Between Flesh and Steel
Page 32
World War II witnessed a number of major innovations in the soldier’s medical care. Among the most important were the new antibiotics. Sulfonamides had been first identified in 1908 but did not appear as practical antibacterials until shortly after World War I. The military initially utilized them because of their effectiveness against venereal disease. Their successful application in surgical treatment in the Spanish Civil War led to their widespread use in World War II.127 Alexander Fleming (1881–1955) discovered penicillin in 1928, and its gradual perfection by Howard W. Florey (1898–1968) and Ernst B. Chain (1906–1979) in the early 1940s led to the production of the most effective antibacterial wound agent that military physicians had ever used. The discovery in 1943 that large quantities of the drug could be made in cornstarch cultural mediums resulted in mass production and in the Allied armies’ widespread use of the drug in 1944. Until 1943, production was barely sufficient to treat a hundred cases. By 1944, penicillin production escalated to 3 billion units a year.128 By the Normandy invasion that June, the Allies had sufficient penicillin to treat all casualties.
Other significant medical advances in World War II were a better understanding of the causes of shock and the common use of blood transfusions. The first donor-originated, as opposed to cadaver-originated, blood bank was established at Chicago’s Cook County Hospital in 1937. In the late 1930s, the British made efforts to store whole blood but had only limited success. In 1943, an American team working under the auspices of the U.S. National Research Council developed an effective preservative, and within a few months large quantities of preserved blood were shipped to troops overseas.129 The team also developed a process for separating out fibrin and thrombin, valuable coagulants, and made them available to blood users in separate form. Early British experience with civilian casualties in the London air raids showed that the transfusion of blood was vital in preventing shock. It was not until the Battle of El Alamein in July 1942, however, that blood transfusions were attempted on combat casualties on a large scale.130 The armies responded by creating field transfusion units that were regularly attached to the casualty clearing stations and often sent forward to the dressing stations. On average, every hundred casualties required sixty-three pints of blood.131 Even larger quantities of plasma and blood products were needed.
Taken together, the short time from wounding to treatment, the standard practice of debriding and irrigating wounds, the bacteriological testing prior to wound closure, and the improved resuscitation due to available blood transfusions all worked to improve the casualty’s chances of survival. In the Allied armies, 21 percent of the wounded were operated on within six hours of being hit–“the golden period”—but the bulk of the wounded, 47 percent, were operated on within the following six hours. Thus, 68 percent of the wounded received surgical treatment within the first twelve hours of being wounded.132 Only 7 percent waited more than twenty-four hours for medical attention. The impact of such improved medical treatment in World War II was evident in the number of soldiers who reached medical treatment and later died of their wounds. Approximately 4.5 percent of the American wounded who reached treatment died of their wounds, down from 8 percent for American soldiers in World War I.133 In terms of comparison, 19.5 percent of the Russian wounded in the Crimea and 22.1 percent of the French wounded died. In the Civil War, 14.1 percent succumbed to wounds. In the Franco-Prussian War, which saw the advent of antiseptic surgery, 11.5 percent of the German wounded died.134 The death from disease rate of the American Army in World War II was less than 1 percent of what it had been for the Union Army in the Civil War. The only increase was in the amputation rate, which was 5.3 percent in World War II compared to 2.0 percent in World War I.135 This jump reflects the more rapid and efficient evacuation system, which preserved the lives of the wounded until they received medical attention. In World War I, these same wounded would have succumbed long before they reached medical attention.
With the exception of the Soviets, who used essentially the same casualty servicing structure they had in World War I, most Allied armies in World War II organized their medical facilities the same way; thus, spending much time on detailed individual descriptions is not necessary. Some attention, however, is due the German medical service. For the most part, it was organized around the American model as practiced from its inception in 1870. It differed largely in triage, or the sorting of casualties for specialized hospitalization. As would a company medic in the American Army, the German medical officer rendered first aid in a verwundetennest (battalion aid station) in the extreme forward area. The wounded were then evacuated by litter to the truppenverbandplatz (regimental aid station), where an officer corresponding to an American battle surgeon attended the casualty. After stabilization and resuscitation, all wounded were evacuated to a hauptverbandplatz (main dressing station) established about four miles to the rear of the combat line. The sanitäts kompanie (medical company) of the division operated the unit and performed both clearing and hospitalization functions. It was assigned two operating surgeons but could be reinforced by six or eight more in times of casualty stress. Significant surgical procedures and major operations were performed at this level.136
The next unit in the chain of medical evacuation was the feldlazarett (mobile field hospital), which was designed to care for two hundred patients. Staffed by two surgeons, it dealt largely with head and chest wounds. Each German Army group was assigned a kriegslazarett (general base hospital), whose function was to hospitalize all patients who could not be returned to duty in a short time. In periods of heavy casualties, all serious patients were transported directly to the kriegslazarett, while the forward surgical units concentrated on treating only those soldiers whose wounds would allow them to return to the fight. In each division there was an ersatz kompanie (replacement company) that served as a replacement depot and reconditioning unit for lightly wounded men awaiting return to their combat units.137 The entire structure was designed more to salvage manpower for continuing combat than anything else, and for the most part it did a credible job under very difficult combat circumstances.
Given that the German medical service was superior in the wars of 1870 and 1914, it is interesting to compare its reputation then with its performance in World War II. The difficult circumstances under which it had to operate during the war years accounts for some decline. What is most interesting, however, is that the quality of German medical care seems to have slipped far lower than anyone had imagined prior to the country’s defeat in 1945. For example, an American military study after the war showed that the Germans apparently failed to incorporate developments in blood transfusion technology and had no regular blood banks to provide sufficient supplies of blood.138 The Germans had not discovered the secret of storing blood and still administered almost all blood transfusions from donor to recipient.139 More puzzling was the widespread belief among German doctors that blood should never be transfused in amounts greater than 1,000 cubic centimeters. If the soldier was not resuscitated by then, they neither made further attempts at resuscitation nor performed surgery.140 Most shocking was that German doctors seemed to have practiced poor hygiene when inspecting wounded patients, routinely lacking gloves and not washing their hands between patient examinations. German military doctors came to believe that suppuration of wounds was a natural condition and lacking penicillin and facing critical shortages of sulfonamides, the wound infection rate must have been high.141
One consequence of the Nazification of the German officer corps was the substitution of political criteria for medical criteria when determining military assignments, including assignments to the medical service. Especially at the higher ranks of the medical service, political criteria predominated. Within the ranks themselves, the high number of casualties seems to have forced the Germans to reduce the training requirements for medical personnel. Many “graduate wonders,” or poorly trained surgeons with little experience, found their way into the medical corps. For whatever reasons, one outcome
of World War II was the decline of the German military medical service, a sad fate for a service that had been the envy of the military medical world for more than six decades.
THE KOREAN WAR
In the Korean War the U.S. military lost 8,769 men killed in action, and another 77,788 wounded were admitted to medical facilities for treatment. An additional 14,575 men were slightly wounded and “carded for record only” before being returned to their units.142 Of the wounded, only 1,957 men died, for a wound mortality rate of only 2.5 percent.143 Excellent preventive medicine also reduced disease rates considerably. Acute respiratory infections accounted for a fifth of all disease admissions, followed by ill-defined general symptoms of illness and then various parasitic diseases. The psychiatric admissions rate of thirty-six per thousand slightly exceeded that of World War II.144 The success of sulfa and penicillin in preventing wound infection had become so common that young surgeons serving in the medical corps forgot the lessons of previous wars and, in the early days, failed to practice debridement and closed wounds prematurely. These oversights produced an initially high wound infection rate until the surgeons relearned the old lessons.145 A total of 89,974 surgical operations were performed, an average of 1.2 operations per wounded soldier.146
Four major innovations in military medical care were introduced during the Korean War. Among the most important was the introduction of the mobile army surgical hospital (MASH) units, an outgrowth of the mobile field surgical detachments first introduced in World War II. A typical MASH unit had from sixty to two hundred beds and was staffed with special teams of surgeons. The unit was not positioned within the normal vertical medical evacuation chain; instead, it was placed next to the regimental collecting station and the division clearing station. The idea was to provide high-level surgical care as close to the battlefront as possible. The most serious surgical cases were filtered out of the normal vertical chain of evacuation and moved laterally to the MASH unit for immediate emergency surgical care. After treatment, it moved casualties directly to the evacuation hospital for further treatment and evacuation disposition.147 With its complement of twenty-four medical officers and surgeons and forty-one nurses, MASH units sometimes served as many as twelve thousand surgical admissions a month.148
The army transported most of the wounded by vehicle. Curiously, U.S. forces ran short of proper ambulance vehicles throughout the conflict. The most common form of frontline casualty transport was the litter-jeep, which was capable of carrying four patients and was first used in World War II. Its virtues lay in its availability in sufficient numbers and its low profile, which made it a less inviting target on the roads. A major innovation was using the helicopter in medical evacuation for the first time, although the military’s critical shortage of these machines prevented the helicopter from playing a major role. The early helicopters were light and could carry no more than two casualties in external pods attached to the landing skids. In normal practice these machines transported the seriously wounded from the regimental and division clearing points to the MASH units. They also carried cases requiring more sophisticated treatment to the evacuation hospitals. In only a few instances did helicopters pick up casualties on the battlefield, a practice that became common during the Vietnam War. The medical evacuation system in Korea worked relatively well. Fifty-eight percent of the wounded received medical care within two hours of being wounded, and 85 percent were treated within the first six hours. The median time between wounding and treatment was only 1.5 hours.149 Fifty-five percent of the wounded were hospitalized within the same day of being wounded.150
A major medical advance arrived when battle surgeons could treat vascular injuries on a routine basis. Arterial repair was first tried in 1910, and the Russians reported their first large-scale series of attempted vascular repairs in the Balkan Wars of 1912–1913. In World War I, the Germans sought to undertake vascular repair in military hospitals, but the severity of the shrapnel wounds and the high infection rates halted progress in vascular surgery.151 The increased use of high-speed projectiles and shrapnel in World War II produced a sharp rise in the number of arterial wounds. Arterial wounds accounted for only 0.29 percent of the wounds during the Civil War and only 0.4 percent in World War I. The rate of these wounds doubled in World War II to 1.0 percent and doubled again during the Korean War to 2.4 percent.152
Small numbers of vascular surgeons served during World War II, when the standard treatment for injuries to the major arteries was ligation (tying the artery itself in a small knot). But this technique produced only marginal results, with 49 percent of the ligated patients contracting gangrene and requiring eventual amputation. Thirty-six percent of the patients upon whom arterial repair was attempted had to undergo eventual amputation. Taken together, 62.1 percent of cases of arterial injury to the lower extremities eventually needed amputation.153 When vascular surgeons first regularly operated in the frontline hospitals in Korea, they saw a dramatic drop in the amputation rate. In the early days of the war, the amputation rate from vascular injuries remained at the World War II rate of 62 percent. During the last eighteen months of the war, however, the amputation rate dropped to 17.7 percent and, finally, to 13 percent.154
Yet another advance in medical treatment was the great improvement in the management of shock. The ready availability of blood and transfusion helped greatly. Still, soldiers suffering from crushing injuries or prolonged shock often died of renal insufficiency while appearing to recover from their wounds. Doctors recognized this phenomenon during World War II, but no satisfactory treatment was available until the Korean War. A number of special medical units designed to treat acute renal insufficiency were placed near the MASH hospitals. The results of proper medical treatment were dramatic, and deaths due to renal failure declined by 50 percent.155
THE VIETNAM WAR
Between 1965 and 1970, 133,447 American wounded were admitted to medical facilities for treatment, of which 97,659 were admitted to a hospital.156 In Vietnam, small arms automatic weapons fire produced about a third of the injuries, while fragmentation missiles—often from booby traps—produced most of the rest.157 Burn injuries were frequent. Some resulted from explosions inside armored vehicles and bunkers, but more than half the burn injuries were accidental. Burn injuries were often accompanied by inhalation injuries, and wounds of this type produced 70 percent of the total burn fatalities.158
The official hospital wound mortality rate for the Vietnam War was 2.6 percent compared to 2.5 percent for Korea and 4.5 percent for World War II. These statistics are misleading, however, for they do not take into account how the excellent medical evacuation system successfully moved to hospitals seriously wounded men who would have died on the battlefield or at the battalion aid station in previous wars. A better way of understanding the medical care provided to the American soldier in Vietnam is to examine the “deaths as a percentage of hits ratio,” that is, the number of wounded men who survived. Viewed from this perspective, in World War II this ratio was 29.3 percent, in Korea 26.3 percent, and in Vietnam 19.0 percent. Stated another way, in World War II for every soldier who died, 3.1 survived their wounds. In Korea, the figure was 1 to 4.1 and in Vietnam 1 to 5.6.159
The nature of counterinsurgency warfare in Vietnam produced a war of small units widely scattered over inhospitable terrain, a situation that forced a rethinking of the casualty evacuation system. The classic pattern of ground evacuation of casualties while passing them through five echelons of medical care could not work rapidly enough to save the wounded in Vietnam, where distance and terrain slowed ground evacuation to a crawl. The helicopter permitted the greatest flexibility of movement in evacuating casualties, and the complete control of the air by U.S. forces made it possible for helicopters to land very close to where the casualty was wounded. Once the casualty was aboard a helicopter, the pilot could bypass the battalion and regimental aid stations and take the casualty directly to a hospital equipped for major surgery. Casualties were routinely transport
ed directly to a field hospital, evacuation hospital, or even a hospital ship offshore.160 Hospital ships were used most often for surgical treatment of U.S. Marine casualties since the Marines came under the jurisdiction and control of the navy medical corps. Shipboard evacuation to hospital ships offshore for treatment of Marine casualties had been established during World War II when Marine units were used to assault Japanese positions on Pacific islands. Corpsmen at the battlefront first treated the wounded Marines, who were then transported to battalion aid stations on the beach. From there boats took them to medical facilities located on ships offshore.
At the peak of ground operations during the Tet Offensive in 1968, American troops received aeromedical support via 116 air ambulance detachments, each with five to seven UH-1E (“Huey”) helicopters capable of transporting six to nine patients at a time. Each division had aeromedical helicopters organic to its medical detachment.161 These medevac helicopters had trained medics aboard to provide in-flight advanced first aid to the casualty. The average medical evacuation flight from point of wounding to a hospital was only thirty-five minutes. The more seriously wounded usually reached a major surgical hospital within two hours of being wounded. Of the wounded who were still alive when they reached the hospital, 97.5 percent survived.162