Surgical Techniques and Technology Amputation has been performed since ancient times, as observed by Peruvian votive figures and Egyptian mummies.

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Courtesy of Otis Historical Archives, National Museum of Health and Medicine. Fever and reform: the typhoid epidemic in the Spanish-American War.

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The Austrian Karl Landsteiner — and coworkers described blood types A, B, and O in , and the AB blood group in [ ]. Subsequent blood typing greatly reduced the potential complications of blood transfusion.

Expanded transfusion offered the promise of preventing many fatalities of war caused by or complicated by blood loss. It also posed medical and logistic challenges to military caregivers. The British Army began routine use of blood transfusion for treatment of combat casualties. In , surgeons performed direct transfusions on patients whose conditions were considered desperate.

Of the 19 casualties it was tried on, 15 died. Despite the inauspicious start, surgeons with the British Second Army routinely performed direct transfusions on patients using a syringe cannula technique. In November , American surgeon Captain Oswald Robertson — concluded it would be better to stockpile blood before the arrival of casualties. He collected mL of blood from each donor and stored it in an icebox to be administered to a patient 10 to 14 days later.

Blood could be stored and transported to be administered at casualty clearing stations close to the front, creating the first blood bank [ 82 ]. Despite the lessons of World War I, many surgeons still believed shock was caused by inadequate arterial pressure rather than inadequate capillary perfusion.

Although the British had entered the war with large quantities of blood and plasma and Charles Drew — of the American Red Cross had developed an international blood collection and distribution system for the Blood for Britain campaign of [ 50 ], the US Army had no blood banks, and when blood was given, it was only in small amounts — mL [ 59 ].

Under the leadership of US Surgeon General Kirk, an organized system to provide whole blood transfusions instead was developed by army field hospitals in and By the second half of , with huge numbers of soldiers in the field across Europe and in the Pacific, army policy finally changed to provide air shipments of whole blood from the United States. By March , the army was shipping units a day Figs. The system was implemented rapidly, was highly efficient, and doubtless saved thousands of lives but was completely dismantled by the onset of the Korean War.

In a hastily constructed tent on Okinawa, US 10th Army medics complete a cast on a soldier wounded by shell fragments. Assistants, meanwhile, administer blood plasma. This photograph was taken on April 9, Blood plasma is given to the wounded at a medical station near the front line somewhere in the South Pacific during World War II. At the outbreak of fighting in Korea, with the US military in rapid retreat, collections stateside were shipped to the th General Medical Laboratory in Tokyo.

Type O was greatly preferred to eliminate the need for crossmatching, specialized technicians, and larger stocks. According to the Armed Services Blood Program ASBP records, only four major hemolytic reactions resulting in acute renal failure were reported of approximately 50, transfusions in All four were attributable to locally acquired blood. US military blood programs reflected the experience in Korea during the early years of engagement in Vietnam.

Approximately every 10 days, units of Type O blood were shipped from Japan [ 83 ]. Every unit used to support the war was donated voluntarily by military personnel, dependents of military personnel, and civilians working on military bases—approximately 1. For the first time, forward medical units received all four types of blood. The ASBP coordinated collection stateside, and blood was processed at McGuire Air Force Base in New Jersey before shipping to Vietnam.

Blood also was collected from volunteers representing all services in Okinawa, Japan, and Korea and distributed by the th Mobile Medical Laboratory in Saigon [ 14 ]. After Vietnam, the US military maintained its capacity to collect, package, and transport blood.

Improvements in anticoagulants and technology to freeze blood greatly enhanced its efforts. In the 18th century, infection control was not considered an issue, because physicians assumed disease was caused by an imbalance of humors rather than microbes.

Yet, the practice was never adopted by the Continental surgeons. Gunshot wounds continued to be treated as inherently infected by gunpowder until Hunter published his Treatise on Blood, Inflammation, and Gunshot Wounds [ 75 ] in Physicians throughout the late 18th and early 19th centuries continued to experiment with various compounds to prevent the spread of infection in patients with compound fractures, including wood tar, chlorine, tincture of benzoin, silver nitrate, and various alcohol solutions [ ].

The Civil War famously showed the value of sanitary practices, or the consequences of their absence. Contrary to popular belief, surgeons usually washed, but did not disinfect, their hands and surgical instruments.

The aseptic environment of 21st century hospitals was not even a concept during the Civil War [ 15 ]. Suppuration still was regarded as a sign of proper healing rather than a risk for pyemia [ 12 , 13 ]. Of his patients treated in this fashion, only eight 2. Bromine was used widely thereafter to treat gas gangrene, although surgeons were never sure if it was effective [ , ].

Carbolic acid and sodium hypochlorite also were used to treat established gangrene, but not as prophylaxis [ 96 ]. Surgeons began to associate wound shock with sepsis and administered a saline solution subcutaneously or rectally to hydrate their patients [ 59 ].

Trench warfare during the First World War had several consequences. Soldiers were entrenched in farm fields fertilized with manure, which was rich with anaerobic organisms to infect wounds. Static warfare allowed for fixed lines of communication, which with motorized ambulances reduced evacuation time [ 47 ]. Machine guns and high-explosive shells caused massive wounds and extensive soft tissue damage.

It also allowed surgeons to experiment with other surgical techniques, such as leaving bone fragments in place in patients with compound long-bone fractures [ 31 ]. Only after the wound had been disinfected thoroughly was closure attempted.

Carrel and Dehelly described the successful treatment of various wounds—fresh, phlegmonous, gangrenous, and suppurating—all of which were disinfected and closed within 20 days [ 24 ]. Fleming also contributed an early description of the bacteriology of combat wounds. He noted the initial watery, odiferous, red-brown drainage and the presence of anaerobes and streptococci. A week later, in a second phase, the drainage was less bloody and foul-smelling, growing in purulence.

Approximately 3 weeks after wounding, in the third phase, streptococci and staphylococci proliferated, as indicated by blood cultures [ 43 ]. The equine tetanus antitoxin had been discovered in and was first distributed on a large scale by British physicians during late Cases of tetanus decreased from nine per wounded in September to 1.

Dissatisfaction with the cumbersome Carrel-Dakin treatment led to its abandonment. During the Spanish Civil War, Josep Trueta — used a closed plaster method to treat patients with open fractures, with only six deaths and four subsequent amputations.

The open wound was wrapped in gauze; the fracture was reduced and then immobilized with plaster [ , ]. In a previous review of military medicine, RM Hardaway, who treated many of the wounded after Pearl Harbor, met with a team sent by the Army Surgeon General after the attack:. They were amazed at the uniformly well-healed wounds and asked how we treated them.

By , sulfa powder no longer was issued to soldiers or medics. Fleming discovered penicillin in , but it was not until that an Oxford pathologist, Howard Florey — , and his team showed its usefulness in vivo.

Penicillin was not used successfully for treatment of a patient until March [ 17 ]. In November , it was first administered to US troops wounded during an assault in Oran, Africa [ 96 ]. By then, with British manufacturing dedicated to the production of munitions, development of penicillin for mass production was focused in Peoria, IL, by the US Department of Agriculture, and then later with the US pharmaceutical giants Merck, Squibb, Pfizer, and Abbott. British and American production grew from 21 billion units in to 6.

The first large-scale military use was during the D-Day invasion of Normandy in June The decrease in time from wounding to surgical care thanks to rapid evacuation and MASH units was linked to an impressive reduction in the occurrence of gas gangrene; one study of wounds revealed a 0. Antibiotics were commonly used prophylactically, but at a risk that only became evident in retrospect, as increasingly resistant bacteria were reported from infected war wounds 3 to 5 days after injury [ 86 , ].

Physicians made a greater effort to identify bacteria and evaluate outcomes of antibiotic strategies. A — evaluation of neurosurgical patients in the Tokyo Army Hospital revealed, of 58 isolates from infected wounds, 48 were resistant to penicillin, 49 were resistant to streptomycin, and seven were multidrug resistant [ ]. Wound infection data from Vietnam may be misleading. Hardaway, in his classic study of 17, patients from to , found a postoperative infection rate of 3.

Seventy percent of the wounded received antibiotics, usually penicillin and streptomycin, and usually intravenously. Again, physicians increasingly found patterns of antibiotic resistance. The study of Tong [ ] of 30 Marines injured in combat tracked bacterial flora in wound cultures at injury, after 3 days, and after 5 days, with blood cultures obtained every 8 hours. All bacteria from blood cultures were resistant to penicillin and streptomycin [ ].

The study of Kovaric et al. During the US engagement in Vietnam, military physicians pioneered the use of pulsatile lavage to reduce bacterial and other contamination and to remove necrotic tissue from crush wounds [ 80 ]. However, topical antibiotics remain controversial and have yet to become a standard of care in military or civilian medicine. Murray et al. In Iraq and Afghanistan, broad-spectrum antibiotics generally are not administered during early treatment.

Antibiotic therapy is directed by cultures taken on admission to US military hospitals. In addition to methicillin-resistant Staphylococcus aureus, other resistant strains of pathogens have been found in US war wounds [ 97 , ]. Gram-negative and gram-positive bacteria were resistant to a broad array of antimicrobial agents [ ].

It is reasonable in many ways to view the history of military trauma care as a story of constant progress over the long term. Mortality from all wounds decreased dramatically across the 20th century, from 8. Although the historical trend is reasonably clear, mortality rates can be deceiving, depending, for example, on how those wounded who quickly returned to action were accounted for statistically and aspects that cannot be quantified easily and that have nothing to do with medical advances.

Holcomb et al. This is likely the result of numerous factors, including improved body armor, tactics, the very nature of the mission undertaken by troops, improved front line medical attention, and prompt evacuation. The speed of evacuation increased dramatically from the horse carts of the 19th century and even the motorized transport of World War I; in World War II, the average time from injury to hospitalization was 12 to 15 hours, but by Vietnam it generally was less than 2 hours.

As noted, wounded troops in Iraq and Afghanistan can be transported to a combat support hospital in 30 to 90 minutes. Misconceptions regarding wound healing persisted in military and civilian medicine until the age of Lister and Pasteur, and the failure to understand wound shock and substitute unsubstantiated theories in place of knowledge resulted in higher mortality rates in both world wars. Worse yet, the lessons regarding shock and delayed primary closure, learned at great human expense in World War I, had to be relearned by Americans in World War II.

In World War II, the ratio decreased to 0. The lessons of the history of military emergency medicine are on display in the current operations in Iraq and Afghanistan. It is undoubtedly the best-trained, best-equipped, and fastest system of military trauma care in history.

Of crucial importance is the problem of wound infection. As survivorship has increased, even among patients with devastating extremity wounds that would have been fatal in the past, multidrug-resistant pathogens are complicating recovery [ 78 ]. Additional study in military and civilian settings is needed to refine protocols for antibiotic prophylaxis on the battlefield.

Projects currently funded by the OTRP include studies of prevention and treatment of heterotopic ossification; rabbit and rat models of osteomyelitis to evaluate infected extremity wounds; novel therapies for A baumannii; cellular therapy for rapid bone formation; and strategies for treating bone defects involving mesenchymal stem cells, antibiotic-impregnated bone cement, and controlled delivery of growth factors [ , ].

The experiences of war-time trauma caregivers have had an undeniable impact on civilian practices, with lessons learned in evacuation, wound management, emergency surgery, infection control, and blood banking.

Just the same, the capability of combat medical care has always reflected the technology of its time as, for example, wounded were transported by horse-drawn carriages, then trucks, trains, ships, planes, and helicopters.

Throughout modern warfare, medical care has been reorganized to fit the exigencies of the time and the needs of the wounded. We thank Adrianne Noe, PhD, and the staff of the National Museum of Health and Medicine, Armed Forces Institute of Pathology.

All they that were princes among us are lying struck down and wounded at the hands of the Trojans, who are waxing stronger and stronger. For of the physicians Podalirius and Machaon, I hear that the one is lying wounded in his tent and is himself in need of healing, while the other is fighting the Trojans upon the plain.

What can I do? I am on my way to bear a message to noble Achilles from Nestor of Gerene, bulwark of the Achaeans, but even so I will not be unmindful your distress. With this he clasped him round the middle and led him into the tent, and a servant, when he saw him, spread bullock-skins on the ground for him to lie on. He laid him at full length and cut out the sharp arrow from his thigh; he washed the black blood from the wound with warm water; he then crushed a bitter herb, rubbing it between his hands, and spread it upon the wound; this was a virtuous herb which killed all pain; so the wound presently dried and the blood left off flowing.

Disclaimer: The opinions or assertions contained herein are the private views of some of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the US government.

This work was prepared as part of their official duties and, as such, there is no copyright to be transferred. National Center for Biotechnology Information , U.

National Library of Medicine Rockville Pike , Bethesda MD , USA. NCBI Skip to main content Skip to navigation Resources How To About NCBI Accesskeys My NCBI Sign in to NCBI Sign Out. PMC US National Library of Medicine National Institutes of Health. Journal List Clin Orthop Relat Res v. Clin Orthop Relat Res. Published online Feb PMCID: PMC Manring , PhD, 1 Alan Hawk , 2 Jason H.

Calhoun , MD, FACS, 3 and Romney C. Andersen , MD 4, 5. Manring 1 Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO USA Find articles by M. Alan Hawk 2 National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, DC USA Find articles by Alan Hawk. Jason H. Calhoun 3 Department of Orthopaedic Surgery, The Ohio State University, N Doan Hall, W 10th Ave, Columbus, OH USA Find articles by Jason H.

Romney C. Andersen 4 Orthopaedic Traumatology, Walter Reed National Military Medical Center, Bethesda, MD USA 5 Orthopaedic Traumatology, Walter Reed National Military Medical Center, Washington, DC USA Find articles by Romney C. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Jun 16; Accepted Jan This article has been cited by other articles in PMC.

Abstract The treatment of war wounds is an ancient art, constantly refined to reflect improvements in weapons technology, transportation, antiseptic practices, and surgical techniques. Introduction 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 [ 41 ].

Open in a separate window. In , the Office of the Surgeon General summarized the general approach to wound care during the Second World War: As the initial wound operation is by definition a limited procedure, nearly every case requires further treatment. Surgical Techniques and Technology Amputation has been performed since ancient times, as observed by Peruvian votive figures and Egyptian mummies.

Blood Transfusion The Austrian Karl Landsteiner — and coworkers described blood types A, B, and O in , and the AB blood group in [ ]. Infection and Antibiotics In the 18th century, infection control was not considered an issue, because physicians assumed disease was caused by an imbalance of humors rather than microbes. Discussion It is reasonable in many ways to view the history of military trauma care as a story of constant progress over the long term.

Acknowledgments We thank Adrianne Noe, PhD, and the staff of the National Museum of Health and Medicine, Armed Forces Institute of Pathology. What stays with you latest and deepest? I onward go, I stop, With hinged knees and steady hand to dress wounds, I am firm with each, the pangs are sharp yet unavoidable, One turns to me his appealing eyes—poor boy! I never knew you, Yet I think I could not refuse this moment to die for you, if that would save you.

In mercy come quickly. I dress the perforated shoulder, the foot with the bullet-wound, Cleanse the one with a gnawing and putrid gangrene, so sickening, so offensive, While the attendant stands behind aside me holding the tray and pail. References 1. Aldrete JA, Marron GM, Wright AJ. The first administration of anesthesia in military surgery: on occasion of the Mexican-American War.

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Bagwell CE. Ambroise Pare and the renaissance of surgery. Surg Gynecol Obstet. Ballard A, Brown PW, Burkhalter WE, Eversmann WW, Feagin JA, Mayfield GW, Omer GE Jr. Orthopedic surgery in Vietnam. Accessed September 11, Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med. Better OS. Josep Trueta — : military surgeon and pioneer investigator of acute renal failure. Am J Nephrol. Blagg CR. Triage: Napoleon to the present day.

J Nephrol. Blaisdell FW. Medical advances during the Civil War. Arch Surg. Civil War vascular injuries. World J Surg. Boe GP, Chinh TV. The military blood programs in Vietnam. Mil Med. Bollet AJ. Civil War Medicine Challenges and Triumphs. Tucson, AZ: Galen Press Ltd; Brav EA, Jeffress VH. Fractures of the femoral shaft; a clinical comparison of treatment by traction suspension and intramedullary nailing. Am J Surg. Brown K.

The history of penicillin from discovery to the drive to production. Pharm Hist Lond. Brown PW. Recollections of Sterling Bunnell. J Hand Surg [Br]. War wounds of the hand revisited. J Hand Surg [Am]. Bunnell S. Surgery of the Hand. Philadelphia, PA: JB Lippincott; Hand Surgery. Washington, DC: Office of the Surgeon General, Department of the Army; Burkhalter WE. Orthopedic Surgery in Vietnam. Washington, DC: Office of the Surgeon General and Center of Military History; Campion DS, Lynch LJ, Rector FC Jr, Carter N, Shires GT.

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Hoeber; Carter PR. The embryogenesis of the specialty of hand surgery: a story of three great Americans—a politician, a general, and a duck hunter: The Richard J. Smith memorial lecture. Christensen NE. Technique, errors and safeguards in modern Kuntscher nailing. Chung KK, Perkins RM, Oliver JD 3rd. Renal replacement therapy in support of combat operations. Churchill ED. The surgical management of the wounded in the Mediterranean theater at the time of the fall of Rome [Foreword by Brig.

Rankin, M. Ann Surg. Cirillo VJ. Fever and reform: the typhoid epidemic in the Spanish-American War. J Hist Med Allied Sci.

The Spanish-American War and military radiology. AJR Am J Roentgenol. Cleveland M. Surgery in World War II Series: Orthopedic Surgery in the European Theater of Operations. Accessed September 9, Cleveland M, Grove JA. Delayed primary closure of wounds with compound fractures. Connor H. The use of chloroform by British Army surgeons during the Crimean War.

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