Tuesday, May 24, 2016

Treatment of War Wounds: A Historical Review (Excerpt)

M. M. Manring, PhD, Alan Hawk, Jason H. Calhoun, MD, FACS, and Romney C. Andersen, MD

The treatment of war wounds is an ancient art, constantly refined to reflect improvements in weapons technology, transportation, antiseptic practices, and surgical techniques. Throughout most of the history of warfare, more soldiers died from disease than combat wounds, and misconceptions regarding the best timing and mode of treatment for injuries often resulted in more harm than good. Since the 19th century, mortality from war wounds steadily decreased as surgeons on all sides of conflicts developed systems for rapidly moving the wounded from the battlefield to frontline hospitals where surgical care is delivered. We review the most important trends in US and Western military trauma management over two centuries, including the shift from primary to delayed closure in wound management, refinement of amputation techniques, advances in evacuation philosophy and technology, the development of antiseptic practices, and the use of antibiotics. We also discuss how the lessons of history are reflected in contemporary US practices in Iraq and Afghanistan.

The need for surgical care of survivors of accidents or animal attacks is part of the story of civilization, as is the story of medical care of those wounded in that other peculiarly human endeavor, warfare. During the past 250 years, and particularly during the 20th century, developments in military trauma care for musculoskeletal injuries have greatly influenced civilian emergency medicine. The history of military trauma care must be understood in terms of the wounding power of weapons causing the injury and how the surgeon understood the healing process. Improvements in weapons technology forced surgeons to rethink their interventions in their effort to tip the odds of survival in favor of their patient.

Our purpose is to review the evolution of military trauma care during the past two and a half centuries in major conflicts in the West. The major areas of emphasis are medical evacuation and organization; wounds and wound management; surgical technique and technology, with a particular focus on amputation; infection and antibiotics; and blood transfusion.

Medical Evacuation and Organization
Perhaps the most basic problem facing physicians during wartime historically has been whether (and how) to transport the wounded to care or transport the caregivers to the wounded. A secondary problem historically has been how best to organize the delivery of care as modern nations began to dispatch vast armies and navies to fight across vast distances.

For example, Pikoulis et al. reviewed the wounds depicted in The Iliad and determined the arrow wounds such as the one suffered by Menelaus carried a mortality rate of 42%, slingshot wounds 67%, spear wounds 80%, and sword wounds 100%. These high mortality rates suggest surgeons were unable to get to wounded soldiers during the melee, treating only the higher class or those who survived after the battle had concluded. These Greek surgeons, whether they realized it or not, faced the same issues as all future practitioners engaged in wound care: wound management, The Golden Hour (the principle that a victim’s chances of survival are greatest if he receives resuscitation within the first hour after a severe injury), and infection control.

During the American Revolution (1775–1783), the Continental Congress authorized one surgeon to serve in each regiment. Few of the regimental surgeons, mostly trained through the apprenticeship system as there were only two medical schools in the United States (King’s College [now Columbia University] in New York, NY, and the University of Pennsylvania in Philadelphia, PA), had any experience treating trauma. The organization was minimal, and regimental surgeons tended to work for their unit instead of seeing themselves as part of the Hospital Department, which was rendered ineffective by bureaucratic infighting.

The outstanding military surgeon of the Napoleonic Wars (1792–1815), Baron Dominique-Jean Larrey (1766–1842), generally is regarded as the originator of modern military trauma care and what would become known as triage. He placed surgical teams near the front lines to shorten the time elapsed after injury and instituted specially designed horse-drawn “flying ambulances” in which the wounded rode with an early version of emergency medical technicians. Care was prioritized to provide first for the most badly wounded, without regard to the patient’s chances of survival or the need to restore less gravely wounded soldiers to the front lines quickly. After Larrey’s system was used during the Battle of Metz (1793), he was ordered to organize medical care for the entire French Army. Rapid access to care and immediate amputation reduced morbidity and mortality.

The Crimean War (1854–1855) underscored the importance of methods used by Larrey decades earlier, particularly the importance of organized evacuation and surgical care close to the front line. The war revealed a stark contrast between the battlefield care provided by the French, with their expert organization and system of light ambulances, and the poorly organized British Medical Services. Outrage over the poor treatment offered to the British wounded led the War Office to send a young nurse, Florence Nightingale (1820–1910), and a staff of 38 volunteers to the British barracks in Istanbul, Turkey, where Nightingale’s first act was to thoroughly scrub the hospital, provide clean bedding, improve ventilation and sewage disposal, and reorganize everyday sanitary procedures. She was an early theorist of sanitation and the design of hospital buildings. Although her efforts created intense resentment in the army bureaucracy, she was one of the founders of the modern nursing profession. She broke the monopoly of health care as the sole providence of the physician, which led to the development of the healthcare team in modern medical practice.

Nikolai Pirogoff (1810–1881), who served in the Imperial Russian Army, brought skilled nurses into military hospitals and worked to modernize Russian medical equipment. He is the namesake for a conservative technique of foot amputation.

At the onset of the American Civil War (1861–1865), the US Army and Navy combined had about 100 physicians, many with no experience with battlefield trauma, almost 30 of whom resigned to join the Confederacy. The structure of the Medical Department was decentralized with no clear chain of command and control of supplies. The US Army Quartermaster’s Corps, whose primary duties were supplying and provisioning troops, were responsible for direct battlefield evacuation. The Regimental Band served as litter bearers. The first Battle of Manassas (July 21, 1861) was a rout for the federal forces and the soldiers fled back to Washington. Ultimately, 2708 men were killed or wounded and the Medical Department could not handle the load. Regimental surgeons, because they worked for their unit only, were either swamped with casualties or idle. Regimental band members and civilian ambulance drivers hired by the quartermaster’s corps fled from the battle. Most of the wounded had to walk the 27-mile distance from the battlefield to Washington to reach the hospitals in the rear. Those who could not walk remained on the battlefield for several days until they were picked up by ambulances, captured by Confederate forces, or died.

The Union Army quickly reorganized its Medical Department in 1862 after prodding by a Sanitary Commission created by President Lincoln. Jonathan Letterman (1824–1872) reorganized the medical care in the Army of the Potomac. Wounded soldiers were removed from the battlefield by litter bearer, the predecessor to the medic or corpsman. Regimental Surgeons were responsible for dressing wounds and patients were evacuated in ambulances driven by Medical Corps noncommissioned officers to a division level field hospital for surgical treatment. By the end of the war, the Medical Department expanded this system by creating a national network of hospital trains, hospital ships, and general hospitals that could treat the patient near his hometown if he so desired. The main advance in American medicine during the Civil War was the creation of an effective military medical corps with medical evacuation, hospitals, and surgical specialists. Health care was beginning to become a system. Still missing was a formalized approach to care that recognized the severity of injuries. The poet Walt Whitman, who worked at several Union hospitals in Washington, DC, noted, “The men, whatever their condition, lie there, and patiently wait until their turn comes to be taken up”. Whitman’s poem “The Wound Dresser” (1865) poignantly illustrates the state of care at the time.

From: ncbi.nlm.nih.gov

Image: Civil War Gunshot Wound Of Private Cyrus Straus Of Illinois


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