THE REAPPEARANCE OF THE MILITARY SURGEON
The emergence of the military barber-surgeon as a familiar figure in the armies of the period greatly influenced the military medicine’s development in the Renaissance. As in the Middle Ages, the practice of surgery within the traditional medical establishment remained separate from the practice of medicine. Control of the medical profession and its educational establishment remained firmly in the hands of the internist-physicians, while surgeons occupied the lower levels of medical status. Although the medical faculties of the day regarded surgery suspiciously, the formal medical establishment nonetheless recognized educated, medically trained, and licensed surgeons. These “surgeons of the short robe” (physicians usually wore red robes of various lengths) relied upon the distorted works of Galen and Avicenna for their anatomy knowledge, and their surgical techniques had changed little since the Middle Ages.
Quacks, sorcerers, sow gelders, barbers, and other unsavory types mostly practiced the medicine available to common people. This group of practitioners, especially those who attempted surgery, had been outlawed by medical and secular authorities since the Middle Ages. With little financial incentive for the medical establishment to provide medical care to the commoner, these medical mountebanks were the people’s only source of medical treatment. Despite their clear legal status as felons, these common practitioners often found their way into military service during wartime. State authorities even impressed them into military service in some instances. These army “cutters” trailed along with the army, tending the wounded for a fee extracted from the soldier himself. Soldiers would often hire these practitioners out of their own pockets to attend the wounded. These quacks probably caused more death and injury, but in an age where medical care was restricted to the officers and others of noble birth, the “cutters” were the only source of any medical attention for the common soldier.
Falling between these extremes were the trained barber-surgeons or military wound surgeons (wundärtzne in German), whose profession developed during the frequent wars of the period. These practitioners were almost exclusively of low birth, and many started their careers as common cutters. But they acquired a high level of medical craftsmanship, especially in surgery, through extensive military service. Most often these surgeons had no formal medical education of any sort, although later some of the educated surgeons of the short robe served in the military, a condition that quickly brought their formal training and medical knowledge into collision with the bloody empirical realities of the battlefield. Having no formal medical education, the barber-surgeons were completely unhindered by the distorted medical theories and practices of the period, and they rapidly acquired new knowledge and treatment techniques as a consequence of their raw experience. Barber-surgeons like Paré (1510–1590) became quite famous, served as personal attendants to kings and senior officers, and authored medical books that were printed in the vernacular and thus widely read. These barber-surgeons were responsible for numerous more important advances in the military surgery of the period.
The barber-surgeons’ ability to acquire medical reputations and their effective medical techniques gradually made them an important military component of the armies of the day. The more the traditional medical establishment relied upon old doctrines and practices to protect their status and position, the more the empirically accurate and effective medical practices of the barber-surgeons spread in opposition. In this struggle for recognition and status, the printing press played a decisive role in distributing the new medical knowledge as military surgery began to emerge as an important subdiscipline. In the sixteenth century, barber-surgeons published in the vernacular no fewer than forty-five works or parts of works on the subject of military surgery. One work on military pharmacy, one on military hygiene, and eleven on various diseases associated with military service were also published.9 Where once no such texts had been available, now there were more than two score, all published in a cheap and easily read format that spread the new medical knowledge throughout Europe.
The status of the military surgeons as legitimate medical practitioners gradually became recognized in law, and some of the medical schools admitted them to faculty. In 1506, the Paris Medical Faculty admitted some of these surgeons to the college where they lectured and trained other physicians in surgery.10 Accompanying this rise in status was the gradual formation of the barber-surgeons into self-governing guilds. As early as 1462, the Guild of Barbers in England became the Company of Barbers under royal charter. In 1492 they obtained a special charter, and in 1540 Henry VIII (1491–1547) united the Guild of Surgeons with the barbers to form the United Barber-Surgeon Company.11 By the end of the Renaissance, the empirically trained barber-surgeon had become a legitimate member of the medical profession, although he still ranked below the internists and general physicians who continued to control the medical profession for at least three more centuries. Once organized into guilds, the new surgeons established training regimens and licensing requirements for future generations of practitioners. These military surgeons became regular features of the military establishments of the day. Having been absent from the battlefield for more than a thousand years, the true military surgeon, trained in empirical medicine and wound management, had reappeared.
NEW MEDICAL CHALLENGES
The most significant change in military operations of the Renaissance period was the introduction of gunpowder weapons on a large scale. The use of gunpowder in cannon had occurred almost a hundred years earlier, and by the Renaissance cannon had become common military equipment in all armies. While used almost exclusively for siege operations prior to this time, during the Renaissance cannon was commonly used as antipersonnel weapons to disrupt packed infantry formations. This tactic brought into existence canister and grapeshot, or soft metal containers filled with steel balls, rocks, metal shards, nails, and scrap glass. The most lethal gunpowder weapon, however, was the reliable musket and pistol. The musket enhanced the infantry’s power against cavalry, but it became vulnerable when cavalry equipped with pistols delivered counterfire. Gunpowder weapons greatly changed the nature of the medical challenges that the military surgeon faced by introducing three new types of battlefield injuries: compound fractures, gunshot wounds, and burns.
The soldiers of ancient armies rarely suffered compound fractures because their muscle-powered weapons could not produce sufficient impact energy to break bones in more than one place. The ancient soldier’s edged weapons cut deeply into the flesh but did so relatively cleanly and leveraged the impact of the blow over a narrow area of bone surface. When a bone did break, it usually did so only in one place and along a narrow area, factors that facilitated splinting and setting it if the soldier survived the battlefield. Compound fractures were so rare that Hippocrates considered a compound fracture an almost always fatal wound and one of the few instances when amputation of the shattered limb ought to be attempted.
Gunpowder weapons, however, easily produced the impact energy to shatter a bone in more than one place. More important than the impact energy of a musket ball, however, was the nature of musket shot itself. These early weapons fired a lead ball weighing a half ounce. The projectile’s muzzle velocity was relatively slow, and the bullet highly unstable in flight.12 The lead shot also became deformed as it left the barrel. Solid lead shot, unlike modern copper- or steel-jacketed bullets, did not retain integrity upon entering the body; instead, it spread flat upon impact. This combination of shot weight, deformity, softness, and low speed produced horrible wounds. When the bullet struck a bone, a compound fracture was a common result.13
Gunshot-induced compound fractures presented a new medical challenge to the battle surgeon. The common treatment for these fractures was amputation, and it is hardly surprising that the surgical works of the period are filled with references to amputation and contain the first portrayal of this technique for gunshot wounds. The commonality of these gunshot-induced compound fractures stimulated experime
ntation into effective amputation techniques, which also emerged in the military medical manuals of this period.
The gunshot wound unattended by fracture still produced its own problems. Unjacketed bullets traversing the soldier’s clothing at slow speeds often forced bits of cloth and leather into the wounds, increasing the risk of infection. For the first time in history, the battle surgeon confronted the problems of how to remove shattered bullets from the human body and how to determine the circumstances under which the spent projectile could be left within the patient. The common technique of enlarging the wound and then probing for the bullet with fingers or unsterile probes increased infection rates. The old and dangerous doctrine of laudable pus and necessary suppuration led to the common practice of stuffing gunshot wounds with all sorts of foul materials to produce suppuration and promote healing; instead, it resulted in a horrifying rate of wound infection. Likely only a few combatants suffering gunshot wounds healed without infection, if they healed at all.
Confronted with exceptionally high rates of infection for gunshot wounds after traditional treatments, the medical establishment was at a loss. The idea gained currency that gunshot wounds were altogether different kinds of wounds in that they were by their very nature poisonous. The first evidence of this new doctrine appeared in Alsatian Army surgeon Hieronymus Brunschwig’s Book of Surgery (1497). The doctrine gained wide currency under the influence of Pope Julius II’s personal physician, Giovanni da Vigo (1460–1520), who published it in his medical treatise in 1514.14 Although infection continued to carry off thousands of slightly wounded soldiers, other battlefield surgeons of the period—notably Paré, Hans von Gersdorff (1455–1529), and Philippus Aureolus Paracelsus (1493–1541)—argued from empirical observation that nothing about gunshot wounds was inherently poisonous and that, if left free from the common treatment of cautery and boiling oil, they would heal. The debate continued for almost three centuries with little agreement.
Gunpowder introduced yet another new medical problem, a high proportion of burns. Cannons often exploded as a consequence of defective casting. Soldiers reloading the powder charge after failing to swab the barrel properly suffered flash burns. The production of gunpowder itself was highly dangerous, and flash burns and explosions were common. Unstable powder transported in the baggage trains often exploded. The most common cause of gunpowder burns stemmed from the design of the musket itself. The soldier poured the powder into a flash pan secured to the side of the musket. Under stress, soldiers frequently poured too much powder into the pan, and when the pulled trigger moved the burning punk to ignite the power, it resulted in an explosion. Since sighting over the barrel required the soldier to press the stock to his cheek beneath his eye, these “flashes in the pan” often produced horrifying burns on the soldier’s face and blinded him. Paré recalled treating this type of injury.15 He tried various burn treatments on soldiers’ faces, comparing the results while searching for more effective methods. The most commonly used medicines for facial burns were various vegetable and animal ointments that usually produced blistering and scarring. One treatment was to use various inks that contained tannic acid, an effective anti-blistering agent.16 As recorded in his medical writings, one of Paré’s innovations, which he obtained from an old country woman, was a paste of crushed onions and salt that greatly reduced blistering and scarring. American military physicians during World War II noted that Soviet battle physicians used this same treatment in 1945.17
The problems that military medical personnel faced in treating gunpowder weapons greatly increased in another way. Because the reliable musket forced infantry formations to spread out to avoid destruction under cannon and rifle fire, armies deployed for battle over larger areas. The combat formations of the past in which densely packed masses of men clashed with one another at close range had made it comparatively easy to locate the wounded once the battle ended. The new dispersed infantry formations left the wounded scattered over a much greater area than ever before, making them much more difficult to locate. Because commanders retained the doctrine forbidding medical aid on the battlefield during engagement, the wounded lingered for hours and sometimes days before any medical treatment could be attempted. Not until the Napoleonic Wars when Dominique-Jean Larrey (1766–1842) invented the “flying ambulances,” whose task was to locate and evacuate the wounded, did this situation change even marginally for the better.
The new technology of gunpowder weapons largely shaped the military medical challenges of the Renaissance. That effective medical knowledge concerning infection, amputation, and blood loss had progressed only marginally since the Roman military medical service collapsed more than a thousand years earlier hindered dealing with these challenges. Worse, the entrenched medical establishment regarded surgery and empirical observation as a threat to its position and continued to hamper whatever progress the barber-surgeons made. They upheld the doctrine of necessary suppuration of wounds despite the clinical observations and printed commentaries of the battle surgeons who practiced otherwise. They did the same with cautery and boiling oil in amputation. Although a few bright lights in Renaissance medicine introduced new ideas and treatment protocols, the medicine of the period, even the military medicine, remained largely unchanged from the Middle Ages. Because the new military technology had changed the nature and severity of battle wounds considerably, however, the resulting casualties and the rates of infection not surprisingly increased dramatically.
A few empirically minded surgeons and physicians of the Renaissance, meanwhile, did contribute significantly to the advancement of medicine in that period. Although they differed widely in background and training, they all shared the new empirical clinical perspective and were willing to abandon the scholastic approach to medicine and rely more heavily on their own observation and experience. Some, such as Paracelsus and Andreas Vesalius (1514–1564), were members of the medical establishment and worked to change it. Paracelsus was the major critic of the scholastic approach to medicine and attacked the methodological roots of traditional medical knowledge. He raged against those who opposed the new empiricism and suggested throwing the works of Galen and Avicenna into a bonfire. He is regarded as the essential reformer of Renaissance medicine. Vesalius, meanwhile, had served as a battlefield surgeon in the armies of Charles V. He taught medicine using public dissection, lectured in the vernacular, and accomplished the only physiological experiments in anatomy after Galen and before William Harvey (1578–1657). The publication of his De humani corporis fabrica in 1543 obliterated the old Galenic anatomy, which had been based on the anatomy of apes and swine, and was the first comprehensive book on anatomy, complete with medical drawings, produced in almost fifteen hundred years.18 His work was considered so accurate that others imitated and improved upon it for centuries. Vesalius is correctly admired as the father of modern anatomy.
By far the most important surgical contributions of the period came from the new barber-surgeons, the most important of whom was Paré, the era’s most famous surgeon. Born of low station in Bourg Hersent, France, he was a self-taught barber-surgeon. He became the chief military surgeon to four monarchs; wrote important medical treatises, the most important of which was his Method of Treating Gunshot Wounds (1545); and served as an army surgeon all his life. Paré invented many surgical instruments, introduced the use of artificial limbs and eyes, wrote of flies as carriers of contagion, attempted implantation of artificial teeth, and tried to organize medical care for the common soldier.19 All his clinical experience was obtained on the battlefield, and Paré naturally concentrated on diagnosing and treating those medical conditions that arose from warfare.
Paré’s most important contribution was his development of successful techniques for performing battlefield amputations. His own experience showed that the traditional practice of amputation accompanied by cautery and boiling oil, a technique that da Vigo had popularized to treat the supposedly poisonous nature of gunshot wounds, more often produced pain and dea
th than recovery. Paré reintroduced the practice of ligature prior to amputation, a procedure lost since Aulus Cornelius Celsus performed it in the second century. This Roman practice greatly reduced bleeding and shock. Paré abandoned the barbarous technique of plunging the amputated stump into boiling elder oil mixed with treacle; instead, he treated the amputated limb with a mixture of egg yolk, oil of roses, and turpentine. The results were dramatic, with infection rates dropping as recovery rates increased. Paré applied similar poultices to regular gunshot wounds, also reducing infection rates. He concluded that nothing about gunshot wounds was poisonous per se and that infection was carried into the wound from external sources. He urged secondary and repeated debridement of wounds to allow healing by secondary intention. Paré used adhesive bandages in closing wounds to facilitate healing and astringent red wine, similar to the Roman acetum, as an antiseptic.20 Later, Bartolommeo Magi’s (1477–1552) experiments with firearms and wounds demonstrated that Paré’s assumption that gunshot wounds were not inherently poisonous was correct.21 Despite Paré’s findings, however, traumatic amputation treated by cautery and boiling oil remained a basic application up to the nineteenth century.
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