Philip Trubee is a second-year student at Grinnell College. He is a Political Science and History major, and is employed at the Faulconer Gallery Print and Draw Room. His post on Trauma Treatment is inspired by his family’s work within that field of medicine.
Trauma Medicine, as practiced in Emergency Rooms and field hospitals all across the world, developed uniquely in the field of medicine. The rise of palliative care, the use of antibiotics, and the evolution of the doctor-patient relationship were all facilitated by advancements in wartime. Today, trauma such as ballistic entry/exit and multiple amputation wounds boast a historically high survivability rate. Traumatology continues to be researched primarily through the military, with the forefront of trauma research headed by the Journal of Special Operations Medicine. Yet, the origins of such medical care lay in the bloodiest battlefields both in the United States and abroad. It is my aim to trace the improvement of battlefield trauma medicine.
Before the Civil War, the United States was a haven of humoral theory and a misguided Galenic ideal of how the body mitigated shock, fever, and injury. Besides medicinal alcohol, no medically administered opiates or chloroform existed at the onset of the early nineteenth century. The 1847 invention of chloroform and its rapid adoption for surgeries created the field of anesthesiology, and the onset of the Civil War forced the creation of the modern ambulance, and also changed the treatment of patients.
On July 21st, 1861, the First Battle of Bull Run marked the bloodiest engagement thus far in the Civil War. Over 1,000 Union soldiers were wounded in five hours. The wounded streamed across North-eastern Virginia into Washington D.C. Amongst the pews at Trinity Church and the couches of the Union Hotel, soldiers succumbed not to immediate trauma but to the dangers of infection. The entire Union Army Medical Department numbered a mere 87 people, 26 of whom would defect to the Confederacy within the first month of the war [1]. The first Medical Director of the Union Army “considered general hospitals general nuisances”, and medical theory at this time was dominated by humoral theory as well as miasmatic potential for infections [2].
By 1864, Medical Director T. McParlin and Surgeon J. Milhau had organized, on paper, an extensive and revolutionary ambulance corps to tend to front-line trauma patients [3]. Despite the contemporary motif of a battlefield nurse tending to patients as they fell, the reality was that a majority of casualties were extracted by cart. The field hospitals were intended to be mobile and fluid according to the position of the front, and each casualty was intended to be directed to their respective Division hospital [4]. In the course of the war, most extremities with ballistic wounds were amputated. Almost all ballistic surgeries were invasive and done with unsterilized tools which spread infection [5]. Wounds were dressed and cleaned, but often only after the patient had been moved from a field hospital to a general which was sometimes a hundred miles away.
The first regular tent field hospital was not established until the Battle of Shiloh in 1862. It could accommodate some three hundred patients, and they were “better provided for and more comfortable in every way than those who were moved aboard the hospital transport” as claimed by the Medical Inspector of the 4th Division [5]. There were, however, some eight thousand four hundred wounded on the Union side. For those unlucky enough to be stranded on the battlefield after sustaining a wound, seeking private care would be the only option. Thousands of casualties throughout the war were known to have violated the 3rd Amendment and illegally quartered themselves in private homes seeking medical treatment. Amputations were the most frequent surgeries for leg and arm wounds regardless of depth or angle of penetration.
Despite the gruesomeness of the Civil War, trauma medicine and treatment exponentially grew. The invention of the stethoscope, refining percussion, and verbal/physical examination strengthened the doctor-patient relationship. After the Civil War, some 11,000 surgeons and nurses were discharged into public and private healthcare, and by 1870 only around 200 medical professionals actually were on the books in the Army [6].
In the three decades between the Civil War and the Spanish-American War, virtually all practical experience of trauma medicine evaporated. Yet in those years, medicine advanced. The 1893 appointment of George Sternberg to Surgeon General allowed the rise of bacteriology and many other vogue advancements to be incorporated into trauma medicine. Additionally, the opening of 200 nursing schools across the United States kept attendant medical practitioners well-versed on germ theory and sterilization.
Although the Spanish-American War did not yield the same overwhelming casualties, many post-war technologies and ideas affected the probability of survival. With the rise of the X-ray came instant analysis of ballistic wounds as well as fractures and breaks. Additionally a mixed-race corps of 300 Nurses was created, which had a 10% lower typhoid rate in their wards than their male counterparts due to sanitation training and better qualifications [7]. The war allowed medical professionals to study tropical diseases and infections, as well their impact on wounded soldiers in great detail. The biggest impact, however, was overall trauma wound survivability due to germ theory and sanitation. Out of 1,400 wounded at San Juan Hill, only 14 died from their wounds.
World War I did not have the same lapse in practical trauma knowledge. As the French invented the battlefield ‘triage’ system, American doctors quickly found that a simple categorization of treatment urgency greatly improved patient survivability. However, the rise of chemical weapons such as chlorine, phosgene, hydrogen cyanide, arsine, and mustard gas caused mass casualty occurrences and was overwhelming to field hospitals. Battlefield litter carriers and standalone medics also rose in usage. The loss of practical trauma medicine was significantly lessened by the shorter period of time between the major wars.
Penicillin was the greatest medical discovery for infection care in its day. Other anesthetics and palliative medicine at the time included morphine and other opiates. No antibiotic existed before penicillin, and its mass production proved crucial. Almost 15% of Allied casualties were directly saved by penicillin [8]. That’s 2.4 million military personnel, let alone the civilian lives saved. Penicillin was so crucial to the Allied war effort that it was not marketed to civilian doctors until mid-1945. Besides this wonder drug, there’s the rise of prefabricated mobile hospitals which were ideal for the front-line. The militarization of the Army Nurse Corps was the precursor to our modern ideas of nursing. Finally, World War II brought about a modern understanding of shock and blood transfusion [9]. The toxic theory of shock and nervous system theory of shock came into vogue, and medics now had a full understanding of blood types and transfusions.
By World War II, the social aspects of trauma medicine had changed. In this type of medicine, patients have no say in treatment, there are psychological ramifications regardless of the success of the treatment. Trauma medicine has always had the potential to require a disfiguring amputation, and such injuries can dramatically alter self-perception. Patients are also viewed by the doctor as immediate medical concerns due the triage system and urgency of the injuries. Holistic medicine and trauma medicine are totally separate fields. When trauma medicine becomes holistic medicine, it is because the patient is in long-term care and therapy, and thus not does not constitute immediate attention.
In the Civil and Spanish American Wars, officials that often were part of Public Health Services and institutions were also the same leaders of military institutions [10]. Adding to the power of the respected doctor and nurse came the power of rank. Rank was rarely a direct reflection of medical knowledge, which created two power dynamics in the ward. After World War II, however, medicine was further legitimized by war, as well as allowing for a more trusting relationship between doctors and veterans.
Modern military trauma medicine involves the concept of the Golden Hour. If someone is brought to surgery and treated with proper trauma medicine within one hour, regardless of injury, they have an incredibly high survivability rate. In our most recent war, the wounds due to improvised explosive devices cause grave and gruesome injuries. Yet trauma medicine works in tandem with plastic surgery, prosthesis, and muscular surgeries to enable not just extremity retention, but functionality.
Another aspect of modern warfare is the rise of cross cultural treatment. While immunizations and other forms of medicine has been a way to make inroads with communities, trauma medicine is the most immediate form of medical interaction. A vast majority of Afghan National Army (ANA) personnel that have been wounded in the War in Afghanistan have treated at NATO hospitals if they were triaged the as requiring critical care.
While trauma medicine is a fascinating subject, and its evolution has saved countless lives, there is a darker side. Trauma medicine is concerned with the survivability of the patient, not necessarily the psychological or physical function in the long-term. Recent advancements in prosthesis and post-trauma stress disorder (PTSD) care have some consolation. However, trauma medicine improvement is dependent on large numbers of individuals having similar critical injuries, enough to facilitate the large enough revenue to operate such a level of complicated care. Trauma medicine fuses psychology, physical therapy, and critical surgery into one. As trauma continues to evolve, the doctors of the future may view our methods in the same manner we view those of the civil war.
Endnotes
[1] Ira Rutkow. Bleeding Blue and Gray: The Untold Story of Civil War Medicine. New York: Random House, 2005.
[2] Joseph Barnes. The Medical and Surgical History of the Civil War. 2nd ed. Vol. XII. Wilmington, NC: Broadfoot Pub., 1990.
[3] Ibid.
[4] Ibid.
[5] Ibid.
[6] Vincent Cirillo. Bullets and Bacilli: The Spanish-American War and Military Medicine. New Brunswick, NJ: Rutgers University Press, 2004.
[7] Graham Cosmas. An Army for Empire; the United States Army in the Spanish-American War. Columbia: University of Missouri Press, 1971.
[8] Mary Condon-Rall and Albert E. Cowdrey. The Medical Department: Medical Service in the War against Japan. Washington, D.C.: Center of Military History, United States Army, 1998.
[9] Albert Cowdrey. Fighting for Life: American Military Medicine in World War II. New York: Free Press, 1994.
[10] Vincent Cirillo. Bullets and Bacilli: The Spanish-American War and Military Medicine. New Brunswick, NJ: Rutgers University Press, 2004.
Further Reading:
Bollet, Alfred J. Civil War Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press, 2002.
Moulton, Candy. Valentine T. McGillycuddy: Army Surgeon, Agent to the Sioux. University of Oklahoma Press, Norman, Oklahoma. 2011
Taliaferro, William H. Medicine and the War. University of Chicago Press, Chicago, Illinois. 1944.
