Introduction

Ballistic wounds are those attributed to trauma from firearms. Worldwide, these injuries resulted in approximately 270,000 deaths in 2016 alone.¹ In the United States, there have been a recorded 300,000 deaths from firearm-related injuries in the last decade.² However, the Centers for Disease Control and Prevention (CDC) report that 66% of individuals with these injuries do not die as a result. For these individuals, a multidisciplinary approach dependant on wound location and severity, along with proper rehabilitation, is imperative.³ With the impact and care of these wounds in mind, an understanding of how certain practices arose can put into perspective how care is delivered today.

Ballistic Wounds Through the Lens of History

Despite its cruelty, war can offer the opportunity to improve medical care. The frequent military conflicts in Europe during the Renaissance period provided many opportunities. The use of gunpowder ushered in the age of ballistic warfare and with it, a new challenge for military physicians and surgeons.

Medicine in general was still largely under the influence of the Humoral Theory, as proposed by Claudius Galen from the Roman era. Bloodletting and purging were still the first-line treatment for almost any ailment. As the centuries progressed, the old dogma was questioned by those who embraced innovation.

In the Galenic fashion, the standard treatment for ballistic injuries was to cauterize the wounds with boiling oil.⁴ It was believed that gunpowder poisoned the wounds, and the only cure was this caustic and agonizing treatment method. Quite frankly, it did more harm than good. The mortality rate for a wounded soldier of this period was high due to detrimental remedies coupled with the inability to combat infection.

The Father of Military Surgery: Improving Standard of Care

French military surgeon Ambroise Paré (c. 1509-1590) noticed the poor outcomes of patients who were treated with boiling oil, including fever and eventually death.⁵ To alleviate suffering and loss of life, he applied a mixture of egg yolks, turpentine, and rose oil to the wounded body part instead of the old standby (hot oil).⁴

Paré was pleasantly surprised at the improved condition and general survival rate following his new topical regimen. He published his Treatise on Gunshot Wounds in 1545.⁵ The development of new surgical instruments to address ballistic injuries was crucial for success, and Paré had an inventive streak! He designed both the bec de Gruë (crane’s beak) and bec de Cane (duck’s beak) forceps, with thin blades designed for efficient bullet extraction in deep wounds.⁴ During this period, he also challenged the accepted protocol for treating fresh limb amputation sites with boiling oil to stop bleeding. Instead, he was a staunch advocate for the use of ligatures to tie off blood vessels resulting in much improved and less painful clinical outcomes.⁴

Paré was born of humble origins and thus went the path of the barber-surgeon, as medicine was still stratified by class, with surgery seen as a trade rather than an academic profession.⁵ During his barber-surgeon apprenticeship, he performed haircuts and shavings while also learning phlebotomy.⁴ The perceived lower-class stigma and trouble with mastering Latin did not hold him back from clinical excellence. He embraced the principles that a surgeon should be skillful, educated, merciful, kindly to the sick, and honorable while rendering care for patients, regardless of their ability to pay.⁵ These values were put forth by his predecessor, Guy de Chauliac (c. 1300-1368), a famous French surgeon of the Middle Ages.⁴ His modesty is reflected in his famous quote “Je le pansai, Dieu le guérit” which translates to I bandaged him, God cured him.⁴

Paré’s skill and gentle manner did not go unnoticed, as he was appointed personal master surgeon to 4 French kings spanning 30 years.⁵ He also developed a lifesaving clamp called a bec de Corbin (crow’s beak), to control bleeding from penetrating neck wounds that were often fatal.⁴

Conclusion

Ambroise Paré is considered the father of military surgery for his innovations that have helped shape the practice of modern wound healing and technique. With his introduction of various forceps and the use of ligatures, Pare not only saved patients' lives but also improved their quality of life. Paré’s legacy and patient-centered philosophy have truly stood the test of time.

References

1. Ditkofsky N, Nair JR, Frank Y, et al. Understanding ballistic injuries. Radiol Clin North Am. 2023; 61(1):119-128. https://doi.org/10.1016/j.rcl.2022.08.005
2. Eze A, Leraas H, Eze O, et al. Factors associated with discharge to skilled nursing facility following gunshot wounds. J Surg Res. 2024; 294:1-8. https://doi.org/10.1016/j.jss.2023.08.059
3. Stewart S, Tunstall C, Stevenson T. Gunshot wounds in civilian practice: a review of epidemiology, pathophysiology and management. Orthop Trauma. 2023; 37(4):216-221. https://doi.org/10.1016/j.mporth.2023.05.002
4. Tanner AM, Weissler MC. Ambroise Pare: The gentle barber-surgeon. The American College of Surgeons. 2017; 52–55. 
5. Packard FR. Life and Times of Amroise Pare, 1510-1590. Paul B. Hoeber, Inc; 1926:

About the Author
Christine Miller, DPM, PhD is a certified wound specialist by the American Board of Wound Management and a Fellow of the American College of Clinical Wound Specialists. She currently serves as the Co-Director of the Limb Salvage Program at the University of Florida, College of Medicine-Jacksonville.