THE STORY OF HOW THE REVOLUTION IN MILITARY CASE LEADED TO THE REVOLUTION IN MILITARY MEDICINE AND TO THE APPEARANCE OF MODERN SURGERY
It is well known that the new type of weaponry, the gunpowder weapon, which appeared at the end of the 13th century and became widespread during the 14th century, led to serious changes in military affairs. Already in the 15th century, guns began to be widely used by the most progressive armies of both Europe and Western Asia, and not only during sieges of cities, but even in field battles. And in the second half of the 15th century we owe the appearance of hand-held firearms ("hand arms", "squeaks", "arquebus", "pistols", etc.), which immediately began to conquer its place on the battlefields.
Thus, already at the beginning of the 16th century, firearms were firmly in use among the leading European armies. However, a new type of weaponry led to the emergence of a new type of wounds - deep gunshot wounds, which, even despite their seeming ease for doctors of that time, began to lead to death in the vast majority of cases. For a long time, the doctors of that era could not understand why this was happening, why new wounds from bullets were comparatively more lethal than previous wounds from knives and arrows.
The result of the research was the opinion that bullet wounds received from a new type of weapon have more serious consequences for two main reasons: poisoning of adjacent tissues with bullet lead and powder soot, and their inflammation from pieces of clothing or armor getting into the wound. Proceeding from this, doctors of the late 15th - early 16th centuries began to recommend neutralizing the "bullet poison" as soon as possible. If there was an opportunity, it was recommended to try to quickly remove the bullet and clean the wound from extraneous materials that got there, and then pour a boiling oil mixture into the wound. If there is no such possibility or the bullet does not come out, then it was recommended to just immediately fill the bullet wound with hot oil to neutralize the "poisonous" action of foreign materials that got there.
Yes, now it seems to us, living after 500 years, in the era of antibiotics and laser scalpels, a crude and barbaric method, but for the beginning of the 16th century, such a technique made it possible to save the lives of at least a few wounded, tk. if nothing was done with bullet wounds, then this almost always guaranteed the death of a soldier.
Various recipes for the "bullet-free" oil mixture were offered, but one way or another, at each tent of the military field "barber", "barber surgeon" or "surgeon with a diploma", a fire burned, on which "healing" oil was boiled, which was poured into gunshot wounds.
At that time, the main European conflict, where handguns were increasingly used, were the so-called. The Italian wars, which lasted intermittently from 1494 to 1559, and in which most of the countries of the Western Mediterranean participated. And during the so-called "Third War of Francis I with Charles V" (1536-1538), when French troops occupied Savoy and the troops of the Habsburg dynasty invaded Provence, events took place thanks to which modern military field surgery appeared.
A certain Ambroise Pare, a young "barber-surgeon" enthusiastic about surgery, who volunteered to join the French army that then invaded Piedmont, went to a number of battles and became closely acquainted with their terrible consequences when he bypassed the battlefields and tried to save the wounded. For him, as a person who had an undeniable vocation for medicine, and at the same time humanistic and eminently philanthropic views, this was a turning point.
Once, during the siege of Milan in 1536, as he himself later recalled about this, he found several seriously wounded who were conscious, and, declaring himself a doctor, asked if he could somehow help them? However, they rejected his offer, stating that there was supposedly no point in treating their wounds, and asked to simply finish them off. A. Pare refused such a request, but just at that time one of their fellow soldiers approached them and, after a short conversation with the wounded, stabbed them all. Shocked by what he saw, the French surgeon lashed out with curses at "such an indifferent and cold-blooded villain towards his Christian brothers," but he simply replied that "if I were in their position, then I would pray to God in the same way so that someone would do something like that for me …”After this incident, the young“barber-surgeon”decided to devote his life to saving the wounded, improving their care and developing medicine as such.
Ambroise Paré was born around 1517 in the town of Laval in Brittany, in northwestern France, into the family of a poor craftsman who made chests and other pieces of furniture. Once, together with his older brother, he witnessed an amazing and successful operation, when the "barber-surgeon" Nikolai Kahlo, who arrived from Paris, removed stones from the patient's bladder. From that moment on, the young Breton began to dream not of the craft of a "barber", but of a career as a surgeon - to become not just a "barber" (who at that time performed the duties of not only barber, but rather "people's paramedics", that is, they could supply banks, leeches or bloodletting), but at least a "barber-surgeon" (ie, perform probing, tamponades, some basic operations, and sometimes very complex ones, such as stone cutting). A poor young man from a remote province could not even dream of becoming a certified "doctor" with a diploma from the University of Paris or at least a certified "surgeon - master of the lancet" …
To fulfill this dream, Ambroise Pare, along with his brother, went to the capital of France, where both entered a lower medical school. Soon there the brothers established themselves as "promising" and were sent for an internship at the oldest hospital in Paris - "Divine Shelter", "Hotel-Dieu". For several years, Paré studies there, in parallel with operations, earning a living by shaving, but carrying out more and more operations to those poor people who needed them (and with the same razors with which he shaved visitors, only occasionally washing them in water or igniting them on fire, which was the generally accepted norm in an era when the world of bacteria was still 200 years away).
And, having gained a certain qualification, he received a certificate of "barber-surgeon" and joined the army that was being formed in order to help the wounded soldiers, as we have already mentioned. Shortly after the above-mentioned episode, where he witnessed the killing "at the mercy" of wounded soldiers, whom, in his opinion, could be attempted to be rescued, a second event took place that influenced European medical science in the future.
After one of the battles, during the siege of the small castle of Sousse in 1537, Pare healed those who received gunshot wounds in the traditional method: a funnel neck was squeezed into a hole punched by a bullet, and boiling elderberry oil was poured into it with the addition of other components. The wounded writhed from the pain of the wound and from the pain of the burn, and the young healer from the realization that he was hurting them, but could not help in any other way.
However, this time there were a lot of wounded, and very little elderberry oil. And although A. Pare exhausted the possibilities to treat in the way prescribed by the luminaries of official medicine of that period, he decided not to leave without the help of all the wounded who arrived and arrived to him. Under these circumstances, a young French surgeon decides to try for the treatment of gunshot wounds not boiling oil, but a cold, home-made mixture based on egg white, rose and terpentine oils (and sometimes turpentine). The recipe for this mixture, as he later said for greater seriousness, allegedly read in one late antique book, however, given the fact that he did not know Latin, it is very difficult to believe in this, and most likely he invented it himself.
In the evening, having treated all the remaining wounded with his "balm", the "barber-surgeon" went to bed, however, he recalled, at night he was tormented by a nightmare where the wounded, who did not have enough oil mixture, died in agony. At dawn, he rushed to examine his patients in the infirmary tent, but the result surprised him greatly. Many of those who received the boiling elderberry oil treatment were in agony; just like those who were brought in too late, when he had already completely exhausted his strength and medicine and went to bed. And almost all of his patients who received treatment with his own cold "balm" were in relatively good condition and calm wounds.
Of course, over the decades since the widespread use of firearms, no doubt many simple "barbers-surgeons", "surgeons" with a diploma of the "lancelet guild" and even scientists "doctors" with university degrees (medicum purum) ran out in the field stocks of their oil mixture and they tried alternative therapies. But it was Ambroise Paré, the first and only one, who turned a seemingly simple case into a repeated one and analyzed by its consequences, i.e. scientifically proven observation.
After that, the young French "barber" used boiling elderberry oil less and less for treating gunshot wounds, and more and more often using his "balm", which made the result better and better. And by this practice, he proved that boiling "antidote" is more likely to cause harm than good, and there is less traumatic and more effective treatment.
At the same time, Ambroise Pare proposed a new method for stopping bleeding, which turned out to be a way out of the impasse that surgery had entered by that time in this practical issue, and which in many ways modern surgeons still use today. The fact is that before A. Pare's discovery, what surgeons knew and used to stop bleeding caused additional suffering to the wounded and did not guarantee the preservation of their lives.
At that time, if a large vessel was damaged during injury or amputation, then cauterization of wounds with a red-hot iron was used to stop the blood. If (in the case of very abundant injuries or an extensive excision field during amputation) this did not help, then the stump was dipped for a short moment in a kettle with boiling resin. At the same time, the bleeding, even from the main arteries, stopped, and a kind of sealing of the wound took place, but sometimes subsequently burnt bones and tissues under the layer of resin began to rot, and the patient died from blood poisoning or gangrene.
What Parey proposed was as simple and humane as gauze dressings with balm instead of hot oil - he proposed to tie up blood vessels with an ordinary strong thread. The great Breton surgeon suggested pulling the cut artery out of the wound with tweezers or small forceps and not cauterizing it, but just bandaging it tightly. During amputations, he recommended preventing bleeding in advance: in his opinion, it was necessary first to expose the artery above the place of amputation, tie it tightly, and then amputate the limb; small vessels could be dealt with in the wound itself.
Truly, all ingenious is simple! With this decision, Paré brought the surgery out of the impasse. Since then, for more than 500 years, vascular ligation has been the main method of combating bleeding during operations. Despite the fact that in our century operations are performed on the brain, operations on the heart are performed, and eye microsurgery has reached unprecedented heights, the "Pare thread" still remains among the basic instruments of the surgeon (although in some way the medicine of the XXI century has returned to medieval standards, but using the latest technical advances - so vascular ligation is now more and more inferior to its position of electro-plasma coagulation, i.e. the same cauterization).
However, the new method of treatment that he proposed using not hot oil, but a cool balm for a long time did not receive recognition even from doctors who practiced with him in the French army operating in Piedmont, and who saw with their own eyes the radically different results he received. And only over the years, the "strength of the medical tradition" began to yield to the onslaught of scientific discovery …
At the end of the war in 1539, the army in which he served was disbanded and A. Pare, thus demobilized, again began to treat people in Paris. At the same time, the funds accumulated in the military service and the enormous military field practice allow him to abandon the craft of the "barber" proper and begin genuine scientific and broad publicistic work. Immediately upon his return in 1539, he successfully passed the qualifying exam and finally received a diploma of a professional surgeon, becoming no longer a simple "barber doctor" (then something like a modern nurse or paramedic), but a "barber surgeon" (roughly corresponds to a modern student of higher courses Medical University) and returns to surgical practice in the well-known Parisian "Shelter of God".
But soon, after a short break, the Italian wars resumed with renewed vigor - the next Franco-Habsburg war of 1542-1546 began, and Parey again voluntarily joined the French army, deciding that there would be a huge number of people at the front who would be in dire need of precisely in his help. Again, endless campaigns, many sieges and battles fall to his lot, again hundreds and thousands of wounded, whom he operates, more and more improving his art, inventing more and more new methods of extracting bullets, carrying out amputations, etc.
But most importantly, he, unlike many of his colleagues, keeps records, analyzes the consequences of using various surgical and restorative techniques, and works on books that will soon come out of his pen. And the second war, in which he took a personal part, had not yet ended, as in 1545 he submitted his first major work for printing to a familiar publisher, which received the title "Methods for the treatment of gunshot wounds, as well as wounds inflicted by arrows, spears and other weapons. ".
This book, in which Ambroise Paré summarized his 5 years of experience as a military field surgeon and many years of experience as a practicing doctor in a Paris hospital, was written in a very good language, in French (since he did not know Latin), and became the first European textbook on military field surgery, while generally accessible to all doctors, and not only to the elite of the medical community. The first edition of this work came out immediately, in 1545, and gained wide popularity, which neither the author nor the publisher expected from this book. This book was such a wild success that a number of reprints were made over the next few years.
We can say that thanks to this textbook, among other things, the French school of surgeons had already taken the leading positions in Western Europe by the end of the 16th century and remained on them for about 200 years, losing its leadership only in the 18th-19th centuries to the British and German surgical schools (Russian the military surgical school became one of the world leaders in the 2nd half of the 19th century).
Thus, it was the simple but original methods of treating various wounds that Paré proposed that played a significant role in transforming both surgery in general and military field surgery in particular, from a relatively low-profile "craft" into one of the most important areas of scientific medicine. And how many there were, these methods introduced by him! Pare was the first to describe and propose a treatment for a hip fracture. He was the first to carry out resections of the elbow joint. The first of the European Renaissance surgeons to describe the operations of stone cutting and cataract removal. It was he who perfected the improvement of the technique of craniotomy and the introduction of a new type of trepan - an instrument for this operation. In addition, Paré was an outstanding orthopedist - he improved several types of prostheses, and also proposed a new method of treating fractures, in particular a double fracture of the leg.
During the Second Franco-Habsburg War, in 1542, Ambroise Pare took part in the siege of the fortress city of Perpignan on the Franco-Spanish border, where the next incident happened to him, which contributed to his further career. One of the main commanders of the French army - the incredibly brave and very charismatic Charles de Cosset, Count of Brissac (1505-1563), better known as "Marshal de Brissac", led the French army that carried out this siege, in parallel with the dauphin, who was still inexperienced in military affairs (future King Henry II).
And one day, in a small skirmish near the walls of the city, Marshal de Brissac is seriously wounded from an arquebus. By order of the Dauphin, a council of the best doctors of the army urgently gathered, but the general decision was to recognize the wound as fatal - the bullet entered very deeply into the chest, and a number of attempts to at least find it, not only to pull it out, failed (recall that 400 years were left before the appearance of the X-ray, and 500 years before the advent of computed tomography). And only A. Paret, the junior in rank and age of the doctors present (who was called to the consultation almost by accident, only remembering his vast practical experience) declared, after probing the wound, that the wound was not fatal. He explained to those present that, miraculously, the vital organs were not critically damaged, and that he was undertaking to pull out the bullet, but asked to be assisted in this by the personal surgeon of King Nicolas Laverno. The Life Surgeon had already tried to get this bullet, but could not, and only on the direct order of the Dauphin again agreed to help in a seemingly hopeless operation.
Correctly assessing the situation, Ambroise Paré decided to perform the operation not on a bed patient, but came up with the idea of putting him in the same position that the marshal had at the time of the bullet wound. Thanks to this, Nicola Laverno, as a leading surgeon, was still able to pull a bullet deep from under the marshal's shoulder blade (which, from our point of view, it was almost impossible to find and extract, having only the 16th century tools at hand), and the young Breton took responsibility for wound closure and postoperative care. And, oddly enough for everyone who was present during this operation, but after such a severe injury, even for the medicine of the 20th century, the famous marshal fully recovered and after a while continued commanding the troops.
This incident glorified Pare not only among the Parisian poor or ordinary soldiers, but among the highest French aristocracy and introduced him to the circle of persons personally familiar to the king. After this incident, the fame of the young Breton surgeon only grew, and along with the growth of his medical professionalism. So, for the first time in the history of European surgery, A. Paré produced and began to practice the isolation of the elbow joint for persons whose hands were crushed by shots or cut by fragments or blade weapons, and also developed several other, qualitatively new surgical techniques.
And, recall, he carried out his operations more than 500 years ago, in the war, in the field conditions of a tent camp. Without medical anesthesia, which was not even in the projects at that time, and which was invented only 300 years later by the American dentist William Morton and introduced into surgical practice by the Russian doctor Nikolai Pirogov. Without antiseptics, which was also discovered 300 years later and introduced into everyday practice by the British surgeon Joseph Lister, not to mention aspetika. Without sulfonamides and antibiotics, which, respectively, were discovered and introduced only 400 years later by German and British scientists and doctors.
And Ambroise Pare already in the 16th century did the most complex operations, having at his disposal only what was in his time, and did his operations in most cases successfully. Of course, he also had setbacks, the most famous of which was the 1559 attempt to rescue a mortally wounded in the face with a broken spear at the tournament of King Henry II of Valois. However, “only the one who does nothing is not mistaken,” and in this case, a priori, everyone was convinced of the fatal nature of the wound, and Paré only suggested that they try to save the King of France …
Returning to Paris at the end of his second, but far from the last war in his fate, the outstanding young Breton surgeon continued his traditional practice at the Hotel Dieu hospital. At the same time he received a diploma of "professional surgeon", "master of the lancet", and was admitted to the guild brotherhood named after the saints healers Cosma and Damian - the main and oldest professional association of Parisian surgeons.
But the recognition of his merits and immense popularity on the part of patients - from commoners to the highest aristocrats - caused an extremely hostile attitude from "colleagues in the shop". Soon, the medical faculty of the University of Paris even filed a petition to the king, in order to deprive Pare of the title of "certified surgeon" and withdraw his book from sale. Fortunately for European surgery, the royal administration did not support the protest. Moreover, a few years later, Pare became the head of the surgical department of his beloved Parisian hospital "Divine Shelter", and some time later, in 1552, he was even appointed as a physician-in-chief of the King of France, Henry II of Valois.
And it was during this period, in the middle - the 2nd half of the 16th century, that the name of Paré became known far beyond the borders of France. Thanks to his research, which was widely disseminated at that time in print media (and, interestingly, equally in both Catholic and Protestant countries), from Madrid to Warsaw, and from Naples to Stockholm, solid foundations of modern military field surgery.
Unfortunately, Russia at this time was still on the sidelines of the progress of European medical science. Only during the reign of Boris Godunov, a well-known "Westernizer", did the Russian government start talking about the need to invite "foreign aesculapians", and then only purely for the needs of the troops of the Muscovite kingdom; the question of the development of national health care was not even raised at that time. However, a well-conceived project for creating a prototype of the military medical service remained only on paper - the Godunov dynasty fell, the Troubles began, and the question of the development of domestic military field surgery and the provision of medical personnel to the troops of the Muscovy was further developed only under Tsar Alexei Mikhailovich. At the same time, unfortunately, more or less serious military medical support of the Russian troops began only with the reign of Peter I, in parallel with the creation of a regular army according to the Western European model.
However, back to Ambroise Paré. Despite the failure to save the life of King Henry II, in another, very similar case of injury - a penetrating defeat of the head of the Duke de Guise (the very one who will be the leader of the Catholic party in France and one of the inspirers of St. Bartholomew's Night), the outstanding Breton surgeon fully confirmed his skill.
During the siege of Boulogne, the Duke de Guise was wounded in the eye by a thin and sharp fragment of a spear that penetrated the viewing slot of his helmet. A piece of wood entered the inner corner of the eye socket and came out already behind the auricle, and besides, when the duke fell from the horse, both ends of the chips sticking out of his head broke off. Even by modern standards, such a wound is very serious. Several doctors have already tried to remove the spear shard, but unsuccessfully, and most of the urgently gathered doctors recognized the wound as incurable and fatal.
When Pare arrived, after examining the wound and getting acquainted with the unsuccessful attempts made, he went to the field forge and demanded the master to show him all the available types of ticks. Having chosen one of them, he ordered them to urgently finalize and, thus receiving a new surgical instrument, returned to the wounded duke and pulled out a piece of wood from his head. Despite the fact that a huge stream of blood gushed from de Guise's skull, Pare was able to stop the bleeding, and then healed and sealed the wound.
And, surprising as it may seem even to modern doctors, a person with such a monstrous penetrating wound to the head recovered after this operation, carried out with primitive instruments, without the use of antiseptics and asepsis, without the use of antibiotics, not to mention the absence of X-rays and computed tomography. Moreover, the Duke de Guise, despite the perforating wound to the skull, retained all his mental and physical activity, and after a few weeks he was able to ride a horse again!
So, thanks to the skill of an outstanding surgeon, the seemingly doomed duke suddenly resurrected, and the name Paré turned into a legend and gained fame not only throughout France, but throughout Western Europe.
And this glory once served him a great service. In the course of another war, in which the founder of modern military surgery again directly participates, he is still captured. When opponents from the army of the Habsburg dynasty found out who fell into their hands, they urgently brought him to their commander - the Duke of Savoy, who invited Pare to join him. However, despite the promise of a huge salary and a high position, the French surgeon, although he was a Breton by birth, was a convinced general French patriot, and therefore refused. Then, enraged by the refusal, the duke ordered him to enter his service by force, practically without salary, and on pain of death. But Pare again refused, and then it was announced to him that at sunrise the next day he would be executed.
It would seem that the life of the great surgeon came to an end, but the soldiers and officers from the Habsburg army decided to do everything to save such an outstanding personality, and although they did not dare to contradict the direct order of their commander about the execution, they ensured the safe escape of the chief surgeon of the French army to to their own. Pare's absolutely unexpected return to the camp of the French troops was greeted with triumph, and the glory of a convinced patriot of France was added to his glory as a great surgeon.
It should be noted that it was at the suggestion of Ambroise Paré, as well as the army surgeons and officers of several armies who supported him, that in Western European countries, already in the 16th century, the question of the manifestation of philanthropy on the battlefield towards defeated opponents was raised. So, it was Pare who became an active propagandist of the idea that a wounded enemy is no longer an enemy, but only a suffering person who requires healing, and who has comparatively the same rights to this as a warrior of his army. Until that time, the practice was widespread, in which most of the wounded soldiers of the defeated army who remained on the battlefield were killed by the victors, and often even the seriously wounded soldiers of the victorious side faced the same fate.
Faced with this in his youth, A. Pare, after a few decades, was still able to achieve general European recognition of the idea that all wounded, without exception, have the right to life and medical assistance, and wounded soldiers of the enemy army have the same right to treatment as and the soldiers of the victorious army.
The killing of not only prisoners or those wounded on the battlefield by the victors, but even the "mercy killing" of their seriously wounded, who still had a chance of recovery, although not immediately, several decades after Paré's death, was recognized as an international crime in most countries Western Europe. And it not only became some kind of private rule, but was enshrined in a number of international agreements, including those that ended the Thirty Years' War in 1648.
This is how the skills and ideas of one simple but brilliant person influenced the course of European history and laid the practical and ethical foundations of modern military field surgery for the following centuries.
Notable facts
1. Ambroise Paré never learned Latin until the end of his life and wrote all his fundamental works in French, and therefore any educated Frenchman could read his works, not just the medical aristocracy. But since it was Latin that was (and partly remains) the language of international communication in the medical environment, in order to spread his knowledge outside France, Pare asked several of his colleagues, who knew Latin perfectly, but not so brilliant surgeons, to translate his books for publication in other countries. Europe. And it was the Latin versions of his books that came to the territory of the Moscow kingdom in the baggage of a German doctor at the end of the 17th century, thereby having some influence on the beginning of the formation of the Russian military surgical school.
2. The Parisian hospital "L'Hotel-Dieu de Paris" ("Orphanage of the Lord"), within the walls of which Ambroise Pare lived and worked, is the oldest hospital on our planet. This institution was created back in 651 as a Christian shelter for the poor thanks to the activities of the Bishop Landre of Paris, Chancellor of King Clovis II, and with small interruptions for reconstruction it has been functioning for almost 1400 years.
3. In honor of Ambroise Pare, a hospital created by the French in the colonial period is named, located in the city of Conakry, the capital of the Republic of Guinea (formerly French Guinea, West Africa), which is still the best clinic in the country.
List of used literature
1. Borodulin F. R. Lectures on the history of medicine. - M.: Medgiz, 1955.
2. Mirsky M. B. History of Medicine and Surgery. - M.: GEOTAR-Media, 2010.
3. Shoyfet M. S. "One hundred great doctors" - M.: Veche, 2010.
4. Yanovskaya M. I. A very long journey (from the history of surgery). - M.: Knowledge, 1977.
5. Jean-Pierre Poirier. Ambroise Pare. Un urgentiste au XVI siècle. - Paris: Pygmalion, 2005.
6. The Barber of Paris, or the Glorious Deeds of the Great Surgeon Ambroise Pare // Pharmaceutical Practitioner, September 2015.
7. Surgeons left the barbers // AiF. Health. No. 32 dated 2002-08-08.
8. Berger E. E. Ideas about poison in the medical literature of the XVI century // Middle Ages. 2008. No. 69 (2), pp. 155-173.
9. Berger E. E. Features of surgical education in medieval Europe // History of medicine. 2014. No. 3, p. 112-118.
