Between Flesh and Steel (10 page)

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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.