The Greatest Benefit to Mankind. Roy Porter

the Hôtel Dieu; and from 1537, for almost thirty years, he divided his time between tending the Paris sick and following the army. Enrolled in 1554 into the confraternity of St Côme, the surgeons’ college, five years later Paré attempted in vain to save the life of Henri II after he had been wounded in a jousting tournament.

      Paré gave a conventional account of the ‘five duties’ of his art: ‘to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided and to redress the defects of nature’. His prime innovation lay in rejection of the standard treatments for gunshot wounds: the use of cautery (the burning iron) or scalding oil (‘potential cautery’) to destroy poison and forestall putrefaction before beginning restorative therapy. In his La methode de traicter leys playes faictes par hacquebutes et aultres bastons à feu (1545) [Treatise on Gunshot Wounds], he described how, as a greenhorn on campaign in Italy in 1537, he had been forced to innovate. Initially, as taught, he had used boiling oil on what were considered to be poisonous gunpowder wounds:

      But my oil ran out and I had to apply a healing salve made of egg-white, rose-oil and turpentine. The next night I slept badly, plagued by the thought that I would find the men dead whose wounds I had failed to burn, so I got up early to visit them. To my great surprise, those treated with salve felt little pain, showed no inflammation or swelling, and had passed the night rather calmly – while the ones on which seething oil had been used lay in high fever with aches, swelling and inflammation around the wound.

      At this, I resolved never again cruelly to burn poor people who had suffered shot wounds.

      Thenceforth he relied on restorative methods, using a digestive (wound-dressing) made of egg, oil of roses and turpentine, justifying this on the supposition that the gunpowder and shot were not, after all, poisonous. Piously, he always said that he had dressed the wound but God had healed the patient: Je le pansay; Dieu le guarit.

      Another innovation mentioned in his Dix livres de la chirurgie (1564) [Ten Books of Surgery] was the use of ligatures in conducting amputations. Other writers had recommended tying off the veins and arteries so as to stop the blood, but Paré worked out the practical details. This made successful thigh amputations possible – William Clowes reported performing one in 1588, as did Fabricius a little later. There was, however, one drawback. No fewer than fifty-three ligatures were necessary in a thigh amputation, and this required trained assistance. Consequently, ligatures could come into general use only after a method had been found to control blood flow until the surgeon could tie the blood vessels, something accomplished in eighteenth-century France when J. L. Petit invented the first effective tourniquet.

      Paré’s Cinq livres de chirurgie (1572) [Five Books of Surgery] dealt at length with fractures and dislocations, while in the Deux livres de chirurgie (1572) [Two Books of Surgery] he addressed the study of obstetrics, showing the art of podalic version (turning a baby in the womb, to facilitate feet-first delivery, as earlier described by Soranus) – and also seeking to explain monstrous births. His successes, however, did not go unchallenged. In 1575, the Paris faculty condemned him for publishing on ‘medical’ topics – an affront reflecting the tetchiness of physicians towards surgeons’ encroachments on their turf.

      The practice of early modern surgeons challenges the myth that before anaesthesia and antisepsis their craft was crude and often lethal. The case notes of the London surgeon Joseph Binns (d. 1664) present a different picture. In a career stretching from 1633 to 1663 he recorded 616 cases. Of these no fewer than 196 related to gonorrhoea or syphilis; 77 were of swellings and 61 were more properly medical – including ague, stomach-ache, headache, insomnia, diarrhoea and epilepsy. Fifteen individuals suffered battle wounds, 14 were hurt at work, 19 suffered from falls from horses and 41 were injured in fights. Of the 402 outcomes recorded, 265 were cured and 62 improved; 22 showed no improvement and 53 died.

      As Binns’s cases show, surgeons’ work remained mainly routine, small-scale and fairly safe – if often agonizing. Next to dressing wounds, drawing teeth, dealing with venereal sores and chancres, treating skin abrasions and so forth, the most common surgical procedure (indeed the profession’s badge) was blood-letting, often performed at the patient’s request. Galenic medicine had warned about the dangers posed by a ‘plethora’, believing that fevers, apoplexy and headache followed from excessive build-up of blood. Venesection was the obvious corrective. The normal method for phlebotomy was to tie a bandage around the arm to make the forearm veins swell up, and then open the exposed vein with a lancet: this was popularly called ‘breathing a vein’. Cupping with scarification was another procedure for drawing blood.

      A few surgeons came up with ambitious new operations. In Italy Gaspare Tagliacozzi (1545–99) described in his De curtorum chirurgia per insitionem (1597) [On the Surgery of the Mutilated by Grafting] the procedure of rhinoplasty or nose reconstruction, which was obviously attractive in the era of syphilis. Rhinoplasty had been known in India since ancient times; in southern Italy the operation was apparently practised by empirics. Tagliacozzi was thus far from the technique’s inventor, but he published and claimed to have perfected it. In his rhinoplastic procedure, a skin flap was partially detached from the flesh of the upper arm, and allowed to establish itself as a viable tissue. Then the flap, still attached to the arm, was shaped and sewn to the remains of the nose. The patient remained with his arm thus attached to his nose for fourteen days, before the flap was severed from its original site. After a further period, the process began of reshaping the flap to form the new nose. The whole business took from three to five months.

      Overall, however, with its deep-seated craft basis, surgery remained rather traditional. Paré concluded:

      A Chirurgion must have a strong, stable and intrepide hand, and a minde resolute and mercilesse, so that to heale him he taketh in hand, he be not moved to make more haste than the thing requires; or to cut lesse than is needfull; but which doth all things as if he were nothing affected with their cries; not giving heed to the judgement of the common people, who speake ill of Chirurgions because of their ignorance.

      Whether surgeons were ignorant or not, there remained severe limits upon what they could achieve.

      PHARMACY

      Pharmacy underwent significant change as the range of remedies was extended, thanks to the retrieval of classical drugs, the discovery of new vegetable products from America and the Indies, and the increasing use of chemical substances. Herbs – understood in the widest sense as the leaves, seeds or fruits, bark and roots of plants, shrubs and trees – had always been the prime ingredients of medical remedies. If used individually, apothecaries called them ‘simples’; combined into a compound drug, perhaps with animal and mineral ingredients, they would be called ‘Galenicals’. Herb gathering (simpling) and preparation of remedies were domestic skills practised in the family, but there was also a commercial side to herbal medicine.

      With the Greek revival, physicians became concerned that the remedies then in use were inferior, and sought to recover the original materia medica used by the ancients. This required the reform of botany, since there was no uniform nomenclature, leaving plant identification chancy. Botany enjoyed its own humanist renaissance: medieval authors were denounced for their barbaric language and for corrupting ancient texts, and there was a call for pure editions of classical botanical works. The great scourge of the pharmacists was the Paris humanist Symphorien Champier. About 1513 he issued his Myroel des Apothecaires, whose subtitle reveals his position: The Mirror of the Apothecaries and Druggists in Which is Demonstrated How the Apothecaries Commonly Make Mistakes in Several Medicines Contrary to the Intention of the Greeks … on the Basis of the Wicked and Faulty Teachings of the Arabs.

      Around the mid fifteenth century manuscripts of Theophrastus’ Historia plantarum [The History of Plants] and De causis plantarum [On the Causes of Plants] were brought from Constantinople and translated into Latin by Theodore Gaza. Galen’s De simplicium medicamentorum facultatibus [On the Powers of Simple Remedies] had been used in the medieval universities, but in 1530 a new Latin translation was published, corrected by reference to ‘old manuscripts’. More important, however, as a vehicle for medical botany was