THE PROSTHESES OF AMBROISE PARI~

By THOMAS GIBSON, M.B., F.R.C.S.(Ed.)

Plastic Surgery Unit, Glasgow Royal Infirmary

" Now it remains, that we speak of the fourth O_~ce or Duty of the Chirurgeon which is to supply or repair those things that are wanting by nature . . . or by some mischance."

--AMBROISE PARI~.

" LES (Euvres d'Ambroise Par6 " is one of the outstanding surgical treatises of all time. Written in his native French, since he was ignorant of Latin, it comprises some twenty-nine livres ranging in subject from anatomy to embalming of the dead, and it includes discourses on all branches of surgery, on obstetrics and gynmcology, and on some not entirely surgical topics such as fever and the plague. The first French edition of the complete works appeared in I575, and during the next hundred years or so his writings must have been widely read all over Europe, since in that time they ran to twelve further editions in French, seven in Latin, three in English, five in Dutch, and five in German.

Much of Par6's extensive experience, on which his writings are based, was gained as a military surgeon during the French campaigns of the middle third of the sixteenth century, and his own account of these "voyages made into divers places " still makes excellent reading. His skill and resourcefulness in tending the wounded soon became renowned, and he found favour with successive French kings, a fact which was no doubt responsible for the wide and varied experience of civilian practice, from which he also draws freely in his works. His denunciation of the universal use of boiling oil to cauterise wounds caused by gunpowder, his use of the ligature in amputations, and his frequent use of the phrase " I dressed him and God cured h i m " (" Je le pansay et Dieu le guarit ") are well known. It is the purpose of this note to call attention to the seventeenth livre of his works, which is but little known, although Malgaigne (184o) describes it as " un des livres les plus originaux et les plus int6ressants."

This livre is entitled in the original " Traitant des moyens et artifices d'adiouster ce qui defaut naturellement ou par accident," which is slightly misleading in so far as it is not a treatise on reparative surgery but a surprisingly complete account of external prostheses. His only reference to plastic surgery is a detailed description of the Italian method of rhinoplasty which he had at second hand from " a gentleman named the Cadet of Saint Thoan who, having lost his nose and having long worn one of silver, became angry at the remark that there was never a lack of laughing matter when he was present. And having heard that there was in Italy a master remaker of lost noses, he went to find him, and he made a new nose for him in the way described above, as an infinite number of people have since seen him, not without the great marvelling of those who had known him before with a silver nose" (Gnudi and Webster's translation). It is generally agreed that the "master remaker of new noses " was one of the Vianeo family and not Tagliacozzi himself who, at the time when Park's description was published, was only 3o years of age. Par6, while admitting that such a reparative

4 B R I T I S H J O U R N A L OF P L A S T I C SURGERY

procedure is not impossible, shows little enthusiasm for it and obviously prefers his prostheses.

His illustrations show examples of practically all the external prostheses which are in use at the present time. Handicapped as he was in the choice of materials, he seems to have had a complete understanding of the problems involved in fixation and although it is difficult to evaluate from the line drawings

FIG. I

F:G. 3

FIG. 2 FIG. 4

Figs. i to 4 . - - T h e external facial prostheses.

how closely some of the prostheses simulated nature, they must have had considerable clinical value.

The chief external facial prostheses which he describes and illustrates are shown in Figs. I to 4. The eye (Fig. t) was m a d e " of Gold or Silver, counterfeited and enamelled so that it may seem to have the brightness or gemmy decency of the natural eye." For those who could not retain an indwelling eye, he describes one complete with eyelids and a retaining band to encircle the head (Fig. 2), the whole made from " a string or wire of Iron bowed or crooked." The artificial

THE PROSTHESES OF AMBROISE PARI~ 5

noses (Fig. 3) were to be " of Gold, Silver, Paper, or linnen cloths glewed together . • • so coloured, counterfeited and made both of fashion, figure and bigness, that it may as aptly as is possible resemble the natural nose." The threads are to bind the nose " unto the hinder part of the head or the hat ."

The prosthetic ear (Fig. 4) is to be made in much the same way. What is more interesting, however, although not illustrated, is his description of fitting a prosthesis when only part of the ear is missing ; " . . . but that some portion thereof doth yet remain, then must it not be neglected but must have many holes made therein with a bodkin ; and after that the holes are cicatrized, let some convenient thing, made like unto the piece of the ear that is lost be tied or fastened unto it by these holes."

His obturateurs du palais (Figs. 5 and 6) are perhaps the most ingenious of his appliances. They are designed not for cleft palate cases but for those to whom " i t happeneth that a portion or part of the bone of the Palat, being broken with

FIG. 5 FIG. 6

Figs. 5 and 6 . - -The palatal obturators and their ingenious retention devices.

the shot of a Gun or corroded by the virulency of the Lues Venerea falls away." Self-retaining dentures were unknown to Pard (his artificial teeth carved from bone or ivory were tied or wired to the existing teeth) and his palatal obturators had to carry their own retention device. Tha t shown in Fig. 5 depends on the use of a piece of sponge " which when it is moistened with the moisture distilling from the brain will become more swollen and puffed up, so that it will fill the concavity of the Palat that the artificial Palat cannot fall down . . . . " The second device (Fig. 6) seems the more reliable of the two, particularly when the defect is elliptical ; it consists of a turnbuckle which can be rotated through 9o degrees by the forceps illustrated.

Fig. 7 is a copy of his illustration of an artificial penis. He writes : " Those that have their Yards cut off close to their bellies are greatly troubled in making of Urin for that they are constrained to sit down like women. For their ease, I have devised this Pipe or Conduit having an hole through it as big as one finger which may be made of Wood or rather L a t t i n " (tin). A soldier so maimed and possessing such a device would no doubt be spared much Rabelaisian ribaldry in the army camps of the period.

He illustrates several artificial limbs (Figs. 8 to II), some of which are reproduced here. " I have gotten," he writes, " t h e forms of all those members made so by art . . . of a most ingenious and excellent Smith dwelling at Paris

6 B R I T I S H JOURNAL OF PLASTIC SURGERY

who is called . . . the Little Lorrain, and here I have caused them to be pourtraid, or set down that those that stand in need of such things, after the example of them may cause some Smith or such like Workman to serve them in the like case."

The hand and arm prostheses (Figs. 8 and 9) are ingenious if massive. Malgaigne in his annotated text of Par6's works (v. 2, p. 617) cites an instance of a French Army captain who wore such an arm in combat when it probably served for both offence and defence. The drawing of the leg (Fig. Io) "made artificially of Iron " is noteworthy chiefly for the wild life on the landscape underneath; such a prosthesis must have been almost too weighty to wear apart from on horseback. Probably the most useful of all the artificial limbs is his " Wooden Leg made for poor Men " (Fig. II).

FIG. 7

An artificial penis to be made of wood or tin.

The prostheses mentioned are by no means all of the appliances and devices he describes. There is his instrument " t o help such as cannot speak by reason of the loss of some part of the Tongue," a sort of wooden clapper which was tied to the lower front teeth and overlay the stump of the tongue. He illustrates two varieties of masks or spectacles for correcting squints, splints to correct spinal deformities, bootees for children with varus or valgus deformities of the feet, a device to help those with a drop foot and a crutch which takes the body weight from the ischial tuberosity as well as from the axilla. There is also an ingenious tin reservoir to be worn within the thighs of those who are incontinent of urine.

In the fourth French edition (i585), Par6 rounded off his seventeenth livre with these added sentences :--

" Those who have lost their hair from shock, alopecia or other cause can have a false wig. Also those ladies who have silvered hair, for fear of being thought old, may wear artificial fronts of hair which they know well how to arrange and disguise so as often to deceive the men. And also to make themselves appear taller than they are, they wear high heels after the style of Italian and Spanish women. They do also several other things to deceive the men which I do not wish to describe here for fear of incurring their bad grace " (Author's translation).

THE PROSTHESES OF AMBROISE PARI~ 7

FIG. 8 FIG. 9

FIG. Io FIG. I I

Figs. 8 to I I . - - I n des igning these artificial l imbs considerable mechanica l ingenui ty has been used, bu t the weight m u s t have been a lmos t prohibi t ive. Note the landscape

and wild life in Fig. io, a feature of m a n y of Par6 's i l lustrations.

8 BRITISH JOURNAL OF PLASTIC SURGERY

REFERENCES

In preparing this note I have had the assistance of Dr A. L. Goodall, the Hon. Librarian, and Mr Terry, the Librarian of the Royal Faculty of Physicians and Surgeons of Glasgow, to whom I am most grateful.

The illustrations are taken from the sixth French edition of Pard's works (I6o7), while the English descriptions are quoted from the English edition of I678 translated by Thomas Johnson " Out of Latin and compared with the French." Pard's "Voyages made into divers places " have been recently reprinted with selected excerpts from his works under the title o f " The Apologie and Treatise of Ambroise Pard" and edited by Geoffrey Keynes (I95 I). Malgaigne's three-volume work (Paris, I84o), which includes a history of surgery to the time of Pard, a biography, a complete bibliography, and an annotated text of "Les (Euvres" remains the standard work. The English translation of the paragraph referring to rhinoplasty is taken from " The Life and Times of Gaspare Tagliacozzi," by Gnudi and Webster.