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Ambroise Paré: His Contribution to the Future Advancement of Neurosurgery and the Hardships of His Times Affecting His Life and Brilliant Career
Journal Pre-proof Ambroise Paré: His contribution to the future advancement of neurosurgery and the hardships of his times affecting his life and brilliant career Bruno Splavski, Krešimir Rotim, Frederick A. Boop, Andrew J. Gienapp, Kenan I. Arnautović PII:
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Please cite this article as: Splavski B, Rotim K, Boop FA, Gienapp AJ, Arnautović KI, Ambroise Paré: His contribution to the future advancement of neurosurgery and the hardships of his times affecting his life and brilliant career, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.10.187. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
TITLE: Ambroise Paré: His contribution to the future advancement of neurosurgery and the hardships of his times affecting his life and brilliant career AUTHORS AND AFFILIATIONS: Bruno Splavski1-3; Krešimir Rotim1,2,4; Frederick A. Boop5-7; Andrew J. Gienapp5,7; Kenan I. Arnautović5,6 1. Department of Neurosurgery, Sisters of Mercy University Hospital Center, Zagreb, Croatia 2. Osijek University School of Medicine, Osijek, Croatia 3. Osijek University School of Dental Medicine and Health, Osijek, Croatia 4. University of Applied Health Sciences, Zagreb, Croatia 5. Semmes Murphey Clinic, Memphis, TN, United States 6. Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States 7. Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, TN, United States
CORRESPONDING AUTHOR: Kenan I. Arnautovic, MD, PhD Semmes-Murphey Clinic 6325 Humphreys Blvd Memphis, TN 38120 Phone: (901) 522-7700 Fax: (901) 522-2600 e-mail: [email protected]
ACADEMIC DEGREES: Bruno Splavski, MD, PhD; Krešimir Rotim, MD, PhD; Frederick A. Boop, MD; Andrew J. Gienapp, BA; Kenan I. Arnautović, MD, PhD
KEY WORDS: Ambroise Paré; History; Neurosurgery; 16th Century France
RUNNING TITLE: Ambroise Paré: His life, hardships, career, and influence on neurosurgery
ABBREVIATIONS: No abbreviations in the manuscript
1
TITLE: Ambroise Paré: His contribution to the future advancement of neurosurgery and the
2
hardships of his times affecting his life and brilliant career
3 4
AUTHORS AND AFFILIATIONS: Bruno Splavski1-3; Krešimir Rotim1,2,4; Frederick A.
5
Boop5-7; Andrew J. Gienapp5,7; Kenan I. Arnautović5,6
6 7
1. Department of Neurosurgery, Sisters of Mercy University Hospital Center, Zagreb, Croatia
8
2. Osijek University School of Medicine, Osijek, Croatia
9
3. Osijek University School of Dental Medicine and Health, Osijek, Croatia
10
4. University of Applied Health Sciences, Zagreb, Croatia
11
5. Semmes Murphey Clinic, Memphis, TN, United States
12
6. Department of Neurosurgery, University of Tennessee Health Science Center,
13 14
Memphis, TN, United States 7. Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, TN, United States
15 16
CORRESPONDING AUTHOR:
17
Kenan I. Arnautovic, MD, PhD
18
Semmes-Murphey Clinic
19
6325 Humphreys Blvd
20
Memphis, TN 38120
21
Phone: (901) 522-7700
22
Fax: (901) 522-2600
23
e-mail: [email protected]
24
1
1
ACADEMIC DEGREES: Bruno Splavski, MD, PhD; Krešimir Rotim, MD, PhD; Frederick
2
A. Boop, MD; Andrew J. Gienapp, BA; Kenan I. Arnautović, MD, PhD
3 4
KEY WORDS: Ambroise Paré; History; Neurosurgery; 16th Century France
5 6
RUNNING TITLE: Ambroise Paré: His life, hardships, career, and influence on
7
neurosurgery
8
ABBREVIATIONS: No abbreviations in the manuscript
9 10
2
1
ABSTRACT
2
Ambroise Paré was celebrated surgeon of the 16th Century whose practical
3
accomplishments, books, and ideas transformed surgery and was a precursor for the later
4
development of neurosurgery. He developed many surgical innovations related to wound
5
management, arterial ligation for the prevention of hemorrhage during limb amputations, and
6
the treatment of war-related head and spine injuries. He maintained that a surgeon should
7
operate gently to reduce pain and improve outcome, and he dedicated his career to the
8
wounded, sick and poor. He also served four consecutive French monarchs—Henri II and his
9
three sons François II, Charles IX, and Henri III. As a Huguenot (a Reformed Protestant) by
10
faith, he lived in an environment dominated by Catholicism. Hence, his practice and life were
11
sometimes hindered by political circumstances and religious prejudice.
12
In this historical vignette, we will discuss the professional accomplishments of
13
Ambroise Paré that influenced the future development of neurosurgery, including his
14
descriptions of phantom-limb pain and peripheral nerve injury, his innovations in
15
neurotraumatology, and the saws he invented for use in skull surgery. We will also highlight
16
Paré’s broad neurosurgical contributions to the field. Finally, we will discuss his personal life
17
during the difficult and dangerous political circumstances of 16th Century France.
18
3
1 2
INTRODUCTION Ambroise Paré (c. 1510–1590; Fig. 1) was a prominent and celebrated surgeon of the
3
Renaissance, considered by many to be the founder of modern surgery (1, 2). He was a
4
leading innovator who was responsible for the advancement of most surgical techniques and
5
medical education in the 16th Century. He also promoted empirical observation and scientific
6
thinking, establishing a methodology for evidence-based medicine that modern anatomy,
7
surgery, and neuroscience uses today (3). However, Paré’s influence on neurological surgery
8
remains far less known than his contributions to surgery.
9
During the 16th Century Renaissance, a wide-range of new medical methodologies
10
and education, innovative surgical techniques, and scientific publications became possible
11
(4). However, outmoded Galenist views of anatomy, medical knowledge, and medical
12
education dominated medicine, which prevented physicians from using treatments based on
13
practical observation and empirical analysis (5-7). In Galenist-based medicine, anatomy and
14
surgery were considered less important to other medical disciplines. Practical surgical
15
procedures were, therefore, left to barber-surgeons, who were skilled and well-trained but did
16
not have formal academic education (8).
17
By this time, the use of guns and other firearms were emerging in European warfare,
18
which dramatically increased the number of soldiers killed and wounded. Firearms were
19
responsible for new types of wounds that had not been previously seen, such as head wounds
20
with retained foreign bodies that can lead to infection and fatal outcomes. As a battlefield
21
doctor, Paré saw these types of wounds frequently himself, which led him to write some of
22
the first texts dedicated to the treatment of gunshot wounds (Fig. 2) (9).
23
France in the 16th Century, where Paré spent his life, was also dominated by religious
24
wars and extreme tension between Catholics and Protestant Huguenots. Despite his reputation
4
1
and incredible professional and scientific accomplishments, his life was sometimes
2
threatened due to the political and social circumstances around him.
3
This brief historical vignette will discuss chronological facts and the political and
4
religious circumstances influencing Amboise Paré’s brilliant career and personal life. We will
5
discuss how he managed to overcome the hardship of his times. This is also a tribute to Paré
6
in which we will honor his work in establishing a distinguished and modern scientific
7
discipline that was a forerunner to contemporary surgery, including neuroscience and
8
neurosurgery.
9
As a final point, we will try to document his particular contributions to the future
10
advancement of neurosurgery, including his descriptions of phantom-limb pain and
11
peripheral nerve injury, innovations in neurotraumatology, and the invention of saws for use
12
in skull surgery. This paper will also substantiate Paré’s wide-ranging neurosurgical
13
accomplishments, adding some additional understanding to the field.
14 15 16
POLITICAL CONDITIONS IN 16TH CENTURY FRANCE The 16th Century was a time when the power of Western Europe, including France,
17
grew to new heights. However, the religious conflicts between Catholics and Protestants
18
dominated the century, initiating the Wars of Religion in France, during which about three
19
million people disappeared due to violence, famine, or disease.
20
In 1515, François I (1494–1547) ascended the French throne as an absolute monarch.
21
He was a patron of the arts who initiated the French Renaissance by attracting Leonardo da
22
Vinci (1452–1519) and other famous artists to France. Da Vinci helped construct his royal
23
manor houses—designing the central stairs of the Château de Chambord—and brought his
24
famous painting of Mona Lisa to France. However, during François I’s reign, continuous
5
1
wars and political oppression hampered comprehensive reforms. He was succeeded by his
2
son, King Henri II of France (1519–1559).
3
The Italian War of 1536–1538 between the French King François I and his main rival,
4
Charles V (1500–1558)—the Habsburg King of Spain and Holy Roman Emperor—was
5
fought over lands in Northern Italy, which resulted in French occupation of Turin. The
6
occupation further provoked the animosity between France and Spain, rival countries vying
7
for European dominance. Charles V also laid the unsuccessful siege to city of Metz, which
8
was defended by French forces of King Henri II in 1552 during the Last Italian war (1551–
9
1559), which emphasized the importance of gunpowder technology However, the prolonged
10
wars ultimately destabilized and financially weakened both countries and caused further
11
political fragmentation in Italy. It allowed also the expansion of Protestantism into France,
12
where Protestants were called Huguenots. Political and religious turbulence culminated with
13
the massacre of Huguenots on the night of St. Bartholomew’s Day in Paris on August 24,
14
1572, during the short reign of young King Charles IX (1550–1574).
15 16
EXPERIENCED MILITARY MEDICAL PRACTITIONER, EDUCATOR, AND
17
ROYAL SURGEON TO THE VALOIS DYNASTY
18
Ambroise Paré was born in the French countryside and was initially trained as a
19
barber surgeon. He became a surgical resident in 1533 at the famous Hôtel Dieu hospital in
20
Paris (10), a prominent hospital and residence of medical education of the time (Fig. 3).
21
Thanks to his academic training, he become an accomplished medical practitioner, military
22
surgeon, and royal surgeon to the French monarchy (11). As an experienced military
23
practitioner, he tended to wounded battlefield soldiers during the numerous armed conflicts
24
between the French and Spanish forces (Fig. 43).
6
1
During the military occupation of Turin by French forces in 1536, gunshot wounds
2
were typically treated by boiling an oil solution to seal wounds; the solution was also thought
3
to prevent alleged gunpowder poisoning (3, 9). While working as a military surgeon in the
4
campaign, Paré, ran out of oil while attending to wounded soldiers and improvised a wound-
5
dressing composed of egg yolk, rose oil, and turpentine instead. Soon, he observed that
6
soldiers with wounds dressed with this treatment recuperated better than soldiers treated with
7
boiling-oil cauterization (12, 13). Consequently, he concluded that gunpowder was not toxic
8
and, therefore, each gunshot wound did not require cauterization (13). This is quite possibly
9
one of the earliest known examples of evidence-based medicine as we know it today
10
employed in surgical practice. Furthermore, his new method of wound treatment was shown
11
to be less damaging; it was far more successful in treating wounds while also being much
12
more comforting to the patient (3, 9). Nevertheless, Paré never entirely gave up the use of
13
hot-oil cauterization and continued to use it in limb amputations for hemostasis from bone.
14
However, he did abandon it when it came to bleeding vessels and instead introduced arterial
15
ligation to prevent hemorrhaging (1, 13, 14).
16
At the beginning of 16th Century, methods for perioperative pain relief were
17
extremely limited. Opium and strong spirits were the only available anesthetics, and many
18
techniques generated unbearable pain—an unfortunate but necessary part of surgical
19
procedures (15). Paré, on the other hand, came to realize that a surgeon should operate gently
20
and less aggressively to reduce pain and damage to the tissue, which is beneficial in
21
improving patient outcome (3). This was a transformative notion that enhanced the capability
22
of a surgeon as well as improving surgical practice from that time on. The idea was also an
23
early precursor that underpins the contemporary notion of minimally-invasive surgery.
24 25
Ambroise Paré published books on surgery that went beyond mere explanations of procedure. Paré was an anatomist, a founder of modern forensic pathology, and an inventor
7
1
of surgical instruments (16). His revolutionary work formed the foundation of surgery as a
2
modern medical discipline (2, 15) and laid the groundwork that allowed for the future
3
development of neurosurgery as a distinguished surgical field on its own. While he was
4
involved in treating battle and tournament injuries, he emphasized the importance of
5
understanding anatomical body structure, insisting that surgery must be based on anatomy.
6
In 1559, the rival rulers of France and Spain, who were both Catholic, reached a peace
7
agreement to contain the spread of Protestantism. The truce was affirmed by the wedding of
8
King Philip II (1527–1598) of Spain to Elisabeth of Valois (1545–1568), the teenage
9
daughter of Catherine de Medicis (1519–1589) and King Henri II of France. However, at a
10
jousting tournament to celebrate the marriage, the French King was fatally wounded by a
11
wooden lance fragment that penetrated his brain through the right orbit (17-20). Paré was
12
asked to give an advice concerning medical treatment of the King, together with the famous
13
anatomist Andreas Vesalius (1514–1564) (17, 21, 22). However, he was unable to give
14
direct care to the King. Senior royal doctors decided on the King’s treatment by their own,
15
inappropriately advocating for a wait-and-see approach to his treatment (20). The King died
16
11 days post-injury, probably of meningoencephalitis caused by hematoma of cerebral
17
contusion (18-20, 23). During the autopsy of the King’s body, Paré recorded an occipital
18
subdural hematoma with a secondary infection (empyema), but he believed it was a brain
19
contusion on the opposite side to the blow (ie, a contre-coup injury) that mainly resulted in
20
the King’s death (20), which is how this term entered future neurosurgical practice.
21
Afterwards, Paré successfully treated many other head injuries. He served King
22
François II (1544–1560), the short-lived young successor to the throne, who died suddenly of
23
mastoiditis in 1560 (24). Although Paré was technically skillful enough to perform surgery on
24
the King’s post-auricular abscess, he did not attempt it. It is possibly that he was worried of
25
being accused of poisoning or killing the king if surgery was unsuccessful (24).
8
1
Although Paré’s professional capability and humanist attitude to his patients made
2
him an ideal practitioner, his theories and writings were often opposed by university
3
authorities who still clung to older incorrect ideas that we would consider backward today.
4
His book Apologie and Treatise was written in response to one such attack made by the Dean
5
of the University of Paris School of Medicine, who tried to discredit Paré’s scientifically-
6
based methods (25), especially his use of the ligature in amputations (14).
7
Paré was a Protestant, specifically a Huguenot, but he seemed to have maintained the
8
appearances of being Catholic to avoid danger. He was married twice, his children were
9
baptized, and he was eventually buried in the Catholic faith (11). During the St.
10
Bartholomew’s Massacre of August 24, 1572, anti-Huguenot mob violence was rampant in
11
the streets of Paris. King Charles IX—a Catholic himself—locked Paré in a closet to save his
12
life (11, 13). While Charles initiated many anti-Protestant purges himself, paradoxically he
13
spared Paré’s life. It is likely that Paré would not have survived despite being a well-known,
14
respected, and distinguished professional and scientist.
15 16 17
A REVIEW OF PARÉ’S INFLUENCES IN NEUROSURGERY Ambroise Paré introduced many innovations and made various observations that
18
influenced the future development of neurological surgery to the great extent. However, these
19
contributions are less well-known than his surgical achievements. In his 1564 book Treatise
20
on Surgery, Paré described the pain suffered by amputees when they felt “phantom”
21
amputated limbs, indicating that phantom pain originates in the brain and was not in the
22
remaining part of the limb (14). This particularly astute observation formed the basis for the
23
development of neuroscience as a distinctive scientific discipline in the future. Paré
24
successfully applied his concept of vessel ligature to the treatment of migraine headache and
25
described ligation of the superficial temporal artery for relieving headache pain (26). He 9
1
eventually ligated his own superficial temporal artery to treat self-migraine pain (11). He also
2
meticulously depicted the brain and nerves of the head and neck in his book Les Oeuvres
3
d'Ambroise Paré (The works of Ambroise Pare) in 1575 (Fig. 5).
4
Although altered consciousness after head injury had been recognized since the Edwin
5
Smith Papyrus (1700 BC), an ancient Egyptian composite manuscript, the term “brain
6
concussion” was first used in the Renaissance to define the effects of brain damage without a
7
skull fracture. It was described by Jacopo Berengario da Carpi (c.1460–c.1530), a professor
8
of Anatomy at the University of Bologna, and Ambroise Paré himself, both of whom defined
9
concussion as commotio cerebri (27). Paré further described concussion as shaking of the
10
brain, and was the first to label contrecoup injury as a consequence of a closed head injury to
11
the brain parenchyma on the opposite side of the blow (12). A contre-coup injury was noted
12
by Paré in his description of the autopsy of the King Henri II of France (20).
13
Paré was particularly concerned with war neurotrauma and described in detail the
14
management of comminuted depressed skull fracture by using a cutting forceps and a trepan
15
technique (10). However, he considered the dura as a boundary of harmless surgery, although
16
he recognized that blood clot might accumulate in the subdural space (10). Skull trepanation
17
is one of the oldest surgical techniques known and was used for many indications, including
18
head injuries from war. Its use increased with the introduction of firearms and gunpowder.
19
During a siege of the strategic French city of Metz in 1552 by forces of Holy Roman
20
Emperor and the King of Spain Charles V, Paré treated an unconscious soldier with
21
convulsions who had received a blow to the head from a stone cannonball. He saved a
22
soldier’s life by performing a skull trepanation and protected his wounds with a mixture of
23
alum and honey (10). Afterwards, he successfully performed the same procedure on a series
24
of other soldiers with head wound (25).
10
1
Instruments for head surgery were largely modernized by Ambroise Paré himself. He
2
devised a trepan (a round saw for cutting out a circular piece of skull bone), which was used
3
in the same way as a modern-day hand drill (Fig. 6). He designed the instrument with a
4
protective lid that was less harmful in unskilled hands and improved its safety by moving
5
from a two-point to a three-point bearing trepan, which made the drill more stable on the
6
skull (16). The trepan, however, did not gain popularity among surgeons of his time since it
7
was heavy and clumsy (16). Paré also applied a skeletal traction to the spine injury in a case
8
of spinal dislocation (10).
9
In his many writings, Paré contributed to the understanding of peripheral nerve
10
injuries, describing a case of a median nerve injury—a young Charles IX (10) had suffered an
11
injury after a bloodletting for smallpox (11). Paré defined a detailed explanation of painful
12
median nerve neuroma (causalgia) for the first time, describing persistent pain and
13
contractures of the arm that resembles a complex regional pain syndrome in modern medicine
14
(11).
15
Ambroise Parė also described several items of interest to pediatric neurosurgeons,
16
such as cephalohematoma as a consequence of forceful labor, which was incised and
17
evacuated (10), as well as congenital hydrocephalus, which was clinically distinguished from
18
macrocephaly (28, 29). He also described a simple depressed skull fracture in an infant that
19
was treated by exploration and bone elevation in a manner similar to that done today (10).
20
Paré, however, never rejected Galen’s centuries’ old ventricular-pneumatic doctrine of
21
cognition whereby mental tasks were contained within the cerebral ventricles, which was the
22
earliest attempt to locate mind functions in separate physical sites of the brain (30, 31).
23 24
CONCLUSION
11
1
The practice, works, and multiple-skills of Ambroise Paré puts him in the rare
2
category as one of the true giants in the history of medicine. His ideas and methods
3
substantially improved surgery and advanced it beyond religiously dogmatic medieval
4
limitations. He established a solid foundation for modern surgery in general and neurosurgery
5
in particular by paving the way for the development of both specialties in the centuries to
6
come. Ambroise Paré also developed many inventions and made many contributions that
7
impacted the future development of neurosurgery. He understood the importance of personal
8
experience and expertise, as well as how experience could affect the acquisition of new
9
knowledge. He was also able to exert a powerful influence on future surgical practice by
10
questioning outdated and incorrect academic tradition and dogma. Thus, because of his
11
critical mind, he is seen as a true and an authentic representative of the Renaissance in the
12
field of medicine.
13
Despite his tremendous professional and scientific achievements, his life’s work—as
14
well as his alleged religious beliefs—was burdened by ever-changing political circumstances
15
and social upheaval. However, it seems that he successfully overcame this by his tolerance
16
and calm sense personality.
17 18 19
DISCLOSURES No financial or material support was accepted as part of this study. Dr. Boop is a
20
consultant for Medtronic. Drs. Splavski, Rotim, and Arnautović and Mr. Gienapp have no
21
financial relationships to disclose.
22
12
1
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15
1
FIGURE LEGENDS
2 3
Figure 1. A portrait of Ambroise Parė, age 72 (“Portrait of Ambroise Pare [1510–1590],
4
French surgeon”; credit: Wellcome Collection; CC BY).
5 6
Figure 2. Engraving from a 1634 English translation of Ambroise Paré’s writings,
7
specifically from a chapter on gunshot wounds. (Image reproduced from the public domain
8
book, The workes of that famous chirurgion Ambrose Parey, (p. 440). Available from the US
9
National Library of Medicine Digital Collections at: http://resource.nlm.nih.gov/2393053R.)
10 11
Figure 3. Hôtel Dieu Hospital and Notre Dame Cathedral in Paris at the time of Ambroise
12
Paré (“Paris; The Hôtel-Dieu and Notre Dame”; credit: Wellcome Collection; CC BY).
13 14
Figure 4. Paré attending wounded battlefield soldiers. “Ambroise Paré. Colored line
15
engraving by C. Manigaud after E. J. C. Hamman.” by E. J. C. Hamman; credit: Wellcome
16
Collection; CC BY.
17 18
Figure 5. The brain and nerves of the head and neck as depicted by Ambroise Paré in his
19
book Les Oeuvres from 1575. Reprinted from
20
http://www.biusante.parisdescartes.fr/pare/images/gd/029.jpg; reuse granted under the
21
French Licence Ouverte de type Etalab (Open License).
22 23
Figure 6. A set of trepanation instruments for head wound management as illustrated in the
24
book Les Oeuvres by Ambroise Paré. (Top) “A. Pare, Les oeuvres d'Ambroise Pare”; credit:
16
1
Wellcome Collection; CC BY. (Bottom) “Hand colored illustration of surgical instruments”
2
by Ambroise Paré; credit: Wellcome Collection; CC BY.
17
TITLE: Ambrois Paré, founding father of surgery and neurosurgery: a bridge over troubled waters, or how he managed to overcome the hardships affecting his life and a brilliant career
ABBREVIATIONS: No abbreviations in the manuscript
TITLE: Sepsis caused by bacterial colonization of migrated distal ventriculoperitoneal shunt catheter into the pulmonary artery: a first case report and review of literature
DISCLOSURES: No financial or material support was accepted as part of this study. Dr. Boop is a consultant for Medtronic. Drs. Splavski, Rotim, and Arnautović and Mr. Gienapp have no financial relationships to disclose.
S1878-8750(19)32825-6
DOI:
https://doi.org/10.1016/j.wneu.2019.10.187
Reference:
WNEU 13658
To appear in:
World Neurosurgery
Received Date: 2 July 2019 Revised Date:
29 October 2019
Accepted Date: 30 October 2019
Please cite this article as: Splavski B, Rotim K, Boop FA, Gienapp AJ, Arnautović KI, Ambroise Paré: His contribution to the future advancement of neurosurgery and the hardships of his times affecting his life and brilliant career, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.10.187. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Elsevier Inc. All rights reserved.
TITLE: Ambroise Paré: His contribution to the future advancement of neurosurgery and the hardships of his times affecting his life and brilliant career AUTHORS AND AFFILIATIONS: Bruno Splavski1-3; Krešimir Rotim1,2,4; Frederick A. Boop5-7; Andrew J. Gienapp5,7; Kenan I. Arnautović5,6 1. Department of Neurosurgery, Sisters of Mercy University Hospital Center, Zagreb, Croatia 2. Osijek University School of Medicine, Osijek, Croatia 3. Osijek University School of Dental Medicine and Health, Osijek, Croatia 4. University of Applied Health Sciences, Zagreb, Croatia 5. Semmes Murphey Clinic, Memphis, TN, United States 6. Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, United States 7. Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, TN, United States
CORRESPONDING AUTHOR: Kenan I. Arnautovic, MD, PhD Semmes-Murphey Clinic 6325 Humphreys Blvd Memphis, TN 38120 Phone: (901) 522-7700 Fax: (901) 522-2600 e-mail: [email protected]
ACADEMIC DEGREES: Bruno Splavski, MD, PhD; Krešimir Rotim, MD, PhD; Frederick A. Boop, MD; Andrew J. Gienapp, BA; Kenan I. Arnautović, MD, PhD
KEY WORDS: Ambroise Paré; History; Neurosurgery; 16th Century France
RUNNING TITLE: Ambroise Paré: His life, hardships, career, and influence on neurosurgery
ABBREVIATIONS: No abbreviations in the manuscript
1
TITLE: Ambroise Paré: His contribution to the future advancement of neurosurgery and the
2
hardships of his times affecting his life and brilliant career
3 4
AUTHORS AND AFFILIATIONS: Bruno Splavski1-3; Krešimir Rotim1,2,4; Frederick A.
5
Boop5-7; Andrew J. Gienapp5,7; Kenan I. Arnautović5,6
6 7
1. Department of Neurosurgery, Sisters of Mercy University Hospital Center, Zagreb, Croatia
8
2. Osijek University School of Medicine, Osijek, Croatia
9
3. Osijek University School of Dental Medicine and Health, Osijek, Croatia
10
4. University of Applied Health Sciences, Zagreb, Croatia
11
5. Semmes Murphey Clinic, Memphis, TN, United States
12
6. Department of Neurosurgery, University of Tennessee Health Science Center,
13 14
Memphis, TN, United States 7. Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, TN, United States
15 16
CORRESPONDING AUTHOR:
17
Kenan I. Arnautovic, MD, PhD
18
Semmes-Murphey Clinic
19
6325 Humphreys Blvd
20
Memphis, TN 38120
21
Phone: (901) 522-7700
22
Fax: (901) 522-2600
23
e-mail: [email protected]
24
1
1
ACADEMIC DEGREES: Bruno Splavski, MD, PhD; Krešimir Rotim, MD, PhD; Frederick
2
A. Boop, MD; Andrew J. Gienapp, BA; Kenan I. Arnautović, MD, PhD
3 4
KEY WORDS: Ambroise Paré; History; Neurosurgery; 16th Century France
5 6
RUNNING TITLE: Ambroise Paré: His life, hardships, career, and influence on
7
neurosurgery
8
ABBREVIATIONS: No abbreviations in the manuscript
9 10
2
1
ABSTRACT
2
Ambroise Paré was celebrated surgeon of the 16th Century whose practical
3
accomplishments, books, and ideas transformed surgery and was a precursor for the later
4
development of neurosurgery. He developed many surgical innovations related to wound
5
management, arterial ligation for the prevention of hemorrhage during limb amputations, and
6
the treatment of war-related head and spine injuries. He maintained that a surgeon should
7
operate gently to reduce pain and improve outcome, and he dedicated his career to the
8
wounded, sick and poor. He also served four consecutive French monarchs—Henri II and his
9
three sons François II, Charles IX, and Henri III. As a Huguenot (a Reformed Protestant) by
10
faith, he lived in an environment dominated by Catholicism. Hence, his practice and life were
11
sometimes hindered by political circumstances and religious prejudice.
12
In this historical vignette, we will discuss the professional accomplishments of
13
Ambroise Paré that influenced the future development of neurosurgery, including his
14
descriptions of phantom-limb pain and peripheral nerve injury, his innovations in
15
neurotraumatology, and the saws he invented for use in skull surgery. We will also highlight
16
Paré’s broad neurosurgical contributions to the field. Finally, we will discuss his personal life
17
during the difficult and dangerous political circumstances of 16th Century France.
18
3
1 2
INTRODUCTION Ambroise Paré (c. 1510–1590; Fig. 1) was a prominent and celebrated surgeon of the
3
Renaissance, considered by many to be the founder of modern surgery (1, 2). He was a
4
leading innovator who was responsible for the advancement of most surgical techniques and
5
medical education in the 16th Century. He also promoted empirical observation and scientific
6
thinking, establishing a methodology for evidence-based medicine that modern anatomy,
7
surgery, and neuroscience uses today (3). However, Paré’s influence on neurological surgery
8
remains far less known than his contributions to surgery.
9
During the 16th Century Renaissance, a wide-range of new medical methodologies
10
and education, innovative surgical techniques, and scientific publications became possible
11
(4). However, outmoded Galenist views of anatomy, medical knowledge, and medical
12
education dominated medicine, which prevented physicians from using treatments based on
13
practical observation and empirical analysis (5-7). In Galenist-based medicine, anatomy and
14
surgery were considered less important to other medical disciplines. Practical surgical
15
procedures were, therefore, left to barber-surgeons, who were skilled and well-trained but did
16
not have formal academic education (8).
17
By this time, the use of guns and other firearms were emerging in European warfare,
18
which dramatically increased the number of soldiers killed and wounded. Firearms were
19
responsible for new types of wounds that had not been previously seen, such as head wounds
20
with retained foreign bodies that can lead to infection and fatal outcomes. As a battlefield
21
doctor, Paré saw these types of wounds frequently himself, which led him to write some of
22
the first texts dedicated to the treatment of gunshot wounds (Fig. 2) (9).
23
France in the 16th Century, where Paré spent his life, was also dominated by religious
24
wars and extreme tension between Catholics and Protestant Huguenots. Despite his reputation
4
1
and incredible professional and scientific accomplishments, his life was sometimes
2
threatened due to the political and social circumstances around him.
3
This brief historical vignette will discuss chronological facts and the political and
4
religious circumstances influencing Amboise Paré’s brilliant career and personal life. We will
5
discuss how he managed to overcome the hardship of his times. This is also a tribute to Paré
6
in which we will honor his work in establishing a distinguished and modern scientific
7
discipline that was a forerunner to contemporary surgery, including neuroscience and
8
neurosurgery.
9
As a final point, we will try to document his particular contributions to the future
10
advancement of neurosurgery, including his descriptions of phantom-limb pain and
11
peripheral nerve injury, innovations in neurotraumatology, and the invention of saws for use
12
in skull surgery. This paper will also substantiate Paré’s wide-ranging neurosurgical
13
accomplishments, adding some additional understanding to the field.
14 15 16
POLITICAL CONDITIONS IN 16TH CENTURY FRANCE The 16th Century was a time when the power of Western Europe, including France,
17
grew to new heights. However, the religious conflicts between Catholics and Protestants
18
dominated the century, initiating the Wars of Religion in France, during which about three
19
million people disappeared due to violence, famine, or disease.
20
In 1515, François I (1494–1547) ascended the French throne as an absolute monarch.
21
He was a patron of the arts who initiated the French Renaissance by attracting Leonardo da
22
Vinci (1452–1519) and other famous artists to France. Da Vinci helped construct his royal
23
manor houses—designing the central stairs of the Château de Chambord—and brought his
24
famous painting of Mona Lisa to France. However, during François I’s reign, continuous
5
1
wars and political oppression hampered comprehensive reforms. He was succeeded by his
2
son, King Henri II of France (1519–1559).
3
The Italian War of 1536–1538 between the French King François I and his main rival,
4
Charles V (1500–1558)—the Habsburg King of Spain and Holy Roman Emperor—was
5
fought over lands in Northern Italy, which resulted in French occupation of Turin. The
6
occupation further provoked the animosity between France and Spain, rival countries vying
7
for European dominance. Charles V also laid the unsuccessful siege to city of Metz, which
8
was defended by French forces of King Henri II in 1552 during the Last Italian war (1551–
9
1559), which emphasized the importance of gunpowder technology However, the prolonged
10
wars ultimately destabilized and financially weakened both countries and caused further
11
political fragmentation in Italy. It allowed also the expansion of Protestantism into France,
12
where Protestants were called Huguenots. Political and religious turbulence culminated with
13
the massacre of Huguenots on the night of St. Bartholomew’s Day in Paris on August 24,
14
1572, during the short reign of young King Charles IX (1550–1574).
15 16
EXPERIENCED MILITARY MEDICAL PRACTITIONER, EDUCATOR, AND
17
ROYAL SURGEON TO THE VALOIS DYNASTY
18
Ambroise Paré was born in the French countryside and was initially trained as a
19
barber surgeon. He became a surgical resident in 1533 at the famous Hôtel Dieu hospital in
20
Paris (10), a prominent hospital and residence of medical education of the time (Fig. 3).
21
Thanks to his academic training, he become an accomplished medical practitioner, military
22
surgeon, and royal surgeon to the French monarchy (11). As an experienced military
23
practitioner, he tended to wounded battlefield soldiers during the numerous armed conflicts
24
between the French and Spanish forces (Fig. 43).
6
1
During the military occupation of Turin by French forces in 1536, gunshot wounds
2
were typically treated by boiling an oil solution to seal wounds; the solution was also thought
3
to prevent alleged gunpowder poisoning (3, 9). While working as a military surgeon in the
4
campaign, Paré, ran out of oil while attending to wounded soldiers and improvised a wound-
5
dressing composed of egg yolk, rose oil, and turpentine instead. Soon, he observed that
6
soldiers with wounds dressed with this treatment recuperated better than soldiers treated with
7
boiling-oil cauterization (12, 13). Consequently, he concluded that gunpowder was not toxic
8
and, therefore, each gunshot wound did not require cauterization (13). This is quite possibly
9
one of the earliest known examples of evidence-based medicine as we know it today
10
employed in surgical practice. Furthermore, his new method of wound treatment was shown
11
to be less damaging; it was far more successful in treating wounds while also being much
12
more comforting to the patient (3, 9). Nevertheless, Paré never entirely gave up the use of
13
hot-oil cauterization and continued to use it in limb amputations for hemostasis from bone.
14
However, he did abandon it when it came to bleeding vessels and instead introduced arterial
15
ligation to prevent hemorrhaging (1, 13, 14).
16
At the beginning of 16th Century, methods for perioperative pain relief were
17
extremely limited. Opium and strong spirits were the only available anesthetics, and many
18
techniques generated unbearable pain—an unfortunate but necessary part of surgical
19
procedures (15). Paré, on the other hand, came to realize that a surgeon should operate gently
20
and less aggressively to reduce pain and damage to the tissue, which is beneficial in
21
improving patient outcome (3). This was a transformative notion that enhanced the capability
22
of a surgeon as well as improving surgical practice from that time on. The idea was also an
23
early precursor that underpins the contemporary notion of minimally-invasive surgery.
24 25
Ambroise Paré published books on surgery that went beyond mere explanations of procedure. Paré was an anatomist, a founder of modern forensic pathology, and an inventor
7
1
of surgical instruments (16). His revolutionary work formed the foundation of surgery as a
2
modern medical discipline (2, 15) and laid the groundwork that allowed for the future
3
development of neurosurgery as a distinguished surgical field on its own. While he was
4
involved in treating battle and tournament injuries, he emphasized the importance of
5
understanding anatomical body structure, insisting that surgery must be based on anatomy.
6
In 1559, the rival rulers of France and Spain, who were both Catholic, reached a peace
7
agreement to contain the spread of Protestantism. The truce was affirmed by the wedding of
8
King Philip II (1527–1598) of Spain to Elisabeth of Valois (1545–1568), the teenage
9
daughter of Catherine de Medicis (1519–1589) and King Henri II of France. However, at a
10
jousting tournament to celebrate the marriage, the French King was fatally wounded by a
11
wooden lance fragment that penetrated his brain through the right orbit (17-20). Paré was
12
asked to give an advice concerning medical treatment of the King, together with the famous
13
anatomist Andreas Vesalius (1514–1564) (17, 21, 22). However, he was unable to give
14
direct care to the King. Senior royal doctors decided on the King’s treatment by their own,
15
inappropriately advocating for a wait-and-see approach to his treatment (20). The King died
16
11 days post-injury, probably of meningoencephalitis caused by hematoma of cerebral
17
contusion (18-20, 23). During the autopsy of the King’s body, Paré recorded an occipital
18
subdural hematoma with a secondary infection (empyema), but he believed it was a brain
19
contusion on the opposite side to the blow (ie, a contre-coup injury) that mainly resulted in
20
the King’s death (20), which is how this term entered future neurosurgical practice.
21
Afterwards, Paré successfully treated many other head injuries. He served King
22
François II (1544–1560), the short-lived young successor to the throne, who died suddenly of
23
mastoiditis in 1560 (24). Although Paré was technically skillful enough to perform surgery on
24
the King’s post-auricular abscess, he did not attempt it. It is possibly that he was worried of
25
being accused of poisoning or killing the king if surgery was unsuccessful (24).
8
1
Although Paré’s professional capability and humanist attitude to his patients made
2
him an ideal practitioner, his theories and writings were often opposed by university
3
authorities who still clung to older incorrect ideas that we would consider backward today.
4
His book Apologie and Treatise was written in response to one such attack made by the Dean
5
of the University of Paris School of Medicine, who tried to discredit Paré’s scientifically-
6
based methods (25), especially his use of the ligature in amputations (14).
7
Paré was a Protestant, specifically a Huguenot, but he seemed to have maintained the
8
appearances of being Catholic to avoid danger. He was married twice, his children were
9
baptized, and he was eventually buried in the Catholic faith (11). During the St.
10
Bartholomew’s Massacre of August 24, 1572, anti-Huguenot mob violence was rampant in
11
the streets of Paris. King Charles IX—a Catholic himself—locked Paré in a closet to save his
12
life (11, 13). While Charles initiated many anti-Protestant purges himself, paradoxically he
13
spared Paré’s life. It is likely that Paré would not have survived despite being a well-known,
14
respected, and distinguished professional and scientist.
15 16 17
A REVIEW OF PARÉ’S INFLUENCES IN NEUROSURGERY Ambroise Paré introduced many innovations and made various observations that
18
influenced the future development of neurological surgery to the great extent. However, these
19
contributions are less well-known than his surgical achievements. In his 1564 book Treatise
20
on Surgery, Paré described the pain suffered by amputees when they felt “phantom”
21
amputated limbs, indicating that phantom pain originates in the brain and was not in the
22
remaining part of the limb (14). This particularly astute observation formed the basis for the
23
development of neuroscience as a distinctive scientific discipline in the future. Paré
24
successfully applied his concept of vessel ligature to the treatment of migraine headache and
25
described ligation of the superficial temporal artery for relieving headache pain (26). He 9
1
eventually ligated his own superficial temporal artery to treat self-migraine pain (11). He also
2
meticulously depicted the brain and nerves of the head and neck in his book Les Oeuvres
3
d'Ambroise Paré (The works of Ambroise Pare) in 1575 (Fig. 5).
4
Although altered consciousness after head injury had been recognized since the Edwin
5
Smith Papyrus (1700 BC), an ancient Egyptian composite manuscript, the term “brain
6
concussion” was first used in the Renaissance to define the effects of brain damage without a
7
skull fracture. It was described by Jacopo Berengario da Carpi (c.1460–c.1530), a professor
8
of Anatomy at the University of Bologna, and Ambroise Paré himself, both of whom defined
9
concussion as commotio cerebri (27). Paré further described concussion as shaking of the
10
brain, and was the first to label contrecoup injury as a consequence of a closed head injury to
11
the brain parenchyma on the opposite side of the blow (12). A contre-coup injury was noted
12
by Paré in his description of the autopsy of the King Henri II of France (20).
13
Paré was particularly concerned with war neurotrauma and described in detail the
14
management of comminuted depressed skull fracture by using a cutting forceps and a trepan
15
technique (10). However, he considered the dura as a boundary of harmless surgery, although
16
he recognized that blood clot might accumulate in the subdural space (10). Skull trepanation
17
is one of the oldest surgical techniques known and was used for many indications, including
18
head injuries from war. Its use increased with the introduction of firearms and gunpowder.
19
During a siege of the strategic French city of Metz in 1552 by forces of Holy Roman
20
Emperor and the King of Spain Charles V, Paré treated an unconscious soldier with
21
convulsions who had received a blow to the head from a stone cannonball. He saved a
22
soldier’s life by performing a skull trepanation and protected his wounds with a mixture of
23
alum and honey (10). Afterwards, he successfully performed the same procedure on a series
24
of other soldiers with head wound (25).
10
1
Instruments for head surgery were largely modernized by Ambroise Paré himself. He
2
devised a trepan (a round saw for cutting out a circular piece of skull bone), which was used
3
in the same way as a modern-day hand drill (Fig. 6). He designed the instrument with a
4
protective lid that was less harmful in unskilled hands and improved its safety by moving
5
from a two-point to a three-point bearing trepan, which made the drill more stable on the
6
skull (16). The trepan, however, did not gain popularity among surgeons of his time since it
7
was heavy and clumsy (16). Paré also applied a skeletal traction to the spine injury in a case
8
of spinal dislocation (10).
9
In his many writings, Paré contributed to the understanding of peripheral nerve
10
injuries, describing a case of a median nerve injury—a young Charles IX (10) had suffered an
11
injury after a bloodletting for smallpox (11). Paré defined a detailed explanation of painful
12
median nerve neuroma (causalgia) for the first time, describing persistent pain and
13
contractures of the arm that resembles a complex regional pain syndrome in modern medicine
14
(11).
15
Ambroise Parė also described several items of interest to pediatric neurosurgeons,
16
such as cephalohematoma as a consequence of forceful labor, which was incised and
17
evacuated (10), as well as congenital hydrocephalus, which was clinically distinguished from
18
macrocephaly (28, 29). He also described a simple depressed skull fracture in an infant that
19
was treated by exploration and bone elevation in a manner similar to that done today (10).
20
Paré, however, never rejected Galen’s centuries’ old ventricular-pneumatic doctrine of
21
cognition whereby mental tasks were contained within the cerebral ventricles, which was the
22
earliest attempt to locate mind functions in separate physical sites of the brain (30, 31).
23 24
CONCLUSION
11
1
The practice, works, and multiple-skills of Ambroise Paré puts him in the rare
2
category as one of the true giants in the history of medicine. His ideas and methods
3
substantially improved surgery and advanced it beyond religiously dogmatic medieval
4
limitations. He established a solid foundation for modern surgery in general and neurosurgery
5
in particular by paving the way for the development of both specialties in the centuries to
6
come. Ambroise Paré also developed many inventions and made many contributions that
7
impacted the future development of neurosurgery. He understood the importance of personal
8
experience and expertise, as well as how experience could affect the acquisition of new
9
knowledge. He was also able to exert a powerful influence on future surgical practice by
10
questioning outdated and incorrect academic tradition and dogma. Thus, because of his
11
critical mind, he is seen as a true and an authentic representative of the Renaissance in the
12
field of medicine.
13
Despite his tremendous professional and scientific achievements, his life’s work—as
14
well as his alleged religious beliefs—was burdened by ever-changing political circumstances
15
and social upheaval. However, it seems that he successfully overcame this by his tolerance
16
and calm sense personality.
17 18 19
DISCLOSURES No financial or material support was accepted as part of this study. Dr. Boop is a
20
consultant for Medtronic. Drs. Splavski, Rotim, and Arnautović and Mr. Gienapp have no
21
financial relationships to disclose.
22
12
1
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Achievements Affected his Professional Life and Destiny. World Neurosurg 129:202-
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A. Paré, The Apologie and Treatise of Ambroise Paré, Containing the Voyages Made
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into Divers Places with Many of His Writings Upon Surgery. G. Keynes (ed).
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Chicago, University of Chicago Press, 1952.
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P.M. Dunn, Ambroise Pare (1510-1590): surgeon and obstetrician of the Renaissance.
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Arch Dis Child Fetal Neonatal Ed 71:F231-232, 1994. 29.
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2009. 30.
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M. Vinchon, Ambroise Pare, surgery, and obstetrics. Childs Nerv Syst 25:639-640,
T. Manzoni, The cerebral ventricles, the animal spirits and the dawn of brain localization of function. Arch Ital Biol 136:103-152, 1998.
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F.C. Rose, Cerebral localization in antiquity. J Hist Neurosci 18:239-247, 2009.
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15
1
FIGURE LEGENDS
2 3
Figure 1. A portrait of Ambroise Parė, age 72 (“Portrait of Ambroise Pare [1510–1590],
4
French surgeon”; credit: Wellcome Collection; CC BY).
5 6
Figure 2. Engraving from a 1634 English translation of Ambroise Paré’s writings,
7
specifically from a chapter on gunshot wounds. (Image reproduced from the public domain
8
book, The workes of that famous chirurgion Ambrose Parey, (p. 440). Available from the US
9
National Library of Medicine Digital Collections at: http://resource.nlm.nih.gov/2393053R.)
10 11
Figure 3. Hôtel Dieu Hospital and Notre Dame Cathedral in Paris at the time of Ambroise
12
Paré (“Paris; The Hôtel-Dieu and Notre Dame”; credit: Wellcome Collection; CC BY).
13 14
Figure 4. Paré attending wounded battlefield soldiers. “Ambroise Paré. Colored line
15
engraving by C. Manigaud after E. J. C. Hamman.” by E. J. C. Hamman; credit: Wellcome
16
Collection; CC BY.
17 18
Figure 5. The brain and nerves of the head and neck as depicted by Ambroise Paré in his
19
book Les Oeuvres from 1575. Reprinted from
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http://www.biusante.parisdescartes.fr/pare/images/gd/029.jpg; reuse granted under the
21
French Licence Ouverte de type Etalab (Open License).
22 23
Figure 6. A set of trepanation instruments for head wound management as illustrated in the
24
book Les Oeuvres by Ambroise Paré. (Top) “A. Pare, Les oeuvres d'Ambroise Pare”; credit:
16
1
Wellcome Collection; CC BY. (Bottom) “Hand colored illustration of surgical instruments”
2
by Ambroise Paré; credit: Wellcome Collection; CC BY.
17
TITLE: Ambrois Paré, founding father of surgery and neurosurgery: a bridge over troubled waters, or how he managed to overcome the hardships affecting his life and a brilliant career
ABBREVIATIONS: No abbreviations in the manuscript
TITLE: Sepsis caused by bacterial colonization of migrated distal ventriculoperitoneal shunt catheter into the pulmonary artery: a first case report and review of literature
DISCLOSURES: No financial or material support was accepted as part of this study. Dr. Boop is a consultant for Medtronic. Drs. Splavski, Rotim, and Arnautović and Mr. Gienapp have no financial relationships to disclose.