J R Soc Med 2004;97:446-449
doi:10.1258/jrsm.97.9.446
© 2004 Royal Society of Medicine
'Proper to the duty of a chirurgeon': Ambroise Paré and sixteenth century paediatric surgery
A N Williams MSc MRCP
J Williams BA RGN
Child Development Centre, Northampton General Hospital, Northampton NN1
5BD, UK
Correspondence to: Dr A N Williams E-mail:
anw{at}doctors.org.uk
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INTRODUCTION
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Ambroise Paré rose from humble origins to become surgeon
to four
kings of France. Though he is remembered mainly for
his work as a military
surgeon and for his advocacy of podalic
version, his contribution to surgery
was far greater than
this.
1 In France his
works were a mainstay of surgical practice for
250 years. To illustrate his
contributions to paediatric surgery
we have translated excerpts from the 1849
facsimile copy of
his
Oeuvres of
1585,
2 particularly
the seventeenth book which
deals with the means and artificial devices used to
treat those
who have natural defects or defects caused by an accident. We
also
borrow from the posthumous English translation by Thomas
Johnson, 1633, edited
in the 1950s by Geoffrey
Keynes.
3
Paré's aim was to raise the reputation of surgery to honour and
esteem. He wrote:
'Five things are proper to the dutie of a chirurgeon. To take away
that which is superfluous, to restore to their places such things as are
displaced, to separate those things which are joined together, to joyne that
which is divided, and to supply the defects of
nature.'3
From a time when paediatric surgery was still in its infancy and there was
little other recorded writing in this area, Paré's works give an
insight into what was surgically possible in the sixteenth century.
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TO TAKE AWAY THAT WHICH IS SUPERFLUOUS
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In 1545 Paré had proposed pincers for trimming broken
bones in hands
mutilated by ball and chain; and in the second
edition (1552) he recommends
the same technique for removal
of superfluous digits in the young:
'Fleshy digits can be easily
amputated, cutting with a razor all that is
superfluous. Bones
could be cut with "cutting pincers"'. The
pincers (
Figure 1)
could also
be used for chronic inflammation of the finger (the
concept of infection was
unknown at that time).
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TO RESTORE TO THEIR PLACES SUCH THINGS AS ARE DISPLACED
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Club foot
In a chapter entitled 'The defect in the legs called varus and
valgus...'
Paré relates his understanding and management of these
deformities
of the feet. He speculates that the condition is caused prenatally
by
the mother sitting with her legs crossed or postnatally by the
mother
holding the child with its feet pressed inward. Following
Hippocrates he
emphasizes restoration to the natural anatomical
position, with bandages in
the first instance. However, Paré
goes beyond this treatment by
devising special orthopaedic boots:
'... one must not make varus and valgus children walk until the joints
are well strengthened, so that they do not dislocate. And when one wants to
make the children walk, one should split open some high shoes, little half
boots, and laced up at the front, or fastened by little hooks: they should be
of hard leather so as always to keep the bones firmly on the joints, and so
that they have to stay there. And the sole must be higher than the side where
the malformation will be inclined to turn, in order to force it to turn back
to the necessary side'.
The boot (Figure 2), with
its wedged sole, was softened with turpentine. Paré does not advocate
surgical treatment, and the success rate with his boot is unlikely to have
been high. Today, even in the best hands, conservative management of talipes
equinovarus through stretching and strapping achieves a lasting correction in
only one-third of cases, the remainder requiring
surgery.4
Scoliosis
Paré's seventeenth book includes a treatise on scoliosis in
which he recognizes the female preponderance. He was the first to describe
congenital scoliosis, but in cases of later onset he included among probable
causes trauma, poor posture, and in girls the use of bodices and the
requirement to
curtsey.5
For adults with scoliosis he recommended the Hippocratic treatment
involving forcible horizontal
traction,5 but for
children he was the first to prescribe iron corsets:
'... they should wear fine iron corsets with holes in so that they are
not too heavy, and they will be so well fitted and padded that they will not
cause any injury. They would be changed often if the invalid does not achieve
the three dimensions. And for those girls who grow, it would have to be
changed every three months, more or less as necessary: for otherwise, instead
of doing good, it would do harm'.
Paré's corset (Figure
3) remained in use for over a century. In our own time it is well
recognized that, if the scoliosis is already severe when diagnosed, bracing
will be
ineffective.6
Dislocation of the hip
Paré recognized that hip dislocation could be caused not only by
external forces but also by defects in the structures of the joints. He does
not recommend a specific treatment for children but comments that, if the
bones are easily dislocated, they can be 'easily restored without the
assistance of a
surgeon'.1
Strabismus
Strabismus (squint) affects 4% of children under 6 years of age and leads
to amblyopia in one-third or more. Paré's speculations on the
origin of this condition include positioning the infant's cot in the
light and also the child imitating his cross-eyed nurse, and he recommends a
face mask be held in place by strings, well fitted to prevent daylight
entering through gaps (Figure
4):
'Such a face mask would have only two small holes where the pupils
are, to allow light in. This would mean that the child only sees light through
these holes, would only look straight ahead, so that the eyes would become
accustomed to staying straight and still, and this would become the normal
habit rather than looking to the side'.
An alternative method used spectacles
(Figure 5).
'Instead of this mask, one could similarly make spectacles from horn,
which would be moulded onto leather and placed over the eyes. In the middle
would be a little hole through which the child would see and therefore correct
the problem'.
These were not true innovations in ophthalmology; strabismus masks had been
used before. However, in adults Paré was the first to describe the use
of glass eyes.7
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TO SEPARATE THOSE THINGS WHICH ARE JOINED TOGETHER
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In the chapter of the fifteenth book discussing superfluous
fingers
Paré also deals with fingers fused through accident
(usually a burn) or
by nature:
'If the surgeon knew that there was little thickness, having only the
thickened skin and very little flesh holding them together and attaching them
to each other, they could be easily separated with a sharp blade; on the
contrary, if they more significantly joined so that the tendons and the nerves
were joined together, the surgeon should not touch them'.
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TO JOYNE THAT WHICH IS DIVIDED
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Hare lip
Together with cleft palate, hare lip is the most common congenital
abnormality
in the head and neck area, with an incidence of about 1 in 7000.
Paré's
method for repair of simple hare lip is as follows:
'This method of suturing is used on lips and also necessary for lips
split from birth through a failure of the vertical formation. This suturing
would have no effect if there was thick hard skin between the lips. Therefore
there is a need to cut everything, otherwise there would be no healing. Other
methods of suturing are of little use with such wounds, because the areas are
mobile, through both chewing and talking. Consequently the thread would cut
through the flesh: and, again for this reason, the needles must take in much
flesh as in the figure' [Figure
6].
Today hare lip is usually repaired at 3 months of age, with a wide variety
of techniques.
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TO SUPPLY THE DEFECTS OF NATURE
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Artificial ear
Paré described an artificial ear for use in managing
congenital
defects or ears damaged by animal bites or infection:
'... where the ear might have been completely amputated, one would
attach an artificial ear made of glued paper or boiled leather shaped with
good grace as in the illustration [Figure
7]. And this would be held with straps around the head or the
patient would let his hair grow long or wear a skull cap'.
This artificial pinna might have been effective in aiding vertical
localization of sound in users with good high-frequency
hearing.8
Artificial nipple
Though a strong advocate of breastfeeding, Paré cites Galen's
dictum that infants should be breastfed only 'for as long as one knows
that the nurse has enough to feed the child as he grows'. He recognized
that breastfeeding can be painful, especially when the infant acquires teeth,
and to allow continued feeding by a woman with an ulcer he devised a nipple
shield made of lead, with small holes for passage of the milk. The inside of
the shield is polished to promote healing of the ulcer.
The dangers of exposing infants to lead were not, of course, appreciated in
Paré's time.
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FINAL DUTY OF A CHIRURGIEN
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Paré's surgical practice does not end with the death
of his
patient. In his book
How to Make Reports he lists the
features he
finds useful in distinguishing between natural and
suspicious death:
'For if the infant were in good health before, if he were not froward
or crying, if his mouth and nosethrills now being dead, be moystned or bedewed
with a certaine foame, if his face be not pale but of a Violet and purple
colour: if when the body is opened the Lungs be found swolne and puffed up, as
it were with certain vaporous foame and all the other entralls sound, it is a
token that the infant was stifled, smothered or strangled by some outward
violence'.
Nevertheless, in his practice Paré records the history and necropsy
of an infant who had died unexpectedly in whom he was unable to determine a
cause of death. He concluded that it was due to teething. Later Paré
counsels that when a pregnant woman dies the necropsy should always include
the fetus, 'for he meriteth farre greater punishment, who hath killed a
child perfectly shaped, and made in all the members: that is he which hath
killed a live childe, than he which hath killed an embryon, that is a certaine
concretion of the spermaticke
body'.3
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CONCLUSION
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Many surgical subspecialties regard Paré as their founding
father.
The written works are a monument to his integrity, honesty
and courage in
dealing with cases that even today would be challenging.
It is extraordinary
that, in an era before Harvey, anaesthesia,
and the understanding of sepsis,
Paré was able to practise
such a wide range of treatments with a
measure of success.
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Acknowledgments
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We thank Dr Michelle Dominic and Dr Margaret Holloway for advice
and the
Postgraduate Library, Northampton General Hospital and
the Centre for
Medicine, University of Birmingham, for support.
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REFERENCES
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|---|
- Dunn PM. Ambroise Paré (1510–1590): surgeon and
obstetrician of the Renaissance. Arch Dis Child1994; 71:F231
-2
- Paré A. Oeuvres Complètes.
Geneva: Slatkine, 1970
- Keynes G. The Apologie and Treatise of Ambroise
Paré. London: Falcon Educational,1951
- Fixsen J, Lloyd-Roberts G. The Foot in
Childhood. London: Churchill Livingstone,1988
- Moe J. Historical aspects of scoliosis. In: Bradford DS, Lonstein
JE, Moe JH, Ogilvie JW, Winter RB, eds. Moe's Textbook of
Scoliosis and Other Spinal Deformities. Philadelphia: WB
Saunders, 1987: I
- Le Vay. The History of Orthopaedics.
Carnforth: Parthenon, 1990
- Edwards DD. Ophthalmology in the Middle Ages and Renaissance. In:
Albert DM, Edwards DD, eds. The History of
Ophthalmology. Oxford: Blackwell Science, 1996:44
- Byrne D, Sinclair S, Noble W. Open earmold fittings for improving
aided auditory localization for sensorineural hearing losses with good
high-frequency hearing. Ear Hear1998; 19:62
-71[Medline]
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INTRODUCTION
TO TAKE AWAY THAT...
