Between Flesh and Steel
Also by Richard A. Gabriel
Man and Wound in the Ancient World: A History of Military Medicine from Sumer to the Fall of Constantinople
Hannibal: The Military Biography of Rome’s Greatest Enemy
Philip II of Macedonia: Greater than Alexander
Thutmose III: A Military Biography of Egypt’s Greatest Warrior King
Scipio Africanus: Rome’s Greatest General
The Battle Atlas of Ancient Military History
The Warrior’s Way: A Treatise on Military Ethics
Muhammad: Islam’s First Great General
Soldiers’ Lives Through History: The Ancient World
Jesus the Egyptian: The Origins of Christianity and the Psychology of Christ
Empires at War: A Chronological Encyclopedia
Subotai the Valiant: Genghis Khan’s Greatest General
The Military History of Ancient Israel
The Great Armies of Antiquity
Sebastian’s Cross
Gods of Our Fathers: The Memory of Egypt in Judaism and Christianity
Warrior Pharaoh: A Chronicle of the Life and Deeds of Thutmose III, Great Lion of Egypt, Told in His Own Words to Thaneni the Scribe
Great Captains of Antiquity
The Culture of War: Invention and Early Development
The Painful Field: Psychiatric Dimensions of Modern War
No More Heroes: Madness and Psychiatry in War
Military Incompetence: Why the American Military Doesn’t Win
To Serve with Honor: A Treatise on Military Ethics and the Way of the Soldier
With Donald W. Boose Jr.
Great Battles of Antiquity: A Strategic and Tactical Guide to Great Battles That Shaped the Development of War
With Karen S. Metz
A Short History of War: The Evolution of Warfare and Weapons
History of Military Medicine, Vol. 1: From Ancient Times to the Middle Ages
History of Military Medicine, Vol. 2: From the Renaissance Through Modern Times
From Sumer to Rome: The Military Capabilities of Ancient Armies
Between Flesh and Steel
A HISTORY of MILITARY MEDICINE from the MIDDLE AGES to the WAR in AFGHANISTAN
RICHARD A. GABRIEL
Copyright © 2013 Potomac Books, Inc.
Published in the United States by Potomac Books, Inc. All rights reserved. No part of this book may be reproduced in any manner whatsoever without written permission from the publisher, except in the case of brief quotations embodied in critical articles and reviews.
Cover image: This Civil War cartoon depicts the military surgeon in his most-feared role as the amputator of limbs. The term “sawbones” to describe a surgeon dates from this period when the most common military surgical procedure was amputation. Original artwork by James Dunn; color rendition by Daniel Pearlmutter.
Library of Congress Cataloging-in-Publication Data
Gabriel, Richard A.
Between flesh and steel: a history of military medicine from the Middle Ages to the war in Afghanistan / Richard A. Gabriel. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-61234-420-1 (cloth: alk. paper)
ISBN 978-1-61234-421-8 (e-book)
I. Title.
[DNLM: 1. Military Medicine—history. 2. History, Early Modern 1451–1600. 3. History, Modern 1601–. 4. War. 5. Weapons—history. 6. Wounds and Injuries—surgery. WZ 80]
616.9’8023—dc23
2012039781
Printed in the United States of America on acid-free paper that meets the American National Standards Institute Z39-48 Standard.
Potomac Books
22841 Quicksilver Drive
Dulles, Virginia 20166
First Edition
10 9 8 7 6 5 4 3 2 1
for Jude Alfred Nurik and the miracle of life
and
for Suzi, my beloved wife, whose pretty blue eyes warm my soul
CONTENTS
List of Illustrations
1 The Emergence of Modern Warfare: 1453 to the Twenty-First Century
2 The Renaissance and the Rebirth of the Empirical Spirit
3 The Seventeenth Century: Gunpowder and Slaughter
4 The Eighteenth Century: The First Effective Military Medical Systems
5 The Nineteenth Century: The Age of Amputation
6 The Twentieth Century: The Emergence of Modern Military Medicine
7 The Twenty-First Century: Unconventional Warfare
8 Some Thoughts on War
Bibliography
Index
About the Author
ILLUSTRATIONS
FIGURES
1 Weapons Lethality and Dispersion over History
2 Battle Casualties: 1600–1973 CE
TABLES
1 Historical Army Dispersion Patterns for Units of 100,000 Troops
2 Battle Mortality from Antiquity to the Korean War
3 Anatomical Distribution of Injuries from High-Explosive (HE) Fragments and Gunshot Wounds (GSW)
4 Mortality from Head Injuries from GSW and HE Fragments
5 Mortality from Penetrating Injuries of the Skull
6 Lethality of War Wounds among U.S. Soldiers from the Revolution to the Afghan War
7 Major Medical Advances of the Nineteenth Century and the First Half of the Twentieth Century
8 Special Causes of Death in the Union Army
9 Wounds and Sickness in the Union Army
10 Amputations in the Union Army
1
THE EMERGENCE OF MODERN WARFARE
1453 to the Twenty-First Century
Death came quickly to soldiers wounded on the battlefields of antiquity. The muscle-powered weapons that tore at their flesh inflicted death suddenly. Bodies pierced by spears or hacked by swords lingered in agony for only a short time until the loss of blood brought on shock and the merciful unconsciousness that precedes death. The lethality of the ancient soldier’s weapons and the primitive condition of military medical care, where it existed at all, ensured that death could not be protracted. The stricken soldier did not suffer long before slipping away.
With the appearance of gunpowder, wounding took on a more terrible character. Bullets drove fragments of clothing deep into the body, broke the long bones, and caused tracking wounds that, unless extensively incised and cleansed of loose tissue, became seats of infection. Gunpowder-driven projectiles instantly amputated arms and legs, grossly disfigured the face, laid open the skull to expose the brain, and caused multiple penetrations of the intestines. The new weapons caused terrible wounds that stimulated the search for medical techniques to deal with them. But medical innovation was unable to keep pace, and its treatments served mostly to prolong the suffering of the wounded without ultimately preventing their death from shock, blood loss, or infection. The wounded now simply took longer to die. The Middle Ages brought with it the introduction of new medical techniques that held out the promise, mostly unfulfilled, of saving the soldier’s life. But this progress was only a glimpse into the medical future and the beginning of the long road to effective military medical care.
The armies of the Middle Ages were a reflection of the political, social, and economic decentralization of the larger feudal social order. Most wars in this period were fought not by nation states but by rival monarchs that raised armies by levying requirements for soldiers and arms upon their vassals. Centralized arms industries, permanent standing armies, and logistical organizations or trained armies did not exist.1 Military doctrine and tactics of the day were almost nonexistent, and battles revealed the low sophistication of armed
scuffles among groups of mounted men. It was, as has been remarked, “a period of squalid butchery.”2 The knights returned home under the command of their local lords, and the armies disbanded after each battle. Tax collections for military purposes were sporadic, usually taken in-kind, and left to local military commanders, who were also the political officials of the realm. As the fourteenth century dawned, Europe found itself in a period of political, economic, social, and military transition between feudalism and the rise of the embryonic nation state.
The decentralization of feudalism placed the armored knight at the pinnacle of the socio-military order, and the form of individual mounted combat at which the knight excelled had swept infantry from the field almost a thousand years earlier. The last time Europe had seen a disciplined infantry force command the battlefield was under the Roman Empire. At the start of the Hundred Years’ War (1337–1457), the supremacy of the mounted knight remained unchallenged. When this series of dynastic wars ended, new military forms were emerging that signaled that supremacy’s decline.
To counter the power of the mounted knight, the infantry had to be able either to withstand the shock of a mounted assault or to deliver sufficient missiles from a distance great enough to inflict casualties on the mounted formation and prevent it from closing with the infantry. At the Battle of Laupen (1339) Swiss infantry annihilated a force of mounted French knights by reinventing the Macedonian phalanx, complete with eighteen-foot-long pikes similar to the sarissae that Alexander the Great’s infantry had used sixteen hundred years earlier.3 Comprising sturdy and disciplined citizen soldiers, the Swiss infantry stood its ground against the mounted charge, stopping the French cavalry with their pikes. With the cavalry halted before the wall of pikes, Swiss halberdsmen and ax throwers attacked, chopping off the legs of the horses and butchering the fallen knights as they lay helpless on the ground. At Crécy (1346) the English reinvented the second solution for confronting a cavalry charge and destroyed a force of French knights with hails of metal-tipped arrows fired from longbows.4 In both instances, the solutions represented the rediscovery and reapplication of long-forgotten techniques that Alexander and the Romans once had used for defeating cavalry. For the first time in more than a thousand years, disciplined infantry forces again began to appear on the battlefields of Europe.
The Hundred Years’ War witnessed the beginning of national identity and loyalty as a series of dynastic wars crystallized national identities. The need for large military forces, including mercenary contingents, gave rise to the replacement of in-kind taxes with regular tax collections of specie. This effort required developing a centralized governmental mechanism, and the embryonic nation states began to build governmental infrastructures under the national monarchs’ control. Both during the war and for more than a hundred years afterward, bands of demobilized ex-soldiers who fought for pay and constantly switched sides plagued Europe. The rulers’ problem was how to bring these military bands under the authority of a national army. Their solution was to offer permanent pay, to build regular garrisons, to enforce strict codes of military discipline, and to establish military rank and administrative structures. By the 1600s, for the first time since the collapse of Rome, Europe began to develop stable, permanent armed forces directed by central national authorities and supported by taxation.
The emergence of national authorities spurred the organizational, tactical, and technological development of armies during this period and set the pattern for the next four centuries. A standing army of professionals could be disciplined, schooled in new battle tactics, and trained to utilize the new firearms with great effect. This preparation, in turn, helped stabilize the new role of infantry, whose musket and pike tactics permitted thinner linear formations of infantry on the battlefield. The appearance and evolution of the firearm increased the demand for a disciplined soldier, and this requirement ushered in a permanent and articulated rank and administrative structure to train and lead the soldier. Permanent rank and military organization reappeared, and by the time of the Thirty Years’ War (1618–1648), all the major elements of the modern army were in place.
THE GUNPOWDER REVOLUTION
The most significant invention in weaponry of the Hundred Years’ War was gunpowder, which when coupled with new techniques for casting metal produced the primitive cannon. Siege mortars used to batter down castle walls quickly came into widespread use. In 1453, the Ottoman armies used cannon to destroy the walls of Constantinople, bringing the Byzantine Empire to an end. Mobile siege guns played a leading role in several battles of the Hundred Years’ War,5 which also saw the first effective use of field artillery in Europe. True field artillery appeared in the final decade of the fifteenth century when the French mounted light cast bronze cannon on two-wheeled, horse-drawn carriages. The introduction of the trunnion—a device for raising and lowering the gun independently of the carriage—increased the soldier’s ability to aim these guns with greater accuracy. By the seventeenth century, gun manufacture had progressed to where the range, power, and types of guns would change little for the next two centuries.
During the fifteenth and sixteenth centuries, gunpowder was revolutionizing the battlefield. The appearance of the musketeer, the forerunner of the modern rifleman, and his firelock musket made it possible for the first time for tightly packed infantry formations to stop cavalry without engaging in close combat. The slow rate of fire of these early weapons, however, required that musketeers be protected from the hostile advance, a problem that led to mixing musketeer formations with those of pikemen. Although the mix of pike to musket changed considerably over the next three hundred years, the mixed infantry formation remained the basic infantry formation during that time.
The cavalry most immediately felt the effect of portable firearms on the battlefield. The invention of the wheel lock allowed the soldier to aim and fire the pistol with one hand. As the introduction of pike and musket to the infantry reduced the shock effect of cavalry, the cavalry armed itself with saber and pistol and began to rely more on mobility and firepower than on shock.6 After more than a thousand-year interregnum, infantry again became the arm of decision on the battlefield. Leaders now used the cavalry, no longer decisive, to pin the flanks of infantry formations so that they could rake them with artillery and musket fire. At the same time, the siege mortar gave way to the smoothbore cannon that could function as genuine field artillery. By the seventeenth century, genuine horse artillery had replaced horse-drawn artillery, and all members of artillery units rode into battle. This development greatly increased the flexibility and mobility of field artillery, making it a full partner in the newly emerging maneuver warfare.7
By the sixteenth century, the feudal order was creaking toward its demise, and in its place arose the nation state governed by the absolute monarch in command of a permanent standing army. The professional army was the instrument of creating and protecting the nation state. Whereas feudal armies had attempted to capture the enemy’s strong points, the new armies engaged in wars of attrition with the primary goal of destroying the enemy’s armed force. The time was right for the ideology of nationalism and dynastic rivalry to propel a new round of national conflicts, which, in turn, would spawn yet another generation of new and more destructive weapons.
The Thirty Years’ War was the most destructive of these conflicts. What began as a clash of feudal armies ended by setting the stage for the emergence of modern war. During this period, the musket revolutionized the role of infantry. The original musket was a firelock, itself a great improvement on the earlier matchlock, which had required a forked stand to hold its long barrel. The rifleman had to ignite the powder in the touchhole with a hand-held burning wick, conditions that made the weapon impossible to aim or fire quickly. The firelock used a trigger attached to a rod that moved a serpentine burning wick to the touchhole, thereby allowing the rifleman to hold the weapon with both hands and aim. The lighter, more reliable, and more mobile firelock could fire a round every two to t
hree minutes. For the first time the infantry had a relatively reliable and accurate weapon.
The firelock was later replaced by the wheel lock, in which a rotating geared wheel powered by a cocked spring caused a flint to ignite the powder in the flash pan. A century later, the wheel lock was replaced by the flintlock, in which a spring-loaded hammer struck a flint to ignite the charge. By the 1800s, the percussion cap, a truly reliable system, had replaced the former mechanism. With each development, the rifle became more certain to fire on cue and the rate of fire increased.
Corned gunpowder was another significant innovation of this period. Early gunpowder for rifles and cannon tended to separate into its component materials when the powder was stored for long periods or when moved in the logistics train. The separation made it unlikely that the powder would explode evenly in the rifle barrel, increasing misfires and propelling the bullet at much lower velocity. Corned powder was made of component materials shaped into little nuggets that reduced settling and made the powder more certain to fire evenly, maintaining the projectile’s velocity. This configuration resulted in longer range and deadlier firearms and cannon.8
In the sixteenth century, the rifleman carried his powder and ball, ranging from .44- to .51-caliber lead shot, in small leather bags. In rainy weather, the weapons often would not fire because of damp powder. In the Thirty Years’ War King Gustavus Adolphus of Sweden (1594–1632) invented the paper cartridge, which protected the powder from dampness and greatly improved the rifle’s reliability. Musketeers could now fire two rounds a minute instead of a single round every two or three minutes. By the end of the American Civil War (1861–1865), the completely self-contained modern cartridge with powder and bullet in a single metal container made its appearance. By the Franco-Prussian War of 1870–1871, the breech-loading rifle had become standard issue for European armies. Two decades later, the clip- and magazine-fed infantry rifle revolutionized infantry tactics. The breech-loading, clip-fed, bolt or lever action rifle made it unnecessary for the rifleman to stand or kneel to reload. This freedom of action made the introduction of modern dispersed infantry tactics possible and further increased the infantry’s ability to fire and maneuver.9
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