The new empirical spirit of the Renaissance threatened much more than the storehouse of knowledge inherited from the Middle Ages. The spirit of empirical inquiry was rooted in new notions of individualism, themselves products of the wide-ranging social disruption that the plagues and wars of the period engendered. The same spirit of individual inquiry that made the new knowledge possible also undermined the collectivism that had underpinned the European social order for more than a millennium. It was this “spirit of individual disorder” as much as the plagues, wars, and new technologies of the seventeenth century that weakened the social institutions of the old order.
The old intellectual tradition of inquiry based on scholastic reasoning, first principles, and absolute causes remained strongly in place as the new century dawned. The new empirical knowledge had not yet achieved a level of generalization or acceptance capable of challenging the old approaches to medicine and science on any scale. At the same time, the new knowledge was sufficiently accurate to seriously call into question the ability of scholastic assumptions and methods to explain the physics, science, and medicine of the day. As the intellectuals of the seventeenth century conceived it, the challenge was not to discard the age-old idea of a universal order but to utilize empiricism to demonstrate the validity of that order.
The period was the age of Isaac Newton (1642–1727), himself a devoutly religious man, who wrote his Principia Mathematica precisely to demonstrate the empirical reality of a divine order that governed human affairs. The new approach to science was never intended to discredit the conclusions of the old system of reasoning as much as to introduce new methods of demonstrating the validity of those conclusions through empirical observation. The difficulty was that while the new empiricism could collect data that had yet to await eventual theoretical synthesis, the new knowledge created disturbing observable facts that undermined the assumptions upon which the old scholastic approach was based. It resulted in creating as much of a threat to the old intellectual order as if the assumptions of that order had been directly challenged in the first place.
The seventeenth century witnessed the progressive weakening of the old social, political, and epistemological system as the press of epidemics, wars, and social disruption continued to cripple the social institutions that gave expression to the assumptions of the old knowledge in everyday life. The collectivism that had underpinned the old order was also undermined. The old order had been based upon reciprocity of obligations, but the new knowledge was based on rights.
The erosion of the collective spirit brought with it a decline in those social practices that thrived on collectivism, among them organized nursing, charitable care of the sick, well-managed hospitals, and the general power of the church. In its place, the new experimenters could only offer the promise of eventually complete explanations of human events. With the exception of Newton’s work, the seventeenth century produced no new tested theories or agreed-upon set of empirical observations. While the period did generate a number of important discoveries in medicine, few of them were integrated into the medical practice of the day.
Among the more important advances in medical knowledge was William Harvey’s demonstration of the circulation of the blood in 1616. Harvey proved mathematically that given the volume and speed of blood in the body, there was no alternative to circulation. Harvey’s work destroyed the Galenic dictum that blood passed through “pores” in the heart ventricles; instead, Harvey demonstrated that the heart pumps blood to the body and the veins return blood to the heart. Another major invention, the microscope, belongs to this period. While the instrument’s origins are obscure, Athanasius Kircher (1602–1680) was probably the first to use the microscope in investigating the causes of disease. Antonj van Leeuwenhoek (1632-1723) made further advances in medical microscopy, wrote more than 250 papers from data assembled from microscopic investigation, and produced the first scientific description of red blood corpuscles. Marcello Malpighi (1628–1694), the father of histology, was the greatest microscopist of the period and introduced a theory of respiration. Franz de le Boë (1614–1672) established the science of physiological chemistry, and Robert Boyle (1627–1691) conducted experiments on gasses that made a cogent theory of respiration possible.1
The decline of collectivism was evident in these discoveries. Individuals working in private laboratories with little in the way of institutional affiliation or support achieved most of them. The universities and medical schools of the day continued to cling to Galenic and other theories, and their rigorous enforcement of these perspectives prevented them from attracting the best minds to their faculties. Men associated with universities made few of the era’s great discoveries. In an age of individualism, individualism propelled investigation and discovery. Yet, the new knowledge cried out for an integrative theory to oppose the standing scholasticism. The search for a new theoretical structure influenced medicine as well.
The search for an integrative medical theory based on empirical observation manifested itself in the development of two major schools of thought that sought to organize the new medical knowledge into a systematic whole. The pull of universal order, assumed for more than a millennium, influenced medicine as much as it did Newton’s laws of physics. The two new schools of medical theory were the Iatro-mathematical school and the Iatrochemical school.
The Iatromathematical school sought to apply the new principles of mechanics and mathematics to medical investigation. As represented by René Descartes (1576–1650), Giovanni Borelli (1608–1679), and Santorio Sanctorius (1561–1636), the human body was conceived of as a mechanical machine in which all bodily processes—thinking, respiration, digestion, locomotion, and so forth—were regarded as mechanical processes subject to physical and mechanical laws. The Iatrochemical school, represented by Jean-Baptiste van Helmont (1577–1644), Franciscus Sylvius (1614–1672), and Thomas Willis (1621–1675), saw the body as the product of a series of chemical reactions and processes.2 Both schools ended in sterile failure, as they sought to generalize to operational principles of larger scope without sufficient empirical data upon which the structure of their analysis was built. Both schools were examples of what the new experimentalism was attempting to achieve. Because neither succeeded in enforcing a new theory of medicine upon the discipline, the process of experiment and discovery that characterized the period continued.
A number of important medical advances laid the groundwork for further development in the coming centuries, although few found large-scale application in daily medical practices. The new knowledge of physiological chemistry and of the behavior of liquids and gases was applied to medical experiments. One application was the intravenous injection of drugs, which Christopher Wren (1632–1723) first attempted on dogs. Others experimented with the technique, and Caspar Scotus carried out the first successful intravenous drug injection on a man in 1664. In England, John Graunt (1620–1674) introduced the science of vital statistics by compiling a statistical study of mortality. Stephen Bradwell (1588–1665) published the first handbook on first aid for common injuries in 1663. Daniel LeClerc (1652–1728) wrote the first comprehensive history of medicine, and the newly introduced medical dictionary became commonplace.3
The seventeenth century also saw the introduction of copperplate engraving to replace the woodcut, revolutionizing the art of anatomical illustration. Johannes Scultetus (1595–1645) wrote Armamentarium Chirugicum, the first complete book of surgical instruments with each instrument drawn to scale and complete with illustrations of their application in surgical settings. It was published posthumously in 1655.4 Until this time, armorers, blacksmiths, and razor makers had made surgical instruments to individual specification, with little in the way of standardization. Now highly skilled silversmiths, cutlers, and pewterers made these instruments and produced implements of standard design, balance, and quality.5
The quality of medical instruction, while still generally poor, was improved somewhat by the gradual introduction of clinical instruction in hospitals. A century earlier the Italians had introduced clinical instruction, and in the seventeenth century it was introduced to the universities in Holland, where it became a model for other medical universities. Dissection as a means of teaching anatomy became more common, especially in Italy, France, and Holland, and the anatomical theater became an established common feature of medical education. While corpses and skeletons were difficult to obtain, dissection increased as a means of instruction and discovery. Raymond Vieussens (1641–1716) is said to have conducted five hundred dissections in the course of his career.6
Two other innovations greatly spurred the development and communication of scientific and medical knowledge during this period. The first was the invention of the scientific society. The emphasis on individual efforts of discovery unencumbered by institutional affiliation created the need for a mechanism whereby scholars and scientists could gather, share, and test each other’s ideas. The idea for the resulting professional scientific society may have originated during the Renaissance in Italy, where such societies were a well-kept secret lest their members fall afoul of ecclesiastical authority. In 1560, one such secret academic society in Naples was called, appropriately enough, the Secret Academy. In 1603, the Academy of the Lynxes was founded along similar lines in Rome. Thirty-two years later, Cardinal Richelieu (1585–1642) founded the Académie Française. In 1660, the Oxford Philosophical Society of England opened its first journal book, and two years later Charles II (1630–1685) bestowed its charter as the Royal Society of London. In 1665, Jean-Baptiste Colbert (1619–1683) founded the French Academy of Sciences, and in 1683, the Dublin Philosophical Society came into being. These societies provided invaluable vehicles for transferring scientific knowledge across national borders. The idea survives today in the many societies and professional associations to which scholars, scientists, and other academics routinely belong.
The second stimulus to developing and communicating scientific knowledge was the introduction of periodical literature on a wide scale. First in the form of newspapers, then political tracts, and finally professional journals, these periodicals provided important channels for publishing research results and engendering learned debate. The French Journal of Medicine was first published in 1681. The first English medical journal was the Medicina Curiosa published in 1684, followed by Progress in Medicine in 1695.
The seventeenth century saw the establishment of national medicine in Russia and the United States. In the sixteenth century, Ivan III of Russia (1468–1505) had invited foreign physicians to settle in Moscow, a tradition continued to the end of the Romanov Dynasty in 1917. Both Peter the Great (1672–1725) and Catherine the Great (1729–1796) increased the number of foreign physicians hired. In many ways these foreigners had similar experiences to the Greek physicians in ancient Rome; they were skilled by comparison to Russian folk medicine, but the government and people always regarded them suspiciously for their strange ways. The first native Russian physician was Peter V. Postnikoff, whom Czar Peter sent to study in Padua in 1694.7
With regard to Russian military medicine, the first mention of a physician attached to the army appears in 1615. It seems to have been prior common practice for the state to provide money for barber-surgeons to care for the troops during wartime. In the second half of the century, the first regimental dispensaries appeared. Under Peter the Great, the Ministry of Medical Affairs became a chancellery, and the need to provide medical care to his army stimulated Peter’s efforts to attract foreign medical talent. By the end of Peter’s reign (1725), Russian military medical care was probably on a par with the rest of Europe, and a royal edict assigned each division of the army a physician, a staff barber, and an apothecary. A surgeon was assigned to each regiment and a field barber to each company. As with the armies of the other nations of Europe, the Russian armies also used field hospitals behind the lines. There is no mention in contemporary literature, however, of any provision for the long-term care of the wounded or disabled.8
The early settlement of the United States led to the creation of another national medical establishment. Although two doctors, Samuel Fuller and John Winthrop, were among the party on the Mayflower in 1620, and the establishment of Harvard College (1636) and the College of William and Mary (1693) gave further impetus to medical training in the early days, Americans traditionally studied abroad at European medical schools. The greatest number of American doctors during the colonial period, however, was trained through apprenticeship programs. Lacking a strong medical establishment made such an innovation possible. Further, the frontier nature of the early American society produced sufficient barriers to education and communication such that on-the-job training and experience were the rule for training physicians. Few of these medical apprentices were encumbered by theoretical knowledge, so similar to the education of the wound surgeons of the Renaissance, observation and experience became the primary emphasis of American medical education. This highly pragmatic emphasis, moreover, distinguishes American medicine to this day. The long-standing conflict between the physician and surgeon that crippled the development of European surgery for more than four centuries never developed in the United States. Meanwhile, in 1663, the first hospital was constructed on Manhattan Island.
Dynastic and religious rivalries caused constant wars that wracked the seventeenth century. The Thirty Years’ War and the English civil wars were among the period’s major conflicts. The increased number of firearms used by armies and the advent of the mobile field cannon greatly increased mortality rates in these wars, as did epidemic disease. The chief disease killers of the period were bubonic plague, typhoid, typhus, dysentery, and diphtheria. Horrible epidemics were common. In 1665, the Great Plague of London carried off sixty-nine thousand people. In 1679, the plague killed seventy thousand in Vienna. In 1681, more than eighty thousand fell victim to the disease in Prague, and in the Venetian states as many as half a million died.9 Nathaniel Hodges (1629–1688) was the first physician to conduct a postmortem inspection of a plague patient.10
On military campaigns, typhus, typhoid, and dysentery took a heavy toll. Typhus was so common in eastern Europe that it was called the “Hungarian disease,” and so many Germany troops died from it that they called Hungary the “Graveyard of the German Army.” This area remained a cesspit of infection for centuries, with yet another outbreak of typhus in 1915 decimating the British and Turkish armies there. Smallpox was pandemic in 1614, and a deadly epidemic broke out in England in 1666. Child mortality was high throughout the period, and it is estimated that as many as half of the English children born during the Restoration died from disease.11 The period’s only medical high points were that leprosy seems to have died out almost completely, and the treatment of syphilis by mercurial fumigation and inunction had slowed the rate of the disease’s spread.
The quality of military medicine in the seventeenth century showed no great advance over that of the Renaissance, in large part owing to the rigid divorce of surgery from medicine that had begun under Galen, was maintained by the Muslims, and then standardized into law and custom by the ecclesiastical interdictions of the Middle Ages. As the rivalry among physicians, surgeons, and barbers continued unabated throughout the new century, the battlefield care of the soldier and the common people remained the province of the few qualified wound surgeons and the usual collection of quacks. The number of competent, trained surgeons was very small, or less than a dozen of any note.12 Tension in the universities between surgeons and physicians produced generally poor surgical instruction even though dissection and the clinical amphitheater had become regular features in medical education. Unifying the barbers and surgeons into common guilds, however, did nothing to reduce the tension or to raise the general status of surgery.
Much of the new anatomical knowledge had yet to be integrated into the medical profession in any practical way, and most physicians still regarded surgery as dangerous. They generally avoided difficult operations on the grounds of legal liability and potential damage to their reputations and positions. Most armies also maintained the rigid separation of physicians and surgeons, with the physician attending general internal complaints while barbers and wound doctors did field surgery.
The generally low quality of military medicine was evident in the sparse publication of new works on the subject. Given the stimuli of the Thirty Years’ War and the English Revolution, one might have expected a greater number of original works on military medicine to have been published; however, for the first fifty years of the century, only eight works on surgery—none of them original or very valuable—and only nine on disease were printed. While in the previous century forty-five books had been published on surgery alone, the seventeenth century saw the publication of only thirty-four. While the production of epidemiological works was also sparse, twenty-eight new works on the subject of diseases in the military, two on diseases associated with ship duty, and ten on particular diseases associated with ground force campaigns appeared.13 A particularly bright light was the book Medical Observations in Hungarian Camps (1606) by Tobias Cober, a physician with the army of Bohemia. After seeing seven years’ service in the long war between the Hungarians and Turks, Tober provided the first clinical notice of the relationship between pediculosis in military camps and the outbreak of fever, probably typhus.14 Meanwhile, the era’s low level of military medicine was reflected in the rise to prominence of a new breed of field medical practitioners, the executioners! Some executioners acquired medical reputations based on the knowledge they gained while practicing their trade. The idea was that because executioners knew how to break bones, in some manner they also possessed some ability to set them.15
The three noteworthy physicians in wound surgery were men who had seen extensive military service in England and Germany. Perhaps the most important was Wilhelm Fabry (also known as Fabriz von Hilden, or Fabricius, 1560–1624) of Germany, who invented a number of new surgical instruments and advocated amputation above the diseased or damaged part of the limb to ensure the stump would be suitable for prosthesis. Fabry also used a primitive tourniquet in which he twisted a strap around a stick. He described the first army field surgical chest, which was based on that first introduced by Maurice of Nassau in 1612. Another important military surgeon was Matthaeus Purmann (1649–1711), a bold German surgeon who sutured intestines and gained extensive experience with gunshot wounds. His Fifty Strange and Wonderful Cures for Gunshot Wounds (1693) demonstrates, however, his belief in the magical curative powers of two common but useless methods of treating gunshot wounds—the “weapons salve” and “sympathetic powder,” which were applied to the weapon and not to the wound. The greatest English surgeon of his time, Richard Wiseman (1622–1676) was also a soldier. His book Several Chirugicall Treatises (1672) reveals a true medical empiricist who performed amputations, treated gunshot wounds, and provided a compendium of empirical military medical knowledge to future generations.
After all is taken to account, however, the seventeenth century did not produce anyone of Paré’s stature in military medicine.16 Even the most empirically oriented surgeons of the period continued to prescribe compounds that ranged from useless to dangerous and to believe in superstitious and magical cures for all kinds of medical conditions. Whatever advances in medical knowledge had been made during the Renaissance were either forgotten or long in coming into vogue in everyday military medical practice.
For the most part, then, the soldier often received indifferent or poor medical care for his wounds. Valid theories for treating the most common military medical conditions were, at best, in their embryonic stages of development. The combination of poorly trained medical personnel, sporadic systems of casualty servicing in the armies of the day, deadly medical practices, increasingly lethal weaponry, poor diet, and a complete lack of understanding of the causes of disease and illness combined to make the lot of the wounded soldier truly pathetic. Throughout the entire century only one voice, that of Polish knight and soldier Janus Abraham Gehema (1647–1715), cried out against these conditions. A combat soldier with extensive battle experience, Gehema wrote numerous short books on caring for the military wounded. Although he himself was not a physician or surgeon, the titles of his works suggest a keen appreciation of the military medical care of his time. His The Well Experienced Field Physician (1684), The Officer’s Well-Arranged Medical Chest (1688), and The Sick Soldier (1690) were all attacks on the contemporary military medical practices as being mostly useless, dangerous, and barbaric.17 In the spirit of the day, however, he was ignored.
The seventeenth century saw the continued evolution in weaponry and tactics that had begun during the Renaissance with the introduction of the first practical firearms. The number of firearms to pikes in infantry units increased enormously. Renaissance armies had armed between 25 and 35 percent of infantry with muskets. Gustavus Adolphus’s armies almost doubled the rate of firearms to pikes during the Thirty Years’ War. On average, 65 percent of his infantry forces carried muskets, and almost all the cavalry were armed with pistols.18 Swedish armorers redesigned the long heavy musket with a shooting fork to shorten it and made it lighter to allow quicker firing with better accuracy. The introduction of the paper cartridge with its standard powder load reduced the rate of misfires to practically zero, and the introduction of standard-caliber ammunition both increased the weight of the musket ball and eased supply efforts. Standardized ammunition and powder loads propelled the musket ball at a greater velocity than was possible a century earlier and, as noted previously, resulted in bullets becoming more commonly deformed upon impact, creating more ghastly wounds.
Although a number of fundamental medical discoveries had been made in the previous century, the application of this knowledge to military surgery was marginal at best. Wound surgery remained essentially unchanged from the Renaissance. The doctrine of necessary suppuration, long in vogue and buttressed by the still prevalent belief that gunshot wounds were inherently poisonous, led to the practice of attempting to remove the bullets with probes and extractors and increased the chances of infection. Standard surgical practice was not to close the wound but to widen it, allowing the wound to become infected and drain. Surgeons often placed bits of leather and cloth in a minor wound to bring on infection. Draining infected wounds did not become standard practice until Dominique Larrey, the surgeon in chief of the Napoleonic Armies, helped establish it in the nineteenth century.
Military surgeons, faced with an almost 100 percent rate of infection of battle wounds, fell back on miraculous and spurious treatments to combat a clinical condition that rendered them powerless. Physicians of the day placed great faith in a treatment called “the sympathetic powder,” which Kenelm Digby (1603–1665), a former privateer and con man, had introduced. Digby saw an opportunity to cash in on the then current propensity of military physicians to try all sorts of pharmaceutical materials. Digby’s sympathetic powder was ostensibly made from “moss scraped from a dead man’s skull and mixed with powdered mummy’s flesh.”19 It is a measure of the low quality of field surgery of the time that this wound treatment gained wide acceptance. No less a figure than Francis Bacon, who advocated the scientific method, included sympathetic powder in his scientific collection of drugs.
Other cures for gunshot included “the transplantation cure” in which a bit of wood was dipped in the blood or pus of the wound and wedged into a tree. If the sliver of wood took root and grew, it was believed the patient would recover. Most amazing was “weapon’s salve,” an ointment that was applied to the wounded soldier’s weapon in the belief that this process created some “influence from afar” that would cause the wound to heal.20 These attempts to deal with infected wounds suggest how helpless the military surgeons were when confronted with the clinical challenges that the more accurate and highly powered rifles of the period wrought.
The mystical quality of wound treatments during this period is evident from its materia medica, or what is more appropriately called a “filth pharmacopoeia.” Part of the problem was the growth of the apothecary guilds that controlled the distribution of medicinal compounds. In 1607, James I (1566–1625) recognized the apothecaries as a special guild distinct from grocers, and throughout Europe the apothecaries soon built a rich and powerful organization. In 1682, the apothecaries won the exclusive right to supply drugs to the army and navy in England. Like any salesmen, the apothecaries needed merchandise to sell.21 The result was an explosion in spurious mixtures for which all kinds of miraculous claims were made.
The field medical chests that were routinely supplied to the armies provide an interesting glimpse into the pharmacopoeia of the day. A description of a Bavarian field chest that an artillery unit used in the Turkish campaign of 1688 notes that fully loaded the chest weighed 320 pounds and contained thirty surgical instruments. It also held the following medicinal remedies for the wound surgeon’s use: powdered sandalwood, rhubarb, palm juice, spermaceti, mummy dust, scorpion oil, rain worm oil, oil of vipers, angle worms, earwigs, zinc oxide, Vigo’s plaster of frog spawn, mercury, human and dog fat, aloes, tartar emetic, sugar of lead, alum, sassafras, and opium.22 Most of these concoctions were not only useless but also often deadly. Almost all provoked infection when applied to an open wound. One marvels at the poor quality of this pharmacopoeia when compared with what Roman field physicians used more than sixteen hundred years earlier. The seventeenth-century pharmacopoeia is a good example of what happens to medical science when practitioners ignore empirical observation and adopt a method of reasoning in which logical elegance and religious superstition is allowed free rein in determining the nature of medical reality.
The musket’s increased power made the protective armor of the Renaissance obsolete; it could no longer protect the soldier from the penetrating power of the musket ball. The increasing national identity of the armies of the period led them to wear regulation field dress to distinguish the combatants from one another amid the smoke on the battlefield. They replaced the steel helmet and body armor with standardized uniforms, shakos, and soft hats, and the helmet did not again become a standard item of military issue until the later years of World War I.23 This change in military costume also introduced a special uniform for the army surgeon that consisted of a tight-waisted long coat reaching to the knees, the usual stockings, and buckled shoes. The civilian physician also copied the military costume as his professional dress and usually wore a red hat.
For the soldier, the disappearance of the protective helmet proved to be a medical disaster, and the rate of head injuries rose considerably. A black powder musket could indeed fire a ball fast enough to penetrate a steel helmet but only at very close range. A musket ball produced approximately 350 foot-pounds of energy upon impact, and the amount of impact energy required to penetrate a steel helmet is approximately 300 foot-pounds. The impact energy of a musket ball, however, dissipates quickly after the first forty yards and then drops off exponentially. At a hundred yards, the impact energy is far less than that required to penetrate a steel helmet.24 Without the helmet, though, only 90 foot-pounds of energy are required to penetrate the human skull.25 The impact energy of a musket ball at even two hundred yards is easily enough to penetrate an unprotected skull but insufficient at that range to penetrate a helmeted skull. Thus, the increase in both head wounds and lethality resulted far less from technological improvements to the rifle than from abandoning the helmet and body armor.
It would still have been wise to retain the helmet if only for protection against exploding cannon fragments, grenades, and canister, all of which proved lethal to the soldier not wearing a helmet. These fragments usually did not achieve sufficient velocity to penetrate a helmeted skull, and most struck the soldier when much of their velocity was already considerably spent as a consequence of traversing some distance after the burst. Even in modern times, the helmet is designed more to prevent these kinds of secondary penetrations than to stop a direct hit from a rifle bullet. Abandoning the helmet, therefore, greatly increased the soldier’s vulnerability to secondary weapons’ effects. Once the idea took hold that the helmet was no longer a valuable protective device, however, the search for effective head and body armor was dropped for three centuries.
The increase in head wounds became a major topic of medical literature of the period. Wiseman, the English battle surgeon, devoted large sections of his writings to head wounds, especially penetrating wounds of the skull. As with the Egyptian physicians more than three millennia earlier, the key distinction for Wiseman was whether the projectile had penetrated the dura of the brain. Wiseman’s treatment techniques for non-penetrating head wounds—essentially lifting the depressed bone fragments from the surface of the brain—are remarkably similar to the techniques that the Egyptians invented and that the Greek and Roman military physicians used extensively.26 The surge in head injuries paralleled the introduction of two new surgical instruments—the crown saw and the circular bit, both of which made skull surgery somewhat easier.27 Not surprising, this period also saw a great rise in trephining to deal with head wounds.
Gunshot wounds and the tendency of bullets and shell fragments to shatter limbs resulted in a greater willingness on the part of military surgeons to amputate limbs. The almost inevitable onset of infection in bullet wounds and the inability to combat it in any clinically effective manner convinced surgeons that the best way to treat wounds to the limbs was amputation. The result was an enormous increase in field amputations, no doubt many of them performed unnecessarily. Lopping off limbs under primitive conditions led to thousands of deaths caused by shock and bleeding. Lacking facilities for the soldier’s long-term care, the cities and towns of Europe teemed with thousands of crippled and maimed war survivors. The number of crippled soldiers reduced to beggary became such a public problem in France that Louis XIV (1638–1715) issued an edict making begging a crime punishable by death. He had gibbets erected throughout the realm to give credence to the edict.
Although surgeons practiced amputation more frequently in the seventeenth century, they developed little improved technical knowledge or techniques. In most respects, they performed amputations under more difficult medical circumstances than ever. Military surgeries were usually makeshift arrangements with operations performed in barns, tents, or ruined buildings, where elementary concepts of cleanliness were absent. Stench, filth, and decay were common characteristics of these field hospitals. The operating tables became cesspits of infection, and surgeons routinely used the same instruments in several operations after giving them only a slight rinse in a basin of cold water. Leather suture material was also a source of infection. Wounds were left unstitched to allow for early suppuration, and a piece of sponge or lint was inserted into the wound to encourage infection. After amputation surgery, a patient usually ran a high fever while the wound ran with puss. In most cases, the stump was not suitable for prosthesis.28
Among the more disastrous and barbaric practices in amputation was the continued use of the cautery, or what Wiseman called the “Royal Styptic.” Paré’s innovative technique of ligature to control bleeding was not practiced under field conditions. The reason was that amputation required the use of several assistants (whom the physicians commonly called “servants”) to aid in the operation. Some held the patient down, others passed instruments to the surgeon, and still others held lamps and candles so the surgeon could see what he was doing. One military surgeon of the day noted that an arm amputation required at least four assistants, including one to offer the patient pain-relieving cordials. Not only were these assistants often in critically short supply, but also there was never enough light in the indoor field hospitals to tie off the crucial blood vessels when attempting ligature.29 Wiseman, himself a military surgeon in the English Civil Wars, was well acquainted with Paré’s ligature technique, but he did not use it because “it required too much light and too many assistants to be ordinarily used in battles on sea and land.”30 Paré’s favorite pupil and biographer, Jacques Guillemeau (1550-1613), even gave up the use of ligature in amputations because of the difficulties involved.31
Thus overburdened military surgeons greatly relied upon cautery simply because it was more convenient, did not require as many assistants, and did not need much light. The military surgeon Hughes Ravaton (1719–1785) noted that in an average day’s work in battle, a surgeon assigned to a twenty-thousand-man force saw two thousand wounded requiring medical attention. This case load was handled by one surgeon, ten surgical aides, and thirty students of surgery to hold lamps and do other chores.32 As in the Middle Ages, the surgeon administered anesthesia, when used at all, by allowing the patient to breathe a sponge or cloth soaked in a mixture of opium, hyoscyamus, and belladonna.
Most amputations were performed below the knee. The fact that a thigh amputation required fifty-three separate ligatures militated against attempting them.33 Ligature could only become an acceptable technique for thigh amputations once some method was found to stop the flow of blood in the femoral artery. Some surgeons occasionally attempted thigh amputations, however, with William Clowes (1540–1604) performing one in 1588 and Fabry in 1614. Fabry is generally credited with introducing a primitive form of tourniquet to military surgery when he placed a block of wood under the bandage encircling the limb. Etienne Morel also used a block tourniquet at the siege of Besançon in 1674. As noted in chapter 2, Jean-Louis Petit invented the modern form of the screw tourniquet, but its widespread use was not adopted until the eighteenth century.34
Military hygiene improved little from the Renaissance period, as a cogent theory of disease transmission continued to elude medical thinkers. While most armies had some primitive hygienic ordinances, few practiced them with any degree of consistency. Disease continued to kill more men than bullets did, a condition that remained unchanged for another three centuries. Disease and sickness were regarded as a normal part of military operations. The English commander of the garrison at Tangier noted in 1660 that his men had been decimated by disease and that “1200 men will not produce 800 duty men.”35 A sickness rate of 33 percent appeared to be normal.
Few commanders took an interest in camp hygiene. An exception was the Duke of Marlborough (1650–1722), who issued regulations governing the use of water supplies and required camp butchers to bury their offal daily. Animals’ and men’s quarters were inspected daily, as were the cookhouses and food supplies. Marlborough required that a medical officer accompany the provost marshal on daily inspections. Latrines were filled in and moved every six days, dead animals buried immediately, and anyone found committing “casual disorders” (urinating or defecating) around the camp was liable for severe punishment.36
If conditions in a military camp were often primitive and filthy, they were almost always better than conditions found aboard ships. The unhealthy living conditions of sailors had changed little since the days of the Spanish Armada (1588). One commentator described the conditions aboard English ships as “the pox above board, the plague between decks, hell in the forecastle, and the devil at the helm.”37
The seventeenth century saw the nationalism of the last two centuries emerge full blown into the national armies of the nation states. Among the most important were France, Sweden, Brandenburg-Prussia, Switzerland, and England. The development of military medical care varied greatly from army to army and conflict to conflict as the century progressed. While the provision of medical care for the soldier had not yet become a recognized and routine function of government, this period saw the beginnings of a movement in this direction. As soldiers were asked to serve in wars on grounds of national identity and loyalty, inevitably governments would come to recognize some responsibility for treating and caring for the sick and wounded as a reciprocal obligation of military service. Staffing armies with surgeons, physicians, and field barbers became a regular practice, but the military establishment had yet to employ professional military surgeons continually. As in earlier times, the shortage of trained medical personnel forced armies to issue orders of impressment to obtain any medical resources at all. In 1628, Charles I (1600–1628) issued such an edict. Apart from the usual collection of barbers and field surgeons, the female camp followers, who routinely accompanied the army, still provided most nursing and long-term care to the soldier.
The period’s most advanced system of military medical care available was in the armies of France. The ambulance hospitals that Maximilien, the Duke of Sully (1560–1641), established at the siege of Amiens in 1597 were the starting point for later French monarchs to try and improve the medical care of the soldier. In the first third of the century in France, as elsewhere, no stationary military hospitals were behind the lines of the field armies. Medical care was rendered in mobile field hospitals that moved with the armies. The hundreds of wounded, sick, and crippled men left behind crowded into the civilian hospitals of the towns and cities; consequently, government efforts on improving the soldier’s lot focused on the treatment of the disabled.38
As noted in chapter 2, Henry IV of France (1553–1610) opened to disabled soldiers the Maison de la Charité Chrétienne, where they received room and board. Shortly thereafter, the privilege was extended to the widows and children of soldiers killed in battle. Louis XIII (1611–1643) allowed this arrangement to atrophy and reestablished the droit d’oblat system of the previous century in which disabled soldiers were assigned to monasteries as lay brothers and earned their keep by doing menial chores. Under Louis XIV, the French established a pension system and raised special taxes to care for the sick and disabled soldiery. The soldiers often exhausted their pension money in the first few months and spent the rest of the year begging in the streets. Thus the system was abandoned, and in 1674 the Hôtel National des Invalides was opened to care for the disabled. The facility housed four thousand people, who slept three to a bed. Although basically a warehouse, the soldiers nonetheless received shoes, clothes, food, and a small sum of expense money. Military discipline was maintained, and those who were able were encouraged to work in the workshops. Patients were permitted to take leave and visit their families, and some of the more able were even assigned to military garrison duty at half pay. While care of the military’s disabled had been under control of ecclesiastical authorities since the Middle Ages, in France, the system of veterans’ hospitals was placed in the hands of an intendant, a government official who reported directly to the minister of war.39 It was the first clear example of a nation state recognizing its responsibility for the long-term welfare of the soldier.
As social care for the French soldier improved, so did his medical care. In 1627 at the siege of La Rochelle, Cardinal Richelieu assigned Jesuits and cooks to provide bread and soup at the state’s expense to the sick and wounded in the field hospitals. Two years later, Richelieu established the first permanent stationary hospitals in the rear of the field armies.40 Generally of poor construction, however, these hospitals were little more than spacious halls in which patients slept three to a bed in squalid conditions. These facilities became nests of infection, filth, and death, and contributed greatly to the average soldier’s general fear of hospitals. These hospitals’ construction and conditions improved over time, and by the end of Louis’s reign permanent military hospitals had been built at Arras, Calais, Dunkirk, and Perpignan. From 1666, the famous French fortification engineer Sébastien le Prestre, Marquis de Vauban (1633–1707), routinely provided space and buildings for a military hospital in all the towns for which he planned fortifications.41
The French practice of caring for the wounded and disabled was imitated in England. In 1614, Sir Thomas Coningsby (died 1625) founded a relief house for destitute soldiers. During the Protectorate (1653–1659), the English Parliament provided homes and pensions for the disabled who had fought on the Republican side but did not make any provisions for those who fought on the Royalist side. In 1633, a house for disabled seamen was erected at Chelsea, in 1693 a soldiers’ home was built in Kilmainham, and a “benevolent institution” was established in Greenwich for destitute sailors in 1695.42
The permanent hospital system offered some employment opportunities for medical practitioners with military experience, and in the French armies the provision of combat medical support seemed to improve as the century wore on. While the quality of field medical support remained low, supplying surgeons and barbers to the armies seems to have become routine. In 1674 at the Battle of Seneffe, the French Army’s medical chief was able to furnish 230 surgeons assisted by nurses in three field hospitals located in nearby villages. Each of the field stations was adequately equipped with medical supplies as well.43
The Swedish Army of Gustavus Adolphus was fairly well equipped with medical personnel thanks largely to the vision of a previous Swedish king, Gustavus Vassa (1496–1560), who first organized the barbers’ guild and extracted a pledge from them to tend the troops in time of war. Under Adolphus, the normal medical complement of two surgeons and barbers per regiment was increased to four, and medical support and supply was made a command responsibility. Civilian hospitals were exempt from pillage, and one-tenth of the spoils of war were set aside for the troops in the hospital. Adolphus made it practice to transport the sick and wounded in wagons to the nearest hospital and to leave medical and command detachments behind with the wounded to oversee their care. He began the convention of gathering the enemy wounded to his camp, where they received medical care or were sent to hospitals with his own wounded. At the siege of Dömitz in 1631, the Swedes provided wagons to transport the enemy wounded to hospitals. Upon recovery, they were granted free passes to return to their units. Adolphus’s treatment of the men—his own men and that of the enemy—represented a continuation of the Renaissance practice of attending the wounded in a humane manner.44
Switzerland, it will be recalled, had the oldest military medical service in Europe. By the Thirty Years’ War, Swiss arms had sunk to a low level. The military medical service, however, endured. Muster rolls of various Swiss cantons during the war show that each company of artillery and infantry had a barber-surgeon attached to it at the state’s expense. They also had regimental barber-surgeons, and those from the Zurich regiment were the best-trained surgeons in the city. Military physicians received complete medical chests supplied to them at state expense and field manuals on wound management and sanitation. Still, the Swiss military medical system does not appear to have improved much from the previous century when it was the model of European armies.45 Meanwhile, it had taken the rest of Europe almost a century to catch up.
The field hospitals of the Landsknechte in Germany became the first permanent field hospitals when, in 1620, Maximilian I, Duke of Bavaria (1573–1651), founded field hospitals for the armies of the Catholic League. One of these massive multi-storied hospitals served as a clearing station and fed casualties into a larger hospital located in a nearby town. In 1689, Konrad Behrens (1660–1736) drew up a set of regulations for these hospitals, which were situated on high ground near good water supplies and woods from which the staff could obtain firewood for heat and cooking. Patients were segregated by disease into separate wards. The staff consisted of physicians, field barbers, wound surgeons and their attendants, priests, and female camp followers. An officer supervised each entire hospital. In 1685, one of these hospitals handled eight hundred sick and wounded daily. Medical care, as in every army of the period, however, was still rudimentary.46
In the armies of Prussia, every regiment had a barber, and every company of infantry and cavalry had a field barber. When in garrison, a physician looked after the troops’ sick complaints while a wound surgeon dealt with their injuries. Because of the devastation wrought by the Thirty Years’ War, the training of German field surgeons and barbers seems to have been of particularly low quality. Although regulations required military commanders to provide wagons and clean straw to transport the wounded, the Prussian armies had neither field nor permanent hospitals and simply treated the wounded in their barracks.
The English Civil Wars (1642–1651) retarded the development of military medical structures of any sophistication and scope. Oliver Cromwell (1599–1658) did provide his New Model Army with medical officers in 1645, and P. B. Adamson writes that he was the first English commander to assign such officers to the standing army on a permanent basis.47 By 1700, field medical chests were provided to the military medical service as items of regular issue.48
Military medical care during the seventeenth century was not appreciably better than that provided to the soldier during the Renaissance. Although the new nation states took the first tentative steps in recognizing an obligation to care for the wounded and disabled of war, no nation developed a system approaching even rudimentary effectiveness in accomplishing this task. The almost-two-hundred-year-old regulations of the Swiss Army were still more advanced in providing this type of care than anything developed or even contemplated in the seventeenth century. Medical care in the field remained elementary at best and lethal at worst. Separating surgery from the general practice of medicine made it impossible to develop a corps of adequately trained surgeons for the military’s use; thus, most of the practitioners who treated the common soldier possessed little medical skills. The soldier was still at as great a risk from his own medical officers as from enemy bullets and perhaps more so.
In some ways medical care actually deteriorated. The increased use of firearms, their greater killing power, their higher rates of fire, and the abandonment of body armor and helmets in favor of standardized field dress exposed the soldier to a much greater risk of death and injury than he had faced a century earlier. A number of advances in medical knowledge and surgical technique, most notably ligature in amputation, were ignored in practice; consequently, the rate of amputations, infections, and resulting death increased. The provision of long-term care in permanent military hospitals did little to aid the wounded’s recovery as the hospitals’ filthy conditions raised the chances of incurring infection. As it had been for so many centuries, the combat soldier of the seventeenth century remained at great risk to life and limb. That some of the armies provided him with subsistence care if he was disabled did not go far to change this basic fact of military life.
1. Garrison, Introduction to the History, 245–309. See the chapter on the development of medicine in the seventeenth century.
2. Ibid.
3. Ibid.
4. J. R. Kirkup, “The History and Evolution of Surgical Instruments,” Annals of the Royal College of Surgeons of England 63 (1981): 283.
5. Ibid.
6. Garrison, Introduction to the History, 283.
7. Garrison, Notes on the History, 127.
8. Ibid.
9. Ibid., 130.
10. Encyclopedia Britannica, 11th ed. (1910), 49.
11. Garrison, Introduction to the History, 307.
12. Heizmann, “Military Sanitation,” 294.
13. Ibid.
14. Garrison, Notes on the History, 130.
15. Jay W. Grissinger, “The Development of Military Medicine,” New York Academy of Medicine 3, no. 5 (May 1927): 316. A common form of capital punishment at this time was “to be broken on the wheel,” where the victim was strapped to a large wheel that was then rotated until his bones were broken.
16. Garrison, Introduction to the History, 275–77.
17. Garrison, Notes on the History, 133–34.
18. Heizmann, “Military Sanitation,” 292.
19. Forrest, “Development of Wound Therapy,” 270.
20. Grissinger, “Development of Military Medicine,” 316.
21. Roderick E. McGrew, Encyclopedia of Medical History (New York: McGraw-Hill, 1985), 253–54.
22. Ibid., 315.
23. Frank Aker, Dawn Schroeder, and Robert Baycar, “Cause and Prevention of Maxillofacial War Wounds: A Historical Review,” Military Medicine 148, no. 12 (December 1983): 923.
24. I am indebted to Edward Cielecki and Tom Tremonte, experts in the ballistics of black powder weapons, for these figures.
25. Richard A. Gabriel and Karen S. Metz, From Sumer to Rome: The Military Capabilities of Ancient Armies (Westport, CT: Greenwood Press, 1991), 63.
26. Charles G. H. West, “A Short History of the Management of Penetrating Missile Injuries to the Head,” Surgical Neurology 16, no. 2 (August 1981): 146.
27. D. S. Gordon, “Penetrating Head Injuries,” Ulster Medical Journal 57, no. 1 (April 1988): 3.
28. Allen C. Wooden, “The Wounds and Weapons of the Revolutionary War from 1775 to 1783,” Delaware Medical Journal 44, no. 3 (March 1972): 61–62.
29. Owen H. Wangensteen, Jacqueline Smith, and Sarah D. Wangensteen, “Some Highlights in the History of Amputation Reflecting Lessons in Wound Healing,” Bulletin of the History of Medicine 41, no. 2 (March–April 1967): 102.
30. James Young, “A Short History of English Military Surgery and Some Famous Military Surgeons,” Journal of the Royal Army Medical Corps 21 (1913): 487.
31. Wangensteen et al., “Some Highlights,” 103.
32. Ibid.
33. McGrew, Encyclopedia of Medical History, 322.
34. Ibid. See also Encyclopedia Britannica, 11th ed. (1911), 128; and Robert Lawson, “Amputations through the Ages,” Australian–New Zealand Journal of Surgery 42, no. 3 (February 1973): 222.
35. Hargreaves, “The Long Road to Military Hygiene,” 441.
36. Ibid.
37. Ibid.
38. Garrison, Notes on the History, 121–22.
39. Taylor, “Retrospect of Naval and Military Medicine,” 589.
40. Grissinger, “Development of Military Medicine,” 316.
41. Ibid.
42. Taylor, “Retrospect of Naval and Military Medicine,” 317.
43. Heizmann, “Military Sanitation,” 291.
44. Ibid., 291–93.
45. Garrison, Notes on the History, 124–25.
46. Ibid., 131.
47. P. B. Adamson, “The Military Surgeon: His Place in History,” Journal of the Royal Army Medical Corps 128 (1982): 47.
48. Weston P. Chamberlain, “History of Military Medicine and Its Contributions to Science,” Boston Medical and Surgical Journal (April 1917): 237.