Read The Last Full Measure Online
Authors: Michael Stephenson
The Last Full Measure (56 page)
All too often, those field hospitals that did follow the army on campaign were as much a threat to the soldier’s life as the enemy. The American doctor James Tilton, a pioneer of rational hospital design, viewed the field hospitals servicing the patriot army during the American War of Independence as lethal, where more men “were lost by death and otherwise wasted, at general hospitals, than by all other contingencies that have hitherto affected the army, not excepting the weapons of the enemy.”
8
It is probably true that before the twentieth century, fragile medical facilities for soldiers on campaign were overwhelmed by any serious battle. A famous example, in relatively modern history, was the Crimean War (1854–56)—catastrophic even by the laissez-faire standards of the time. George Munro, an officer with the Ninety-Third Sutherland Highlanders, remembered:
We had a large number of regimental medical officers, but no regimental hospitals, and there were no field hospitals, with proper staff of attendants. We had no ambulance with trained bearers to remove the wounded from the battle-field, and no supplies of nourishment for sick or wounded.
On landing in the Crimea, the regimental hospital was represented by one bell tent, and the medical and surgical equipment by a pair of panniers containing a few medicines, a small supply of dressings, a tin or two of beef-tea, and a little brandy.…
The instruments were the private property of the surgeon, paid for out of his own pocket, as one of the conditions attached to promotion. The only means of carrying sick or wounded men consisted of hand-stretchers, entrusted to the [members of the regimental] band.
9
At the beginning of the American Civil War, care for the wounded was entirely inadequate. At the outset the Union Medical Department consisted of a grand total of 98 officers. The early battles were a disaster on the medical front. At the first battle of Bull Run (Manassas, July 21, 1861) the Union wounded were abandoned, and just over a year later at second Bull Run, many of the wounded were left on the field for three days. The provision of field hospitals during the Peninsular campaign was lamentable. After the battle of Fair Oaks (Seven Pines, May 31, 1862) the Union field hospital had 5 surgeons and no nurses to treat 4,500 casualties.
10
By the end of the war, however, the Union had the most sophisticated mobile military hospital and ambulance system in the world—and one that served pretty much as the organizational model for US battlefield medical care until the Vietnam War. This was due in large measure to the organizational genius of Dr. Jonathan Letterman, medical director of the Army of the Potomac, and William A. Hammond, who was appointed surgeon general in 1862. An illustration of the effectiveness of the Union medical system was that during Grant’s bloody campaign through Virginia in the later phase of the war, of the 52,156 gunshot casualties from March 1864 through April 1865, only 2,011 died from their wounds, a 3.2 percent mortality rate compared with the 10–25 percent rate for the period from July 1861 to March 1864.
11
An organizational element of fundamental importance—transporting the wounded—was, until the late eighteenth century, either nonexistent or so cruelly jarring that it did more to kill men than save them. Improvements in either ambulance services that got the wounded soldier to a medical facility or, conversely, delivered medical services to the soldier in the field have been massively important in increasing casualty survival. All too often the wounded were simply left on the field, helped off by their comrades, or thrown into carts—or they crawled off as best they could.
Although the Austrians had some “flying ambulances” in the 1750s, it was not until the Napoleonic Wars that Napoleon’s surgeon general of the Imperial Guard, Dominique-Jean Larrey, emphasized the overwhelming importance of treating traumatically wounded men as soon after their wounding as possible, rather than waiting until the battle was over. The light field ambulances (
ambulances volontes
) he devised did two things: They not only got soldiers off the field and to a surgeon as quickly as possible, but they also delivered medical teams to men while the combat still raged—a model of battlefield medicine on which all modern practice is predicated. Nor did Larrey merely preach the doctrine of fast response. His own actions on the battlefield were inspirationally courageous. At Eylau (1807) he had become so involved in the combat zone that he had to be rescued by a cavalry detachment of the Imperial Guard, and at Waterloo he worked so close to the front line that Wellington recognized him and ordered his gunners to direct their fire elsewhere.
12
In addition, Larrey refused to prioritize treatment on the basis of rank and social distinction, as had been the norm for centuries. The most grievously hurt were dealt with first, which has become the moral basis of triage in all modern military medicine.
Apart from the establishment of a system of divisional field hospitals, ambulance services gave the Union supremacy in battlefield medicine in the later half of the Civil War. In the beginning, though, it was dire. At the first and second battles of Bull Run (Manassas), civilian teamsters hired to drive wagons simply skedaddled (at first Bull Run not one Union casualty reached a hospital by ambulance). On the peninsula an army corps of thirty thousand had ambulance transportation for precisely one hundred men. At Shiloh (April 1862) and Perryville (October 1862) the ambulance service was shambolic. Letterman’s reforms of 1862 created a retrieval system that proved itself at Fredericksburg in 1862 and at Gettysburg in 1863, where there were one
thousand ambulances and three thousand ambulance drivers and stretcher men.
13
In the First World War the average time it took to get a wounded US soldier from first responder to definitive care was ten to eighteen hours. In World War II it dropped to six to twelve hours; in Korea, four to six hours; and in Vietnam, one to two hours (although it could be as short as forty minutes).
14
As comforting as these ever speedier responses might seem (and in general they do reflect recovery systems of dramatically increasing effectiveness), it depended very much on where the wounded soldier was fighting. For example, within the tight perimeter of, say, Guadalcanal, a wounded US Marine could be extracted and delivered to a hospital ship in two hours. On the other hand, on Papua New Guinea the wounded had to be hand-carried down the Kokoda Trail for many hours, even days. In North Africa in 1942–43 “a wounded man could spend a day in a motor ambulance or a day and a night on a train reaching treatment.”
15
Yet it was in those areas where evacuation was most difficult that air transportation of casualties was pioneered (the first helicopter evacuation, for example, was on April 23, 1944, in Burma).
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By the end of the war, 212,000 US wounded had been evacuated by air.
17
BEFORE A CASUALTY
can be mended by medical intervention, he must not be killed by medical intervention. It was not until the middle of the nineteenth century that such pioneers as Joseph Lister and William Detmold made the scientific link between uncleanliness, bacteria, and infection. Although there had been some understanding that uncleanliness and infection were linked (essentially that the wounded soldier should be treated in “clean” surroundings if possible), there were two problems. First,
wartime circumstances often meant that soldiers were operated on under horrifically unhygienic conditions. Second, there was little understanding of how infection was transmitted. So doctors explored wounds with filthy hands and probes, swabbed wounds with sea sponges rinsed out in already contaminated water, irrigated wounds with unsterilized water, licked the silk sutures before threading them through unsterilized needles, wiped bloody instruments on dirty rags, and so on. General Carl Schurz described the scene after Gettysburg: “There stood the surgeons, their sleeves rolled up to the elbows, their bare arms as well as their linen aprons smeared with blood, their knives not seldom held between their teeth, while they were helping a patient on or off the table, or had their hands otherwise occupied; around them pools of blood and amputated arms or legs in heaps, sometimes more than man-high. Antiseptic methods were still unknown at the time. As a wounded man was lifted on the table … the surgeon snatched his knife from between his teeth, … wiped it rapidly once or twice across his blood-stained apron, and the cutting began.”
18
Gangrene, pyemia, tetanus, erysipelas, osteomyelitis, all blossomed. A Civil War surgeon describes losing a patient to pyemia after surgery:
Many a time have I had the following experience: A poor fellow whose leg or arm I had amputated a few days before would be getting on as well as we then expected—that is to say, he had pain, high fever, was thirsty and restless, but was gradually improving, for he had what we looked on as a favorable symptom—an abundant discharge of pus from his wound. Suddenly, overnight, I would find that his fever had become markedly greater; his tongue dry, his pain and restlessness increased; sleep had deserted his eyelids, his cheeks were flushed; and on removing the dressings I would find
the secretions from the wound dried up, and what there were were watery, thin, and foul smelling, and what union of the flaps had taken place had melted away. Pyemia was the verdict, and death the usual result within a few days.
19
Pyemia had a 98 percent mortality rate. In 1863 William Detmold made a connection between pyemia and puerperal fever—the great killer of women immediately following childbirth—and the connection was the doctor’s unclean hands and instruments. Like Lister he recommended thorough hygiene (Lister prescribed washing with carbolic acid), but “there is no evidence that Detmold’s precepts were followed.”
20
Tetanus, with a death rate of 89 percent, thrived in the manure-rich battlefields of the Civil War and World War I. Stables were often the location of field hospitals in the Civil War and were nurturing environments for
Clostridium tetani
. Erysipelas, a streptococcal infection, was also introduced into wounds by dirty instruments, dressings, and hands. Infected soldiers had a 41 percent chance of dying.
21
Gangrene killed about 46 percent of its victims.
22
This example happens to be from the notorious Andersonville POW camp in Georgia during the American Civil War but was probably representative of many military hospitals of the period: “Our patients have been crowded together on the same ground with other patients suffering from the various diseases incident to the prisoners, and in very many instances in the same tent, or even on the same bed. Again, we have only one wash pan to the tent, … and owing to the great scarcity of bandages we are compelled to use the same bandages several times, and in washing they not unfrequently [
sic
] get changed, and thus the disease may be transmitted from one patient to the other by actual contact.”
23
This was the remorseless timetable for one Union soldier:
J. Mailer, aged twenty-four years, admitted August 5, with large sphacelus [dead tissue] covering the whole arm up to within two and a half inches of the shoulder joint. The arm was very much tumefied [swollen], and presented around the border of the large sphacelus a kind of erysipelatous inflammation. This inflamed surface was covered with green and yellow spots; these in turn opened and discharged filthy and very offensive sanies [ulcers]. The pulse beat 120 to the minute, was weak, and had a peculiar vibratory thrill. Tongue dry and glazed, very red at the tip and edges. Bowels a little loose, but not amounting to diarrhea. Appetite weak. Urine scant and highly colored; complained of considerable pain in the affected arm and shoulder; had copious night-sweats; complained of chilliness of mornings and fever in the afternoon.… Apply pure nitric acid to the sphacelus, envelope the whole arm in pulverized lini poultices [made from crushed flaxseed].
[August] 6th: Patient no better; is very anxious to have the arm amputated; gangrene extending. Pulse 125 in the morning, 137 in the evening.… continued prescription.
[August] 7th: Gangrene still extending above the elbow; presents a pea-green appearance, and emits an intolerable odor.… Bowels painful; has mucous discharges. Appetite weak.…
[August] 8th: This morning the gangrene has extended into the shoulder joint and half way to the hand. Pulse 140 … Has dysentery. Prescription continued about turpentine emulsion. In this condition the patient remained up to the 10th, at which time he began to sink, and as we could do nothing more we continued with the same treatment up to the 14th, at which time the patient died, with the whole arm in a state of sphacelus.
24
Occasionally, and paradoxically, foul conditions saved men with gangrene. Confederate surgeons who were POWs at the Union stockade at Chattanooga were denied medical supplies, and many men’s wounds were left exposed to flies, which inevitably resulted in the wounds becoming infested with maggots. The received wisdom was, not unnaturally, that everything should be done to clean the wound (often with injections of chloroform), but in the case of the maggot-ridden Confederates, their doctors were amazed to discover that because maggots eat only necrotic tissue, they performed a vital scavenging role, and that the recovery rate was better than for those soldiers with conventionally cleaned wounds. It was a lesson relearned during World War I and led to the breeding of maggots specifically for treating osteomyelitis.
25
The discovery of sulfonamide antibiotics in the 1930s and penicillin, first used for battle casualties in 1943, temporarily halted their use but more recently they have made something of a comeback and wound debridement with maggots is now an accepted treatment.
