He who desires to practice surgery must go to war.
—Hippocrates
In the Iliad, Homer describes nearly 150 distinct wounds including entrance and exit points, various weapons (sword, arrow, lance), internal injuries, and the differences between fatal and nonfatal injuries. The treatment of these wounds is well illustrated in many surviving Greek urns (Fig. 1-8). Greek and Roman generals traveled with private physicians but the troops, as illustrated in this and many other urns, treated each other. A later illustration of the wounds seen before the introduction of gunpowder is well illustrated in the “Wound Man” (Fig. 1-9).
Many variations on this image appeared in surgical texts from the 1400s to the 1600s. The introduction of gunpowder changed the nature of the injuries and scarring
from war and encouraged the formal introduction of military surgeons for all troops, not just officers. Ambroise Paré (1510 to 1590) was among the first physicians to be identified as a military surgeon serving under several French kings for nearly 30 years beginning in 1536. Paré seems to have been a keen observer, noting that using boiling oil on fresh gunshot wounds was less effective than simply bandaging the wound with egg yolk, turpentine, and rose oil.22 He also notes that his method caused less suffering as well as less damage to the tissues. He recommended ligation of arteries during amputations rather than cautery with a hot iron. His accounts of the treatment of gunshot wounds provide descriptions of the first interventions that were more likely helpful than harmful, in contravention to the standard practices of that time. Less well known, Paré is also credited with designing prostheses for both upper and lower limbs, as well as ocular prostheses that he formulated out of gold, glass, porcelain, and silver.23,24
Scar breakdown is one sign of scurvy, a condition that became a serious impediment to naval exploration. Vasco da Gama lost two-thirds of his crew during his 1499 voyage to India. A British expedition to the South Seas in the 1740s lost 1,300 sailors (out of the original 2,000) as well as six of their seven ships. Richard Walter, chaplain on this expedition, describes: “Skin black as ink, ulcers, difficult respiration, rictus of the limbs, teeth falling out and perhaps most revolting of all a strange plethora of gum tissue sprouting out of the mouth, which immediately rotted and lent the victim’s breath an abominable odor.”25 It is estimated that scurvy killed nearly 2 million sailors between 1500 and 1800. There are numerous accounts of the military consequences of scurvy affecting naval forces, including that of the Spanish Armada in 1588, whose defeat by the English set the stage for British dominance in the coming centuries.26 James Lind (1716 to 1794), a British Naval surgeon, is often described as the “discoverer” of the fact that citrus fruit prevented and cured scurvy. His famous experiment with 12 sailors who had the disease is often acclaimed the original clinical trial, first published in 1753. This myth is thoroughly debunked by Michael Bartholomew through a close reading of Lind’s own work.27 Historical research demonstrating that scurvy continued to affect middle-class Victorians and the Scott expedition at the beginning of the 20th century additionally challenges the persistent tale of how the British Navy became “Limey’s.”28
FIGURE 1-9 Hans von Gersdorff (1455 to 1529). Field book of surgery 1517. (From https://upload.wikimedia.org/wikipedia/commons/7/73/Gersdorff_p21v.jpg. Accessed November 11, 2016.)
War on land in the 19th century carried high mortality, whether from direct injury or as a result of starvation, exposure, and disease. Napoleon’s invasion of Russia in 1812 with 680,000 men resulted in the loss of nearly 90% of his troops in the 6 months of the campaign. Minard’s chart (Fig. 1-10) is the first successful example of a graph depicting multiple types of data. It demonstrates the progress of the army into and out of Russia, the diminishing size of French military forces, geographic progress, temperature during the retreat, and sites of importance along the way. An excellent biography of Dominique Jean Larrey, the chief military surgeon to Napoleon, documents the awful conditions faced by the medical staff.29 Delays in equipment and supplies made providing emergency care difficult. Larrey describes using his own clothing as bandages. During the Battle of Vitebsk, he personally performed 11 amputations at the shoulder over 24 hours, and he reports that nine survived and two died of dysentery. Later, at the Battle of Borodino, he is reported to have performed 200 amputations (of all types) within 24 hours. Larrey describes bureaucratic obstruction, administrative incompetence (widespread graft, theft, bribery), and other obstacles to his ability to care for the injured. Larrey further states that nearly all the wounded died of hunger. Despite the huge losses and medical disasters, the innovations Larrey brought to the war, including a
new type of mobile “flying” ambulance, the deployment of a trained medical corps, and the provision of medical care at the front, all set the stage for military surgery during the coming century. Larrey is remembered for his humanity, his concern for the common soldier, his honesty, and his ability to innovate with whatever was at hand.
FIGURE 1-10 Charles Minard’s 1869 chart showing the number of men in Napoleon’s 1812 Russian campaign army, their movements, as well as the temperatures they encountered on the return path. Lithograph, 62 × 30 cm. (From https://commons.wikimedia.org/wiki/Commons:Reusing_content_outside_Wikimedia. Accessed November 11, 2016.)
Among the many wars of the 19th century, the US Civil War (1861 to 1865) carried the highest mortality of any US military action with nearly 620,000 military deaths (2% of the total population), or 1 in 4 soldiers who went to war. Of those who returned, 1 in 13 had suffered the amputation of an arm or a leg.30 The medical advancements introduced during the Civil War included the introduction of photography for documentation, the establishment and organization of a nursing corps, the use of anesthesia near the front lines, the use of morphine or whisky for pain, the establishment of standardized treatments for specific injuries, and an increased appreciation for the types of hygiene that could prevent dysentery, typhoid fever, and other contagions. William A. Hammond, the Surgeon General of the Union Army, developed a system of triage, evacuation, and the design for clean, well-ventilated buildings that decreased mortality in field hospitals from nearly 40% to 8% by the end of the war.31 In the aftermath of the war, veteran benefits and support became a new national priority with the establishment of the Veterans Homes, a precursor to the current Veterans Administration system.
With the introduction of anesthesia, the adoption of aseptic surgical technique, and an evolving understanding of infections, the next great leap in military medicine came with preparations for World War I. Disastrous experiences during the Garza War (1891 to 1893) and the Spanish American War (1898) led to the formation of formal medical, surgical, nursing, dental, and reserve corps, as well as the formalization of medical
supply sources. Field hospitals were designed, and in 1910 permanent specialized units were established. These preparations were tested in the Mexican Border conflict in 1916, and included the first use of motorized ambulances. Additional interest in field sanitation led to marked improvements later applied to the American Expeditionary Forces when the United States entered World War I. The 1916 experience also led to the consolidation of all medical and dental corps into a single Medical Department. Prominent American physicians including George Crile, Harvey Cushing, William C. Gorgas, William Welch, and William Mayo all participated in the Council of Medical Preparedness. Fifty base hospitals of 500 beds each for the Army, and 8 distinct 250 bed hospitals for the Navy were prepared in cooperation with the Red Cross.32 Most notably, this era ushered in the reconstructive era of plastic surgery.
In 1917 the British assembled a team of physicians in Sidcup, England, headed by Sir Harold Gillies (1882 to 1960), specifically designed to treat facial injuries and disfigurements. The team at Queens Hospital provided reconstruction with skin and bone grafts, flaps and prostheses. Activity in this dedicated center resulted in numerous advances, not just in treating scars and deformities, but in anesthesia as well. Sir Gillies is considered the father of modern plastic surgery. However, his work would not have been possible without the efforts of Sir Ivan Magill (1888 to 1986), a general practitioner before the war who invented the laryngoscope, endotracheal tube, eponymous forceps, and the use of closed circuit gas delivery. Magill is considered the father of modern anesthesia. Work at the hospital included treatment for over 5,000 men during over 11,000 surgical procedures, without a single death attributed to anesthesia.
The ability to provide efficient first aid, transport the injured to secure facilities, and render appropriate medical care creates an entirely new set of challenges. Formerly fatal wounds require complex closures, reconstruction after potentially devastating tissue losses, and the restoration of function. The development of clinical uses of antibiotics during World War II and continued advances in medical and surgical services during the Korean, Vietnam, and first Gulf War led to decreasing mortality from increasingly severe wounds; these in turn led to more difficult reconstructive challenges and scar management requirements. This progression continues into the present day associated with more than a decade of conflict in Iraq and Afghanistan. Staggeringly complex and dramatic injuries have been countered with sophisticated gear (built-in tourniquets and hemostatic dressings). Rapid evacuation by helicopter to mobile hospital units and the capacity to move the injured to higher echelons of care within 24 hours have helped to increase the battlefield survival rate of those wounded from 76% during the Vietnam conflict to well over 90% today.33