Between Flesh and Steel
Page 12
In the armies of Prussia, every regiment had a barber, and every company of infantry and cavalry had a field barber. When in garrison, a physician looked after the troops’ sick complaints while a wound surgeon dealt with their injuries. Because of the devastation wrought by the Thirty Years’ War, the training of German field surgeons and barbers seems to have been of particularly low quality. Although regulations required military commanders to provide wagons and clean straw to transport the wounded, the Prussian armies had neither field nor permanent hospitals and simply treated the wounded in their barracks.
The English Civil Wars (1642–1651) retarded the development of military medical structures of any sophistication and scope. Oliver Cromwell (1599–1658) did provide his New Model Army with medical officers in 1645, and P. B. Adamson writes that he was the first English commander to assign such officers to the standing army on a permanent basis.47 By 1700, field medical chests were provided to the military medical service as items of regular issue.48
Military medical care during the seventeenth century was not appreciably better than that provided to the soldier during the Renaissance. Although the new nation states took the first tentative steps in recognizing an obligation to care for the wounded and disabled of war, no nation developed a system approaching even rudimentary effectiveness in accomplishing this task. The almost-two-hundred-year-old regulations of the Swiss Army were still more advanced in providing this type of care than anything developed or even contemplated in the seventeenth century. Medical care in the field remained elementary at best and lethal at worst. Separating surgery from the general practice of medicine made it impossible to develop a corps of adequately trained surgeons for the military’s use; thus, most of the practitioners who treated the common soldier possessed little medical skills. The soldier was still at as great a risk from his own medical officers as from enemy bullets and perhaps more so.
In some ways medical care actually deteriorated. The increased use of firearms, their greater killing power, their higher rates of fire, and the abandonment of body armor and helmets in favor of standardized field dress exposed the soldier to a much greater risk of death and injury than he had faced a century earlier. A number of advances in medical knowledge and surgical technique, most notably ligature in amputation, were ignored in practice; consequently, the rate of amputations, infections, and resulting death increased. The provision of long-term care in permanent military hospitals did little to aid the wounded’s recovery as the hospitals’ filthy conditions raised the chances of incurring infection. As it had been for so many centuries, the combat soldier of the seventeenth century remained at great risk to life and limb. That some of the armies provided him with subsistence care if he was disabled did not go far to change this basic fact of military life.
NOTES
1. Garrison, Introduction to the History, 245–309. See the chapter on the development of medicine in the seventeenth century.
2. Ibid.
3. Ibid.
4. J. R. Kirkup, “The History and Evolution of Surgical Instruments,” Annals of the Royal College of Surgeons of England 63 (1981): 283.
5. Ibid.
6. Garrison, Introduction to the History, 283.
7. Garrison, Notes on the History, 127.
8. Ibid.
9. Ibid., 130.
10. Encyclopedia Britannica, 11th ed. (1910), 49.
11. Garrison, Introduction to the History, 307.
12. Heizmann, “Military Sanitation,” 294.
13. Ibid.
14. Garrison, Notes on the History, 130.
15. Jay W. Grissinger, “The Development of Military Medicine,” New York Academy of Medicine 3, no. 5 (May 1927): 316. A common form of capital punishment at this time was “to be broken on the wheel,” where the victim was strapped to a large wheel that was then rotated until his bones were broken.
16. Garrison, Introduction to the History, 275–77.
17. Garrison, Notes on the History, 133–34.
18. Heizmann, “Military Sanitation,” 292.
19. Forrest, “Development of Wound Therapy,” 270.
20. Grissinger, “Development of Military Medicine,” 316.
21. Roderick E. McGrew, Encyclopedia of Medical History (New York: McGraw-Hill, 1985), 253–54.
22. Ibid., 315.
23. Frank Aker, Dawn Schroeder, and Robert Baycar, “Cause and Prevention of Maxillofacial War Wounds: A Historical Review,” Military Medicine 148, no. 12 (December 1983): 923.
24. I am indebted to Edward Cielecki and Tom Tremonte, experts in the ballistics of black powder weapons, for these figures.
25. Richard A. Gabriel and Karen S. Metz, From Sumer to Rome: The Military Capabilities of Ancient Armies (Westport, CT: Greenwood Press, 1991), 63.
26. Charles G. H. West, “A Short History of the Management of Penetrating Missile Injuries to the Head,” Surgical Neurology 16, no. 2 (August 1981): 146.
27. D. S. Gordon, “Penetrating Head Injuries,” Ulster Medical Journal 57, no. 1 (April 1988): 3.
28. Allen C. Wooden, “The Wounds and Weapons of the Revolutionary War from 1775 to 1783,” Delaware Medical Journal 44, no. 3 (March 1972): 61–62.
29. Owen H. Wangensteen, Jacqueline Smith, and Sarah D. Wangensteen, “Some Highlights in the History of Amputation Reflecting Lessons in Wound Healing,” Bulletin of the History of Medicine 41, no. 2 (March–April 1967): 102.
30. James Young, “A Short History of English Military Surgery and Some Famous Military Surgeons,” Journal of the Royal Army Medical Corps 21 (1913): 487.
31. Wangensteen et al., “Some Highlights,” 103.
32. Ibid.
33. McGrew, Encyclopedia of Medical History, 322.
34. Ibid. See also Encyclopedia Britannica, 11th ed. (1911), 128; and Robert Lawson, “Amputations through the Ages,” Australian–New Zealand Journal of Surgery 42, no. 3 (February 1973): 222.
35. Hargreaves, “The Long Road to Military Hygiene,” 441.
36. Ibid.
37. Ibid.
38. Garrison, Notes on the History, 121–22.
39. Taylor, “Retrospect of Naval and Military Medicine,” 589.
40. Grissinger, “Development of Military Medicine,” 316.
41. Ibid.
42. Taylor, “Retrospect of Naval and Military Medicine,” 317.
43. Heizmann, “Military Sanitation,” 291.
44. Ibid., 291–93.
45. Garrison, Notes on the History, 124–25.
46. Ibid., 131.
47. P. B. Adamson, “The Military Surgeon: His Place in History,” Journal of the Royal Army Medical Corps 128 (1982): 47.
48. Weston P. Chamberlain, “History of Military Medicine and Its Contributions to Science,” Boston Medical and Surgical Journal (April 1917): 237.
4
THE EIGHTEENTH CENTURY
The First Effective Military Medical Systems
Medicine in the eighteenth century centered around the effort to develop complete theoretical systems to explain disease and other medical phenomena. This approach was the logical consequence of the nascent empiricism that had emerged two centuries earlier during the Renaissance and had been given strong scientific impetus by the success of Newtonian inductionist approaches to understanding and explaining reality characteristic of the previous century. Medical investigators attempted to systematize medical knowledge along the lines of a single major force or cause that could be demonstrated to rest at the base of all medical phenomena. Medical investigation was attempting to do for medicine what Newton had done for physics and what Thomas Hobbes (1588–1679) had claimed to do for politics.
Searching for underlying unifying principles of medical knowledge, a kind of grand theory of synthesis, helped inform Herman Boerhaave (1668–1738). This great Dutch physician and teacher explained all pathological conditions in terms of chemical and physical qualities, such as acidity and alkalinity or tension and relaxation.1 William Cullen (1710–1790), a Scottish physic
ian whose thinking had a major impact on American medicine at the time, believed that disease could be explained by either an excess or an insufficiency of nervous tension in the nerve pathways of the body and brain.2 Others argued for varying degrees of animism or excitation in the body’s organs. Few of these approaches produced anything of lasting medical value, for the complexity of medical phenomena repeatedly confronted these theoretical schemas with observations that could not be explained by their premises. Nonetheless, the search for the grand medical synthesis continued throughout the century.
The search for theoretical explanations did not hinder the development of an empirical approach to medical research. Indeed, it was precisely the establishment of the empirical method that forced medical theoreticians to continually reexamine their premises as observations time and again produced discoveries that could not be reconciled with theoretical approaches. The empiricism of the Renaissance combined with the rigorous thinking of Newtonian inductionism to produce a method of medical investigation that was soundly grounded in empirical observation. Unlike the scholastic approach to medicine that had characterized the search for knowledge during the Middle Ages, an approach that for centuries permitted empirical data to be rejected on the grounds that it did not satisfy the elegance of logic, the new method did not end in the mind. The willingness of eighteenth-century physicians to attempt to integrate new medical data into mental schemata prevented the development of a complete single-cause theory of medicine from gaining acceptance precisely because such theories did not square with empirical observation. The tyranny of scholastic logic finally came to an end and in its place arose the new methods of empirical observation and experiment. In this sense, the eighteenth century can be said to have laid the methodological groundwork for the progress in medical knowledge and clinical technique that was to follow in the next two centuries.
An individualistic approach to medical investigation had marked the previous century. Much of this trend continued in the eighteenth century and produced a number of important discoveries and surgical advances. The end of the religious and dynastic wars provided some breathing space within which the medical establishment continued its work. The period of peace, interrupted nonetheless by four major wars and three revolutions, also permitted some stability to permeate the social order of the day.3 As a result, the medical profession became institutionalized and medicine became a respected profession with practices passed from father to son. University education for physicians became commonplace. Dissection became a common method of medical study, as did clinical observation in teaching hospitals. Famous professors established a number of private medical schools and gathered students to their practices as a means of providing medical education. The most noteworthy of these students was Scottish-born John Hunter (1728–1793) in England and three generations of Monros in Scotland. Eventually, both schools became associated with universities, bestowing greater prestige on the study of medical pragmatics than ever before. For the first time in history, medicine was separated from superstition and ecclesiastical control, and the foundations of medicine as a science came into being.
In an equally important development, surgery finally became a legitimate discipline, respected even by the physician internists, and slowly began to develop its own teaching institutions. In 1731, the Académie Royale de Chirurgie (Royal Academy of Surgery) was established in Paris with Jean-Louis Petit as its first director. Later, the École Pratique de Chirurgie was established with François Chopart (1743–1795) and Pierre-Joseph Desault (1738–1795) as its first professors. The press of war placed a premium on training surgeons for the army, and for the first time military medical schools were established in Prussia, Russia, Austria, and France to meet the armies’ needs for surgical personnel. Greatly aiding these developments were significant improvements in surgical medicine as a consequence of the renewed empirical emphasis on anatomy and pathology. The greatest of the anatomist-pathologists was Giovanni Morgagni (1682–1771), who pioneered the science of postmortem investigation in an effort to link diseases to their specific anatomical effects. Morgagni was the first writer of a systematic treatise on morbid anatomy. The brilliant surgeons of the day, Hunter and Alexander Monro I (1697–1767), had begun their careers as anatomists, which helped them develop effective surgical techniques that gained wide acceptance. From this point forward, medical education began with studies of human anatomy, and for the first time in history, anatomical knowledge was generally accurate.
Surgery ceased to be merely a technical craft practiced by physicians of low status. Of course, the usual collection of barbers and quacks continued to exist, mostly in the armies, but gradually even their quality began to improve. The military’s need for surgical personnel led to regular examinations for candidates for surgeon’s mates and orderlies, and some countries provided medical training in special schools to even the lowest ranks of military surgical personnel. The millennia-old distinction between physician and surgeon, a distinction that had hindered medical progress for a thousand years, was gradually disappearing, with overall beneficial results for the civilian and the soldier alike.
Medical publishing was established on a large scale, and books and periodicals were readily available to the professional order as vehicles for expanding and spreading medical knowledge. Anatomical illustration reached great heights. The old copperplate method gave way to the steel plate and made producing anatomical illustrations in color possible for the first time.4 The advances in surgery also were evident in the proliferation of new surgical instruments designed for specific purposes. Pierre Dionis (1643–1718) published the Cours d’opérations de chirurgie in 1708 and presented complete sets of surgical instruments specific to particular operations. In 1782, Giovanni Alessandro Brambilla (1728–1800) assembled a folio of virtually all surgical equipment in his Instrumentarium Chirurgicum militare Austriacum.5 Near the end of the century, the numbers and types of surgical instruments had become so complex that the first catalogs for surgical instruments were published.
The eighteenth century can be characterized as the time when medicine first became a science complete with a new empirical approach that emphasized hard data. There emerged a new intellectual habit, first evident in the Renaissance, and a willingness to reject theoretical premises when they were shown to run contrary to clinical observation. The emphasis on anatomy gave physicians and surgeons more accurate medical knowledge, and the erosion of the social barriers between physician and surgeon finally permitted the latter to represent a legitimate branch of the medical discipline. Formalizing medical education permitted the transmission of accurate anatomy and new techniques to fresh generations of students in a more systematic and complete manner than ever before. Moreover, the stimulus of war forced the contemporary military establishments to pay greater attention to the soldier’s medical needs. More than in any century that preceded it, the eighteenth century witnessed the beginnings of truly modern medicine in both its civilian and military aspects.
TRENDS IN MILITARY MEDICINE
In the eighteenth century, the state government recognized its function of providing medical care for its soldiers and provided and paid for it as a matter of course. At the beginning of the century, the pattern of military medical care remained essentially as it had been in the previous century. By mid-century, however, all major armies of the period had moved considerably toward establishing institutionalized systems of military medical care.
This achievement was part of the nation states’ larger effort to improve the general quality and organization of their armies as the age of nationalism came to fruition. Armies encouraged voluntary enlistments, adopted limited periods of military service to replace the old practice of lifelong service, implemented regular medical examinations for recruits, issued standard uniforms, provided daily food rations that were paid for by the state treasury, and housed their soldiers in barracks instead of the usual inns, private houses, and barns. Military organizations generally becam
e more structurally articulated as the century wore on, and permanent ranks, pay systems, and combat formations appeared. Armies were almost exclusively armed with firearms, and field artillery became more mobile. The first military medical schools were established, as were the first journals and periodicals devoted exclusively to military medical matters with articles written almost entirely by military physicians, surgeons, and medical officers. Advances in hospital administration were made, and some attempts were also made to prevent disease and generally improve and maintain the soldier’s health.
Armies became structurally organized into companies, battalions, and regiments with an increasingly professional corps of officers and noncommissioned officers to lead them. In their organizational realignment to increase control of the armies, the leadership put the troops in barracks and gave them regular rations. The old practice of billeting the troops with the citizenry or in rented inns had become increasingly unpopular, and the new system made controlling desertion easier.6 The British Army established its first barracks in Ireland in 1713. Barracks were introduced in Scotland two years later, and George I (1660–1727) constructed the first military barracks in England at Berwick-on-Tweed in 1723.7