George Porter
Newcastle, UK

Hippocrates once said that “war is the only proper school of the surgeon.” War is an undeniable driver of medical innovation, and the structure, procurement and philosophy of military medical services often reflect the societies which commissioned them. This essay will discuss several models of military medicine, all from a similar geographic area, but separated by time, technology, and ideology.

The High and Late Middle Ages (AD 1000–1453) were characterized by decentralized power, inherited titles, and rigid social hierarchies.¹ Armies were commissioned by lords and rulers rather than by nation-states and consisted of various individuals fulfilling their obligation to their immediate superior in the hierarchy.¹ Kings and lords would call on lesser nobles and knights to fight, who in turn would provide a set number of troops drawn from their own lands.¹ This system was based on those lower down in the social hierarchy having an obligation to those above them, which was often not reciprocated. Therefore, soldiers often provided their own armor, weapons, and equipment, with their commanders providing additional items or training only if they desired.²

Similarly, military medical services usually depended on what soldiers could pay for. Nobles and kings could often employ individuals with formal medical training. An example of this is John Arderne (1307–1392), an English surgeon notable for treating knights for sacral or rectal abscesses sustained during horse-riding.³ Poorer individuals, meanwhile, would consult “cutters” or barber-surgeons who followed armies and treated anyone who could pay, with variable results.^2,4 The lack of a formal medical service was consistent with the concept of fealty, with soldiers fighting out of obligation and with no practical or societal pressure to provide anything more than the bare essentials.

This system began to shift slightly towards the end of the Middle Ages and the beginning of the Early Renaissance. Infantry forces such as English longbowmen and Swiss halberdiers showed how well-trained and well-led commoners could defeat forces of more heavily armed, horse-backed nobles.¹ Equally, with the depopulation of Europe by the Bubonic Plague (1346–1353), the value of remaining serfs and peasants rose considerably.⁵ The concept of fighting for their nation-state became increasingly common, especially towards the end of the Hundred Years’ War (1337–1453).⁶ Armies also became larger and increasingly professionalized, the epitome of which was perhaps the Black Army of Hungary (1448–1494).⁷ These trends brought with them more attention to medical services, as illustrated by particular barber-surgeons like Ambroise Pare (1510–1590) rising to prominence,⁴ and barber-surgeons on the whole becoming increasingly incorporated into armies, such as when Swedish King Gustav I Vasa (1496–1560) provided one barber to every 400–500 man troop of his army.⁸ Despite this, formal military medical services were absent from most European armies up until the nineteenth century.^9,10

Contrast the scant, heterogenous nature of medieval military medicine with the pervasive and organized medical corps of the Roman military. Within the legions, soldiers who had developed special skills were granted the designation of immunes.⁹ These troops were exempt from more arduous or dangerous duties, and they included engineers and artillerymen as well as medics, who were known as milites medici or capsarii and are still visible to this day in reliefs on Trajan’s Column (113).⁹ These men were usually led by a medicus ordinarius, a military doctor with a rank equivalent to a centurion.¹¹ Roman wound care was advanced, utilizing honey dressings, suturing (using fibulae), and even successful amputation.^9-11 Indeed, the standard of Roman wound care would not be equaled in western Europe for over a millennium after their decline.⁹

The Romans also had a sophisticated system to evacuate the wounded. It consisted of field medical posts and military hospitals (valetudinaria) placed from Serbia to Hadrian’s Wall, and even of soldiers receiving formal sick leave to recover in safer parts of the empire.¹¹ Legionaries, drawn from Roman citizenry, also had their training, accommodation and equipment provided at minimum cost to the individual.¹² They were even promised retirement benefits in a parcel of land or an equivalent monetary sum.¹²

The considerable benefits offered to legionaries reflect the position held by the army in Roman society. The army was a powerful political force whose loyalty had to be secured by any would-be emperor.¹³ Some, like Vespasian (9–79), were styled as “chosen” directly by the soldiers for their records as commanders, while others, like Hadrian (76–138), made a point of personally visiting troops.¹³ Soldiers were also paid in coins bearing the emperor’s image, directly tying their loyalty to their financial wellbeing.¹³ Equally, Roman citizens fighting on behalf of other Roman citizens may have engendered a “duty of care” from the state to its soldiers. This can be seen by senators such as Clodius Pulcher who, perhaps disingenuously, publicly advocated for legionaries’ wellbeing.¹⁴ Soldiers were also seen as an integral security force and produced many well-regarded public works, further endearing themselves to the populace.¹³ The Roman army’s medical services were therefore part of a suite of benefits given to legionaries both to ensure loyalty and to follow societal pressure to care for them.

Much later, the Service de Santé of the Revolutionary and Napoleonic French armies (1792–1815) was similarly ahead of its time, albeit born from subtly different motivations. It had a dedicated battlefield ambulance service (Ambulance volante), a corps of professional military surgeons, and excellent leadership under Dominique Jean Larrey.^9,15 The original Officiers de Santé of the French Revolution began their roles as part of efforts to provide standardized healthcare to all of France, keeping with the revolutionary ideal of égalité (equality).¹⁶ This principle spread to the battlefield with triage, the most famous innovation of the Service, as casualties were prioritized by injury severity rather than by rank.^15,17 This system is still in use today. One can therefore trace a direct link between a political ideology and clinical innovation. Meanwhile, British soldiers, referred to as “the scum of the earth” by their commander, were subjected to the poorly organized and under-resourced Army Medical Department which would repeatedly underperform until the latter stages of the Crimean War (1863).¹⁷

Modern militaries recognize several practical advantages of medical services. Soldiers’ morale improves if they know they will be cared for if injured, and prompt medical care can make troops feel valued and more motivated to fight.¹⁸ Medical services can also return injured soldiers to service, retaining their expertise and keeping an army healthy and combat-effective.¹⁷ These motivations to commission medical services have always existed to a certain degree and alone do not explain the heterogeneity of historical military medical services. These services constitute an interesting amalgamation of science, practicality, and morality, offering an interesting view of how societies perceive conflict and medicine.

References

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