Pierre Franco (1505–1578)

Pierre Franco was a surgeon in Europe in the sixteenth century who developed a variety of surgical procedures, including some to repair hernias, cleft lips, and bladder stones. A hernia occurs when an internal organ protrudes through a weak spot in a muscle or tissue, typically in the abdomen, which can cause severe pain, nausea, and vomiting. A cleft lip is a congenital abnormality where the tissues of the upper lip and roof of the mouth do not form properly as the fetus develops during pregnancy, causing problems with eating and speaking. Bladder stones are hard masses of minerals that build up from a person’s urine and form in their bladder, often causing pain or bleeding during urination. Franco described the congenital origin of the cleft lip and was one of the first to develop a repairing procedure for hernias without the removal of genitals. As of 2024, surgeons have continued to innovate upon many of Franco’s surgical procedures, including those to repair hernias and cleft lips, to help children born with congenital defects and other patients in need of surgery.

1. Early Life and Education
2. Religious Persecution
3. Professional Career
4. Married Years
5. Legacy and Impact

Early Life and Education

According to Arthur Joseph Barsky, a plastic surgeon who wrote about Franco, researchers know little about Franco’s family, ancestry, and early life. However, both Barsky and Kostas Markatos, a surgeon who studies the history of surgery and also wrote about Franco, claim that Franco was born around 1505 in Turriers of the Haute-Provence in France. Barsky claims that, in the sixteenth century, records often referred to the name Franco as Franc, Francou, Francoul, and Franccone. Thus, he speculates that much of Franco’s familial information may be hidden behind those other names, which could explain why researchers cannot find much information about Franco’s life.

Around 1526, when Franco was around twenty years old, he began his surgical training. Barsky writes that barber surgeons, operators, apprentice clerks, and army surgeons were the forefathers of modern surgery. Franco was an operator, or a surgeon of a low rank, many of whom worked as urologists, surgeons who operate on the urinary tract, herniotomists, surgeons who operate on hernias, or ophthalmologists, surgeons who specialize in eye care. Barsky mentions that Franco’s rank as a provincial operator was lower and less prestigious than that of his colleague and mentor, Ambroise Paré, a French military barber surgeon trained in the hospital and in the field. Barber surgeons were surgeons skilled in both haircutting and surgery and often were responsible for taking care of soldiers. Apprentice clerks are trainees preparing to become surgeons under the guidance of an experienced surgeon. Franco’s training was a combination of observations and experience with surgeries. Franco also learned through an apprenticeship with a hernia surgeon. However, Franco perfected his techniques by reading books, teaching himself to be ambidextrous, and practicing on cadavers and animals.

Religious Persecution

Franco worked in France after he completed training, but in 1541, he left due to religious persecution against protestants and took refuge in Switzerland, where he practiced surgery in the cities of Bern and Lausanne. Franco lived through the Protestant Reformation, which was a religious reform movement that began in 1517 in Europe and led to a group of religious followers, later called Protestants, to separate from the Roman Catholic Church. During the Protestant Reformation, King Henry VIII, who reigned in England from 1509 to 1547, executed Protestants under heresy laws. Reformation therefore caused many people to migrate to foreign places for religious freedom. Franco practiced the Protestant faith, and Barsky attributes the statements Franco often made in his books about praying before performing surgery, God guiding his work as a surgeon, and serving God through his noble work to his strong religious beliefs. Researchers used payment records from Franco’s surgical work as a source for tracking his moves.

Professional Career

In 1556, while still working in Bern and Lausanne, Franco published his first book, Petit Traité Contenant une des Parties Principalles de Chirurgie Laquelle les Chirurgiens Herniaires Exercent, (A Small Treatise Containing one of the Principal Parts of Surgery as Practiced by Hernia Surgeons), hereafter Petit Traité. According to Rosenman, he did so to provide a resource for surgeons who he felt were not operating adequately. He directed his book toward herniotomists, the people who perform hernia surgery, lithotomists, the surgeons who remove kidney, bladder, or gallbladder stones, and cataract surgeons, those who perform operations on the eyes. According to Rosenman, Franco thought that many practitioners were malicious, motivated by money, and ignorant, which he claimed caused complications during their procedures. Franco argued that those practitioners often inflicted harm on their patients, causing them to die, and then ran away to escape punishment. Thus, he wrote his book to teach the practitioners how to better treat their patients. According to Rosenman, Franco also intended for the book to improve the status of operators and cutters because in it he described relevant surgical matters that other, more respected, medical professionals had not published on before.

Petit Traité was a medical handbook that described many of the operations Franco had performed in his thirty years of practice, including some on hernias. Franco wrote about various types of hernias and the complications of intestinal hernias. Before Franco, the most common way to perform a hernia repair entailed removing a person’s genitals, including their testicles. According to Rosenman, Franco recognized the importance of doing hernia repair procedures without removing the genitals even though knowledge on human anatomy was not yet well developed, so he demonstrated a way to perform a hernia repair while conserving the testicles.

Another one of the main descriptions Franco provided in Petit Traité was on the congenital origin of cleft lip and palate and their surgical repair. Surajit Bhattacharya, a plastic surgeon in Lucknow, India, states that Franco was the first to describe the congenital nature of cleft lip, meaning he was one of the first to recognize that the condition is present from birth. Before Franco’s description, people in the sixteenth century thought that accidents were the cause of cleft lips. More specifically, according to Bhattacharya, many people during that time thought that children with cleft lips harbored evil spirits. Surgeons can repair cleft lips and palates through procedures called cheiloplasties and palatoplasties, respectively, and surgeons typically perform them on infants within the first year of their life. Though the first documented cleft lip surgery was as early as 390 BC in China, Barsky indicates that Franco was one of the first to publish a text describing how to perform a cleft lip repair.

In addition to his discussion of hernias, cleft lips, and bladder stones in Petit Traité, Franco also outlined many other procedures that he performed, including some related to amputations, childbirth, and cataracts, which occur when the lens of the eye becomes cloudy. For example, he described that during cataract surgery, he used the couching technique with a needle, and would push the lens of his patient’s eye up when he could not dislodge it to get the proper view and angle of the cataract. Franco also noted how he would position patients while he performed surgeries and some post-operative care instructions regarding his recommendations for the patient’s diet.

Also in 1556, Franco performed one of the first suprapubic incision surgeries, called a suprapubic lithotomy, using what researchers later named the Franconian technique after Franco. A suprapubic lithotomy is a surgery to remove bladder stones, which are hard masses of minerals that build up from a person’s urine and form in their bladder. Franco performed the suprapubic lithotomy on a child in 1556 to remove a stone the size of a hen’s egg from their bladder. In Rosenman’s translation of Franco’s work, Franco stated that he invented the Fondamental and modified the invention of the Four-in-the-bladder, both of which are instruments that he used to remove his patient’s bladder stones. Markatos describes that Franco also invented the forceps used for that suprapubic lithotomy, which he used to immobilize the stone, and the pincers, which he used to crush, grasp, and extract the stone from the bladder. However, Franco cautioned surgeons against his suprapubic incision due to the dangers and lack of experience. Surgeons have since developed his suprapubic lithotomy into a less invasive procedure.

Married Years

Franco returned to France and married Clauda Borrel around 1561 when Barsky claims there was a brief relaxation of religious persecution. His wife was much younger than Franco as she was still a minor in 1554, just seven years before she married him, whereas Franco was in his fifties at the time. Barsky notes that their marriage was a sign of Franco’s rising status in the world because Borrel belonged to the old nobility of Dauphiné, which is a region in Southeastern France.

Franco published his second book Traité des Hernies et Autres Excellentes Parties de la Chirurgie Assavoir la Pierre (Treated Hernias and Other Excellent Parts of the Stone Assuring Surgery) in 1561 when he was living at Orange, a commune in France. According to Markatos and his team, Franco’s second book was more developed than his first. Franco included chapters on anatomy, medicine, pharmacology, and added information from other writers. Adding on to his previous book, Franco meticulously described the surgical correction techniques for both unilateral and bilateral cleft lips. As in his first book, he provided many details about his personal experiences performing each of the operations and recommended techniques.

In 1562, Franco experienced further religious persecution and his payment records show that he moved from France once again. Conflicts between Catholics and Protestants in France began the French Wars of Religion in 1562, in which Catholic troops massacred Protestant citizens and burned Orange. Researchers have found more references and proof of payment to Franco from the cities of Bern and Lausanne dated after the Protestant massacre, alluding to his move out of France and back to Switzerland. Based on the payment records that researchers found, Franco’s annual salary in Switzerland as a surgeon was as high as that of a physician, which Barsky reports was indicative of his reputation and accomplishments. In 1577, Franco created a will, indicating that he was alive, but a 1582 archive entry referred to Borrel as Franco’s widow. So, researchers know that he died before then. Researchers assume that Franco did not have any children because his will did not mention any children.

Legacy and Impact

According to Markatos, many individuals consider Franco to be the most influential surgeon of the sixteenth century after his colleague, Paré. Barsky writes that Franco and Paré drew lessons from each other, and their contributions to medicine complemented each other. For example, Franco benefited from Paré’s work in obstetrics and Paré learned from Franco’s work on hernias and urology. Bhattacharya states that Paré was one of the first to illustrate the suturing method surgeons like Franco used during their cleft repair operation. In comparing Franco and Paré, Barsky argues that while Paré’s publications had more of an impact, Franco was more original. Franco received less glory and recognition for his contributions and professional skills than Paré, but Barsky confirms that the contributions of both men played a large role in the rise of modern surgery during the sixteenth century.

Franco’s surgical descriptions have influenced the procedures that others have performed since he published on them in the 1550s and 1560s, and surgeons still perform procedures to repair cleft lips and hernias and remove bladder stones as of 2024. During his time, Franco was willing to perform technical operations that required extensive surgical skills even though some well-known surgeons in France would not perform them due to fears of surgical complications that could be lethal. As of 2024, the Centers for Disease Control and Prevention reports that one in every 3,600 children in the US are born with diaphragmatic hernia, and one in every 1,600 children in the US are born with cleft lip with cleft palate. Surgeons commonly help treat such conditions using procedures partially derived from Franco. For example, Rosenman states that he suspects that during hernia repairs, Franco used his own variation of a hemostatic clip, which surgeons use as of 2024 to prevent bleeding in the gastrointestinal tract. In his books, Franco also correctly described that patients should purge, or empty their bowels, before undergoing an operation, which is similar to current preoperative requirements of patients not eating or drinking before their surgery. To some degree, surgeons also use various other ideas, techniques, and tools that Franco used during the sixteenth century.

However, surgeons have also adapted some of Franco’s surgical techniques to be more conducive to modern times. For instance, surgeons in the nineteenth century adapted his cleft surgery techniques to require less cutting and suturing to reduce scarring. The invention of surgical mesh in the twentieth century, which surgeons insert into the body through a small incision to support the weakened or damaged tissue around the hernia, has aided hernia surgical advancements. While Franco contributed to cleft lip operations during the sixteenth century, it was not until the early nineteenth century that surgeons could consistently and successfully repair a cleft palate, which entails fixing the opening or split in the roof of the mouth. The introduction of anesthesia in 1846 allowed advancements in cleft procedures by preventing patients from feeling pain during surgery. Additionally, surgeons have found ways to perform cleft surgeries earlier in children’s lives, and they do so in a manner that reduces long term scarring, leading to better patient outcomes. Advancements in imaging technology have also allowed medical professionals to prenatally diagnose clefts, which was not a possibility during Franco’s time.

Franco lived during the Renaissance, a period in European history that took place from the fourteenth to the seventeenth century, and his surgical techniques are some of the many influential innovations from the time. During that period, artists, researchers, doctors, and scientists made many new contributions to their respective fields. Jessica Webster, a professor at Baruch College, in New York, New York, notes that the contributions that emerged during the Renaissance have produced a lasting influence on art, science, literature, philosophy, and more. Franco’s surgical innovations are among those contributions, and according to Georges Androutsos, a researcher who wrote about various aspects of medical history, Franco is a seminal surgeon of the Renaissance era and a pioneer in the field of urology. Although the medical field has evolved, Markatos and his colleagues highlight that Franco made many innovative and original contributions to medicine during his time, some of which have endured as of 2024.

Franco died in Lausanne in 1578.