MILITARY MEDICINE THROUGH THE EIGHTEENTH CENTURY

MD0405
Chapter 1


LESSON 1 Military Medicine Through the Eighteenth Century.
LESSON ASSIGNMENT Paragraphs 1-1 through 1-10.
LESSON OBJECTIVES After completing this lesson, you should be able to:
    1-1. Identify the developments in military medicine prior to the collapse of the Roman Empire.
    1-2. Identify how the use of gunpowder affected military medicine.
    1-3. Identify the developments in military medicine in Europe from the fifteenth through the eighteenth century.

SUGGESTIONS: Read Appendix A first, then read the first lesson . After studying the assignment, complete the exercises at the end of this lesson. These exercises will help you to achieve the lesson objectives.


LESSON 1



1-1. ANCIENT MILITARY MEDICINE


Military medicine is the application of medicine in a military setting for the benefit of the military. It is an outgrowth of "civilian" medicine as practiced in the civilian community.
    a. The ancient military physician knew that the battlefield would yield casualties with predictable injuries such as cuts from sharp swords, penetrating wounds from arrows, broken bones caused by blunt weapons, and head injuries caused by rocks hurled from slings. The same types of wounds occurring to many similar individuals over a short period of time gave the military physician an opportunity to experiment and to find out which treatments helped the casualties and which did not.
    b. The ancient military physician found that rituals performed by shamans and priests in the civilian community were not helpful on the battlefield. Instead, he found that certain treatments, such as the application of honey and salt mixtures to wounds, were helpful in aiding soldiers to recover from their wounds.
Ancient medical tools.

    c. The ancient military physician observed what worked and what did not. He discarded treatments which failed and improved upon those that worked. This does not mean that he knew why they worked. The fact that certain mixtures had bactericidal (kills bacteria) or bacteriostatic (inhibits growth of bacteria) properties were not understood by the early military physician, but he could observe the recovery rates of casualties and determine which treatments were most likely to help future casualties. Likewise, he could form associations which had a bearing on health, such as the connection between locating latrines near the source of drinking water and the subsequent outbreak of disease. Preventive medicine, then, became part of the domain of the military physician.
    d. The military physician did not limit his patients solely to soldiers. An important part of military campaigns involved animals -- those that drew the army's chariots, those that carried supplies and other burdens, and those that were butchered to provide the troops with meat. The military physician often served as the military veterinarian and the military food inspector.

1-2. ANCIENT WARFARE

Wounds inflicted on the battlefield fell into basic groups such as cuts to the arms, legs, and scalp; penetrating wounds to the limbs and trunk caused by arrows or javelins; simple fractures of the limbs caused by impact from swords and other weapons; and concussions caused by missiles from slings. The types of wounds most often treated by military physicians were those in which the soldiers survived long enough to reach medical treatment. Soldiers who had survived that amount of time usually had wounds that were treatable and survivable. The treatment often consisted of cleaning the wound, controlling bleeding, and preventing contamination.
    a. One factor which limited the injuries treated was the type of warfare practiced by the armies. A soldier fighting another soldier face-to-face can generate only so much force. A single hit with a weapon to the arm or leg could generate enough force to cause a simple fracture, but was unlikely to cause multiple fractures or crushing injury.
    b. A soldier who became injured was often slain by his opponent on the battlefield. Most of the casualties were generated when one side broke the formation of the enemy, causing the enemy soldiers to flee from the battlefield in a disorganized rout. The victorious soldiers would follow the defeated army, striking down and killing the fleeing soldiers. This resulted in maximum casualties to the enemy with little danger to the victorious soldiers. Usually, only commanders who could be ransomed were spared from slaughter.
    c. Once an army achieved victory, casualties could be evacuated and treated. Soldiers with serious injuries such as severed arteries and crushed skulls died on the battlefield. Some soldiers, such as those with penetrating abdominal wounds in which the intestines were pierced, died regardless of the medical treatment they received.
    d. Cuts caused by a sharp, clean blade had a minimum of contamination. Simple fractures which involved a single break with no break in the skin could be successfully splinted. Fractures involving several breaks in the bone or major open wounds were rare and were often treated by amputation.

1-3. ANCIENT CIVILIZATIONS

Medical knowledge often spread as a result of warfare. As one empire fell and another grew to power, medical information was passed from the conquered to the conqueror.
    a. Mesopotamia and Egypt. The beginnings of recorded medicine can be traced back to various city-states of Mesopotamia (modern Iraq) and Egypt well over four thousand years ago. Some ancient records refer to physicians who were apparently assigned to army garrisons and treated soldiers. Many of these writings were apparently instructions from experienced physicians to other physicians. These writings dealt with the preparation and use of medications in treating different diseases, splinting fractures, surgical procedures, extracting teeth, treatment of infected wounds, and sanitation. The Egyptian army also appears to have physicians assigned to military units since some of the documents dealt with treating injuries which would be common in battle, but not in civilian life (a type of early military medical manual).
    b. India. Hindu society developed a fairly advanced level of medicine by the fifth century B.C. Among the developments of Hindu medicine were the treatment of various snakebites and the beginning of plastic surgery of the face and nose. Hindu military surgeons also became proficient in extracting missiles that had penetrated the body, suturing, and amputation. Hindu armies developed codes of conduct for conducting warfare. Among the agreements was the recognition of physicians and surgeons as noncombatants and medical treatment for captured enemy soldiers.
    c. Greece. Probably the best known Greek physician was Hippocrates of Cos who lived around 400 B.C. He stressed that medical practice should be based on clinical observations (pulse, temperature, respirations, sputum, etc.). He also stressed the ability of the body to heal itself. Through the military conquests of Alexander the Great (fourth century B.C), Greek culture and Greek medical practices spread throughout the known world, including Egypt, Persia, and part of India. Documents record the presence of Greek and other physicians with the armies under the command of Alexander during their long campaigns. d. Rome. The Roman legions obtained the highest level of military medicine in the ancient world.
Roman armies were needed at first to constantly defend their city-state and, later, to conquer other city-states and empires.
        (1) In 90 B.C, the Roman Republic expanded its military force by allowing many of the poorer Roman citizens to join the army where food and shelter were provided by the state. These soldiers became professional soldiers of a standing army which existed during peacetime as well as time of war. During the period of the Republic, military physicians mainly treated the rich officers within the army. The common soldier was usually left to purchase medical treatment from local civilian physicians or be treated by fellow soldiers.
        (2) After the formation of the Roman Empire under the leadership of Octavian (Augustus) Caesar in the last half of the first century B.C., Rome hired physicians to furnish medical treatment for the entire army, not just officers. Physicians were given an honored position in the army and certain benefits after retirement. Manuals were developed to help standardize medical treatment in the legions. Physical examinations were conducted to ensure that only healthy recruits were accepted into the military. Military physicians were also responsible for sanitation and preventive health measures such as constructing and maintaining latrines, encouraging daily bathing by troops (even in the field), providing netting for protection against mosquitoes, and ensuring that soldiers exercised daily and had an adequate and nutritious diet.
        (3) One Roman innovation was providing limited medical training to certain soldiers who remained with the troops. These soldiers functioned as combat medics who provided far-forward care to injured soldiers, such as using bandages to control bleeding. The army also had special units which evacuated soldiers from the battlefield to the field hospitals where they were treated by medical personnel.
        (4) Medical knowledge and treatment in the ancient world (military as well as civilian) reached its peak in the Roman legions. The development of the tourniquet and ligation to control bleeding allowed amputations to be performed with far greater safety than ever before. New surgical instruments were developed to help extract missiles such as arrowheads. Strong wine (almost vinegar) was applied to wounds which reduced the risk of infection. Drugs were used as pain-killers and as sedatives prior to surgery.

1-4. MIDDLE AGES

The decline of the Roman Empire lasted centuries. By the time the Roman Empire fell in the fifth century, military medical support was almost nonexistent. Following the collapse of the Roman Empire, much of the ancient civilized world regressed to a state of barbarism. However, some of the new political structures served to preserve Roman medical knowledge.
    a. Byzantine Empire. The Byzantine Empire, ruled from Constantinople (Istanbul), existed from the forth century A.D. to the fifteenth century. This remainder from the eastern part Roman Empire preserved much of the cultural and medical knowledge of Rome, but did not add to that knowledge.
    b. Islamic Empire. The Islamic religion provided a bond that united Arab armies to create a new empire. Islamic armies increased their medical knowledge from conquered lands and from trade with the Byzantine Empire.
    c. Feudal Europe. Western Europe slowly recovered from the fall of the Roman Empire. In A.D. 800, Charles the Great (Charlemagne) created a loose confederation under the Holy Roman Empire that lasted until the fifteenth century.
        (1) During this period, Europe launched several wars (the Crusades being the most famous) against the Islamic Empire. This resulted in increased contact with the Islamic and Byzantine Empires and in some of the medical knowledge of the Greeks and Romans flowing back into Europe. The lack of cleanliness in personal hygiene and in everyday urban living in Europe, however, led to increased disease. Epidemics such as the Black Death (bubonic plague) killed large numbers of the European population during the fourteenth century.
        (2) During the fourteenth and fifteenth centuries, European nationalism increased. In 1453, the Holy Roman Empire ceased to exist at the end of the Hundred Years War. In the same year, the Ottoman Empire conquered the Byzantine Empire.

1-5. RENAISSANCE EUROPE

    a. The rebirth of military medicine in Europe began in Spain. During the last part of the fifteenth century, the Spanish forces drove out the Islamic Moors. During the wars, the Spanish military copied the mobile hospitals used by the Moorish armies. Around the same time, surgeons made their appearance in the French armies.
    b. As nations began to form in Europe, they formed armies to defend themselves and to conquer new territory. With the new nations also came a rebirth (renaissance) of learning. Old Greek and Roman texts preserved by the Arab and Byzantine cultures were translated and reintroduced into Europe. Unfortunately, the translation of some medical texts were faulty, resulting in improper treatment of certain injuries. For example, infection was introduced into wounds in the belief that infection assisted in healing even though the Greek and Roman physicians knew this idea to be false.

1-6. INTRODUCTION OF GUNPOWDER

In the fifteenth century, gunpowder became an important military tool as mobile siege guns were used to breech city walls. In the sixteenth century, muskets and hand guns were developed for use by individual soldiers. Improved cannons loaded with steel balls, rocks, pieces of metal and glass, nails, and other objects were used against enemy infantry formations. These antipersonnel cannons caused great injury and death. The use of cannon, muskets, and rifles resulted in a major change in the types of wounds that soldiers suffered. Many more injuries to the limbs occurred. Compound fractures, which were rare in ancient times, were common due to the force of the bullet hitting a bone. Opposing armies now inflicted large numbers of nonfatal injuries on each other.
    a. The primary problem was that of infection. Almost all gunshot wounds became infected either due to the injury itself (clothing, dirt, and other contamination was often forced into the wound by the musket ball), from unsanitary conditions following injury, by the surgeon probing for the musket ball or shrapnel with his unwashed fingers, or even from being deliberately introduced by the surgeon in an effort to promote healing. Death from infection rather than from the injury itself was the primary danger to the soldier on the battlefield.
    b. The force generated by musket balls produced shattered bones, resulting in the need to amputate the injured limb. Amputation often resulted in death from shock or infection.
    c. Warfare had changed and military medicine would be required to develop and change also.

1-7. EUROPEAN MILITARY MEDICINE IN THE SIXTEENTH CENTURY

    a. In general, European armies were manned by two classes -- the aristocracy who bought their commissions and became officers and the enlisted soldiers who came from the unemployed and poor section of society. These enlisted personnel joined the army in return for food and a little money, but were capable of being trained into an excellent army.
    b. Civilian and military medicine were also divided into two general classes -- the physician and the barber-surgeon.
        (1) Physicians, some of which also performed surgery, were educated and were primarily concerned with providing care to the noblemen. Often the officers in the army traveled with their private physicians.
        (2) The barber-surgeons were skilled workers (usually barbers) who trained by apprenticeship to perform surgical and other medical functions. Young apprentices often trained under skilled barber-surgeons in the army and remained with the army even after mastering the trade.
        (3) In time of war, civilian physicians and civilian barber-surgeons were often impressed into the army for the duration of the campaign to treat the enlisted troops.
    c. By the sixteenth century, the printing press (a fifteenth-century invention) had resulted in the publication of many medical manuals which could be used by physicians and barber-surgeons. Not only did the printing press allow knowledge to be wide-spread, it also tended to standardize medical procedures since medical personnel from various nations could consult the same medical references. New discoveries and new medical procedures could be disseminated far more rapidly than ever before.

1-8. EUROPEAN MILITARY MEDICINE IN THE SEVENTEENTH CENTURY

In the seventeenth century, European medical knowledge increased greatly. The functions of the circulatory and respiratory systems were understood, the microscope was invented and used to study diseases, and intravenous injections were performed. Discoveries in chemistry and physics were also used to better understand the functioning of the human body. Surgical instruments were made by highly-skilled craftsmen who standardized the design of these instruments. The printing press made another major contribution, this time in the form of medical periodicals.
    a. Although there were advances in medical knowledge, the actual treatment of diseases and infections progressed far slower. Although some military surgeons used Roman ligation procedures to control bleeding from arteries, it would not be until the beginning of the eighteenth century that major progress would be made in amputation.
    b. A major problem was the failure to use a scientific method of researching medications. All sorts of items were used to treat patients, often being either useless or causing additional harm. A physician, for example, might treat a gunshot wound by applying a mixture of materials to the soldier's rifle. Apothecaries sold salves and powders having no proven benefit to the patient.

1-9. MEDICAL ADVANCES IN THE EIGHTEENTH CENTURY

Some of the major medical advances of the eighteenth century are given below.
    a. In 1718, Jean Louis Petit, a French surgeon, invented a screw tourniquet to control bleeding. The screw tourniquet made thigh amputations possible and reduced the risks associated with amputations below the knee. The screw tourniquet was still in use during the American Civil War. As amputations became safer, military surgeons gave greater emphasis to preparing limbs for prosthesis. Flap and lateral incision amputations became common procedures. The death rate from amputation remained high until methods were developed in the nineteenth century to control infection and shock.
    b. Specialized medical instruments for removing musket balls were developed (but were still not sterilized before use). Locked forceps made their appearance. Wound dressing and bandaging become a skilled art. Styptics were used to stop minor bleeding. Pressure sponges, alcohol, and turpentine were used to treat minor wounds.
    c. John Pringle, physician general to the British forces in 1740, identified jail fever, ship fever, and hospital fever as being one disease, now known as epidemic typhus.
    d. Pierre-Joseph Desault, a military surgeon, developed the debridement technique for treating traumatic wounds in which only the necrotic tissue was cut away to remove a source of infection. Pringle wrote the first English text on military medicine in 1752. In it, his purpose was clear: "My chief intention was to collect materials for tracing the remote causes of military distempers, in order that whatsoever depended upon those in command, and was consistent with the service, might be fairly stated, so as to suggest proper measures for preventing in any future campaign."
    e. Percival Pott, also a military surgeon, reduced the risk of infection in head wounds by extracting blood from extradural and subdural spaces by cranial draining.
    f. Physicians and surgeons began to introduce thoughtful publications about the health of armies, military medicine, and camp diseases. In 1752, John Pringle wrote the first English text on military medicine. In 1764, Richard Brockelsby, an English physician, wrote a book on controlling contagious diseases in military hospitals. In 1794, John Hunter, a military surgeon from Scotland, published his treatise in which he argued against the normal practices of enlarging gunshot wounds and blood-letting.

1-10. MILITARY CHANGES IN THE EIGHTEENTH CENTURY

At the beginning of the century, the pattern of military medical care remained essentially as it had been in the previous century. By midcentury, however, all major armies of the period had moved considerably toward establishing institutionalized systems of military medical care in which providing paid medical care to all soldiers became a recognized function of the national government. This including the provision of food, shelter, and clothing needed to maintain the health of the troops.
    a. Physical Examinations. Armies encouraged voluntary enlistments for limited periods of military service. Large numbers of marginally healthy adults with poor sanitary habits entered the military service, leading military officials to introduce physical examinations for recruits. At first, the recruit was provided only a cursory examination by his commander. In 1726, the French army began regular medical examinations for recruits. By 1764, each French recruit was examined by a regimental surgeon for physical fitness. In 1788, Prussia required medical officers to conduct physical examinations of all soldiers on a regular basis. In 1790, mandatory medical examinations were instituted in the British army.
    b. Rations. The standard military ration greatly improved the general health of the soldier. Most soldiers ate better in the military than they had in civilian life. Rations were provided to the soldier at government expense. Unfortunately, the quality and quantity of food was often less than promised. Armies relied on a contract supply system which lead to fraud, theft, and pressure to reduce expenditures by reducing the quantity or quality of food purchased for troops in the field.
    c. Barracks. In addition to providing troops with regular meals, the military began providing soldiers with buildings specially designed for soldiers to live and sleep. Barracks replaced the old practice of billeting troops with the citizenry or in rented inns. Moreover, the new barracks made control over desertion easier. The first British barracks were introduced in Ireland in 1713 due to a shortage of barns and inns. The first military barracks constructed in England proper were build in 1723.
    d. Uniforms. Regulation uniforms were issued to make it easier to identify friendly units in the smoke of the battlefield. Uniforms were designed without considering the effects on the health of the soldier. Uniforms were often made of cheap cotton which did not provide sufficient warmth in cold climates and rain. Tight stockings restricted blood circulation in the legs and did not provided sufficient padding to the bottoms of the soldiers' feet. The shoes provided little protection from frostbite and trench foot. Tight buttons and belts often restricted the soldier's breathing, Heavy headgear added to the soldier's load without providing protection from shell fragments and bullets.
    e. Military Hospitals. During the eighteenth century, a number of improvements took place in the establishment and organization of military hospitals, especially in the wide-scale introduction of mobile field hospitals that accompanied the armies on the march. Although every army had a hospital medical organization to provide treatment and administration, these organizations were seldom fully staffed and there was a notorious lack of coordination between hospitals. Mobile hospitals were often little more than rapidly constructed huts in the field. Military hospitals remained unsanitary and disease continued to be the major threat to military manpower. Few armies had any organized and dedicated transport to move the wounded to the rear-area hospitals. It often took several days for the casualty to reach the rear hospital and it was not unusual for a third of the patients to die in transit from the front to the rear hospitals.
    f. Dettingen Agreement. In 1743, at the completion of the Dettingen campaign, an agreement was made by opposing forces in which military medical personnel were declared to be noncombatants and that wounded enemy soldiers were to receive medical treatment and be returned after they recovered from their injuries. The Dettingen agreement resulted in the need for larger medical staffs since medical personnel had to treat enemy soldiers as well as their own wounded soldiers.



EXERCISES: LESSON 1
INSTRUCTIONS. The following exercises are to be completed by writing the lettered response that best answers the question or best completes the incomplete statement or by writing the answer on paper that you provide. After you have completed all the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers.



1. Sixteenth century skilled workers who were trained to perform surgery under the apprenticeship method rather than formal education were called what?.

2. Which of the following statements best describes military medicine in the ancient world.
    a. Physicians and surgeons developed medical and surgical procedures based upon a firm understanding of anatomy and physiology, physics, and microbiology.
    b. Physicians and surgeons used procedures that worked and discarded those that did not without a firm understanding of why the treatments worked.

3. Ancient physicians and surgeons usually treated casualties who survived because:
    a. Soldiers with major wounds usually died on the battlefield.
    b. Medical science was highly developed in the military as opposed to its civilian counterpart.
    c. Effective, rapid evacuation ensured quick treatment of both friendly and enemy soldiers.

4. Which of the following ancient empires is known to have trained soldiers to provide basic medical treatment, such as using bandages, to fellow soldiers?
    a. Egypt.
    b. Greece.
    c. India.
    d. Rome

5. The major medical problem introduced by the use of gunpowder in war was:
    a. Infection from gunshot wounds.
    b. Toxic effect of lead bullets.
    c. Toxic effect of gunpowder residue.

6. Which of the following statements is/are true concerning the Dettingen Agreement?
    a. Medical personnel were recognized as noncombatants.
    b. Captured enemy soldiers were to be given medical treatment.
    c. Both "a" and "b" above are true.

7. Which of the following is noted for developing the debridement technique for treating traumatic wounds?
    a. Desault.
    b. Hippocrates.
    c. Petit.
    d. Pringle.

8. Prussia required regular physical examinations of all soldiers beginning in:
    a. 1650.
    b. 1714.
    c. 1788.
    d. 1812.

SOLUTIONS TO EXERCISES: LESSON 1

1. Barber - Surgeons

2. b (para 1-1c)

3. a (para 1-2)

4. d (para 1-3d(3))

5. a (para 1-6a)

6. c (para 1-10f)

7. a (para 1-9d)

8. c (para 1-10a)