Between Flesh and Steel (9 page)

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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.