Between Flesh and Steel

by Richard A. Gabriel

  The musket’s increased power made the protective armor of the Renaissance obsolete; it could no longer protect the soldier from the penetrating power of the musket ball. The increasing national identity of the armies of the period led them to wear regulation field dress to distinguish the combatants from one another amid the smoke on the battlefield. They replaced the steel helmet and body armor with standardized uniforms, shakos, and soft hats, and the helmet did not again become a standard item of military issue until the later years of World War I.23 This change in military costume also introduced a special uniform for the army surgeon that consisted of a tight-waisted long coat reaching to the knees, the usual stockings, and buckled shoes. The civilian physician also copied the military costume as his professional dress and usually wore a red hat.

  For the soldier, the disappearance of the protective helmet proved to be a medical disaster, and the rate of head injuries rose considerably. A black powder musket could indeed fire a ball fast enough to penetrate a steel helmet but only at very close range. A musket ball produced approximately 350 foot-pounds of energy upon impact, and the amount of impact energy required to penetrate a steel helmet is approximately 300 foot-pounds. The impact energy of a musket ball, however, dissipates quickly after the first forty yards and then drops off exponentially. At a hundred yards, the impact energy is far less than that required to penetrate a steel helmet.24 Without the helmet, though, only 90 foot-pounds of energy are required to penetrate the human skull.25 The impact energy of a musket ball at even two hundred yards is easily enough to penetrate an unprotected skull but insufficient at that range to penetrate a helmeted skull. Thus, the increase in both head wounds and lethality resulted far less from technological improvements to the rifle than from abandoning the helmet and body armor.

  It would still have been wise to retain the helmet if only for protection against exploding cannon fragments, grenades, and canister, all of which proved lethal to the soldier not wearing a helmet. These fragments usually did not achieve sufficient velocity to penetrate a helmeted skull, and most struck the soldier when much of their velocity was already considerably spent as a consequence of traversing some distance after the burst. Even in modern times, the helmet is designed more to prevent these kinds of secondary penetrations than to stop a direct hit from a rifle bullet. Abandoning the helmet, therefore, greatly increased the soldier’s vulnerability to secondary weapons’ effects. Once the idea took hold that the helmet was no longer a valuable protective device, however, the search for effective head and body armor was dropped for three centuries.

  The increase in head wounds became a major topic of medical literature of the period. Wiseman, the English battle surgeon, devoted large sections of his writings to head wounds, especially penetrating wounds of the skull. As with the Egyptian physicians more than three millennia earlier, the key distinction for Wiseman was whether the projectile had penetrated the dura of the brain. Wiseman’s treatment techniques for non-penetrating head wounds—essentially lifting the depressed bone fragments from the surface of the brain—are remarkably similar to the techniques that the Egyptians invented and that the Greek and Roman military physicians used extensively.26 The surge in head injuries paralleled the introduction of two new surgical instruments—the crown saw and the circular bit, both of which made skull surgery somewhat easier.27 Not surprising, this period also saw a great rise in trephining to deal with head wounds.

  AMPUTATIONS

  Gunshot wounds and the tendency of bullets and shell fragments to shatter limbs resulted in a greater willingness on the part of military surgeons to amputate limbs. The almost inevitable onset of infection in bullet wounds and the inability to combat it in any clinically effective manner convinced surgeons that the best way to treat wounds to the limbs was amputation. The result was an enormous increase in field amputations, no doubt many of them performed unnecessarily. Lopping off limbs under primitive conditions led to thousands of deaths caused by shock and bleeding. Lacking facilities for the soldier’s long-term care, the cities and towns of Europe teemed with thousands of crippled and maimed war survivors. The number of crippled soldiers reduced to beggary became such a public problem in France that Louis XIV (1638–1715) issued an edict making begging a crime punishable by death. He had gibbets erected throughout the realm to give credence to the edict.

  Although surgeons practiced amputation more frequently in the seventeenth century, they developed little improved technical knowledge or techniques. In most respects, they performed amputations under more difficult medical circumstances than ever. Military surgeries were usually makeshift arrangements with operations performed in barns, tents, or ruined buildings, where elementary concepts of cleanliness were absent. Stench, filth, and decay were common characteristics of these field hospitals. The operating tables became cesspits of infection, and surgeons routinely used the same instruments in several operations after giving them only a slight rinse in a basin of cold water. Leather suture material was also a source of infection. Wounds were left unstitched to allow for early suppuration, and a piece of sponge or lint was inserted into the wound to encourage infection. After amputation surgery, a patient usually ran a high fever while the wound ran with puss. In most cases, the stump was not suitable for prosthesis.28

  Among the more disastrous and barbaric practices in amputation was the continued use of the cautery, or what Wiseman called the “Royal Styptic.” Paré’s innovative technique of ligature to control bleeding was not practiced under field conditions. The reason was that amputation required the use of several assistants (whom the physicians commonly called “servants”) to aid in the operation. Some held the patient down, others passed instruments to the surgeon, and still others held lamps and candles so the surgeon could see what he was doing. One military surgeon of the day noted that an arm amputation required at least four assistants, including one to offer the patient pain-relieving cordials. Not only were these assistants often in critically short supply, but also there was never enough light in the indoor field hospitals to tie off the crucial blood vessels when attempting ligature.29 Wiseman, himself a military surgeon in the English Civil Wars, was well acquainted with Paré’s ligature technique, but he did not use it because “it required too much light and too many assistants to be ordinarily used in battles on sea and land.”30 Paré’s favorite pupil and biographer, Jacques Guillemeau (1550-1613), even gave up the use of ligature in amputations because of the difficulties involved.31

  Thus overburdened military surgeons greatly relied upon cautery simply because it was more convenient, did not require as many assistants, and did not need much light. The military surgeon Hughes Ravaton (1719–1785) noted that in an average day’s work in battle, a surgeon assigned to a twenty-thousand-man force saw two thousand wounded requiring medical attention. This case load was handled by one surgeon, ten surgical aides, and thirty students of surgery to hold lamps and do other chores.32 As in the Middle Ages, the surgeon administered anesthesia, when used at all, by allowing the patient to breathe a sponge or cloth soaked in a mixture of opium, hyoscyamus, and belladonna.

  Most amputations were performed below the knee. The fact that a thigh amputation required fifty-three separate ligatures militated against attempting them.33 Ligature could only become an acceptable technique for thigh amputations once some method was found to stop the flow of blood in the femoral artery. Some surgeons occasionally attempted thigh amputations, however, with William Clowes (1540–1604) performing one in 1588 and Fabry in 1614. Fabry is generally credited with introducing a primitive form of tourniquet to military surgery when he placed a block of wood under the bandage encircling the limb. Etienne Morel also used a block tourniquet at the siege of Besançon in 1674. As noted in chapter 2, Jean-Louis Petit invented the modern form of the screw tourniquet, but its widespread use was not adopted until the eighteenth century.34

  FIELD HYGIENE

  Military hygiene improved little from the Renaissance period, as a cogent theo
ry of disease transmission continued to elude medical thinkers. While most armies had some primitive hygienic ordinances, few practiced them with any degree of consistency. Disease continued to kill more men than bullets did, a condition that remained unchanged for another three centuries. Disease and sickness were regarded as a normal part of military operations. The English commander of the garrison at Tangier noted in 1660 that his men had been decimated by disease and that “1200 men will not produce 800 duty men.”35 A sickness rate of 33 percent appeared to be normal.

  Few commanders took an interest in camp hygiene. An exception was the Duke of Marlborough (1650–1722), who issued regulations governing the use of water supplies and required camp butchers to bury their offal daily. Animals’ and men’s quarters were inspected daily, as were the cookhouses and food supplies. Marlborough required that a medical officer accompany the provost marshal on daily inspections. Latrines were filled in and moved every six days, dead animals buried immediately, and anyone found committing “casual disorders” (urinating or defecating) around the camp was liable for severe punishment.36

  If conditions in a military camp were often primitive and filthy, they were almost always better than conditions found aboard ships. The unhealthy living conditions of sailors had changed little since the days of the Spanish Armada (1588). One commentator described the conditions aboard English ships as “the pox above board, the plague between decks, hell in the forecastle, and the devil at the helm.”37

  MILITARY HOSPITALS

  The seventeenth century saw the nationalism of the last two centuries emerge full blown into the national armies of the nation states. Among the most important were France, Sweden, Brandenburg-Prussia, Switzerland, and England. The development of military medical care varied greatly from army to army and conflict to conflict as the century progressed. While the provision of medical care for the soldier had not yet become a recognized and routine function of government, this period saw the beginnings of a movement in this direction. As soldiers were asked to serve in wars on grounds of national identity and loyalty, inevitably governments would come to recognize some responsibility for treating and caring for the sick and wounded as a reciprocal obligation of military service. Staffing armies with surgeons, physicians, and field barbers became a regular practice, but the military establishment had yet to employ professional military surgeons continually. As in earlier times, the shortage of trained medical personnel forced armies to issue orders of impressment to obtain any medical resources at all. In 1628, Charles I (1600–1628) issued such an edict. Apart from the usual collection of barbers and field surgeons, the female camp followers, who routinely accompanied the army, still provided most nursing and long-term care to the soldier.

  The period’s most advanced system of military medical care available was in the armies of France. The ambulance hospitals that Maximilien, the Duke of Sully (1560–1641), established at the siege of Amiens in 1597 were the starting point for later French monarchs to try and improve the medical care of the soldier. In the first third of the century in France, as elsewhere, no stationary military hospitals were behind the lines of the field armies. Medical care was rendered in mobile field hospitals that moved with the armies. The hundreds of wounded, sick, and crippled men left behind crowded into the civilian hospitals of the towns and cities; consequently, government efforts on improving the soldier’s lot focused on the treatment of the disabled.38

  As noted in chapter 2, Henry IV of France (1553–1610) opened to disabled soldiers the Maison de la Charité Chrétienne, where they received room and board. Shortly thereafter, the privilege was extended to the widows and children of soldiers killed in battle. Louis XIII (1611–1643) allowed this arrangement to atrophy and reestablished the droit d’oblat system of the previous century in which disabled soldiers were assigned to monasteries as lay brothers and earned their keep by doing menial chores. Under Louis XIV, the French established a pension system and raised special taxes to care for the sick and disabled soldiery. The soldiers often exhausted their pension money in the first few months and spent the rest of the year begging in the streets. Thus the system was abandoned, and in 1674 the Hôtel National des Invalides was opened to care for the disabled. The facility housed four thousand people, who slept three to a bed. Although basically a warehouse, the soldiers nonetheless received shoes, clothes, food, and a small sum of expense money. Military discipline was maintained, and those who were able were encouraged to work in the workshops. Patients were permitted to take leave and visit their families, and some of the more able were even assigned to military garrison duty at half pay. While care of the military’s disabled had been under control of ecclesiastical authorities since the Middle Ages, in France, the system of veterans’ hospitals was placed in the hands of an intendant, a government official who reported directly to the minister of war.39 It was the first clear example of a nation state recognizing its responsibility for the long-term welfare of the soldier.

  As social care for the French soldier improved, so did his medical care. In 1627 at the siege of La Rochelle, Cardinal Richelieu assigned Jesuits and cooks to provide bread and soup at the state’s expense to the sick and wounded in the field hospitals. Two years later, Richelieu established the first permanent stationary hospitals in the rear of the field armies.40 Generally of poor construction, however, these hospitals were little more than spacious halls in which patients slept three to a bed in squalid conditions. These facilities became nests of infection, filth, and death, and contributed greatly to the average soldier’s general fear of hospitals. These hospitals’ construction and conditions improved over time, and by the end of Louis’s reign permanent military hospitals had been built at Arras, Calais, Dunkirk, and Perpignan. From 1666, the famous French fortification engineer Sébastien le Prestre, Marquis de Vauban (1633–1707), routinely provided space and buildings for a military hospital in all the towns for which he planned fortifications.41

  The French practice of caring for the wounded and disabled was imitated in England. In 1614, Sir Thomas Coningsby (died 1625) founded a relief house for destitute soldiers. During the Protectorate (1653–1659), the English Parliament provided homes and pensions for the disabled who had fought on the Republican side but did not make any provisions for those who fought on the Royalist side. In 1633, a house for disabled seamen was erected at Chelsea, in 1693 a soldiers’ home was built in Kilmainham, and a “benevolent institution” was established in Greenwich for destitute sailors in 1695.42

  The permanent hospital system offered some employment opportunities for medical practitioners with military experience, and in the French armies the provision of combat medical support seemed to improve as the century wore on. While the quality of field medical support remained low, supplying surgeons and barbers to the armies seems to have become routine. In 1674 at the Battle of Seneffe, the French Army’s medical chief was able to furnish 230 surgeons assisted by nurses in three field hospitals located in nearby villages. Each of the field stations was adequately equipped with medical supplies as well.43

  The Swedish Army of Gustavus Adolphus was fairly well equipped with medical personnel thanks largely to the vision of a previous Swedish king, Gustavus Vassa (1496–1560), who first organized the barbers’ guild and extracted a pledge from them to tend the troops in time of war. Under Adolphus, the normal medical complement of two surgeons and barbers per regiment was increased to four, and medical support and supply was made a command responsibility. Civilian hospitals were exempt from pillage, and one-tenth of the spoils of war were set aside for the troops in the hospital. Adolphus made it practice to transport the sick and wounded in wagons to the nearest hospital and to leave medical and command detachments behind with the wounded to oversee their care. He began the convention of gathering the enemy wounded to his camp, where they received medical care or were sent to hospitals with his own wounded. At the siege of Dömitz in 1631, the Swedes provided wagons to transport the enemy wounded to hospitals. Upon recove
ry, they were granted free passes to return to their units. Adolphus’s treatment of the men—his own men and that of the enemy—represented a continuation of the Renaissance practice of attending the wounded in a humane manner.44

  Switzerland, it will be recalled, had the oldest military medical service in Europe. By the Thirty Years’ War, Swiss arms had sunk to a low level. The military medical service, however, endured. Muster rolls of various Swiss cantons during the war show that each company of artillery and infantry had a barber-surgeon attached to it at the state’s expense. They also had regimental barber-surgeons, and those from the Zurich regiment were the best-trained surgeons in the city. Military physicians received complete medical chests supplied to them at state expense and field manuals on wound management and sanitation. Still, the Swiss military medical system does not appear to have improved much from the previous century when it was the model of European armies.45 Meanwhile, it had taken the rest of Europe almost a century to catch up.

  The field hospitals of the Landsknechte in Germany became the first permanent field hospitals when, in 1620, Maximilian I, Duke of Bavaria (1573–1651), founded field hospitals for the armies of the Catholic League. One of these massive multi-storied hospitals served as a clearing station and fed casualties into a larger hospital located in a nearby town. In 1689, Konrad Behrens (1660–1736) drew up a set of regulations for these hospitals, which were situated on high ground near good water supplies and woods from which the staff could obtain firewood for heat and cooking. Patients were segregated by disease into separate wards. The staff consisted of physicians, field barbers, wound surgeons and their attendants, priests, and female camp followers. An officer supervised each entire hospital. In 1685, one of these hospitals handled eight hundred sick and wounded daily. Medical care, as in every army of the period, however, was still rudimentary.46