Between Flesh and Steel

by Richard A. Gabriel

  The quality of medical instruction, while still generally poor, was improved somewhat by the gradual introduction of clinical instruction in hospitals. A century earlier the Italians had introduced clinical instruction, and in the seventeenth century it was introduced to the universities in Holland, where it became a model for other medical universities. Dissection as a means of teaching anatomy became more common, especially in Italy, France, and Holland, and the anatomical theater became an established common feature of medical education. While corpses and skeletons were difficult to obtain, dissection increased as a means of instruction and discovery. Raymond Vieussens (1641–1716) is said to have conducted five hundred dissections in the course of his career.6

  Two other innovations greatly spurred the development and communication of scientific and medical knowledge during this period. The first was the invention of the scientific society. The emphasis on individual efforts of discovery unencumbered by institutional affiliation created the need for a mechanism whereby scholars and scientists could gather, share, and test each other’s ideas. The idea for the resulting professional scientific society may have originated during the Renaissance in Italy, where such societies were a well-kept secret lest their members fall afoul of ecclesiastical authority. In 1560, one such secret academic society in Naples was called, appropriately enough, the Secret Academy. In 1603, the Academy of the Lynxes was founded along similar lines in Rome. Thirty-two years later, Cardinal Richelieu (1585–1642) founded the Académie Française. In 1660, the Oxford Philosophical Society of England opened its first journal book, and two years later Charles II (1630–1685) bestowed its charter as the Royal Society of London. In 1665, Jean-Baptiste Colbert (1619–1683) founded the French Academy of Sciences, and in 1683, the Dublin Philosophical Society came into being. These societies provided invaluable vehicles for transferring scientific knowledge across national borders. The idea survives today in the many societies and professional associations to which scholars, scientists, and other academics routinely belong.

  The second stimulus to developing and communicating scientific knowledge was the introduction of periodical literature on a wide scale. First in the form of newspapers, then political tracts, and finally professional journals, these periodicals provided important channels for publishing research results and engendering learned debate. The French Journal of Medicine was first published in 1681. The first English medical journal was the Medicina Curiosa published in 1684, followed by Progress in Medicine in 1695.

  The seventeenth century saw the establishment of national medicine in Russia and the United States. In the sixteenth century, Ivan III of Russia (1468–1505) had invited foreign physicians to settle in Moscow, a tradition continued to the end of the Romanov Dynasty in 1917. Both Peter the Great (1672–1725) and Catherine the Great (1729–1796) increased the number of foreign physicians hired. In many ways these foreigners had similar experiences to the Greek physicians in ancient Rome; they were skilled by comparison to Russian folk medicine, but the government and people always regarded them suspiciously for their strange ways. The first native Russian physician was Peter V. Postnikoff, whom Czar Peter sent to study in Padua in 1694.7

  With regard to Russian military medicine, the first mention of a physician attached to the army appears in 1615. It seems to have been prior common practice for the state to provide money for barber-surgeons to care for the troops during wartime. In the second half of the century, the first regimental dispensaries appeared. Under Peter the Great, the Ministry of Medical Affairs became a chancellery, and the need to provide medical care to his army stimulated Peter’s efforts to attract foreign medical talent. By the end of Peter’s reign (1725), Russian military medical care was probably on a par with the rest of Europe, and a royal edict assigned each division of the army a physician, a staff barber, and an apothecary. A surgeon was assigned to each regiment and a field barber to each company. As with the armies of the other nations of Europe, the Russian armies also used field hospitals behind the lines. There is no mention in contemporary literature, however, of any provision for the long-term care of the wounded or disabled.8

  The early settlement of the United States led to the creation of another national medical establishment. Although two doctors, Samuel Fuller and John Winthrop, were among the party on the Mayflower in 1620, and the establishment of Harvard College (1636) and the College of William and Mary (1693) gave further impetus to medical training in the early days, Americans traditionally studied abroad at European medical schools. The greatest number of American doctors during the colonial period, however, was trained through apprenticeship programs. Lacking a strong medical establishment made such an innovation possible. Further, the frontier nature of the early American society produced sufficient barriers to education and communication such that on-the-job training and experience were the rule for training physicians. Few of these medical apprentices were encumbered by theoretical knowledge, so similar to the education of the wound surgeons of the Renaissance, observation and experience became the primary emphasis of American medical education. This highly pragmatic emphasis, moreover, distinguishes American medicine to this day. The long-standing conflict between the physician and surgeon that crippled the development of European surgery for more than four centuries never developed in the United States. Meanwhile, in 1663, the first hospital was constructed on Manhattan Island.

  Dynastic and religious rivalries caused constant wars that wracked the seventeenth century. The Thirty Years’ War and the English civil wars were among the period’s major conflicts. The increased number of firearms used by armies and the advent of the mobile field cannon greatly increased mortality rates in these wars, as did epidemic disease. The chief disease killers of the period were bubonic plague, typhoid, typhus, dysentery, and diphtheria. Horrible epidemics were common. In 1665, the Great Plague of London carried off sixty-nine thousand people. In 1679, the plague killed seventy thousand in Vienna. In 1681, more than eighty thousand fell victim to the disease in Prague, and in the Venetian states as many as half a million died.9 Nathaniel Hodges (1629–1688) was the first physician to conduct a postmortem inspection of a plague patient.10

  On military campaigns, typhus, typhoid, and dysentery took a heavy toll. Typhus was so common in eastern Europe that it was called the “Hungarian disease,” and so many Germany troops died from it that they called Hungary the “Graveyard of the German Army.” This area remained a cesspit of infection for centuries, with yet another outbreak of typhus in 1915 decimating the British and Turkish armies there. Smallpox was pandemic in 1614, and a deadly epidemic broke out in England in 1666. Child mortality was high throughout the period, and it is estimated that as many as half of the English children born during the Restoration died from disease.11 The period’s only medical high points were that leprosy seems to have died out almost completely, and the treatment of syphilis by mercurial fumigation and inunction had slowed the rate of the disease’s spread.

  TRENDS IN MILITARY MEDICINE

  The quality of military medicine in the seventeenth century showed no great advance over that of the Renaissance, in large part owing to the rigid divorce of surgery from medicine that had begun under Galen, was maintained by the Muslims, and then standardized into law and custom by the ecclesiastical interdictions of the Middle Ages. As the rivalry among physicians, surgeons, and barbers continued unabated throughout the new century, the battlefield care of the soldier and the common people remained the province of the few qualified wound surgeons and the usual collection of quacks. The number of competent, trained surgeons was very small, or less than a dozen of any note.12 Tension in the universities between surgeons and physicians produced generally poor surgical instruction even though dissection and the clinical amphitheater had become regular features in medical education. Unifying the barbers and surgeons into common guilds, however, did nothing to reduce the tension or to raise the general status of surgery.

  Much of the new anatomical knowledge had y
et to be integrated into the medical profession in any practical way, and most physicians still regarded surgery as dangerous. They generally avoided difficult operations on the grounds of legal liability and potential damage to their reputations and positions. Most armies also maintained the rigid separation of physicians and surgeons, with the physician attending general internal complaints while barbers and wound doctors did field surgery.

  The generally low quality of military medicine was evident in the sparse publication of new works on the subject. Given the stimuli of the Thirty Years’ War and the English Revolution, one might have expected a greater number of original works on military medicine to have been published; however, for the first fifty years of the century, only eight works on surgery—none of them original or very valuable—and only nine on disease were printed. While in the previous century forty-five books had been published on surgery alone, the seventeenth century saw the publication of only thirty-four. While the production of epidemiological works was also sparse, twenty-eight new works on the subject of diseases in the military, two on diseases associated with ship duty, and ten on particular diseases associated with ground force campaigns appeared.13 A particularly bright light was the book Medical Observations in Hungarian Camps (1606) by Tobias Cober, a physician with the army of Bohemia. After seeing seven years’ service in the long war between the Hungarians and Turks, Tober provided the first clinical notice of the relationship between pediculosis in military camps and the outbreak of fever, probably typhus.14 Meanwhile, the era’s low level of military medicine was reflected in the rise to prominence of a new breed of field medical practitioners, the executioners! Some executioners acquired medical reputations based on the knowledge they gained while practicing their trade. The idea was that because executioners knew how to break bones, in some manner they also possessed some ability to set them.15

  The three noteworthy physicians in wound surgery were men who had seen extensive military service in England and Germany. Perhaps the most important was Wilhelm Fabry (also known as Fabriz von Hilden, or Fabricius, 1560–1624) of Germany, who invented a number of new surgical instruments and advocated amputation above the diseased or damaged part of the limb to ensure the stump would be suitable for prosthesis. Fabry also used a primitive tourniquet in which he twisted a strap around a stick. He described the first army field surgical chest, which was based on that first introduced by Maurice of Nassau in 1612. Another important military surgeon was Matthaeus Purmann (1649–1711), a bold German surgeon who sutured intestines and gained extensive experience with gunshot wounds. His Fifty Strange and Wonderful Cures for Gunshot Wounds (1693) demonstrates, however, his belief in the magical curative powers of two common but useless methods of treating gunshot wounds—the “weapons salve” and “sympathetic powder,” which were applied to the weapon and not to the wound. The greatest English surgeon of his time, Richard Wiseman (1622–1676) was also a soldier. His book Several Chirugicall Treatises (1672) reveals a true medical empiricist who performed amputations, treated gunshot wounds, and provided a compendium of empirical military medical knowledge to future generations.

  After all is taken to account, however, the seventeenth century did not produce anyone of Paré’s stature in military medicine.16 Even the most empirically oriented surgeons of the period continued to prescribe compounds that ranged from useless to dangerous and to believe in superstitious and magical cures for all kinds of medical conditions. Whatever advances in medical knowledge had been made during the Renaissance were either forgotten or long in coming into vogue in everyday military medical practice.

  For the most part, then, the soldier often received indifferent or poor medical care for his wounds. Valid theories for treating the most common military medical conditions were, at best, in their embryonic stages of development. The combination of poorly trained medical personnel, sporadic systems of casualty servicing in the armies of the day, deadly medical practices, increasingly lethal weaponry, poor diet, and a complete lack of understanding of the causes of disease and illness combined to make the lot of the wounded soldier truly pathetic. Throughout the entire century only one voice, that of Polish knight and soldier Janus Abraham Gehema (1647–1715), cried out against these conditions. A combat soldier with extensive battle experience, Gehema wrote numerous short books on caring for the military wounded. Although he himself was not a physician or surgeon, the titles of his works suggest a keen appreciation of the military medical care of his time. His The Well Experienced Field Physician (1684), The Officer’s Well-Arranged Medical Chest (1688), and The Sick Soldier (1690) were all attacks on the contemporary military medical practices as being mostly useless, dangerous, and barbaric.17 In the spirit of the day, however, he was ignored.

  WOUND TREATMENT

  The seventeenth century saw the continued evolution in weaponry and tactics that had begun during the Renaissance with the introduction of the first practical firearms. The number of firearms to pikes in infantry units increased enormously. Renaissance armies had armed between 25 and 35 percent of infantry with muskets. Gustavus Adolphus’s armies almost doubled the rate of firearms to pikes during the Thirty Years’ War. On average, 65 percent of his infantry forces carried muskets, and almost all the cavalry were armed with pistols.18 Swedish armorers redesigned the long heavy musket with a shooting fork to shorten it and made it lighter to allow quicker firing with better accuracy. The introduction of the paper cartridge with its standard powder load reduced the rate of misfires to practically zero, and the introduction of standard-caliber ammunition both increased the weight of the musket ball and eased supply efforts. Standardized ammunition and powder loads propelled the musket ball at a greater velocity than was possible a century earlier and, as noted previously, resulted in bullets becoming more commonly deformed upon impact, creating more ghastly wounds.

  Although a number of fundamental medical discoveries had been made in the previous century, the application of this knowledge to military surgery was marginal at best. Wound surgery remained essentially unchanged from the Renaissance. The doctrine of necessary suppuration, long in vogue and buttressed by the still prevalent belief that gunshot wounds were inherently poisonous, led to the practice of attempting to remove the bullets with probes and extractors and increased the chances of infection. Standard surgical practice was not to close the wound but to widen it, allowing the wound to become infected and drain. Surgeons often placed bits of leather and cloth in a minor wound to bring on infection. Draining infected wounds did not become standard practice until Dominique Larrey, the surgeon in chief of the Napoleonic Armies, helped establish it in the nineteenth century.

  Military surgeons, faced with an almost 100 percent rate of infection of battle wounds, fell back on miraculous and spurious treatments to combat a clinical condition that rendered them powerless. Physicians of the day placed great faith in a treatment called “the sympathetic powder,” which Kenelm Digby (1603–1665), a former privateer and con man, had introduced. Digby saw an opportunity to cash in on the then current propensity of military physicians to try all sorts of pharmaceutical materials. Digby’s sympathetic powder was ostensibly made from “moss scraped from a dead man’s skull and mixed with powdered mummy’s flesh.”19 It is a measure of the low quality of field surgery of the time that this wound treatment gained wide acceptance. No less a figure than Francis Bacon, who advocated the scientific method, included sympathetic powder in his scientific collection of drugs.

  Other cures for gunshot included “the transplantation cure” in which a bit of wood was dipped in the blood or pus of the wound and wedged into a tree. If the sliver of wood took root and grew, it was believed the patient would recover. Most amazing was “weapon’s salve,” an ointment that was applied to the wounded soldier’s weapon in the belief that this process created some “influence from afar” that would cause the wound to heal.20 These attempts to deal with infected wounds suggest how helpless the military surgeons were when confronted with the clinic
al challenges that the more accurate and highly powered rifles of the period wrought.

  The mystical quality of wound treatments during this period is evident from its materia medica, or what is more appropriately called a “filth pharmacopoeia.” Part of the problem was the growth of the apothecary guilds that controlled the distribution of medicinal compounds. In 1607, James I (1566–1625) recognized the apothecaries as a special guild distinct from grocers, and throughout Europe the apothecaries soon built a rich and powerful organization. In 1682, the apothecaries won the exclusive right to supply drugs to the army and navy in England. Like any salesmen, the apothecaries needed merchandise to sell.21 The result was an explosion in spurious mixtures for which all kinds of miraculous claims were made.

  The field medical chests that were routinely supplied to the armies provide an interesting glimpse into the pharmacopoeia of the day. A description of a Bavarian field chest that an artillery unit used in the Turkish campaign of 1688 notes that fully loaded the chest weighed 320 pounds and contained thirty surgical instruments. It also held the following medicinal remedies for the wound surgeon’s use: powdered sandalwood, rhubarb, palm juice, spermaceti, mummy dust, scorpion oil, rain worm oil, oil of vipers, angle worms, earwigs, zinc oxide, Vigo’s plaster of frog spawn, mercury, human and dog fat, aloes, tartar emetic, sugar of lead, alum, sassafras, and opium.22 Most of these concoctions were not only useless but also often deadly. Almost all provoked infection when applied to an open wound. One marvels at the poor quality of this pharmacopoeia when compared with what Roman field physicians used more than sixteen hundred years earlier. The seventeenth-century pharmacopoeia is a good example of what happens to medical science when practitioners ignore empirical observation and adopt a method of reasoning in which logical elegance and religious superstition is allowed free rein in determining the nature of medical reality.