Is war good for medicine?
War's medical legacy
By CHRISTOPHER CONNELL
From Thermopylae to Baghdad, from the Gallic wars to Vietnam, war has proved an exacting but efficient schoolmaster for physicians. Hippocrates wrote, “He who would become a surgeon should join an army and follow it.” Second-century Greek physician Galen honed his skills not only in the sanctuary of Aesclepius, god of healing, but as physician to the gladiators of Pergamon. The American teenager pried from a twisted wreck on a Friday night and sped to a suburban hospital owes a debt of gratitude to the horse-drawn wagons (known as “flying ambulances”) that Dominique Jean Larrey, MD, invented to carry injured soldiers in Napoleon’s army and the professional ambulance corps that Jonathan Letterman, MD, instituted for the Army of the Potomac after the disastrous first Battle of Bull Run, where the wounded were left on the field when Union troops fled back to Washington.
Gunshot victims wheeled into any big city trauma center benefit from techniques that a generation of EMTs and surgeons first learned repairing combat wounds. “Most of the emergency medical response doctrine in practice in the United States today evolved from medical experiences in the jungles of Southeast Asia in the late 1960s,” says Lt. Gen. Kevin Kiley, MD, surgeon general of the U.S. Army.
For all the destruction and chaos it wreaks, war spurs some medical advances. Historically, trauma surgery, emergency care and infectious disease treatments leap the furthest ahead. Military medicine stretches back to antiquity. Augustus Caesar formed a medical corps for his legions. Roman surgeons tied ligatures and clamped arteries to control bleeding, and the vinegar they poured into wounds acted as an antiseptic. Galen, court physician to Marcus Aurelius in Rome, performed bold operations and gained an understanding of the human anatomy that was unsurpassed well into the second millennium. Ambrose Paré, the 16th-century French physician who figured out that wounds healed faster if you didn’t pour boiling oil onto them, observed that the only people who gain from warfare are young surgeons. French Army surgeon Jean Louis Petit’s invention of the screw tourniquet in 1718 made it possible to amputate legs above the knee without bleeding the patient to death. His device, which cut the flow from the femoral artery, would be in every military surgeon’s kit until well after the U.S. Civil War. Even with such equipment, until anesthetics came along, surgeons’ reputations rested principally on the speed with which they could saw off limbs.
Advances real and imagined
While wars provide ample opportunities for surgeons to hone their skills, some historians believe their contributions to the medical arts are modest if not minimal. F.H. Garrison, MD, in An Introduction to the History of Medicine (1929), wrote about World War I, “Viewed after the lapse of a decade, the medical innovations and inventions of the war period seem clever, respectable, but not particularly brilliant.” More recently, British sociologist Roger Cooter, PhD, made the argument that, “For the most part, war has accelerated research into old medical problems of military importance, the bulk of which are highly specific to that context and of little value outside it.” During most modern wars, Cooter says, civilians’ health needs have taken a back seat to the medical needs of the military.
Throughout most of recorded history, disease, not arrows, bullets or bombs, was the scourge of armies. Generals have long understood the importance of sanitation to the health of their troops. The French Army instituted physical exams for new soldiers in the early 18th century; soon recruits and conscripts were being poked and measured in all of Europe’s armies. At Valley Forge in 1777, Gen. George Washington ordered the Continental Army inoculated against smallpox. “Should the disorder infect the Army in the natural way and rage with its usual virulence, we should have more to dread from it than from the sword of the enemy,” wrote Washington, whose visage bore the scars of a bout with smallpox at age 19.
Still, among the 70,000 colonials who died during the Revolutionary War, nine were felled by disease for every one who died at the hands of the redcoats. Among the 31,000 British fatalities, just 4,000 were killed in action. In the Civil War, three-fifths of the 304,369 Union dead were victims of disease, not casualties of battle. It took until the 20th century for the arts of medicine and warfare to advance to the point where more combatants died from battle wounds than from diseases. The United States was a late entrant to World War I, but there were 53,402 Americans killed in action and 63,114 dead from other causes. By World War II, the Pentagon counted 291,557 deaths in action and 113,842 from other causes.
Over the centuries, as armies moved away from frontal combat and learned to unleash deadlier force across greater distances, war became less lethal for combatants and more lethal for civilians. More than 6 million of the 15 million lives lost in World War I were civilians; in World War II, the first global conflict, at least 35 million civilians perished — including more than 200,000 in Hiroshima and Nagasaki from atomic bombs, and 6 million European Jews by genocide — dwarfing the 20 million military fatalities.
Whatever the historians’ verdicts, wars are popularly associated with medical advances in the public mind, such as the blood banks that Oswald Hope Robertson, MD, created for the Army Medical Corps in France in 1918, and penicillin, the antibiotic that came to prominence and became widely available during World War II. But Dale Smith, PhD, who chairs the medical history department at the Uniformed Services University of the Health Sciences, or USUHS, in Bethesda, Md., says that in both instances, the real breakthroughs occurred in laboratories in the decade before the world wars.
Still, when the United States entered World War I, manuals for battle surgeons contained illustrations showing them how to sew a donor’s radial artery to the basilic vein of the wounded comrade for direct transfusion. “By the end of the war, those pages are gone and those same books show how to keep blood in storage boxes protected by ice and sawdust, and how to treat the blood to transfuse it safely,” says Col. David Burris, MD, chief of the Norman M. Rich Department of Surgery at USUHS. While Sir Alexander Fleming’s accidental discovery of penicillin took place in 1928, the antibiotic remained in short supply until the U.S. pharmaceutical industry performed a second miracle in gearing up industrial production of the scarce antibiotic during World War II.
Emergency medicine’s crucible
The Mobile Auxiliary Surgical Hospital, or MASH, not only saved lives in Korea, but entered American folklore thanks to Robert Altman’s 1970 black comedy, M*A*S*H, and the hit television series. The idea for MASH, however, originated in World War II with a Boston chest surgeon, Col. Edward “Pete” Churchill, MD, who in 1943 moved his best surgeons forward into rudimentary, auxiliary field hospitals during the invasion of Italy. A young Michael DeBakey, MD, serving on the surgeon general’s brain trust in Washington, later helped institutionalize the practice.
Vietnam gave new meaning to the term “flying ambulances” as daring Huey helicopter pilots ferried the wounded out of jungle battle zones. Even “dust off” — the military call sign for those evacuations — entered the American lexicon. Indeed, President George W. Bush held a ceremony in the White House in late February to present the Congressional Medal of Honor to Maj. Bruce Crandall, one of those Huey pilots, for darting in and out of a raging firefight in Vietnam’s Ia Drang Valley 14 times on a single day in November 1965 to rescue and resupply a 1st Cavalry battalion. His wingman, Ed Freeman, received the same honor in 2001.
Such feats not only proved the pilots’ mettle, but demonstrated what a lifesaver the sturdy little Huey — the Bell UH-1 Iroquois — could be. That lesson was not lost on hospital administrators and trauma surgeons back home. The Pentagon in 1968 lent helicopters for a pilot program to rescue accident victims from highway crashes in San Antonio and Dallas, and Baltimore trauma surgeon Adams Cowley, MD, convinced Maryland authorities to create the first statewide transport system in the early 1970s. Today, no self-respecting trauma hospital is complete without a helipad.
The crucible of conflict whets appetites for more and better medicine. Cooter, the British sociologist, wrote in the Companion Encyclopedia of the History of Medicine (1993): “Wars such as the American Civil and the First World War exposed large numbers of men to modern medicine and dentistry for the first time: one by one, recruits were stripped for examination, measured, weighed, tapped, and interrogated. Along with the soldiers and sailors whose lives were spared by the skills of military surgeons, such men may have returned home from war with higher demands for and expectations of orthodox medicine than when they left.” Smith, the historian of military medicine, notes the same phenomenon occurred after World War II, in which 30 percent of the nation’s physicians had been pressed into service to attend to the needs of the 8 percent of the population under arms.
Perhaps war’s greatest contribution to medicine is the chance to run public health experiments on a grand scale under exigent circumstances. Letterman’s Civil War ambulance corps was a dry run for today’s emergency medical services. Indeed, the municipal ambulance system that New York’s Bellevue Hospital launched in 1869 was modeled on the medical transports that Edward Dalton, MD, organized for the Army of the Potomac. Back home as sanitary superintendent for New York, Dalton convinced commissioners that the city needed an ambulance corps of its own. Each horse-drawn ambulance was stocked with “a quart flask of brandy, two tourniquets, a half-dozen bandages, a half-dozen small sponges, some splint material, pieces of old blankets for padding, strips of various lengths with buckles, and a two-ounce vial of persulphate of iron,” according to a January 2000 History Magazine account.
The Civil War’s impact on the practice of medicine was profound, according to Civil War buff and surgeon F.W. Blaisdell, MD, class of 1952, who’s known as the father of the modern trauma center. It set the standards for handling mass casualties and for combining field hospitals with large, pavilion-style hospitals in the rear. The latter became the model for municipal hospitals built across the United States for the next 75 years, Blaisdell wrote in The Archives of Surgery in 1988.
Those clean, well-ventilated hospitals were part of the legacy of Surgeon General William Hammond, MD, promoted at age 34 from first lieutenant to brevet brigadier general in 1862 to shake up the Union Army’s backward medical bureaucracy. Hammond laid the groundwork within Army medicine for a culture and passion for science and research, but his strong opinions also made him enemies. He defied medical orthodoxy by banning calomel, a popular mercury-based purgative that Hammond recognized was toxic. Court-martialed and driven from his post in 1864, Hammond went on to postwar distinction as a neurologist.
It was Hammond’s idea, too, to create an Army Medical Museum and to instruct field surgeons to send back to this fledgling museum and laboratory in Washington “specimens of morbid anatomy” in hopes that they might yield insights on improving care of the Union’s soldiers. After the fighting stopped, the museum took on the task of compiling a definitive medical record. Published in six volumes over 18 years, Medical and Surgical History of the War of the Rebellion became an early testament to evidence-based medicine. It was the work of many hands, but its chief compiler was Lt. Col. Joseph Janvier Woodward, MD, who helped conduct the autopsies of both Abraham Lincoln and assassin John Wilkes Booth.
“It stood for many years as the finest example of military medical reporting ever,” says Adrianne Noe, PhD, director of the National Museum of Health and Medicine, located on the campus of Walter Reed Army Medical Center. “We know the date of the soldier’s injury and the history of all of his care. This becomes valuable not only for historians, but also those studying injuries in a contemporary setting.”
Noe holds a position once occupied by the dauntless Maj. Walter Reed, the scientist-physician who conducted the famous experiments in Havana, Cuba, in 1901 confirming that yellow fever was carried by mosquitoes. Notwithstanding the recent scandal over poor outpatient conditions, for nearly a century the storied hospital that bears Reed’s name has cared for generals, privates and presidents, and its researchers have made major contributions to medical science and clinical care.
It isn’t quite a Medical and Surgical History of the War of the Rebellion, but the Vietnam Vascular Registry that military surgeon Norman Rich, MD, class of 1960, established at Walter Reed in 1966 after a year as chief of surgery at a MASH in a jungle clearing in Vietnam’s Central Highlands has paid dividends for American servicemen and servicewoman injured in subsequent wars. Rich went to Vietnam fresh from a surgical residency under Carleton Mathewson, MD, at Letterman Hospital in San Francisco. Mathewson, a Stanford surgical legend, encouraged his protégé to keep careful records on his MASH patients, with an eye toward publishing the results.
Rich became fascinated with vascular surgery, including the repair of popliteal arteries. A tear in this artery behind the knee once portended amputation, but military surgeons had begun doing autologous vein transplants back in Korea, and that remains the treatment of choice today. More than 600 battle surgeons contributed records from 8,000 vascular wound cases to Rich’s registry, which today helps surgeons operating on soldiers who suffer similar wounds in Afghanistan and Iraq.
“Evidence-based medicine is everything today, and this large, unique database lets us know what happens when vessels with certain types of injuries are repaired in certain ways. Our younger colleagues are doing much the same thing with the injured coming back from Afghanistan and Iraq, and we keep comparing the two sets of experiences to come up with the best current management of casualties,” says Rich, the former USUHS surgery chief, who at 73 still gets to work by 5:30 a.m. Recalling Ambrose Paré’s axiom about young surgeons, Rich says, “I did more in a short period than I ever would have done in a civilian setting — around the clock, seven days a week, without distractions. It was a phenomenal experience.”
Burris, the chief of surgery at USUHS, often uses the phrase “new wounds for new surgeons” to explain what surgeons are up against in Iraq and Afghanistan. “The explosions in the wars since World War I all do the same thing to the human body. There are only so many ways you can survive and be badly mangled,” says Burris, who spent three months performing operations in an auxiliary hospital at the Baghdad International Airport. Rich expressed similar sentiments. “People who have not been in a war before are absolutely overwhelmed by the horrors of war — but that doesn’t mean that wars or wounds are getting worse. It just means that new people are seeing horrible wounds that other people have seen in the past.”
Notwithstanding the images Americans see daily on their television screens, most of the 25,000 injuries that U.S. service men and women have suffered in Iraq “are mild to moderate, just like in car wrecks or anything else,” Burris says, and half the wounded return to duty without leaving the theater of war. While it might seem from the television news “like everybody’s lost their leg,” the actual number is fewer than 750, he says. Half those killed in battle die from bleeding before a doctor sees them, and most of the others suffer “massive neurological injuries that are non-survivable. You couldn’t fix them even if they were blown up in front of you,” the trauma surgeon says. The real challenge in this war as in every other is to save the lives of that 5 percent with massive injuries who can survive if “everybody does everything perfectly,” Burris says.
Not every wound involves fractured bones or punctured tissue and organs. In war, some of the gravest injuries occur to the psyche, though the harm might not manifest itself until long after the battle stops. Operation Desert Storm — the 1991 Gulf War to oust Iraq from Kuwait — ended in weeks, with an official Pentagon count of 382 deaths and 467 wounded. But among the 700,000 American troops deployed during Operation Desert Storm, “approximately 80,000 veterans have reported various symptoms in the years following the war, and scientists have agreed that many veterans have unexplained illnesses,” including fatigue, pain, headaches, memory loss, rashes and disturbed sleep, according to a 2004 Government Accountability Office report. There well could be a similarly long shadow to Operation Iraqi Freedom.
Armies have struggled for centuries to help troops cope with the stress of battle. From the late 17th to the late 19th century, “nostalgia” was the official diagnostic term for the homesickness and despair that practically paralyzed some soldiers. But only after Vietnam did “post-traumatic stress syndrome” became recognized as a disorder. The Department of Veterans Affairs in 1989 carried out a congressional order to create a National Center for Posttraumatic Stress Disorder to study PTSD, headquartered at the Veterans Affairs Medical Center in White River Junction, Vt. Its executive director, Matthew Friedman, MD, PhD, a professor of psychiatry and pharmacology at Dartmouth Medical School, says, “The PTSD field has matured to the point where we have evidence-based treatments that work. We couldn’t make that statement following the Vietnam War 30 years ago. But we now have very, very effective psychosocial treatments.” Friedman adds, “We’ve moved way beyond thinking of PTSD as exclusively a military issue. We’ve gotten into post-sexual trauma, disasters, tsunamis, Katrinas, terrorist issues.”
In Iraq, while “we are saving many people who would have died in previous conflicts… it also means that they are at considerable risk to develop psychological problems along with whatever physical sequelae they have,” Friedman says. The military now screens soldiers for mental health problems before and after they are sent to theaters of war. Friedman says military psychiatrists are uncovering and treating problems while these soldiers are still in uniform, rather than letting the problems fester for years, as happened with many veterans of the Vietnam War.
Next challenge: the health-care system
If better understanding and treatment of stress was a medical legacy of Vietnam, traumatic brain injuries may be what soldiers and the American public will remember most from Operation Iraqi Freedom. Today’s improved body armor protects a soldier’s torso and limbs, but the brain remains vulnerable. Thousands of U.S. troops who survived explosive blasts with no visible wounds could suffer neurological disorders because of internal damage, U.S Department of Veterans Affairs neurologists say. And that is on top of the nearly 1,900 U.S. troops who survived with brain injuries caused by severe penetrating trauma.
Saved by heroic medical measures, these mostly young service members must for the rest of their lives deal with brain injuries and other incapacitating wounds. The VA has established four so-called polytrauma centers in Richmond, Va.; Tampa, Fla.; Minneapolis; and Palo Alto. Each of the 350 patients treated to date at these centers has suffered at least two major injuries from a list that includes traumatic brain injury, hearing loss, amputations, fractures, burns and visual impairments. The VA spends $31 billion a year providing health care for the nation’s 24 million veterans and their families. After reforms and changes in the 1990s, the VA’s coordinated system of care is often touted as a model for the nation.
But Kenneth Kizer, MD, architect of that transformation as VA under-secretary for health from 1994 to 1999, and a Stanford University alumnus, is not sanguine about the capacity of the U.S. health system to deliver the care severely injured Iraq war veterans will need. “These traumatic brain injuries combined with multiple amputations and other serious injuries are creating a type of casualty the likes of which has never been seen before, or at least certainly not in the numbers now being produced by this war,” says Kizer.
Kizer, whose Marine son-in-law is on his second tour of duty in Iraq, says, “Places like Stanford and Palo Alto-VA may be relatively well-prepared [for these patients] but they are very special places. These people aren’t going to live in the VA forever. They are going to want to go home to their communities” far from elite academic medical centers. “How many nursing homes are prepared to deal with a patient with multiple amputations, traumatic brain injury and God knows what else?” he asks.It was Abraham Lincoln, in the closing words of his Second Inaugural, who first spoke of the government’s obligation “to care for him who shall have borne the battle, and for his widow, and his orphan.” Despite advances over the years in war and in medicine, that solemn challenge remains daunting.
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