few escaped. I doe not beleeve there was any poyson, but the great stroakes of the Cutlasses, Musket shot, and the extremity of cold were the cause."13 One can only imagine this horrific scene played out repeatedly as Paré faithfully and determinably attended to the injured. Ambroise Paré using a ligature on an artery of an amputated leg of a soldier, during the Siege of Metz, 1553. Photogravure after T. Chartran, 1889. Wellcome Collection. Public domain.

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    During the brutal winters of the Italian Wars, especially during the siege of Metz, Paré reported that many frozen limbs, most of which had also been injured, had to be amputated. Paré noted that there were many injuries that, although they did not require amputation, produced limbs or hands that were nonfunctional because of injuries to nerves and tendons. Some of his designs of prosthetics consisted of gears and triggers, imitating locking joints and bending limbs. Only once did Paré mention the name of an artisan, who collaborated in the design of a prosthetic hand: "I have gotten the forms of all those members made so by Art, and the proper names of all the Engines and Instruments whereby those artificially made are called, to my great cost and charges, of a most ingenious and excellent Smith dwelling at Paris, who is called of those that know him, and also of strangers, by no other name than the Little Lorain […]."13 He appears to have financed many of these developments himself, or they may have been compensated through royal funding. A and B: The 1628 edition of Oeuvres12 describes the components and operation of the hand (A) and leg (B) prosthetics illustrated here. In the subsequent English editions of Paré’s Workes, translator Thomas Johnson incorporated commentary and text that deviated from the original French versions, including eliminating illustration legends, such as those shown with the prosthetics in these illustrations. So many inaccuracies crept into Paré’s texts that the French surgeon, medical historian, and promoter of accurate analysis in medicine Joseph-François Malgaigne returned to Paré’s records and original manuscripts to publish, in 1840, what is regarded as the most accurate re-edition, with clear illustrations of Paré’s collected works.32 C: Recognizing that cosmesis is important to people with physical abnormalities, who were regarded as inferior, Paré wrote: "[Prosthetics] are not onely profitable for the necessity of the body, but also for the decency and comeliness thereof."13 Note also that Paré’s prosthetics were designed so that they were available in different versions according to economic status: "Figure d’une iambe [jambe] de bois pour le pauvres [Figure of a leg made of wood for the poor]."12 Public domain.

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  • 11

    Paré A. La methode de traicter les playes faictes par hacqvebvtes et avltres bastons à feu: et de celles qui sont faictes par fleches, dardz, et semblables: aussy des combustions specialement faictes par la pouldre à canon,. Composée par Ambroyse Paré maistre Barbier, Chirurgien à Paris. Vivant Gaulterot; 1545.

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    Dumaître P. Ambroise Paré, his death and his historians. Article in French. Hist Sci Med. 2001; 35(3):281298.

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    de L’Estoile P. Memoires-journaux de Pierre de L’Estoile. Tome quatrieme 1589-1600. Librarie des Bibliophiles; 1878.

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  • 28

    Paré A. Les oeuvres d’Ambroise Paré. Chez Claude Prost; 1641.

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    Paré A. The Method of Curing Wounds Made by Gunshot. Also by Arrowes and Darts, with their Accidents. Isaac Laggard; 1617.

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    Paré A. Instrumenta chyrurgiae et icons anathomicae. Paris; 1564.

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