Hit Points vs Real Life Injuries

The following essay is a little gory, so if you are squeamish, skip it.

Hit Points vs complex wounds

Anyone who has played DnD or a similar role playing game at high levels, knows that hit points can become a little bit ridiculous. When you have so many that you can kind of laugh off being stabbed with a sword, shot with a crossbow, or even falling off of a cliff, there starts to be a disconnect which undermines suspension of disbelief. We have the idea that hit points are meant to represent abstractions like luck, fatigue, or some kind of quasi-magical hero power, but again, at a certain point that doesn’t ring true for a lot of people.

But are Hit Points less of a problem if you just have fewer of them?

Most RPG systems that focus on realism really get into the weeds on wound details, and also tend to exaggerate the severity of them a lot.  We try to focus a little bit more on the fighting or swashbuckling part of combat, the part that happens before people get killed or maimed, but put the damage potential of the weapons and the survival threshold of the people at the point where being wounded is quite dangerous in the Codex. It’s not something you are going to brush aside casually like in some other RPGs.

Medieval weapons can cause devastating injuries. This is something we know for sure from literary evidence, forensics, and modern living history experiments. I, your humble author, have personally taken a fairly cheap sword replica and cut right through ‘pig knuckles’ with shocking ease, prior to cooking them at a barbeque. Test-cutting on fairly difficult media is now a routine part of many HEMA tournaments, and you can watch many skillful cutters slicing through multiple thick tatami mats repeatedly, and so on.

The thing is, there are caveats. Forensics and history tell us that yes, it was possible to cut someone’s head off or sever a limb with a sword or an axe. Something like 25% of the bodies buried at the Visby battlefield had major injuries to their leg bones which were visible on the skeletons, some had one or both legs severed. We can also see that from test-cutting on targets which we believe are similar, that it is possible to make such epic cuts. But we also know that there is some difficulty associated with cutting that well.

Swords are not light sabers. Cutting properly takes skill, and it helps a lot to have a few moments to prepare before cutting (which you may not have in a real fight). The same applies to other types of attacks. Thrusts have to be properly aimed to disable or kill an opponent and so on. We also have the historical record, and both modern and historical forensics, to tell us that relatively minor wounds were very common. Much more common than catastrophic wounds.

Modern evidence

According to Wikipedia, “the mortality rate associated with stabbing has ranged from 0-4% [per wound] as 85% of injuries sustained from stab wounds only affect subcutaneous tissue”. Most of the data this is based on seems to be from the UK, but 0-4% would be pretty close to an average around the world. An interesting 2019 study from Iceland on “penetrating knife and machete wounds” gives also gives us a 4% mortality rate. Only 20% of the wounds were serious enough for admission to the hospital, with wounds rated as Serious (15 or better on the ISS scale). The rest were given stitches and bandages, antibiotics and painkillers, and sent home. Of those with serious injuries, 64% had surgery and 35% ended up in the ICU, and 4% died. The median hospital stay was 2 days, the median wound rating was 7 on the ISS scale.

Emergency Room Hit Points

What is this ISS scale you ask? It’s a rating used in emergency medicine which goes from 1 to 75, with 15 considered a ‘serious’ injury requiring admission to the hospital, and 75 considered catastrophically life threatening, certain death without immediate intervention. Wounds are rated by location (limbs vs. torso vs. head etc.) and severity, in terms of how much risk of mortality, but also of permanent injury, which in a medieval context we would call maiming.

One of the interesting things about the ISS scale is that it rates a large number of smaller wounds as similar in effect to a single more serious wound. This is because of the cumulative effects of shock and trauma on the body. And that is kind of similar to how Hit Points work.

Historical Evidence

Obviously modern medicine is far superior to medicine in say, 15^th Century Germany, Italy or Poland, but we’ll get back to that in a minute. What we can say from medieval sources though is that the period records indicate that relatively minor wounds were also not so unusual for warriors of the period. This modern ratio is similar to the statistics aggregated by Professor Anne Tlusty from her study of records from 16th Century Augsburg, and published in her 2011 monograph, The Martial Ethic of Early Modern Germany.

According to this book, in Augsburg there were 208 documented incidents of attacks with swords and knives from 1450-1750, 107 (51%) resulted in either no injuries or minor injuries. 50 resulted in serious wounds and 50 resulted in deaths, which is 24% of the incidents. In most cases these however are for multiple wounds. In the same Early-Modern Augsburg survey, she found 35 attacks by blunt instruments, 24 of them (69%) resulted in no injuries or minor injuries, 6 (17%) in serious injuries, and 5 (14%) resulted in death.

We have other similar analysis from medieval records with about the same results. There is another study based on letters of remission in France in the 14th Century, about 36% of attacks resulted in mortality on the same day as the incident, but the source data were letters written to get someone out of trouble, so presumably the sample was of more serious incidents and that skews the ratio upward a bit. The highest mortality was from head wounds and wounds to the torso.

Another good source are the memoirs and records associated with famous warriors and soldiers, like the German knight Gottfried “Götz” von Berlichingen, the Syrian knight Usamah ibn Munqidh, the French knight Jean “Boucicaut” Le Maingre, the Swiss burgher, artist and mercenary Urs Graf, the German burgher and mercenary Paul Dolstein the Spanish soldier Bernal Diaz, and the somewhat violent (mostly) civilian artist Benvenutto Cellini were all wounded several times during their lives. Though most of these were minor wounds, some were quite serious. Götz has his arm cut off for example. And yet they all recovered, repeatedly. Moreover, according to their own accounts and various other records, in most cases the wounds didn’t stop them during the fight itself, they dealt with them after it was all over.

What does this have to do with Hit Points again?

What all this tells us is that while swords, daggers, spears, maces, axes and so on can and did cause catastrophic and fatal wounds, more often they caused much more minor or moderate injuries. This is a factor of both luck and skill. We know from the literary sources and from modern forensics and experiments that weapons can be very effective, especially when they are accurately targeted and effectively used. In the Codex is this is reflected by the Artful Strike and the Critical Hit System, and also rules like Twist the Blade, Knock Out, and the Wrathful Strike.

What these rules mean is that while a routine attack may not instantly kill or maim your target, a more skillfully and carefully made attack is much more likely to have catastrophic effects. The chances of making an Artful Strike go way up when you attack at optimal range and with multiple MP. Critical Hits are much more likely to occur when you make multi-die attacks, and damage scales up very rapidly. A routine one die attack with a longsword will do 1-10 damage. A four die Chopping Critical Hit with a longsword can cause up to 50 Hit Points of damage, and when rolling four dice your odds of rolling a crit go up to 20%. Since Hit Point ceilings are around 30 HP in the Codex even for the most experienced warriors, this is potentially highly lethal. Optionally, any hit causing over 20 HP damage can trigger a visit to the Severe of Grave wounds table if you are using those rules.

Due to the effects of psychological and physiological factors like adrenaline, more minor wounds may not really slow you down much or have much impact during the fight. They may cause you problems later on, but the human mind has the ability to block out even fairly major distractions in life and death situations. And to paraphrase the forensic studies from the UK, most wounds do not penetrate past the subcutaneous layer. That is to say, they do not seriously effect major muscles, blood vessels, or organs, they don’t go through or break bones and so on.

And yet they do have a cumulative effect. Each wound causes blood loss, shock, and pain, which your body will eventually lose the battle to overcome. For this reason, we feel that so long as they are capped at a reasonable level, Hit Points are actually a fairly good model for the minor to moderate wounds which result from most attacks.

Infections and wound recovery

So what about the longer term results of minor and moderate wounds?

For a fight, in combat, the infection aspect is irrelevant. So let’s keep that in mind first. Once the fight is over, if you want to, you can contend with the realities.

We do have information about the longer term effects of such battle wounds in the middle ages, though it’s a bit more anecdotal (I don’t know of longer term statistical analysis, but anecdotal information gives us something to go on). Period medicine seems to have been capable of routinely treating cuts, broken bones and relatively shallow puncture wounds with a fairly high rate of success. There were some limits – wounds which pierced the gut, or which caused a collapsed lung, wounds to the head and neck which penetrated the skull or windpipe, anything which severed the spine, these would typically result in death.

The historical record tells us that certain kinds of wounds were routinely healed, usually with some kind of medical attention, and we have some details about how this was done. But even very serious wounds were sometimes cured. Before he was king, Henry V of England was shot in the face by an arrow that penetrated 6 inches deep. A surgeon named John Bradmore cured him and described how he did it in a book he wrote. The same guy also cured one of Henry’s vassals who had disembowled himself with a sword, though it took a long time for him to recover.

In most cases however, an injury like an arrow stuck six inches into the face, or a disemboweling wound in which the guts are out, or even penetrated, means a very low rate of survival in the long term.

How did they treat wounds?

We do have some evidence as to how wounds were treated. Medieval barber-surgeons and physicians used astringents like alcohol, in the form of strong vinegar and special concoctions like “Four Thieves Vinegar”. They used silk sutures to sew wounds. They used turpentine and pitch. They used honey, plants like aloe and thyme, they used linen bandages soaked in thyme oil (a practice that continued right up to WWI).

For more serious injuries they used fat and salt prior to applying bandages or sutures. Often bear or beaver fat by preference. They had special remedies like Bald’s Eyesalve which we know from modern tests is a highly effective anti-microbial which kills antibiotic resistant bacteria such as MRSA.

Medieval surgeons did more than just apply leeches or bleed people. They knew how to suture wounds, they could set broken bones, they could treat burns and bruises, and even the leeches sometimes helped control certain types of infections. In very serious situations they knew how to amputate infected limbs too. If your guts were out, or your skull was broken open however, you were probably just going to die.

Serious wounds are always a special case, but we can assume that after a fight, moderate and minor wounds might be much more troublesome. You may want to impose a penalty of 1 MP for minor wounds and 2 MP for moderate wounds, the day after receiving an injury. This will go away after proper wound recovery, rest and recuperation. Or you can just ignore it, based on whatever your preference is.

To some extent, it really doesn’t matter except to note, that if you care to match the historical record, it does not seem to be the case that every scratch killed someone of an infection. They did have medical treatments for common injuries which did seem to work much of the time.

Conclusion: Don’t Worry About it too much

So what does all this mean?  It means, basically, that some of our modern pop-culture beliefs about the medieval world aren’t very accurate.  Seeing as most of us do not hack people with swords or axes, our ideas about how that actually works in real life are a little bit distorted as well, being heavily influenced by video games, TV shows and movies.

And it doesn’t really matter. You really don’t need to know any of the stuff covered in this essay. All you need to remember is that when playing out a fight in the Codex, it’s ok to assume that a minor or moderate wound of 5-10 Hit Points, may not necessarily have any special spectacular effect. But multiple wounds like that can bring somebody down. Now go grab some dice and fight a few battles!