Go back to article: Wounded: ‘They had no fever…’ Ambroise Paré (1510–1590) and his method of gunshot wounds management
Early methods of treating gunshot wounds
Medical practitioners in medieval Europe accumulated significant experience in treating wounds (Tracy and DeVries, 2015). However, all the accepted skills became ineffective in the face of a new challenge – the invention of the firearm.
Today, the most revolutionary method of gunshot wounds management is mainly attributed to the French surgeon Ambroise Paré (1510–1590) (Dumaȋtre, 1986), royal surgeon to four kings of France (Henry II, Charles X, Henry III and Henry IV). Paré practiced as a battle-field surgeon in the last Italian wars (1542–1546 and 1551–1559) and in the Religious wars in France (1562–1598) so he experienced first-hand the urgent need to find a way to treat this entirely new type of wound. In this paper we will discuss the context in which his treatment was developed and we will analyse how his methods were received by Paré’s contemporaries and their place in the development of contemporary surgery.
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Portrait of Ambroise Paré
Though the first use of firearms in Europe took place in the battle of Crécy in 1346, there were not many guns in existence at this time, and they were not used regularly in military conflict before the second half of the fifteenth century (Chase, 2003). Although the range of these early firearms was no more than 15 metres and firing accuracy left much to be desired, a bullet could still punch through metal armour and was more deadly than an arrow from a crossbow. An important feature of gunshot wounds was the kinetic impact of the hot bullet. In addition, lead bullets shattered when hitting a target (armour, clothes or a body) and the damage caused often spread wider than the diameter of the entry wound. Foreign bodies which got into the wound channel (mostly fragments of clothes) caused inflammation, suppuration, then sepsis and death.
Kelly DeVries argues that medieval surgeons practiced two different ways of curing wounds. One was cauterisation with a hot iron, but the second method (recommended by Henri de Mondeville, a fourteenth-century French royal surgeon, among others) was to cleanse the wounds with balm or ointment (DeVries, 1990, pp 135–137). Both methods were widely used for treating patients and we do not know exactly how effective they were, but the advent of firearms created new tasks for military surgeons. Mortality from gunshot wounds was much greater than that inflicted by steel weapons; extraction of bullets and foreign bodies, such as chards of cannonballs, had a greater effect on the body than the extraction of an arrow. Nevertheless, only a few surgeons of this period conceptualised gunshot wounds as being of a different nature to the wounds made by cold steel.
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Bullet extractor, made of steel and brass, Europe, 1501–1600
As there was no ancient tradition to explain the mechanism of this kind of wounding, it became necessary to look for new explanations. In 1497, a German surgeon, Hieronymus Brunschwig (1450–1533), published The Book of treating gunshot wounds (Buch der Wund Artzney) (Brunschwig, 1497). He was probably the first to argue that gunshot wounds were poisoned. Saltpetre, an integral part of gunpowder, was already considered a poison, and Brunschwig also argued that the appearance of gunshot wounds was reminiscent of the wounds caused by poisoned arrows or the bites of mad dogs and poisonous animals. It was Brunschwig who suggested that such wounds be treated with cauterisation, following the practice of ancient physicians when treating poisoned injuries and continuing the belief that fire would halt the effects of poison (Sigerist, 1946; Shane Tubbs et al, 2011).
Brunschwig’s reasoning seems to be typical of the time: death that could not be explained by medical practitioners was often understood to be the result of poisoning (Collard, 2003). According to this theory, the common symptoms of gunshot wounds such as fever, physical debility, a blue hue to skin, vomiting and mental confusion, were all explained as the effects of ‘poison matter’ penetrating the body together with the bullet and gunshot powder.
Brunschwig’s treatise was written in German and was not translated into Latin or any other language. Thus, it was not familiar to French surgeons. It is worth noting that in the sixteenth century, Latin ceased to be the lingua franca of scientific communication, as vernacular languages were increasingly adapted (Olschki, 1927). In one sense this increasing vernacularisation of surgical texts increased the spread of knowledge since they could now be accessed by non-university educated medical practitioners (Siraisi, 2001, pp 37–49). In sixteenth-century France, for example, the members of the surgical community Saint-Côme published their textbooks in French, thereby raising the status of their profession in France. (Brockliss, Jones, 1997, p 104). However, this trend also limited the audience of a particular text to a linguistic region. Without access to Brunschwig, most European surgeons learned about the method of cauterisation of gunshot wounds through the writings of Giovanni da Vigo (1450/60–1525) whose book Practice and Surgery (La Practique et Cirurgie, 1542) became the medical bestseller of the sixteenth century. Da Vigo’s work was published in Latin, French, German, Italian and English for almost two centuries and was thus very widely available. The last edition appeared in 1713.
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De Vigo en françoys: s’ensuit la practique et cirurgie, Lyon: Benoist Bounyn, 1525
Da Vigo argued (p 224) that there are three distinctive features of a gunshot wound: 1) mechanical lesion (contusio); 2) the burn from the hot bullet and gunshot powder (combustio); and 3) intoxication of gunshot powder (intoxicatio). The two first points were adapted and accepted, but it was with the concept of intoxicatio (or poisoning) that European surgeons struggled with in the sixteenth century.
Da Vigo’s recommendations followed the ancient medical principles in many respects (Mounier-Kuhn, 2006, pp 155–156). But in emphasising three different impacts, he argued that the management of a gunshot wound is much more complicated than the treatment of a blade weapon wound. While acknowledging that ancient surgeons had no experience of such injuries, da Vigo nevertheless resorted to the authority of Galen who taught that if a person experienced two or more illnesses at the same time, the medical practitioner was to treat the most dangerous. Considering intoxicatio a fatal danger, da Vigo prescribed treatment with hot liquids, for instance boiling olive oil. This method was based on the ancient tradition of curing wounds made with poisoned arrows. According to modern surgical practice, the perceived effect of high temperature liquids on the gunshot wound can be explained by the coagulation of tissues, which da Vigo and his contemporaries understood as stopping the absorption of poison or rendering the poison inactive while healing.
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J da Vigo, Whole worke..., 1586, and signature of W Clowes
Thus, da Vigo seems to have created the first theory-driven approach to curing gunshot wounds. He described the steps of gunshot wound management: the first one is cauterisation with boiling oil to stop the effects of gunpowder poison. The cauterisation provokes an iatrogenic burn, i.e. one caused by the treatment, which was understood to be less dangerous than poisoning. The next step was to treat the burn. For wound treatment after cauterisation, da Vigo recommended several remedies, for example a barley decoction with earthworms and a digestive potion of turpentine, rose oil and egg yolk.
Component DOI: http://dx.doi.org/10.15180/191105/002