MILITARY MEDICINE
How our wartime experience conquered a wide range of problems from hemorrhagic shock to yellow fever
WHEN HIPPOCRATES wrote in the fifth century B.C. that “he who would learn surgery should join an army and follow it,” he illuminated the central irony of military medicine. Destructive as war is, it makes possible quantum leaps in the art of healing. And it is the surgeon who benefits most directly: war has been described as an “epidemic of trauma,” and the vast supply of wounded men provides opportunities for experimentation and innovation unthinkable in a world at peace. But surgery is not the only branch of medicine that advances. In all wars fought before World War I, more men died from disease than from military action, so the necessity of keeping troops on the field provides a powerful impetus to wipe out the illnesses that prey on armies. Finally, there is the matter of logistics—how to move a man quickly to a place where he can be treated. Here, too, lessons learned in wartime have dramatically improved health care when peace came.
The six pictures that follow reveal much about medical care in America’s major wars since the beginning of photography. The Civil War was the last great conflict waged before germ theory entered medicine. Hospitals were unsanitary places, where, as the surgeon W. W. Keen later described it: “We operated in old blood-stained and often pus-stained coats, the veterans of a hundred fights. We operated with clean hands in the social sense, but they were undisinfected hands. … We used undisinfected instruments from undisinfected plush-lined cases. … If a sponge or instrument fell on the floor it was washed and squeezed in a basin of tap water and used as if it were clean. ” The troops were plagued by malaria, diarrhea, dysentery, typhoid, and respiratory diseases. In the first years of the war, ambulances were in short supply, and the civilians hired to drive them fled at the first sounds of shooting. Three days after the second battle of Bull Run, some three thousand wounded men still lay on the field, and Washington hospitals were so overcrowded that cots were set up in the halls of Congress. Like thousands of others, Oliver Wendell Holmes traveled to the front three times to take his son home for treatment rather than leave him to the uncertainties of military medicine.
Two years after the Civil War ended, the British surgeon Joseph Lister published his work on antisepsis, laying the groundwork for accelerated progress in the Spanish-American War, the two World Wars, and Korea. But impressive as its past has been, the future of military medicine is less certain. In Vietnam the advances were primarily in logistics, not medicine. And as the nation’s doctors have tried to make clear, if there is all-out nuclear war, they will be powerless to help.
—Jane Colihan
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THE CIVIL WAR: cutting and sawing
THE PHOTOGRAPH IS posed but the scene is truthful enough: a soldier lies on the operating table, the surgeon has his knife ready, and an anesthetic is being delivered. Ether had been in use since 1846, chloroform since 1847, and both, mercifully, were in adequate supply. Amputation was the common consequence of wounds in the arms or legs, since nothing was known of antisepsis and infection was almost inevitable. At Gettysburg some surgeons did nothing for a week but cut off limbs.
Four-wheeled ambulances like the one pictured here were a major improvement over the two-wheeled versions issued in larger numbers early in the war. The latter were agonizingly uncomfortable for the wounded. Jonathan Letterman, medical director of the Army of the Potomac, brought the ambulances under the control of the medical department instead of the quartermaster corps, and manned them with soldiers trained for the job instead of with civilians, who tended to run away.
The greatest medical benefit of the war was the confirmation for doctors and the public that there was a connection between cleanliness and health, dirt and disease. This awareness, combined with the large number of doctors who gained valuable surgical experience, prepared the way for the rapid advances of the next thirty years as the causes of infection became known.
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THE SPANISH-AMERICAN WAR: conquering yellow fever
A SOLDIER LIES in a tent hospital in Siboney, Cuba, in July 1898, a victim of yellow fever. That month, senior U.S. Army officers fresh from victories at San Juan Hill and Santiago proposed immediate evacuation: “The army is disabled by malarial fever to such an extent. … that it is in a condition to be practically entirely destroyed by the epidemic of yellow fever sure to come. …” Spain surrendered before President McKinley had to weigh the risks of an epidemic against the humiliation of withdrawal. Even so, losses were severe: in the combined theaters of the war, fourteen times as many men died of tropical diseases as from enemy action.
Pressure to conquer malaria and yellow fever did not end with the armistice: to maintain control of Cuba, the Army planned to station ten regiments there. Doctors had quinine to treat malaria, but no drug had proved useful against yellow fever. In an attempt to avert an epidemic, the new recruits were drawn from Southern states already hit by yellow fever—men thought to be immune. When even these men started to fall ill, despite all efforts at sanitation and quarantine, the surgeon general appointed a board to investigate the disease.
Led by Maj. Walter Reed, the board tested a theory, put forward by a Cuban physician named Carlos Finlay, that mosquitoes spread yellow fever. After a series of experiments in which Army volunteers were deliberately infected, Reed proved conclusively that the Aedes aegypti mosquito was the carrier. Maj. William Gorgas then began a campaign to eradicate the insect, and within a year there were no yellow fever cases in Havana for the first time in over a hundred years. Reed’s work was immediately put to use by Gorgas in a peacetime project: cleaning up the Panama Canal Zone.
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WORLD WAR I: tetanus and plastic surgery
VICTIMS OF mustard gas, American soldiers of the 82nd and 89th divisions lie in a field north of Royaumeix, France, too numerous to be cared for in the nearby field hospital. New weapons like gas and the increasing efficiency of conventional weaponry meant ever larger numbers of wounded men: this war saw dramatic improvements in the number and quality of hospitals and in triage—the method of sorting the wounded. At the right of the photograph, a nurse does what she can to alleviate suffering. An Army Nurse Corps had been established in 1901, thanks in part to pioneering efforts by Florence Nightingale in the Crimean War and Clara Barton in the Civil War. World War I was the first of America’s conflicts in which nurses had professional training. They quickly made themselves indispensable. Visible at left is one of the motorized field ambulances that had replaced the mule-drawn wagons of earlier wars. Doctors noticed improved recovery rates when the wounded were removed from the front lines before infection had set in.
World War I battlefields were rich farmland fertilized with manure, ideal conditions for tetanus bacilli. Army doctors tried a new antitoxin, with impressive results. The major disease killer of the war, influenza, was not brought under control until later.
By 1914, surgical techniques were considerably more sophisticated than in previous conflicts. Unfortunately the science of war had kept pace, and surgeons faced a larger percentage of serious injuries caused by shells and shrapnel. But this development, too, propelled medicine forward. Perhaps the greatest lessons of the war were in the field of plastic surgery: the large numbers of men with wounds of the face and jaw prompted daring reconstructive surgery that expanded and developed this new medical specialty.
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WORLD WAR II: plasma, penicillin, and insecticides
WITHIN MINUTES of being hit, a wounded soldier in Sicily receives blood plasma from an Army medical corpsman. Some 80 percent of injuries in World War II were caused not by bullets but by bombs or mortar and shell fire, resulting in grave wounds accompanied by shock. Doctors in the First World War had learned that transfusions were useful in treating shock, but they had no system of collecting and transporting sufficient quantities of blood. Between the wars, researchers perfected two new techniques. First they separated plasma, the liquid part of blood, from the red and white blood cells—this made matching blood types unnecessary. Then they dried the plasma, which preserved it and made it easier to transport. When needed, the plasma was mixed with sterile water and injected into the bloodstream to sustain life until surgery could take place.
To meet the tremendous demand for plasma once the war began, the American Red Cross asked Charles Francis Drew to establish a system for collecting blood from the civilian population. He opened collection centers across the United States; then, when the Army later told the Red Cross to keep non-Caucasian blood separate from other donations, Drew, a black, resigned.
Three other major advances occurred because of the war. The introduction of high-speed, high-altitude aircraft forced the development of oxygen systems and pressure suits, which were later used in civilian aviation and in the space program. Penicillin went into production on a vast scale and was used to treat pneumonia, wound infection, meningitis, gonorrhea, and syphilis. And wartime research produced new drugs to combat malaria and new insecticides, notably DDT, which drastically reduced deaths from typhus.
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THE KOREAN WAR: MASH and vascular surgery
DOCTORS OPERATE on a wounded soldier at a Mobile Army Surgical Hospital. Korea’s MASH units were adaptations of systems devised in World Wars I and II, in which surgical teams were sent forward to clearing stations to stabilize the condition of severely wounded men before sending them to the rear for definitive care. At first Korea’s MASH units moved with the Army; as the war settled down, they tended to remain stationary. The 8209th MASH, pictured here, was the home of an Army medical department clinical research program—formal recognition of war’s role as a laboratory of science. Researchers studied wound infection, dehydration, and kidney problems, and a team of highly trained vascular surgeons instructed less specialized MASH doctors in new ways of repairing arterial wounds, reducing the need for amputation.
The first artificial kidney machine to be brought into a combat zone was used to treat kidney failure in cases of severe shock, and on patients with hemorrhagic fever—an infectious disease later shown to be caused by a virus carried by small rodents.
As in other wars, the climate presented medical challenges. Korea’s severe cold led to advances in the prevention and treatment of frostbite. Twenty years after the Korean War ended, millions of Americans were introduced to the subject of military medicine by the extraordinarily successful television program “M∗A∗S∗H,” which ran from September 1972 to February 1983. It was, comedic effects aside, a reasonably accurate portrayal.
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VIETNAM: helicopter evacuation
A MARINE GUIDES a medevac helicopter to a landing to a near Du Co, South Vietnam, where it will pick up the victims of an ambush and fly them to a nearby hospital. Helicopter evacuation began in Korea, but in that war, land-based ambulances still carried 80 percent of the wounded. In Vietnam, “dust-off” helicopters touched down on the battlefield itself and removed the wounded to air-conditioned fixed-facility hospitals as sophisticated as those in the United States. Because of the speed of evacuation and the quality and proximity of these hospitals, the died-of-wounds rate in Vietnam sank to 2.5 percent, the lowest of any war.
Medical evacuation by air was so successful in Vietnam that, by the late 1960s and early 1970s, helicopters began to transform civilian emergency care. The Departments of Defense, Transportation, and Health, Education and Welfare joined in a project called MAST—Military Assistance to Safety and Traffic. In one of the programs’s early successes, Army helicopters piloted by Vietnam veterans flew more than four hundred missions after Hurricane Agnes in June 1972, evacuating families from flooded areas. Today MAST helicopters are used across the nation to transport victims of heart attacks or traffic accidents, saving lives that might have been lost in the wait for an ambulance.
Heartening as this advance has been, the medical statistics on Vietnam are not yet complete. Unexpected illnesses that may have been caused by the defoliant Agent Orange are just now being diagnosed. Older veterans are being treated for problems that some attribute to doses of atomic radiation received at the close of World War II. The died-of-wounds rates of both these wars may, tragically, need to be revised.
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