Paré’s introduction of ligature also allowed him to amputate limbs damaged from other causes, and he appears to have been the first physician since Celsus to successfully amputate live limbs above the wound.22 Paré’s ligature, as important a medical advance as it was, worked primarily upon amputations below the knee that did not require tying off the femoral artery. Like most surgeons of his day, Paré had no experience in amputating above the knee, where his technique of ligature would have been almost useless in any case. In 1718, Jean-Louis Petit (1674–1750) introduced the screw tourniquet, which achieved temporary hemostasis in thigh and leg amputations by effectively compressing the femoral artery in the groin. His advancement helped reintroduce ligature in surgical amputations.23
MILITARY MEDICINE IN RENAISSANCE ARMIES
Paré’s most significant contribution was his military medical service to several monarchs, and his widely read medical writings raised the status of the battle surgeon and surgery to its highest point in medical history prior to modern times. The needs of kings and nobles for battlefield surgical skills in an age of almost constant warfare greatly aided his achievement; however, increasing medical knowledge and the status of the military surgeon did not greatly improve the medical care available to the common soldier. For the most part, medical care was not significantly different from what it had been in the Middle Ages. Paré and others certainly made attempts to deliver medical care to the common soldiery and regarded it as their duty to do so. But despite advances in medical knowledge, the nature of military medical care remained primitive as armies struggled to find ways to deliver care in a systematic manner. As had been the case for almost a millennium, medical care on the battlefield was still mostly limited to kings and nobles.
Renaissance armies were undergoing a state of transition, moving away from the decentralized and temporary feudal armies of the Middle Ages toward the emerging professional national armies that eventually came to characterize the seventeenth century. Renaissance armies were not yet sufficiently structurally articulated and formed as genuine national armies that could sustain themselves with permanent financial support from their national sovereigns. Consequently, armies of the period contained only the embryonic beginnings of a permanent military medical service to deal with casualties. Also working against the establishment of an effective field medical service was the use of mercenary contingents in the emergent dynastic armies. No national sovereign felt an obligation to tend to the casualties of hired troops. Death and maiming were simply the costs of doing business, and the contract soldier assumed the risk. Although the class structures of the Renaissance states were somewhat looser than those of the Middle Ages, the line between nobles, royals, and commoners were still strictly drawn. Obligations toward one’s fellows were limited to equals within the same class. The idea that medical aid should be extended to the common soldier had yet to take root.
In the meantime, the presence of military medical personnel on the battlefield became increasingly common, with the nobles and kings usually being attended by barber-surgeons while at war. The histories of this early period document a number of military surgeons who attended to the armies.24 The era’s first example of a semi-regular use of surgeons on the battlefields can be attributed to the Italian city-states, which seem to have employed surgeons for campaigns as early as the thirteenth century.25 Even earlier, some Italian states gathered groups of medical practitioners within cities under siege to provide medical support and to enforce hygienic regulations.
The Swiss were the first Europeans of the period to provide regular medical care to the common soldier, perhaps as early as the Battle of Laupen (1339).26 The Swiss considered themselves a union of free peoples in which the citizens’ worth and rights were recognized in law. Because they were a rural people scattered throughout mountainous country, central authority was difficult to maintain, forcing the citizens to rely upon one another. Accordingly, the idea of a citizen’s obligation to the state based on general reciprocal commitments was established early. This principle of citizenship fostered the state’s obligation to care for those citizen-soldiers who waged war to protect the community.
From 1339 onward, the records of Swiss towns and cantons are filled with accounts of public funds being disbursed to care for the sick, wounded, and damaged of war. Some Swiss public authorities commonly hired barber-surgeons to care for the wounded after battle.27 By 1405, all Swiss cantons had done so. Later, it became custom to pay the wounded soldier as long as the army remained under arms. In 1476, the archives note that all of the wounded’s living expenses should be paid out of the public purse. The Council of Lucerne passed an ordinance that the state should legally guard the property of children orphaned by war. If public officials were deficient in this task, the state was to make restitution to the soldier’s heirs. Most enlightened was the decree requiring that the state pay both for the indigent wounded’s medical treatment until they were fully recovered and for the family’s expenses of the wounded until the damaged soldier could return to work.28 After the war between Bern and the five Catholic cantons in 1533, sick and wounded war prisoners were allowed to return to their homes without ransom upon payment of the cost of living expenses and medical attention. The Swiss soldier became so accustomed to these military medical benefits that later, when Swiss armies hired themselves out for duty in the service of foreign kings, they routinely included provisions for the pay of medical services and veterans’ benefits in their contracts.29
In Swiss musters of this period, historians find the first use of the title feldscher, or “field-barber,” which generally was used to describe the barber-surgeon in the European armies until the present day.30 Medical personnel in Swiss armies even commonly bore arms and participated as combatants. They treated the wounded only after the battle. Swiss law required that wounded soldiers remain with their units and not seek safety from the fight under penalty of desertion. This injunction made good military medical sense. It prevented the soldiery from scattering all over the battlefield, making it much easier to locate and treat the wounded when the battle was finished.31 Further, until the middle of the sixteenth century, the victors frequently slaughtered the wounded at will. Wounded men staggering around the battlefield would have been easy prey in an age where the intensity of religious wars severely eroded basic mercy and humanity.
The Swiss military medical service was the first in the Renaissance period; it emerged in a military force recruited from a single nation state bonded by common feelings of national identity. Once other armies of the period began to recruit from their own people instead of hiring bands of mercenaries and thugs, it was to be expected that they would develop the outlines of a military medical service to treat the common soldier as well. Charles VII (1403–1461) of France was the first European monarch to attempt the creation of national forces when he established his compagnies d’ordonnance (units of national troops directly under the orders of the king). Henry VII of England (1457–1509) created a similar force in 1485 with his “yeomen of the guard.” Maximillian I (1459–1519) of Germany formed a similar national force, the famous Landsknechte (native-born soldiers), drawn from the citizenry. This army was further strengthened and enlarged under Charles V (1500–1556) into a truly national military force.32 For the first time in a millennium, Europe once again had a formal military medical service.
Leonhard Fronsperger described the organization of the Landsknechte, including its military medical support, in his treatise on Imperial Courts-Martial (1555), which Col. Charles L. Heizmann translated.33 The Landsknechte were aggregated into hauffen (units of five thousand to ten thousand men), which were divided into regiments consisting of ten to fourteen fahnlein (standard units of four hundred men each). A barber-surgeon was assigned to each of these units of infantry and to each troop of two hundred cavalry.34 Attached to each hauffen was a field physician in chief, who was responsible to the commander for medical support, and an additional field-barber. The chief marshal of
cavalry also had a physician under his command, and a surgeon was assigned to the artillery commander.35 The regulations clearly make providing medical support a command responsibility, and it ensured that medical supplies, surgical chests, and medical transport were given to the medical complement. The surgeon was required to sleep in the command tent so that he could be easily located should the wounded need attention. Medical personnel received double pay from public funds.36
The army also provided wagons to transport the wounded and sick. Each morning, the slightly sick and wounded were transported along with the army, and because no army of this period had yet established a system of military hospitals to tend the wounded, the more seriously ill and wounded were sent to whatever hospitals were in nearby towns. The troops contributed to a common fund out of which they paid a spital meister, or “hospital attendant,” delegated to look after the sick. When the army moved, couriers were dispatched to locate suitable quarters, including a house where the barber-surgeon could attend patients. In battle, the medical personnel were located with the rear guard, and their orders were to bring the wounded out of the line and find a safe place to treat them. As long as the army remained in the field, the wounded and sick continued to receive their pay.37
These regulations governing medical support represent at least the spirit of the new national sovereigns who were attempting to care for the common soldier drawn from the ranks of the citizenry; however, the system was still not very effective in practice. The armies were largely constituted from the dregs of society, and they did not conduct any medical examinations to exclude the mentally or physically unfit. Unlike the Swiss, these armies made no provisions to care for the wounded after military service. A wounded Landsknechte made his way home as best he could and survived upon his own resources, often nursed by one of the many female camp followers who attached themselves to the soldiery as wives and girlfriends.38 It was common practice to abandon the wounded, who were treated where they lay by bands of roving charlatans and cutters that followed in the wake of the army.39 The quality of these medical personnel was not likely to give the soldier much comfort. Surgeons and physicians who attended the officers and nobles were probably barber-surgeons with extensive empirical experience but little formal medical training. Those who treated the troops, however, ranged anywhere from the apprentice barber-surgeon who was seriously trying to learn his trade to crude army cutters or sow gelders. The army still impressed common medical practitioners into service, and most of them ended up treating the troops.
The increasing national character of the Renaissance armies stimulated the formation of medical services for the soldier in other armies of the period. In France, the armies of Charles the Bold, Duke of Burgundy, had a surgeon attached to every company of a hundred lancers or eight hundred infantrymen in addition to the personal physicians of the king and nobles. Edward IV of England (1442–1483) had a chief physician, two body physicians, a surgeon, and thirteen assistant surgeons on his staff.40 At the Battle of St. Quentin in 1557, the English Army had a total of fifty-seven surgeons at its service and established a rudimentary organizational structure of medical care that English authors often cite as the first instance in England’s history where a medical service was provided.41 In Italy, the republics of Florence, Venice, Naples, Ferrara, and Verona had small surgical units attached to their armies, and the galleys of the Genoese Navy had one barber-surgeon and one assistant barber attached to each ship’s complement of 210 men.42 In Spain, each infantry regiment had a physician and surgeon attached to it, and the armada had a hospital ship on which to treat casualties.43
These rudimentary medical establishments gradually grew in size and sophistication as the end of the Renaissance approached, and stationary military hospitals were founded and replaced the temporary field hospitals throughout the various European realms. The permanent structures opened the possibility of long-term care for the wounded. The idea of caring for disabled veterans had gained currency as early as 1318, when the Venetians established a home for disabled mariners. A century earlier, Louis IX (1214–1270) had founded an asylum for blind crusaders, and in the thirteenth century a charter was granted to the Chevaliers de l’Étoile (Knights of the Star) to care for the disabled.44 The earlier medieval hospitals to care for disabled soldiers had their roots in the Carolingian Dynasty (751–987), when the practice was to send the disabled to monasteries, convents, and churches and allow them to earn their keep by performing menial chores as lay brothers.45 By 1600, this system had been mostly abolished, and in 1605 the French replaced it with the Maison Royale de la Charité Chrétienne, where disabled soldiers were supported by whatever surplus could be extracted from the budgets of various charities.46 The idea of permanent care for the wounded, first used by the Roman Army, along with pension benefits did not emerge in full form until the modern era.47
It can be said that the continuous wars of the Renaissance increased the leadership’s concern for their common soldiers’ medical care, but this interest was balanced by the fact that the soldiery came from the lowest social orders, and in general the political and military leadership of the day was indifferent to the people’s welfare. Rudimentary, unsubstantial efforts at medical care were made, but the effect of the era’s advances in medical knowledge on the casualty rate was felt largely among the soldiery drawn from the higher social orders. Since military medical establishments of the time came in and out of existence as the press of war dictated, no corps of military medical professionals developed that could devote its full attention to improving medical care for the soldiery. Further, the degree of organizational articulation of medical support structures remained primitive throughout the period. Military medicine, as distinct from military surgery, for the most part remained dismally behind civilian medicine, which itself was in a less than exalted state.
Military medicine would have been more effective had the leadership given attention to field hygiene. Disease carried off more soldiers than weapons did in every war in history until modern times.48 Armies lost more combat power to temporary disablement due to illness than to any other cause. Controlling and preventing outbreaks of disease depended on advances in medical knowledge that did not occur until the nineteenth century. Moreover, commanders simply regarded the presence of disease and sickness in the army as a normal cost of war, since it had always been the case as long as anyone could remember.
Disease and illness were such common aspects of civilian life of the period that it is hardly remarkable that no one should have taken much note of it in military life. For centuries, for example, monastic orders had forbidden their members to bathe more than twice a year unless a physician ordered them to do so. Queen Elizabeth I (1533–1603) was horrified at the suggestion of washing herself all over more than once in a year.49 As noted earlier, the period saw a number of diseases become epidemic to the population, which commonly accepted death and illness as part of the natural order. The medical profession, having forgotten the old Roman notion of preventive medicine, could do little to prevent outbreaks of disease and even less to cure them once they were under way. Little wonder, then, that few commanders gave much attention to preventing disease and illness on military campaigns.
In Heizmann’s study of military sanitation and hygiene in the Renaissance, he notes that the proportion of sieges to battles during the period was 2 to 1, probably owing to the introduction of the new heavy artillery. Of the fifty-seven besieged towns studied, twenty-four were eventually reduced by assault, twenty capitulated, and in thirteen cases the siege was abandoned.50 In almost every case of capitulation or abandonment, one or both armies suffered heavy casualties from disease. In only a single instance, at the siege of Metz in 1552, can one find any attempt by military commanders to prevent disease. So uncommon were such attempts that the siege of Metz is regarded as the period’s high-water mark for military sanitation.
The siege provides an example of what happened when one army made attempts at military sanitatio
n and the other did not. Charles V laid siege to the town on October 20 with a force of almost 220,000 men going against the city’s force of fewer than 6,000 troops commanded by Francis, Duke of Guise. The besieging army conducted sanitary affairs as usual, and by December 26 it had lost more than 20,000 men to disease. The main killers were typhus, dysentery, and scurvy.51 Although the losses to disease were not unusually large as a percentage of force for that time, they were great enough to force Charles V to abandon the siege.
Within the walls of Metz, the Duke of Guise proved himself a first-rate medical officer who succeeded in keeping his losses to disease relatively low through applying basic rules of field sanitation. Guise increased expenditures for rations to ensure his troops ate well. Water points were checked for purity and placed under guard. Any soldier who fell ill was immediately isolated from the rest of the garrison in hospitals provided at remote spots within the city. Special units of pioneers cleaned and swept the city streets. Any human waste or animal carrion was thrown over the city walls.52 Barber-surgeons were hired to attend the sick within the garrison and in the hospitals, the first time that the physicians of nobles were placed at the regular disposal of the common soldier.53 Physicians were appointed to oversee the quality and distribution of the food supply. No one was permitted to eat fish, venison, or game birds for fear that they might carry disease.54 These efforts were so successful that not a single serious outbreak of disease occurred during the sixty-five-day siege.
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