Medical Advances During War

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Medical Advances During War

Overview

Several great military conflicts occurred during the first half of the twentieth century. With improved weapons came great destruction and mayhem. However, in the backdrop of arenas of war, physicians and scientists learned valuable medical lessons, later applied to civilian care, from the agony of the battlefields and the horrors of war crimes.

World War I (1914-18), including American involvement in 1917-18, took place in the trenches of Western Europe. World War II (1941-45) was a worldwide conflict with many casualties. It has been said that the only benefit from these conflicts was surgery. This statement can well be extended to medicine in general.

Throughout the world, many changes in postwar civilian medicine were a direct result of war medicine. For example, the idea of centralized medical administration and a system of free health care for all emerged, especially in Great Britain and other European countries.

Nazi medical experiments, Japanese atrocities, along with a few Allied abuses, offered a chilling view of medical science that could not be tolerated. The revelation at the Nuremberg trails that Nazi doctors had performed horrendous experiments on living prisoners—presumably conducted in the name of science—led to an international outcry. The ethical principle that there should be no human experimentation without full disclosure and consent has been a lasting legacy from this experience.

Background

Before firearms were introduced, hand-to-hand combat with swords and spears produced little tissue damage. If the soldier survived the initial battle, generally he would live. That changed with gunpowder and firearms. High-powered projectiles could pierce the flesh and cause major tissue destruction. Puncture wounds introduced a group of bacteria called anaerobes. The term "anaerobe" means "without air," and the spores, the inactive state of these organisms, are present in dirt and other places. When objects such as bullets or other debris penetrate the flesh, spores of the anaerobe are sealed in, then the flesh closes around it. The spore's coat dissolves and bacteria start to grow. The major diseases caused by anaerobes and puncture wounds are tetanus and gangrene. Both are fatal if not treated.

In the sixteenth century an army surgeon named Ambroise Pare (1500-1590) was appointed to the Duke of Montejan. At that time, surgeons were attached only to generals and helped the common soldiers only when they had spare time. The common soldiers were treated by their companions, farriers, female camp followers, or anyone around. The best known treatment of the time was pouring boiling oil on the wound. Pare changed the treatment of battlefield wounds from boiling oil to sewing together blood vessels.

For two and a half centuries no more improvements were made until Dominique-Jean Larrey (1766-1842) improved the rapid evacuation of the wounded with his "flying ambulance," a horse-drawn box on wheels. This established the concept that the wounded should be rapidly removed from the battlefield and taken to special surgery areas.

Medicine during the American Civil War was a disaster. More soldiers died from disease and poor care than from actual combat. Previous medical and procedural advances during the Napoleonic Wars were forgotten. The Civil War was indeed a dark time for medicine and warfare.

Impact

One great result of the two world wars was the improvement of surgery. The battlefields taught surgeons important lessons that were then translated into civilian life. While initial principles of casualty evacuation and surgery advanced during the Napoleonic Wars had to be relearned, some of the new investigations led to advances during wartime.

World War I broke the tradition by which surgeons had to study under a master surgeon for years. Suddenly, young surgeons were pressed into dealing with situations that would have daunted their masters. The surgeon's training had been in clean, or antiseptic, surgery of the carbolic acid-sprayed hospital operating rooms, introduced by Joseph Lister (1827-1912). Now, high-speed bullets and missiles were tearing flesh in such a way that bones were shattered and human flesh destroyed. The fertile farmland of Flanders was rife with bacteria that produced infection. When the men were wounded, skin would be punctured and the individual would get the anaerobes that cause tetanus and gangrene. Never had gangrene been seen with such a high incidence. Tetanus was found in 8.8 per 1000 wounds.

Surgical units, called Casualty Clearing Stations, went back to the days of Ambroise Pare, but now frontline surgeons found that they must remove all dead tissue, take out foreign materials, and leave the wound open. This process, called debridement, removes dead, infected and decaying tissue. The wound was lightly packed with gauze so that the well-oxygenated areas would have a chance of overcoming infection. About five days later, a technique called "delayed primary suture" would close the wound. The discovery of debridement and surgical excision of dead and dying tissue became a standard of care during warfare.

There was still a search for antiseptic treatment. Alexis Carrel (1873-1948) and Henry Dakin (1880-1952) developed the Carrel-Dakin treatment, in which a sodium hypochlorite or bleach solution was used to clean the wound. However, this very complicated process was effective only after the wound had been debrided. Other controls included antitoxin for tetanus and antiserum injections for gangrene.

World War I also established some first aid procedures like the early splinting of fractures. Harvey Cushing (1869-1939) treated gunshot wounds to the head with gentle suction and used powerful magnets to remove metal objects from the brain.

Since the days of the South African War, or Boer War (1899-1902), army surgeons left abdominal wounds to heal on their own. By 1915 it became evident that early surgery for abdominal wounds was important, since missile injuries to that area are usually fatal. Chest wounds were opened up to drain pus from the pleural cavity.

An enduring advance from World War I was the treatment of injuries that disfigure the face and other body parts. Harold Gillies (1882-1960), a pioneer in the field of reconstructive surgery, developed the pedicle flap to move skin from one part of the body to another. In this graft, subcutaneous tissues are temporarily attached to the site where the graft was taken. Plastic or cosmetic surgery would later become an important branch of medicine.

World War I gave doctors and medicine a voice. Working previously on their own, doctors were now forced to work together and began to see the value of centralized planning. Nurses became an integral part of medicine and all personnel saw the advantages of a coordinated, well-organized system. World War I confirmed that health was a national concern, so much so that in Great Britain liberal politicians like Lloyd George began to push for a national health service—free to all. The service would come to fruition after World War II when Nye Bevan and the Labor Party passed the National Service into law in 1948.

When World War II began, military doctors were again pressed into service. The urgency of tending to casualties at the earliest possible time was paramount. Air lifting, which had only been hinted at during World War I, helped to evacuate the wounded. Anesthetics were available to help alleviate pain. Blood transfusions, which were enabled by blood typing and understanding of related factors, helped to treat blood loss and shock. World War II marked the first use of blood transfusions on a massive scale.

Sir Alexander Fleming (1888-1955), while experimenting in his laboratory, found that bacterial plates that had mold did not have bacteria growing in the area. The search for an agent that would kill bacteria inside the body soon met with success. At Oxford, Howard Florey (1898-1968) and Ernst Chain (1906-1975) investigated a type of fungi that might have anti-bacterial properties and found Penicillium notatum. By 1941 penicillin was sent to wounded troops in North Africa to fight infection.

Medical research took an unusual twist in Germany. In 1883 Chancellor Otto von Bismarck implemented a national health service for all. During the Weimar Republic (1918-1933), the period between World War I and II, clinics continued to provide services for mothers and children. German pride was intense, and the passion for national fitness meant building the strong and eliminating the weak. When Adolf Hitler became chancellor in 1933, the sentiment that certain groups were weak and inferior had the backing of many doctors and psychiatrists. Physicians and scientists supported sterilization of people with mental disabilities and "mercy deaths" for those with physical handicaps. Between January 1940 and September 1942 physicians sent 70,723 mental patients—whose "lives were not worth living"—to their deaths in the gas chambers. Nazi doctors similarly dictated who would live and die at concentration camps like Auschwitz and others.

German medical scientists also saw the opportunity for human experimentation "for the advancement of science." To study the effects of mustard gas—or phosgene—used in World War I, gangrene, freezing, and typhus, camp doctors used inmates as their test subjects. Children were brutally injected with petrol, frozen, drowned, or slain for dissection.

The leading doctor at Auschwitz was Josef Mengele (1911-1979). A highly trained physician with doctorates in medicine and anthropology, Mengele was dedicated to human experimentation. He chose over 100 pairs of twins, injecting them with typhus and tuberculosis, and after their deaths sent the organs to other doctors for study. Through autopsy, he investigated the different reactions of various races to infectious disease. The projects were financed by the German Research Facility headed by Ernst Sauerbruch (1875-1951), an eminent surgeon.

In the Pacific area, Japanese doctors created "Unit 731" in 1936. In Northern Manchuria, Dr. Shiro Ishii set up studies of lethal microbes—anthrax, dysentery, typhus, cholera, and bubonic plague. Using prisoners, he determined the quantity of lethal bacteria necessary to ensure epidemics and even sent disease bombs into China. Dr. Ishii was never prosecuted because he gave the United States his trade secrets for manufacturing anthrax and other biological weapons. American citizens were shocked to learn that the United States had subjected troops to secret radiation tests as part of the atomic studies program.

Reactions against such tests spawned an ethical movement in medicine drawn up as part of the Nuremberg Code and refined in the Declaration of Helsinki in 1964. The prevailing principle states that "fully informed and voluntary consent of the subject is essential for any human experimentation." Medicine in the early part of the twentieth century was defined by war. By 1950, medicine was the hope to answer all ills. Unfortunately, the era of optimism would not last.

EVELYN B. KELLY