HISTORICAL VIGNETTES IN VASCULAR SURGERY
James O. Menzoian, MD, SECTION EDITOR
Ambroise Pare: Barber vascular surgeon
Steven G. Friedman, MD, MBA, Lake Success, NY
For his work in forensic pathology, pioneering surgi-
cal techniques, battlefield medicine and wound care,
and developing new surgical instruments, Ambroise
Paré is the best known of the barber surgeons and
has been called the father of modern surgery (Fig 1).
Although Paré was not the first to use a vascular liga-
ture, as he is commonly credited, he promoted it
more than any of his predecessors and contempo-
raries. He also developed what was likely the first
vascular clamp.
We know that the Worshipful Company of Barbers, one
of the livery companies of London, has been in existence
since at least 1308. Archival records in the Guildhall
Library inform us that:
RICHARD LE BARBOUR, dwelling opposite to the
Church of Allhallows the Less, was chosen and
presented by the barbers of London on Tuesday,
next after the feast of Saint LUCY the Virgin, in
the second year of the reign of KING EDWARD,
son of KING EDWARD before NICHOLAS DE
FARNDON, then Mayor of London, JOHN DE
WENGRAVE, and other aldermen, to have supervi-
sion over the trade of the barbers.
In 1163, Pope Alexander III issued a decree that
prohibited members of religious orders from spilling
blood. Because of their dexterity with scissors and razors,
barbers began to aid monks in their traditional role as
physicians. In addition to shaving and haircutting,
barbers began performing bloodletting, which was the
treatment of almost all maladies for nearly three
millennia, until the late 19th century. Barbers also per-
formed incision and drainage of abscesses and cysts,
neck manipulation, tooth extraction, enemas, and fire
cupping. Surgeons with little experience in shaving and
haircutting also joined the barbers’ company, but in
1368, surgeons formed their own guild. In 1540, Henry
VIII merged the Fellowship of Surgeons with the
Company of Barbers, to form the United Company of
Barbers and Surgeons. The parliamentary act that led
From the Weill Cornell Medical College.
Author conflict of interest: none.
Correspondence: Steven G. Friedman, MD, MBA, Division of Vascular Surgery,
Weill Cornell Medical College, 1300 York Ave, New York, NY 10065 (e-mail:
sgfmd55@gmail.com).
J Vasc Surg 2018;68:646-9
0741-5214
Copyright Ó 2018 by the Society for Vascular Surgery. Published by Elsevier Inc.
https://doi.org/10.1016/j.jvs.2018.04.053
646
to this merger specified that surgeons could not perform
grooming and barbers could not operate. Their only
common procedure was tooth extraction. (Note the
similarities between dental and barber chairs today.)
The barber pole, with its red (for bloodletting) and white
(for bandages) stripes, was used to promote the barber
surgeon trade. Barbers maintained preeminence and
commanded higher pay until surgeons began caring
for injured seamen aboard British war ships. In 1745,
King George II separated the two groups and surgeons
formed the Company of Surgeons, which became the
Royal College of Surgeons in 1800.1
Little is known about Paré’s early life. He was born in
Bourg-Hersent (now Laval), France, in 1510. Alternate
possible birth years are 1516 and 1517. Various accounts
suggest that Paré’s older brother and brother-in-law
were barber surgeons, so it is likely he did apprentice-
ships with them.2,3 It was vital that early practitioners of
medicine and surgery obtain apprenticeships because
these were the only ways to gain clinical experience
and training. From 1532 to 1535, Paré studied anatomy
and surgery at the Hotel Dieu in Paris. Despite the
relatively recent invention of the printing press, and
the scarcity of textbooks, Paré became acquainted with
the work of Guy de Chauliac, a renowned barber surgeon
of the previous century.3
The widespread introduction of firearms during the
16th century radically altered the landscape of conven-
tional warfare in Europe. Extensive soft tissue damage,
contamination from embedded projectiles, and the
need for limb amputations increased dramatically. Paré’s
first experience with war and gunshot wounds came in
1536 during the French expedition to Turin. Paré joined
his patron, René de Montejan, commander of the French
infantry, and quickly concluded that the accepted
method of cauterizing gunshot wounds with boiling oil
was ineffective and inhumane:
The soldiers within the castle, seeing our men
come on them with great fury, did all they could
to defend themselves, and killed and wounded
many of our soldiers with pikes, arquebuses, and
stones, whereby the surgeons had all their work
cut out for them. Now I was at this time a fresh-
water soldier; I had not yet seen wounds made
by gunshot at the first dressing. It is true I had
read in John de Vigo, first book, Of Wounds in
General, eighth chapter, that wounds made by
firearms partake venomosity, by reason of the
powder; and for their cure he bids you cauterise
Journal of Vascular Surgery
Volume 68, Number 2
Fig 1. Ambroise Paré (courtesy of Wiley).
them with oil of elders scalding hot, mixed with a
little treacle. And to make no mistake, before
I would use the said oil, knowing this was to bring
great pain to the patient, I asked first before I
applied it, what the other surgeons did for their
first dressing, which was to put the said oil, boiling
well, into the wounds, with tents and setons;
wherefore I took courage to do as they did.4
Paré’s oil supply eventually ran out and he resorted
instead to a dressing made with egg yolks, rose oil, and
turpentine. That evening he slept fitfully:
In the night I could not sleep in quiet, fearing
some default in not cauterizing, that I should
find the wounded to whom I had not used said
oil dead from the poison of their wounds; which
made me rise very early to visit them, where
beyond my expectation I found that those to
whom I had applied my digestive medicament
had but little pain, and their wounds without
inflammation or swelling, having rested fairly
well that night, the others, to whom the boiling
oil was used, I found feverish, with great pain
and swelling about the edges of their wounds.
Then I resolved never more to burn thus cruelly
poor men with gunshot wounds.4
Paré heard about a surgeon who had created another
concoction for dressing gunshot wounds and he avidly
sought him:
Friedman 647
While I was at Turin, I found a surgeon famed
above all others for his treatment of gunshot
wounds; into whose favour I found means to insin-
uate myself, to have the recipe of his balm, as he
called it, wherewith he dressed gunshot wounds.
And he made me pay my court to him for two
years, before I could possibly draw the recipe
from him. In the end, thanks to my gifts and pre-
sents, he gave it to me; which was to boil, in oil of
lilies, young whelps just born, and earth-worms
prepared with Venetian turpentine. Then I was
joyful, and my heart made glad that I had under-
stood his remedy, which was like that which I had
obtained by chance.
See how I learned to treat gunshot wounds; not
by books.4
At one point, a senior surgeon was overheard to have
told Montejan about Paré:
Thou hast a surgeon young in age, but he is old in
knowledge and experience: take good care of
him, for he will do thee service and honour.5
Upon the death of Montejan in 1539, Paré returned to
Paris where he was now able to pay for licensure and
gain acceptance into the French Company of Barber
Surgeons. A few months later, he married Jean Mazelin,
the daughter of a wine merchant, with whom he had
three children. Paré also visited the famous physician,
Jacques de Bois, who encouraged him to write about
his experiences treating gunshot wounds. The outbreak
of war with Spain, however, delayed this because Paré
accompanied the Vicomte de Rohan in Perpignan,
Hainaut, and Landrecies.
Paré returned to Paris the following year where he pub-
lished his first book, The Method of Curing Wounds
Made by Arquebeques and Other Firearms, in 1545. The
book provoked a strong reaction from the medical com-
munity in Paris because it represented an attempt by
barber surgeons to raise their status. Physicians viewed
these efforts as a threat to their prestige and power. Never-
theless, it was the barbers even more than the physicians
and surgeons, who raised the bar in the study of
anatomy and the practice of surgery. In that same year, a
surgeon, Estienne de la Rivière, prevailed in a suit for
plagiarism against Charles Estienne, a respected Professor
of Medicine.6
Paré served in many campaigns including Boulogne in
1545; Germany, Danviliers, Chateu le Comte, and Metz
in 1552; Hesdin in 1553; Saint Quentin in 1557; Amiens
in 1558; Bourges and Rouen in 1562; Havre de Grace in
1563; Bayonne in 1564; Saint Denis in 1567; and Montcon-
tour and Flanders in 1569.4 It was in Metz, in 1552, that
Paré began to ligate blood vessels during amputations.7
Charles V had laid siege to Metz and the nobles of the
648 Friedman Journal of Vascular Surgery
August 2018

Fig 2. Paré’s bec de corbin (courtesy of Wiley).

Fig 3. Paré uses a ligature during an amputation (courtesy

of Wiley).
Fig 4. Paré examines a wounded soldier (courtesy of Wiley).

city were determined to hold out at all costs. The mortal-

ity among the wounded was high and a request was sent
to Henry II for Paré, along with a fresh supply of drugs. It
was feared that the drug supply used for dressings in
Metz was poisoned. Paré was smuggled through enemy
lines by an Italian captain who was paid 1500 crowns.
Paré later wrote:
God guided our business so well, that we entered
into the town at midnight, thanks to a signal the
captain had with another captain of the company
of M. de Guise; to whom I went, and found him in
bed, and he received me with high favour, being
right glad at my coming.
My belief is that there was no poison; but the se-
vere cutlass and arquebus wounds, and the
extreme cold, were the cause why so many died.4
used this method of closing the veins and arteries
in recent wounds several times in a case of hem-
orrhage, I thought that it could be done also in
the removal of a limb. I conferred about this
with Estienne de la Riviere, King’s Surgeon-in-
Ordinary, and other Sworn Surgeons of Paris,
and on having disclosed my opinions to them,
we decided to try it on the first patient who
offered himself, keeping the cautery ready for
use as did everyone else, in place of a ligature.
This I have practiced thus many times with very
good results, even a few days ago in the care of
Pirou Garbier, a Postillion of M. Brusquet, whose
right leg was removed four fingers below the
knee for a mortification which had developed
because of a fracture.4

Paré soon got to try his new method of blood vessel

ligation during an officer’s leg amputation. He used the
first arterial forceps or hemostat (his bec de corbin or
crow’s beak; Fig 2) to grasp major arteries and veins,
and a threadlike wire to ligate them (Fig 3). The case
went well and Paré remarked that the officer returned
home gaily with a wooden leg, having gotten off cheaply,
without being miserably burned to staunch the
bleeding. Here is his account:
Galen wrote that it is necessary to tie the vessels
toward their root, which are the liver and the
heart, to staunch a great influx of blood. Having
Despite Paré’s continued success with his new methods,
he battled his contemporaries for years to replace cautery
with ligation for the treatment of bleeding. He was also
resented and maligned by physicians owing to his
growing fame.
In 1554, Paré was admitted as surgeon to the Confra-
ternity of Saint Cȏme although he did not know Latin.
The confraternity was an academic organization of bar-
bers and surgeons that was eventually subsumed by
the University of Paris. Statutes required that a candi-
date for surgeon be examined in Latin, so it was
remarkable that Paré was exempted from this
Journal of Vascular Surgery
Volume 68, Number 2
requirement. On December 18 of that year Paré was
made a master, and the Faculté of physicians
remained strangely quiet. The Faculté was composed
of academics and practitioners of medicine who
looked down upon barbers and surgeons. Oddly
enough, it was the barbers, not the surgeons, of the
confraternity, who led efforts to raise the level of prac-
tice in anatomy and surgery. In 1573, Paré remarried
(his first wife had died) and when Henry III succeeded
Charles IX, Paré not only remained premier surgeon
to the new king but advanced to the rank of valet-de-
chamber and conseiller.8
Paré eventually authored more than 10 books on anat-
omy and wound treatment, as well as a wartime
memoir: Journeys in Diverse Places.5 These were gath-
ered together in 1575, in The Works of Ambroise Paré
and disseminated throughout the world, despite legal
attempts by members of the Faculté to stop it. This
attempt was born of the intense rivalry between
physicians and surgeons and had no legal basis. Paré
was a military surgeon for 30 years (Fig 4) and served
four successive kings of France (Henry II, Francis II,
Charles IX, and Henry III). Paré saved many hundreds
of lives and he personally survived a bout of plague
and a viper bite. He also made contributions to obstet-
rics, forensics, and the design of limb and ocular
prostheses.
Despite the civil wars raging throughout France, Paré
spent his final years quietly living in Paris. Paré died on
August 29, 1590, 4 months after the siege of Henry IV
was lifted. Despite harboring many of the prejudices
of his time, Paré was an acute observer, highly reason-
able and intelligent, and willing to break with the
Friedman 649
dogma of the past. In his own humble way, he was an
early practitioner of evidence-based medicine and a
product of the Renaissance more than any other
surgeon. In the final paragraph of his memoir, he
explained:
I have published this Apologia, that all men may
know on what footing I have always gone: and
sure there is no man so touchy not to take in
good part what I have said. For I have but told
the truth: and the purport of my discourse is plain
for all men to see, and the facts themselves are my
guarantee against calumny.5
REFERENCES
1. Dobson J, Walker RM. Barbers and barber-surgeons of Lon-
don: A history of the Barbers’ and Barber-Surgeons Com-
panies. Oxford: Blackwell Scientific; 1979.
2. Ambroise Paré, “A Surgeon in the Field”. In: Ross BJ,
McLaughlin MM, editors. The Portable Renaissance Reader.
New York: Viking Penguin; 1981.
3. Paré A In: Packard FR, editor. Life and times of Ambroise Paré,
1510e1590. Lenox, MA: HardPress; 2013.
4. Paré A. Ten books of surgery with the magazine of the instruments
necessary for it. Athens: University of Georgia Press; 1969.
5. Paré A. Journeys in diverse places. Scientific Papers: Physi-
ology, Medicine, Surgery, Geology: V38 Harvard Classics. Bos-
ton: Harvard University Press; 1910.
6. Paget S. Ambroise Paré and his times, 1510e1590 (Classic
Reprint). London: Forgotten Books; 2017.
7. Hernigou P. Ambroise Paré II: Paré’s contribution to ampu-
tation and ligature. Int Orthop 2013;37:769-72.
8. Hamby WB. Amboise Paré, surgeon of the Renaissance. St.
Louis: WH Green; 1967.
Submitted Jan 18, 2018; accepted Apr 20, 2018.