From a military perspective, the Renaissance can be conveniently dated from 1453— the year in which Constantinople fell to the Ottoman Turks, destroying forever the last major cultural center of the ancient world—to 1618, the beginning of the Thirty Years’ War, when the use of contract armies, or the condottieri, and mercenary forces on a large scale was coming to an end as the emerging nation states became more organized and able to raise genuine national armies.1 By 1618, European states were deploying national armies supported by regular taxation, stationed in permanent garrisons, sustained by regular pay, and directed by articulated administrative structures under the command of national sovereigns.
European culture underwent a genuine “revival of learning” during the Renaissance, a period when new methods of scientific inquiry arose. To attempt these new methods, especially with their emphasis on observation and incipient empiricism in science and medicine, and to explore new subjects, particularly those in medicine that the church and governmental edict had long forbidden or ignored as already answered by the scholastic methods of the Middle Ages, the old clerico-secular social order had to be weakened and its power to punish and censor diminished. As a prelude to change, the old alliance between secular and religious authority that for eight hundred years had sustained the feudal order and religious control of knowledge and inquiry had to be reduced.
A number of events came together to attenuate the old establishment’s traditional hold on intellectual life. A major factor was the outbreak of the bubonic plague, which first occurred in 1348 and flared again several times in the same century.2 The devastation it wrought was enormous. An estimated one in every three people in Europe died from the disease, a rate of death that sapped the physical and intellectual life of European culture. Within a century, a devastating outbreak of syphilis followed and became endemic to the European population for the next two centuries. In its wake a population already debilitated by the plague suffered an inevitable physical and mental deformation. The birth rate fell, and the population declined to where it had been a century earlier. Whole regions of Europe were almost completely depopulated. The weakened population became more susceptible to other diseases, and smallpox, influenza, measles, typhus, yellow fever, diphtheria, whooping cough, lead poisoning, and ergotism also became epidemics. Surviving records reveal that all these diseases reached pandemic proportions for the first time in European history.3
The effect of these conditions was to call into question the very basis of the clerico-secular society that had long been regarded as legitimate and ordained by god. The disease epidemics demonstrated the powerlessness of medical knowledge, and the medical profession lost status as society bristled with charlatans and quacks offering miraculous cures and amulets. The clerical elements of society were also revealed as powerless. The old doctrine that god visited death and disease as punishments for sin was hardly credible in an age when disease seemed to strike at random, when saint and sinner alike perished, and when large numbers of priests, monks, and even popes died.
The wave of epidemics also critically weakened the family’s ability to socialize its young to the ideas and values of the old order. As diseases carried off parents, older brothers and sisters, aunts, and uncles—all vital mechanisms for transmitting and enforcing traditional social norms and values—new generations grew to adulthood removed from the familial and societal strictures that were enforced in the past. The randomness of death and the shortened life spans produced in these generations an attention to the present to a degree not seen in Europe for a thousand years. Concern for one’s health provoked an emphasis on the physical body and material goods rather than on the spiritualism and eschatological views that underpinned the old clerico-secular order. The situation was not unlike those following social and military disasters in modern times. The defeats that Russia and Germany suffered in World War I produced a “lost generation” of youth that was no longer socialized to the beliefs and habits of the older Europeans who had suffered the defeats. The result in both cases was a revolution of new ideas, values, and behaviors that utterly destroyed the old orders.4 The plagues and epidemics of the early Renaissance produced similar conditions and bred generations of unsocialized, rebellious, and materially concerned youth freed from the conventional intellectual, moral, and social strictures.
The declining size and quality of the general population made recruiting talent committed to traditional institutions very difficult. The Catholic Church could no longer sustain its monasteries without lowering its admission standards and reducing the harsher aspects of monastic life. Beginning in 1517, the Protestant Reformation produced the ultimate challenge to the old order’s ability to control events. The idea of a single church exercising universal control was broken forever as Europe fragmented into scores of religious sects competing for the loyalty of a population frightened to death by death itself and desperately seeking answers to worldly concerns. The emergence of nation states encouraged secular authorities to take advantage of the religious strife by superimposing upon it an attempt to increase the scope of secular power. Religious issues became central to the dynastic wars of the period as the newly emergent national political authorities attempted to free themselves from the religious and secular power of the church. The resulting century of religious war and massacres further reduced the population and created yet more uncertainty in the world of the average citizen.
The aspirations of the new nation states’ monarchs provoked frequent wars that also facilitated the destruction of the old order. In their efforts to establish effective control within their territorial realms, the monarchs of this period clashed repeatedly with ecclesiastical authorities in an attempt to reduce the power of the clergy in secular affairs and carve out a realm of political action independent of church oversight and censure. At the same time, the cost of these wars moved the monarchs to seize the material resources of the monasteries and churches within their national borders, further reducing ecclesiastical influence and control. The religious tenor of these dynastic wars was clear from the settlement that followed the Thirty Years’ War in which national secular authorities were entitled to determine the religious loyalties of their respective subjects. That the religious loyalties of the national populations came to be regarded as a legitimate concern of the national kings was the clearest indication of the power of the new secular order.
The effect of waging more than a century of warfare further increased the uncertainty of life, forcing the individual back upon his or her own resources for survival. It was almost impossible to travel from one place to another without an armed guard. Bands of mercenaries and gangs roamed over the countryside, pillaging at will. Secular authority was often completely absent in the towns, and the citizenry was left to its own devices to secure its survival and livelihood. Sieges, attacks, and religious massacres were commonplace, and trouble in all social affairs was the order of the day. In many ways the situation was not unlike that which plagued Europe during the period of the tribal invasions that followed the breakdown of Roman authority in the sixth through eighth centuries. It was impossible for the old order to sustain its legitimacy. The time was ripe for new ideas.
Three events accelerated the search for new ideas: the Muslim armies’ capture of Constantinople, the invention of printing, and the emergence of new perspectives on surgery precipitated by the frequent warfare during this period. The fall of Constantinople to the Ottoman Turks produced a flood of Byzantine scholars and physicians fleeing the Turkish sword. These refugees carried the intellectual legacy of Greece and Rome throughout Europe. Large numbers of them settled in Italy and France, where they became members of university faculties. These scholars and physicians then shared the cultural and empirical medical knowledge of Greece and Rome in its accurately preserved form.
The manuscripts and translations of the works of Greek and Roman medicine were available in their original versions only in Byzantium. While some of this knowledge had reached the West during the Middle Ages, much of the original empirical medical knowledge of the Greek and Roman texts had been lost or distorted over the centuries by Arab and Christian scholars, physicians, and clerical authorities who, in translation after translation, had edited and reedited the texts and removed information considered dangerous to the faith. Moreover, the scholastic approach to intellectual inquiry that characterized Western and Arabic medicine during the Middle Ages emphasized logical consistency and ratiocination to the extreme detriment of empirical observation and experimentation. The resulting medical profession was mired in medical questions and treatments in which empirical evidence was largely ignored. There is no more telling example of how corrupted the traditional empirical texts became than the fact that Galen (129–200 CE), the accepted medical authority of anatomy and medical practice in the Middle Ages, was regarded as the father of the doctrine of necessary suppuration of wounds when, instead, he clearly states pursuing the opposite course in the original text.
When the Byzantine refugee scholars reintroduced classical Greek and Roman medical texts to the West, they presented physicians with a new source of empirical medical knowledge that had been lost for more than a thousand years. Most of the texts were written in Greek, and their translation required a determined effort, especially in light of the opposition to the new knowledge that came from the traditional medical and ecclesiastical authorities. A group of courageous physicians and scholars, nonetheless, attempted the task. This group of translator-physicians is known to history as the medical humanists.5 Their translations of the original classical medical texts from the Greek into Latin and then into the vernacular were directly responsible for providing Renaissance physicians with a new stock of empirical medical knowledge from which numerous further discoveries proceeded. Perhaps more important, the empirical methodology of the classical texts introduced to the Renaissance a new mode of reasoning and hypothesis testing that eventually became the new basis of medical diagnosis, treatment, and inquiry. After more than a millennium, Europe had rediscovered its empirical past.
Regaining this knowledge might have remained a useless enterprise were it not for the introduction of the printing press. Its invention in Europe has numerous claimants, but by 1454 the first printed work accomplished in any number was the Gutenberg Bible printed in Mainz, the center of European printing.6 The guilds protected the secrets of the trade, and every effort was made to ensure that the German guilds retained a monopoly. The printing process likely would have remained in German hands for much longer than it did had not Adolf of Nassau laid siege to Mainz and captured the city in 1462. German printers fleeing the sword spread throughout Europe, taking with them the secrets of the new technology. Within a decade, Switzerland, Holland, and Italy had major printing houses. Printing was a free enterprise that remained mostly out of the hands of ecclesiastical authorities. It was free from the strictures of prior review and made the transfer of information cheaper and faster than at any time in man’s history. Compared to hand-copied manuscripts, a printed book could be purchased at half to a third the price.7 The bold, dark print was easy to read, although the introduction of the printed book seems to have coincided with the popular use of spectacles. Spectacles had been invented in the twelfth century but only gained popularity during the Renaissance.
Printing’s impact on medicine was dramatic. For the first time, medical treatises could be produced relatively cheaply and in large numbers. The press greatly reduced the cost of reproducing medical drawings, a great aid in the revival of anatomical study. Printing books in the vernacular instead of Latin made it possible for medical knowledge to spread relatively easily from one country to another. It also made compendiums of medical information available to those medical practitioners who lacked the means or social status to attend medical schools. Equally important, printing opened up a new avenue for these medical practitioners to communicate with one another and exchange experiences and treatment protocols with little official interference.
One of the more important aspects of medical publishing was the introduction of pocket compendiums of anatomy, complete with medical drawings. The Renaissance saw the rediscovery of empirical anatomy based on dissection and observation, and a number of anatomical texts were printed. Most, however, were expensive and bulky to carry, making them of little use to the military barber-surgeon who was always following the army. (Barber-surgeons were untrained practitioners of folk medicine and surgery whose status as medical practitioners lay in their old practice of cutting the tonsures of monks. They earned a living cutting hair, shaving beards, pulling teeth, dispensing folk remedies, and, later, bleeding and applying poultices to the sick.) The solution was the cheap pocket compendium that could be easily transported and referred to under field conditions. Ambroise Paré’s Anatomie Universelle probably was published in this format in 1561. In 1601 Joseph Schmidt, a German military surgeon, published his Mirror of Anatomy precisely to provide a cheap, portable medical compendium written in the vernacular for the military surgeon’s use.8 These pocket books were the first surgical manuals intended for military use that Europe had seen since the days of the Roman medical service, and military barber-surgeons used them extensively in training and practice.
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.
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 experimentation 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 death 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.
Paré’s introduction of ligature also allowed him to amputate limbs damaged from other causes, and he appears to have been the first physician since Celsus to successfully amputate live limbs above the wound.22 Paré’s ligature, as important a medical advance as it was, worked primarily upon amputations below the knee that did not require tying off the femoral artery. Like most surgeons of his day, Paré had no experience in amputating above the knee, where his technique of ligature would have been almost useless in any case. In 1718, Jean-Louis Petit (1674–1750) introduced the screw tourniquet, which achieved temporary hemostasis in thigh and leg amputations by effectively compressing the femoral artery in the groin. His advancement helped reintroduce ligature in surgical amputations.23
Paré’s most significant contribution was his military medical service to several monarchs, and his widely read medical writings raised the status of the battle surgeon and surgery to its highest point in medical history prior to modern times. The needs of kings and nobles for battlefield surgical skills in an age of almost constant warfare greatly aided his achievement; however, increasing medical knowledge and the status of the military surgeon did not greatly improve the medical care available to the common soldier. For the most part, medical care was not significantly different from what it had been in the Middle Ages. Paré and others certainly made attempts to deliver medical care to the common soldiery and regarded it as their duty to do so. But despite advances in medical knowledge, the nature of military medical care remained primitive as armies struggled to find ways to deliver care in a systematic manner. As had been the case for almost a millennium, medical care on the battlefield was still mostly limited to kings and nobles.
Renaissance armies were undergoing a state of transition, moving away from the decentralized and temporary feudal armies of the Middle Ages toward the emerging professional national armies that eventually came to characterize the seventeenth century. Renaissance armies were not yet sufficiently structurally articulated and formed as genuine national armies that could sustain themselves with permanent financial support from their national sovereigns. Consequently, armies of the period contained only the embryonic beginnings of a permanent military medical service to deal with casualties. Also working against the establishment of an effective field medical service was the use of mercenary contingents in the emergent dynastic armies. No national sovereign felt an obligation to tend to the casualties of hired troops. Death and maiming were simply the costs of doing business, and the contract soldier assumed the risk. Although the class structures of the Renaissance states were somewhat looser than those of the Middle Ages, the line between nobles, royals, and commoners were still strictly drawn. Obligations toward one’s fellows were limited to equals within the same class. The idea that medical aid should be extended to the common soldier had yet to take root.
In the meantime, the presence of military medical personnel on the battlefield became increasingly common, with the nobles and kings usually being attended by barber-surgeons while at war. The histories of this early period document a number of military surgeons who attended to the armies.24 The era’s first example of a semi-regular use of surgeons on the battlefields can be attributed to the Italian city-states, which seem to have employed surgeons for campaigns as early as the thirteenth century.25 Even earlier, some Italian states gathered groups of medical practitioners within cities under siege to provide medical support and to enforce hygienic regulations.
The Swiss were the first Europeans of the period to provide regular medical care to the common soldier, perhaps as early as the Battle of Laupen (1339).26 The Swiss considered themselves a union of free peoples in which the citizens’ worth and rights were recognized in law. Because they were a rural people scattered throughout mountainous country, central authority was difficult to maintain, forcing the citizens to rely upon one another. Accordingly, the idea of a citizen’s obligation to the state based on general reciprocal commitments was established early. This principle of citizenship fostered the state’s obligation to care for those citizen-soldiers who waged war to protect the community.
From 1339 onward, the records of Swiss towns and cantons are filled with accounts of public funds being disbursed to care for the sick, wounded, and damaged of war. Some Swiss public authorities commonly hired barber-surgeons to care for the wounded after battle.27 By 1405, all Swiss cantons had done so. Later, it became custom to pay the wounded soldier as long as the army remained under arms. In 1476, the archives note that all of the wounded’s living expenses should be paid out of the public purse. The Council of Lucerne passed an ordinance that the state should legally guard the property of children orphaned by war. If public officials were deficient in this task, the state was to make restitution to the soldier’s heirs. Most enlightened was the decree requiring that the state pay both for the indigent wounded’s medical treatment until they were fully recovered and for the family’s expenses of the wounded until the damaged soldier could return to work.28 After the war between Bern and the five Catholic cantons in 1533, sick and wounded war prisoners were allowed to return to their homes without ransom upon payment of the cost of living expenses and medical attention. The Swiss soldier became so accustomed to these military medical benefits that later, when Swiss armies hired themselves out for duty in the service of foreign kings, they routinely included provisions for the pay of medical services and veterans’ benefits in their contracts.29
In Swiss musters of this period, historians find the first use of the title feldscher, or “field-barber,” which generally was used to describe the barber-surgeon in the European armies until the present day.30 Medical personnel in Swiss armies even commonly bore arms and participated as combatants. They treated the wounded only after the battle. Swiss law required that wounded soldiers remain with their units and not seek safety from the fight under penalty of desertion. This injunction made good military medical sense. It prevented the soldiery from scattering all over the battlefield, making it much easier to locate and treat the wounded when the battle was finished.31 Further, until the middle of the sixteenth century, the victors frequently slaughtered the wounded at will. Wounded men staggering around the battlefield would have been easy prey in an age where the intensity of religious wars severely eroded basic mercy and humanity.
The Swiss military medical service was the first in the Renaissance period; it emerged in a military force recruited from a single nation state bonded by common feelings of national identity. Once other armies of the period began to recruit from their own people instead of hiring bands of mercenaries and thugs, it was to be expected that they would develop the outlines of a military medical service to treat the common soldier as well. Charles VII (1403–1461) of France was the first European monarch to attempt the creation of national forces when he established his compagnies d’ordonnance (units of national troops directly under the orders of the king). Henry VII of England (1457–1509) created a similar force in 1485 with his “yeomen of the guard.” Maximillian I (1459–1519) of Germany formed a similar national force, the famous Landsknechte (native-born soldiers), drawn from the citizenry. This army was further strengthened and enlarged under Charles V (1500–1556) into a truly national military force.32 For the first time in a millennium, Europe once again had a formal military medical service.
Leonhard Fronsperger described the organization of the Landsknechte, including its military medical support, in his treatise on Imperial Courts-Martial (1555), which Col. Charles L. Heizmann translated.33 The Landsknechte were aggregated into hauffen (units of five thousand to ten thousand men), which were divided into regiments consisting of ten to fourteen fahnlein (standard units of four hundred men each). A barber-surgeon was assigned to each of these units of infantry and to each troop of two hundred cavalry.34 Attached to each hauffen was a field physician in chief, who was responsible to the commander for medical support, and an additional field-barber. The chief marshal of cavalry also had a physician under his command, and a surgeon was assigned to the artillery commander.35 The regulations clearly make providing medical support a command responsibility, and it ensured that medical supplies, surgical chests, and medical transport were given to the medical complement. The surgeon was required to sleep in the command tent so that he could be easily located should the wounded need attention. Medical personnel received double pay from public funds.36
The army also provided wagons to transport the wounded and sick. Each morning, the slightly sick and wounded were transported along with the army, and because no army of this period had yet established a system of military hospitals to tend the wounded, the more seriously ill and wounded were sent to whatever hospitals were in nearby towns. The troops contributed to a common fund out of which they paid a spital meister, or “hospital attendant,” delegated to look after the sick. When the army moved, couriers were dispatched to locate suitable quarters, including a house where the barber-surgeon could attend patients. In battle, the medical personnel were located with the rear guard, and their orders were to bring the wounded out of the line and find a safe place to treat them. As long as the army remained in the field, the wounded and sick continued to receive their pay.37
These regulations governing medical support represent at least the spirit of the new national sovereigns who were attempting to care for the common soldier drawn from the ranks of the citizenry; however, the system was still not very effective in practice. The armies were largely constituted from the dregs of society, and they did not conduct any medical examinations to exclude the mentally or physically unfit. Unlike the Swiss, these armies made no provisions to care for the wounded after military service. A wounded Landsknechte made his way home as best he could and survived upon his own resources, often nursed by one of the many female camp followers who attached themselves to the soldiery as wives and girlfriends.38 It was common practice to abandon the wounded, who were treated where they lay by bands of roving charlatans and cutters that followed in the wake of the army.39 The quality of these medical personnel was not likely to give the soldier much comfort. Surgeons and physicians who attended the officers and nobles were probably barber-surgeons with extensive empirical experience but little formal medical training. Those who treated the troops, however, ranged anywhere from the apprentice barber-surgeon who was seriously trying to learn his trade to crude army cutters or sow gelders. The army still impressed common medical practitioners into service, and most of them ended up treating the troops.
The increasing national character of the Renaissance armies stimulated the formation of medical services for the soldier in other armies of the period. In France, the armies of Charles the Bold, Duke of Burgundy, had a surgeon attached to every company of a hundred lancers or eight hundred infantrymen in addition to the personal physicians of the king and nobles. Edward IV of England (1442–1483) had a chief physician, two body physicians, a surgeon, and thirteen assistant surgeons on his staff.40 At the Battle of St. Quentin in 1557, the English Army had a total of fifty-seven surgeons at its service and established a rudimentary organizational structure of medical care that English authors often cite as the first instance in England’s history where a medical service was provided.41 In Italy, the republics of Florence, Venice, Naples, Ferrara, and Verona had small surgical units attached to their armies, and the galleys of the Genoese Navy had one barber-surgeon and one assistant barber attached to each ship’s complement of 210 men.42 In Spain, each infantry regiment had a physician and surgeon attached to it, and the armada had a hospital ship on which to treat casualties.43
These rudimentary medical establishments gradually grew in size and sophistication as the end of the Renaissance approached, and stationary military hospitals were founded and replaced the temporary field hospitals throughout the various European realms. The permanent structures opened the possibility of long-term care for the wounded. The idea of caring for disabled veterans had gained currency as early as 1318, when the Venetians established a home for disabled mariners. A century earlier, Louis IX (1214–1270) had founded an asylum for blind crusaders, and in the thirteenth century a charter was granted to the Chevaliers de l’Étoile (Knights of the Star) to care for the disabled.44 The earlier medieval hospitals to care for disabled soldiers had their roots in the Carolingian Dynasty (751–987), when the practice was to send the disabled to monasteries, convents, and churches and allow them to earn their keep by performing menial chores as lay brothers.45 By 1600, this system had been mostly abolished, and in 1605 the French replaced it with the Maison Royale de la Charité Chrétienne, where disabled soldiers were supported by whatever surplus could be extracted from the budgets of various charities.46 The idea of permanent care for the wounded, first used by the Roman Army, along with pension benefits did not emerge in full form until the modern era.47
It can be said that the continuous wars of the Renaissance increased the leadership’s concern for their common soldiers’ medical care, but this interest was balanced by the fact that the soldiery came from the lowest social orders, and in general the political and military leadership of the day was indifferent to the people’s welfare. Rudimentary, unsubstantial efforts at medical care were made, but the effect of the era’s advances in medical knowledge on the casualty rate was felt largely among the soldiery drawn from the higher social orders. Since military medical establishments of the time came in and out of existence as the press of war dictated, no corps of military medical professionals developed that could devote its full attention to improving medical care for the soldiery. Further, the degree of organizational articulation of medical support structures remained primitive throughout the period. Military medicine, as distinct from military surgery, for the most part remained dismally behind civilian medicine, which itself was in a less than exalted state.
Military medicine would have been more effective had the leadership given attention to field hygiene. Disease carried off more soldiers than weapons did in every war in history until modern times.48 Armies lost more combat power to temporary disablement due to illness than to any other cause. Controlling and preventing outbreaks of disease depended on advances in medical knowledge that did not occur until the nineteenth century. Moreover, commanders simply regarded the presence of disease and sickness in the army as a normal cost of war, since it had always been the case as long as anyone could remember.
Disease and illness were such common aspects of civilian life of the period that it is hardly remarkable that no one should have taken much note of it in military life. For centuries, for example, monastic orders had forbidden their members to bathe more than twice a year unless a physician ordered them to do so. Queen Elizabeth I (1533–1603) was horrified at the suggestion of washing herself all over more than once in a year.49 As noted earlier, the period saw a number of diseases become epidemic to the population, which commonly accepted death and illness as part of the natural order. The medical profession, having forgotten the old Roman notion of preventive medicine, could do little to prevent outbreaks of disease and even less to cure them once they were under way. Little wonder, then, that few commanders gave much attention to preventing disease and illness on military campaigns.
In Heizmann’s study of military sanitation and hygiene in the Renaissance, he notes that the proportion of sieges to battles during the period was 2 to 1, probably owing to the introduction of the new heavy artillery. Of the fifty-seven besieged towns studied, twenty-four were eventually reduced by assault, twenty capitulated, and in thirteen cases the siege was abandoned.50 In almost every case of capitulation or abandonment, one or both armies suffered heavy casualties from disease. In only a single instance, at the siege of Metz in 1552, can one find any attempt by military commanders to prevent disease. So uncommon were such attempts that the siege of Metz is regarded as the period’s high-water mark for military sanitation.
The siege provides an example of what happened when one army made attempts at military sanitation and the other did not. Charles V laid siege to the town on October 20 with a force of almost 220,000 men going against the city’s force of fewer than 6,000 troops commanded by Francis, Duke of Guise. The besieging army conducted sanitary affairs as usual, and by December 26 it had lost more than 20,000 men to disease. The main killers were typhus, dysentery, and scurvy.51 Although the losses to disease were not unusually large as a percentage of force for that time, they were great enough to force Charles V to abandon the siege.
Within the walls of Metz, the Duke of Guise proved himself a first-rate medical officer who succeeded in keeping his losses to disease relatively low through applying basic rules of field sanitation. Guise increased expenditures for rations to ensure his troops ate well. Water points were checked for purity and placed under guard. Any soldier who fell ill was immediately isolated from the rest of the garrison in hospitals provided at remote spots within the city. Special units of pioneers cleaned and swept the city streets. Any human waste or animal carrion was thrown over the city walls.52 Barber-surgeons were hired to attend the sick within the garrison and in the hospitals, the first time that the physicians of nobles were placed at the regular disposal of the common soldier.53 Physicians were appointed to oversee the quality and distribution of the food supply. No one was permitted to eat fish, venison, or game birds for fear that they might carry disease.54 These efforts were so successful that not a single serious outbreak of disease occurred during the sixty-five-day siege.
The siege of Metz is also known for the first instance of the period when a commander showed basic humanity to prisoners. It was common practice to butcher prisoners, especially the sick and wounded, who fell into enemy hands. Guise instead ordered that the enemy sick camps not be burned and that the captured sick prisoners be taken to hospitals within the city and given medical treatment. He communicated with the enemy commander, suggesting safe passage to units designated to police the area for additional wounded and sick, and supplied wagons for this purpose. A number of boats to transport the enemy sick to their home units were supplied, marking the first time since Rome that “hospital ships” were used to evacuate and treat the wounded.55 Guise’s clemency, however, proved a disaster. Once he had transported the enemy sick to the city’s hospitals, an epidemic of typhus spread from the prisoners to the larger population, killing hundreds.
Guise’s example of humane treatment provoked a remarkable change in the treatment of the wounded that other armies gradually adopted. At the siege of Therouanne in 1553, Spanish troops who had fought at Metz remembered the French example of merciful treatment and did not kill a single prisoner. Again at Thionville in 1558, both sides followed Guise’s example. The common practice of massacring those prisoners not reserved for ransom gradually declined. By the seventeenth century, the combatants themselves had established the custom of sparing prisoners, and from it sprung the idea that the wounded and sick should be treated as noncombatants. This idea was codified into international law centuries later in the Geneva Convention.
The Renaissance was more than a “revival of learning” insofar as it saw the discovery and promulgation of new medical knowledge. More important, the period produced a new type of medical practitioner, the military barber-surgeon, who could apply the new empirical medical knowledge on the battlefield. For the first time in a millennium, the soldier had access to some effective empirical medical talent to save his life. At first this talent was reserved for the nobility, but as the feudal armies gradually became national armies drawn from the citizenry, the leadership paid more attention to the medical needs of the common soldier. The first embryonic stirrings of regular medical establishments in the armies of all the major states appeared, and the gradual introduction of humane rules and practices for dealing with the captured, sick, and wounded probably went some distance in reducing casualty rates. The first permanent military hospitals appeared, as did greater concern for caring for the disabled after their return from military service. Yet, it is important to remember that in all these aspects the Renaissance represented only the germination of new military medical ideas and practices. It took another three centuries before any of these ideas were carried to fruition in a manner sufficient enough to make a real difference in the quality of military medical care available to the soldier.
1. The dates used here to define the Renaissance period encompass the most important military and medical events of the period. From a literary, cultural, and artistic perspective, however, the Renaissance can be said to have begun much earlier, perhaps as early as the twelfth century.
2. The first outbreak of the Great Plague in Europe occurred in 1348. Outbreaks of lesser intensity occurred in 1361–1363, 1369–1371, 1374–1375, and 1390–1400. Historians have generally come to accept Jean Froissart’s estimate that as much as a third of the population of Europe succumbed to the disease.
3. Fielding Garrison, Notes on the History of Military Medicine (Washington, DC: Association of Military Surgeons, 1922), 107.
4. The effects of disease and social disorder as they affected socialization mechanisms are found in John Rathbone Oliver, “Medical History of the Renaissance,” International Clinics 1 (March 1928): 239–62.
5. Among the more important medical humanists are Niccolò Leoniceno (1428–1524), who translated the aphorisms of Hippocrates and corrected the botanical errors in Pliny’s National History; Thomas Linacre (1460–1524), who translated the major Galenic treatises on hygiene, therapeutics, temperaments, natural faculties, and the pulse; and François Rabelais (1490–1553), who translated the other major works of Hippocrates.
6. It is probable that the first European press was not invented by Johannes Gutenberg but by Laurens Coster of Haarlem in 1440.
7. Fielding Garrison, Introduction to the History of Medicine (London: W. B. Saunders, 1967), 193.
8. Le Roy Crummer, “Joseph Schmidt: Barber Surgeon,” American Journal of Surgery 4 (February 1928): 237.
9. Charles L. Heizmann, “Military Sanitation in the Sixteenth, Seventeenth, and Eighteenth Centuries,” Annals of Medical History 1 (1917–1918): 283.
10. Garrison, Introduction to the History, 239.
11. Ibid.
12. For the dynamics of bullet flight and impact, see D. A. W. Hopkinson and T. K. Marshal, “Firearm Injuries,” British Journal of Surgery 54, no. 4 (May 1967): 344–53.
13. Firearms experts estimate the muzzle velocity of a black powder smoothbore musket firing a half-ounce .50-caliber ball at standard charge to be approximately 1,100 to 1,350 feet per second, providing an impact energy of 350 foot-pounds at 50 yards. For comparisons with modern military firearms, see E. Stephen Gurdjian, “The Treatment of Penetrating Wounds of the Brain Sustained in Warfare,” Journal of Neurosurgery 39 (February 1974): 157–66.
14. See Robert D. Forrest, “Development of Wound Therapy from the Dark Ages to the Present,” Journal of the Royal Society of Medicine 75 (April 1982): 269. Remarkably, the debate on whether gunshot wounds were poisonous continued until at least the early twentieth century, when in a curious twist it was held that the temperatures generated in firing modern weapons made bullet wounds essentially aseptic! See F. P. Thoresby and H. M. Darlow, “The Mechanism of Primary Infection of Bullet Wounds,” British Journal of Surgery 54 (1967): 359–69.
15. Henry E. Sigerist, “Ambrose Paré’s Onion Treatment of Burns,” Bulletin of the History of Medicine 15, no. 2 (February 1944): 144.
16. Ibid., 143.
17. Ibid., 148.
18. Garrison, Notes on the History, 115.
19. The best short history of Paré’s contributions to Renaissance medicine is Owen H. Wangensteen, Sarah D. Wangensteen, and Charles F. Klinger, “Wound Management of Ambroise Paré and Dominique Larrey: Great French Military Surgeons of the 16th and 19th Centuries,” Bulletin of the History of Medicine 46, no. 3 (May–June 1973): 207–34.
20. Ibid., 214.
21. J. S. Taylor, “A Retrospect of Naval and Military Medicine,” U.S. Naval Medical Bulletin 15, no. 3 (1921): 575–76. Thomas Gale (1507–1586) of England performed similar experiments with firearms at about the same time.
22. Wangensteen et al., “Wound Management,” 213.
23. Ibid., 214.
24. Garrison, Notes on the History, 99. Some famous physicians who served in military campaigns were Nicholas Colnet and Thomas Morestede with Henry V at Agincourt, Hans von Gersdorf with the Swiss at Grandson, Gabriel Miron with Charles VII at Naples, Marcello Cumano with the Milanese armies at Novara, and Symphorien Campier with Francis I at Marignano.
25. Heizmann, “Military Sanitation,” 284.
26. The only extant work on the subject of Swiss military medicine in the Renaissance was written by Dr. Conrad Brunner, Die Verwundeten in den Kriegen den alten Eidgenossenschaft (Tübingen, 1903).
27. Ibid., 57.
28. Ibid., 52–54.
29. Ibid.
30. The Soviet Army used the term “feldscher” as an official title for its combat medics at least until 1990.
31. Modern weaponry’s increased killing power necessitated tacticians’ spreading out their forces, and the consequential dispersal of the wounded still bedevils modern medical planners. Using medevac helicopters as a solution works only if one controls the air over the battlefield. Otherwise, the helicopters are themselves vulnerable to new long-range weapons, as the Soviets found to their dismay in Afghanistan.
32. The Landsknechte were heavy infantry armed with muskets, halberds, and bows. The state partially provided their pay, and they were permitted to loot and keep the booty as a supplement to their pay.
33. Heizmann, “Military Sanitation,” 284. These early regulations are regarded as the birth of the German military medical service.
34. Ibid., 281–83.
35. Ibid., 284.
36. Ibid.
37. Garrison, Notes on the History, 103–4.
38. The thousands of female camp followers who usually attended the armies of the period certainly contributed to the spread of syphilis, which was epidemic.
39. Heizmann, “Military Sanitation,” 285.
40. Garrison, Notes on the History, 104.
41. Heizmann, “Military Sanitation,” 284.
42. Garrison, Notes on the History, 105.
43. Ibid.
44. Taylor, “Retrospect of Naval and Military Medicine,” 598.
45. Ibid.
46. Ibid.
47. Some idea of how slowly the notion of providing long-term care to veterans developed can be obtained from noting that the disabled veterans of the famous Light Brigade at Balaclava during the Crimean War were not provided any care at all. In desperation, the disabled veterans sent representatives to their commander, Lord Cardigan, and asked him to plead their case with the government. Cardigan sent them away, promising to ask the government to grant a special dispensation so that his troops might be given preference in obtaining beggar’s licenses!
48. This remained the case until the Franco-Prussian War of 1870–1871 in which for the first time more men were lost to enemy fire than to disease. The low loss rate to disease resulted in large part from the discoveries of Robert Koch, who developed the theory of the etiology of disease and established regular sanitation officers in German units.
49. Reginald Hargreaves, “The Long Road to Military Hygiene,” The Practitioner 196 (March 1966): 441.
50. Heizmann, “Military Sanitation,” 281.
51. Carey P. McCord, “Scurvy as an Occupational Disease: Scurvy in the World’s Armies,” Journal of Occupational Medicine 13, no. 12 (December 1971): 588.
52. Heizmann, “Military Sanitation,” 285.
53. Garrison, Notes on the History, 106.
54. Heizmann, “Military Sanitation,” 286.
55. Ibid., 287.