Between Flesh and Steel (17 page)

In an equally important development, surgery finally became a legitimate discipline, respected even by the physician internists, and slowly began to develop its own teaching institutions. In 1731, the Académie Royale de Chirurgie (Royal Academy of Surgery) was established in Paris with Jean-Louis Petit as its first director. Later, the École Pratique de Chirurgie was established with François Chopart (1743–1795) and Pierre-Joseph Desault (1738–1795) as its first professors. The press of war placed a premium on training surgeons for the army, and for the first time military medical schools were established in Prussia, Russia, Austria, and France to meet the armies' needs for surgical personnel. Greatly aiding these developments were significant improvements in surgical medicine as a consequence of the renewed empirical emphasis on anatomy and pathology. The greatest of the anatomist-pathologists was Giovanni Morgagni (1682–1771), who pioneered the science of postmortem investigation in an effort to link diseases to their specific anatomical effects. Morgagni was the first writer of a systematic treatise on morbid anatomy. The brilliant surgeons of the day, Hunter and Alexander Monro I (1697–1767), had begun their careers as anatomists, which helped them develop effective surgical techniques that gained wide acceptance. From this point forward, medical education began with studies of human anatomy, and for the first time in history, anatomical knowledge was generally accurate.

Surgery ceased to be merely a technical craft practiced by physicians of low status. Of course, the usual collection of barbers and quacks continued to exist, mostly in the armies, but gradually even their quality began to improve. The military's need for surgical personnel led to regular examinations for candidates for surgeon's mates and orderlies, and some countries provided medical training in special schools to even the lowest ranks of military surgical personnel. The millennia-old distinction between physician and surgeon, a distinction that had hindered medical progress for a thousand years, was gradually disappearing, with overall beneficial results for the civilian and the soldier alike.

Medical publishing was established on a large scale, and books and periodicals were readily available to the professional order as vehicles for expanding and spreading medical knowledge. Anatomical illustration reached great heights. The old copperplate method gave way to the steel plate and made producing anatomical illustrations in color possible for the first time.
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The advances in surgery also were evident in the proliferation of new surgical instruments designed for specific purposes. Pierre Dionis (1643–1718) published the
Cours d'opérations de chirurgie
in 1708 and presented complete sets of surgical instruments specific to particular operations. In
1782, Giovanni Alessandro Brambilla (1728–1800) assembled a folio of virtually all surgical equipment in his
Instrumentarium Chirurgicum militare Austriacum.
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Near the end of the century, the numbers and types of surgical instruments had become so complex that the first catalogs for surgical instruments were published.

The eighteenth century can be characterized as the time when medicine first became a science complete with a new empirical approach that emphasized hard data. There emerged a new intellectual habit, first evident in the Renaissance, and a willingness to reject theoretical premises when they were shown to run contrary to clinical observation. The emphasis on anatomy gave physicians and surgeons more accurate medical knowledge, and the erosion of the social barriers between physician and surgeon finally permitted the latter to represent a legitimate branch of the medical discipline. Formalizing medical education permitted the transmission of accurate anatomy and new techniques to fresh generations of students in a more systematic and complete manner than ever before. Moreover, the stimulus of war forced the contemporary military establishments to pay greater attention to the soldier's medical needs. More than in any century that preceded it, the eighteenth century witnessed the beginnings of truly modern medicine in both its civilian and military aspects.

In the eighteenth century, the state government recognized its function of providing medical care for its soldiers and provided and paid for it as a matter of course. At the beginning of the century, the pattern of military medical care remained essentially as it had been in the previous century. By mid-century, however, all major armies of the period had moved considerably toward establishing institutionalized systems of military medical care.

This achievement was part of the nation states' larger effort to improve the general quality and organization of their armies as the age of nationalism came to fruition. Armies encouraged voluntary enlistments, adopted limited periods of military service to replace the old practice of lifelong service, implemented regular medical examinations for recruits, issued standard uniforms, provided daily food rations that were paid for by the state treasury, and housed their soldiers in barracks instead of the usual inns, private houses, and barns. Military organizations generally became more structurally articulated as the century wore on, and permanent ranks, pay systems, and combat formations appeared. Armies were almost exclusively armed with firearms, and field artillery became more mobile. The first military medical schools
were established, as were the first journals and periodicals devoted exclusively to military medical matters with articles written almost entirely by military physicians, surgeons, and medical officers. Advances in hospital administration were made, and some attempts were also made to prevent disease and generally improve and maintain the soldier's health.

Armies became structurally organized into companies, battalions, and regiments with an increasingly professional corps of officers and noncommissioned officers to lead them. In their organizational realignment to increase control of the armies, the leadership put the troops in barracks and gave them regular rations. The old practice of billeting the troops with the citizenry or in rented inns had become increasingly unpopular, and the new system made controlling desertion easier.
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The British Army established its first barracks in Ireland in 1713. Barracks were introduced in Scotland two years later, and George I (1660–1727) constructed the first military barracks in England at Berwick-on-Tweed in 1723.
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The introduction of voluntary enlistments proved attractive mostly to the urban poor and surplus landless population that had manned armies for centuries. No longer driven by the cudgel or impressment, these social elements were attracted by the prospect of regular food and pay. The health of these recruits, however, proved to be as generally poor as it had historically been. In times of social disruption or difficult economic times, recruits flooded the recruitment stations, and large numbers of marginally healthy adults with poor sanitary habits entered military service. The huge losses to disease in the wars of the period led military officials to launch regular physical examinations for recruits. For the first quarter century, however, the unit or regimental commander conducted only cursory examinations of recruits. Beginning in 1726, the French Army instituted regular medical examinations. After 1763, each recruit regiment had a surgeon whose duty was to examine recruits for physical fitness and weed out those whose health failed during the training process. In France, an inspector general of recruiting was appointed in 1778 and charged with the task of overseeing the selection and health of new troops. Mandatory medical examinations were not instituted in the British Army until 1790. Prussia, meanwhile, had required regimental and battalion medical officers to conduct regular physical examinations of all soldiers since 1788.
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France was the first country to institute uniform clothing as early as the 1670s.
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English regulation military dress was mandated in 1751, following similar regulations by Frederick Wilhelm of Prussia (1688–1740) a few years earlier.
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As noted
in
chapter 3
, the purpose of uniform clothing was to facilitate identifying friendly units on the smoky battlefield, but the leadership gave little thought to the effects of this clothing on the health and endurance of the soldier. Uniforms were most often made of cheap cotton that provided little warmth in cold climates and no protection from the rain. Tight stockings often restricted circulation and had no padding for the leather buckle shoes, which offered little defense against frostbite or trench foot. Adorning the uniform with tight buttons and belts often restricted the soldier's breathing, and with high crowns, the heavy shakos and hats added to the soldiers' load but did not prevent head wounds from enemy shell fragments and bullets. It would be at least another two centuries before anyone seriously considered designing a uniform for battlefield use while taking the health, comfort, and protective needs of the soldier into consideration.
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The standard military ration, meanwhile, did much to improve the soldier's general health, and most soldiers ate better and more regularly in military messes than they had in civilian life.
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Rations were provided by a central commissary and at government expense as a matter of right.
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In France, the soldier's daily allowance was twenty-four ounces of wheat bread, one pound of meat, and one pint of wine or two pints of beer. Frederick the Great provided his soldiers with two pounds of bread daily and two pounds of meat a week.
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Unfortunately, the promise of regular, good-quality food was more often broken than honored. All European armies relied on a supply system in which commissary officers contracted with provisioners, sutlers, and transporters for supplies. This arrangement led to common abuses of fraud and theft, and the pressure to keep expenditures down often reduced food for the troops to less than sufficient quantities or quality.

Before examining the improvements in military surgery, it is worth exploring the casualty burdens that the medical establishments of armies under fire encountered. By the eighteenth century, the armies were universally equipped with more accurate and deadly firearms, and the introduction of truly mobile artillery of increased ranges had the inevitable effect of greatly increasing casualties. Even in the early part of the century, these innovations had an enormous impact on casualty rates. For example, during the War of the Spanish Succession (1701–1714), the allied armies at the Battle of Blenheim in 1704 suffered 5,000 dead and 8,900 wounded. British forces alone endured 670 dead and 1,500 wounded, while the Bavarian armies suffered 12,000 dead and 14,000 wounded. Two years later at Ramillies, the French lost 2,000 dead and 5,000 wounded. It was not unusual during this period for armies to
suffer similar casualty rates, with the usual effect of overwhelming the primitive field medical establishments of the day.

In this era, military medical surgery improved markedly and introduced a number of new techniques. Some of the old wound treatments—such as sympathetic powder and wound salve, mainstays of the previous century—disappeared, giving rise to the more extensive use of styptics to stop minor bleeding. Pressure sponges, alcohol, and turpentine came into widespread use for minor wounds. Military surgeons still cauterized arteries, but less frequently, as they widely began to use the new locked forceps as ligatures. They increasingly applied Petit's screw tourniquet, which made thigh amputations possible and greatly reduced the risk associated with amputations above the knee. Military surgeons placed greater emphasis on preparing limbs for prosthesis, and flap and lateral incision amputations became common.

Although more surgeons questioned the need for the inevitable suppuration of wounds, many still provoked infection by inserting charpie and other foreign matter into wounds. While they continued to use the old oils and salve dressings for wounds, the new technique of applying dry bandages moistened only with water held much practical promise. That many of the old chemical and salve treatments endured is not surprising, since doctors often prepared and sold these potions themselves at considerable profit. The practice of enlarging and probing battle wounds continued unabated, but the new debridement treatment was gaining acceptance as an alternative procedure. Despite a literature that established clinical circumstances and guidelines for carrying out the procedure, the improvements in amputation surgery inevitably provoked a spate of unnecessary operations that continued for many years. Yet, without doubt, military surgery was improving at a rapid pace as military surgeons learned new and improved techniques of wound treatment.

John Hunter is generally credited with the first real improvements in understanding the nature of wound treatment. He began his career as an anatomist, only later becoming a surgeon. His training in linking anatomy to clinical signs of pathology served him well. He accepted a commission in the middle of the Seven Years' War (1756–1763) with France and gained valuable surgical experience at the Battle of Belle Île (1761). Afterward he argued against the normal practice of enlarging gunshot wounds and against bloodletting, pushing instead for a conservative approach to treating gunshot wounds. In 1794, he published his
Treatise of the Blood, Inflammation, and Gunshot Wounds
, which is regarded as a major milestone in the surgical treatment of battle wounds.

Pierre-Joseph Desault coined the term “débridement” and recommended not enlarging wounds as common practice. His new technique recommended cutting away only the necrotic tissue within the wound to remove a source of infection. Desault was the first to use the technique for traumatic wounds.
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For decades bullet wounds to the head had produced great risk of infection. Because doctors believed that blood that accumulated in the extradural or subdural spaces would eventually become pus, they allowed it to remain as a seat of infection. The military surgeon Percival Pott (1713–1788) was the first to argue against this practice, suggesting that this residual blood could be extracted by cranial draining. His contribution is often cited as a major advance in cranial surgery.
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For decades surgeons commonly operated on all head wounds with experimental trephination. Many of these operations were unnecessary and exposed the patient to great risk of infection. Near the end of the century, Sylvester O'Halloran (1728–1807), an Irish surgeon, demonstrated that experimental trephination was usually not needed. Within a decade, the practice generally came to an end. O'Halloran was also the first to improve the treatment of penetrating head wounds by regularly utilizing debridement.
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