NON-TRIVIAL SOLUTION: How to reduce amputation mortality?
Pieter Bruegel the Elder. The Beggars (The Cripples). 1568
ATTENTION — QUESTION!
In the 16th century, a talented barber treated those who lost an arm or a leg as good as he could, and even occasionally saved them, but very rarely.
What helped him to dramatically increase his survival rate for such severe injuries, if at first he was rather afraid of it?
The answer is a little later.
WHERE DOES CIVILIZATION START?
Long ago, renowned anthropologist Margaret Mead asked her students, “Where do you think civilization began? What is the most ancient sign that the community of Homo sapiens has ceased to be a population of representatives of the animal world and has become something bigger?”
Students made a variety of assumptions — they still studied archaeology and knew about many finds, which, in their opinion, could be the answer to this difficult question. They referred to batons, spears, fishhooks, clay pots, processed stones.
But Margaret Mead rejected all of their options and named the one that she considered correct. In her opinion, the first sign of civilization in the entire ancient culture was the found skeleton of an adult, whose femur had been broken, but after the fracture it has united.
Mead explained, that if an animal breaks its thigh bone, in almost all cases it’s going to die. It cannot go to the river to drink, get some food, protect itself from a predator. If this fracture heals, then for such a long time that the animal will not survive.
If the broken femur has managed to unite, there can be only one reason — someone took the injured person to a safe place, fed him, gave him water, protected him from predators and did it for so long, that the bone had time to heal and the person was able to take care of himself…
Mead said, “Helping another person during a difficult period is the very thing that starts civilization”. True, even now (you can’t get away from this) this is not always similar. But still, sometimes we do it — after all, we are already civilized, albeit a little…
A LONG TIME AGO…
There are things that are worse than fractures — sometimes the injury is so severe that it is impossible to save a limb. This operation is commonly known as amputation. Survival after such disease fits the definition of Margaret Mead just like the united fracture
I’m afraid the first mention of amputation is not medical. The Code of Hammurabi says, “If a doctor performed a serious operation on a person with a bronze knife and killed this person, or he opened this person’s thorn with a bronze knife and gouged out the eye, then [this doctor] had to have his hand cut off”. But they did not consider it an execution — he survived, he was rescued …
But in Ancient Egypt they thought of not only amputations, but also prostheses. In the grave of a contemporary of Amenhotep II (this is about the 14th century BC), a wooden prosthetic thumb was preserved on his right leg, which was attached to the foot with leather pads.
The great Hippocrates in his work On the Articulations has already mentioned the amputation of a limb affected by gangrene. Naturally, it was done without any anesthesia — terrible pain is rather better than certain death. The stump was not sutured, but treated with bandages — usually for several months.
The famous Roman physician Aulus Cornelius Celsus improved the technique of Hippocrates, recommending to cut off not the diseased, but the healthy tissue — it was harder, but reduced the risk of relapses and continuation of gangrene. He also spoke about the ligation of blood vessels after amputation.
In general, amputation of a limb, and even because of the Roman wars, became so common that there were reports of amphitheaters, where bald slaves were put in a special row. Nearby above were sitting one-armed veterans, who could applaud with their help — with one hand across their bald head.
MEDIEVAL PROBLEMS
When the Dark Ages began in Europe, the medical arts suffered as much as anything else. But most of the ancient heritage was preserved (as in the situation with other sciences) in the Arab countries, where the most significant works were translated from Latin and Greek long ago.
In 1000, the Arab physician Albucasis published a book with an intricate title A Guide for the Physician Who is Unable to Compose Such. There he talks in great detail about amputations, devoting a whole section to them as the only means of combating gangrene.
This treatise was translated into Latin in the 12th century, and it became one of the main textbooks on surgery in Europe for the next several centuries. In another work by Albucasis, On Surgery and Instruments, more than 150 types of tools suitable for amputation were listed.
Some European doctors, for example, Guy de Chauliac, who is sometimes called “the father of French surgery”, mastered the information described in these books. But soon surgery in Europe was generally taken out of the hands of doctors. This is surprising, but the fact is beyond any doubts.
A SURGEON IS NOT A DOCTOR?
Medieval European medicine has largely passed into the hands of clergymen, who are not befitting to shed blood — even for the sake of human recovery. Cutting off a part of someone’s body was simply beneath their dignity. Let others do it!
Who is it? The answer is not so difficult, because there are professions whose representatives are already cutting off a part of human’s body — hair. That is, barbers. Why don’t they cut something else too? They certainly have sharp instruments — let them cut the limbs too!
This is how surgery was handed over to barbers who did not graduate from universities — along with opening abscesses, repositioning joints and removing teeth, so barbers at that time were both surgeons and dentists. It was believed that their knowledge was enough for such simple things.
Doctors were then a respected class with a university degree. They were paid much more, the doctor had to authorize the operation for the barber, only the doctor, not the barber, had the right to prescribe medications to the patient, taken by mouth, but he did not stain his hands — there is already someone to do this!
In France, it was necessary for a surgeon to pass an exam to a doctor and take an oath, “Swear that you will obey the dean of the faculty in all decent and honest deeds, and you will show honor and respect to all doctors of the same faculty, as a student is obliged to do”.
In general, the unfortunate surgeons, that is, barbers and sometimes the bathhouse attendants who help them in their work (they also cut off the callus, let them cut off something else!), And the horsemen (the veterinarians of that time, they cut horses, why only them?), were not even doctors — they were not considered as such.
AND HERE IS THE GUNPOWDER …
The work of military surgeons and the barbers did not become easier with the outbreak of the Hundred Years’ War. Firearms appeared in fighting armies, and immediately in noticeable quantities. How are these wounds treated, and how different are they from those inflicted with bladed weapons?
Firstly, the German military barber Hieronymus Brunschwig, and then the personal physician of Pope Julius II, Giovanni da Vigo, outlined their observations of gunshot injuries. They came to an unpleasant conclusion — gunpowder is poisonous, and if it is not removed, the wounded will certainly die.
How exactly to remove gunpowder from the body — there was no doubt: only with fire! They began to fill the wound with boiling oil, preferring elderberry oil. The bleeding did stop, but the pain experienced by the wounded was beyond description — sometimes they died from it.
Moreover, it was not so bad. Very often the burned stumps of the arms and legs became inflamed, and the sick died in agony. It was attributed to the noxious gunpowder that had not been removed by boiling oil. Still, some survived, and moxibustion became the rule — everyone did it.
SON OF A CRAFTSMAN
This terrible situation was changed by the son of a rather poor artisan, who seemed to be sewing bags (according to other sources, a peasant). His social position was so low that the occupation of a barber was a prestigious and almost impossible dream for him.
There are two versions about what aroused his interest in the profession — either the job of his neighbor, the barber Violo, or the lithotomia he saw (yes, barbers did it too). He was able to enter the school of barbers at the oldest Parisian hospital Hotel-Dieu, existing since 660, and finish it brilliantly in two years, seizing his chance.
Wars then went on almost continuously — Francis I tried to capture Italy, and Charles V of Austria believed that he would perfectly capture it himself if the French did not interfere with him. Already at the age of 19, the young barber Ambroise Paré is sent to the active army — “the war needs people most of all”.
How to do amputations, the young surgeon, of course, was well explained at the school at the Hotel Dieu. Therefore, as it should be, a fire always burned near his tent – elderberry oil was boiling. After the battle, he had to use it more than once, filling the stump after amputation.
How little it helps, he usually sees for himself — too many people do not heal as it is needed after the correct treatment, performed as it was taught. The diligent medic realizes that something else needs to be tried. But how? After all, he was taught that it is necessary to help people in that special way!
ATTENTION — CORRECT ANSWER!
Every cloud has a silver lining — there were too many wounded, and the oil ran out!
Paré decided that at least something was better than nothing at all, mixed egg yolks with pink and turpentine oil and covered the stumps with them, bandaging them with clean rags — it couldn’t get any worse!
SMALL MIRACLE
He was dreading — what will be the result? But the very next day it turned out that those who were treated with the new method felt better than those, who were lucky to have enough boiling elderberry oil. Moreover, much more of them survived than those who were tortured with boiling oil.
There was a subtlety in the fact that boiling oil reliably stopped bleeding (at least for a while). But Ambroise Paré also found a way out of this difficulty — he revived the binding of an injured vessel with a ligature, a thin thread, mentioned by ancient doctors.
He convincingly proved that Celsus was right, and Hippocrates was not — it is necessary to carry out amputation in healthy tissues. Paré was the first to use amputation in the area of the joint, resection of the elbow joint, proposed the use of limb prostheses, and improved many instruments.
Mortality from amputations plummeted, and the fame and reputation of those who proposed these improvements went up, of course. The result was unexpected and eminently gratifying — he was called to perform his duties in the royal court of Henry II.
ROYAL DOCTOR
Ambroise’s further court career was prosperous and rather long — he treated not only Henry II, but also his three sons, who successively occupied the royal throne: Francis II, Charles IX and Henry III. Kings changed — the court physician remained the same.
Indeed, he could not cure Henry II, who was wounded by a spear in the eye in a knightly tournament. Paré tried to save him and did everything he could — especially for him, four villains were executed so that on their heads he could work out an operation to save the king. But the wound was incurable.
It was hard for him to work — other doctors envied him and resented the fact that he did not have a medical education. He did not even know Latin and wrote his work on the treatment of wounds in French — the doctors were unhappy with everything, right down to the French names of some organs, which are quite appropriate in medical work, but caused indecent thoughts from colleagues.
His opponents often stooped to outright slander. For example, Paré was accused of the death of Francis II, slandering that he had killed him by injecting poison into his ear. Soon Shakespeare wrote Hamlet — is not it from this gossip, the way he described the murder of the king emerged?
But his loyalty and talent were so high that the kings did not listen to the slanderers. Ambroise Paré was even forgiven for being a staunch Huguenot. Once, Charles IX summoned him to his place and imprisoned him in one of the palace rooms, ordering a guard to look after him. It was not a royal disfavor, but St. Bartholomew’s Day massacre — the king did not want to lose him, even by accident.
At the time of his death, he was the most famous physician in the kingdom, despite the fact that he never received a real medical education. On the other hand, his authority helped his fellow surgeons a lot to leave the same shop with the barbers and raise their status.
WORTH NOTICING
Hippocrates can, of course, be called the “father of medicine”, but if you look at it, much of what Hippocrates said is just a repetition of the discoveries of other doctors. Do not get carried away by the race for priority — a lot of unexpected things will come up!
It’s the same with Ambroise Paré — he really invented prostheses, not for the first time, but anew. You can see for yourself — prostheses were known even to the ancient Egyptians!
If there is a generally accepted treatment protocol, it is not necessarily the only correct path. Perhaps, this is another recommendation to fill the wound with boiling oil. It may not be so, but everything needs to be checked many times!
Successful university graduates have not been able to achieve what the son of a poor artisan has achieved. He had to try harder, and it gave the result. It has happened more often than many people think…
Paré liked to say, “I operated on him, God healed him”. Modesty never hurts anyone for a long period of time…
A crisis is not only a danger, but also an opportunity. If you run out of boiling oil, you can sob and leave the sick without help, or you can try to come up with something. Suddenly, something very interesting may turn out …
If you are a good specialist, your authority may be stronger than ideology. Paré’s professional reputation saved him even during St. Bartholomew’s Day massacre. However, it is even more correct not to arrange Bartholomew’s Days. Never ever.
All illustrations from open sources
