The Last Full Measure (57 page)

Before the age of asepsis, antibiotics, anesthesia, and blood transfusion, military surgeons were caught between the devil and the deep blue sea. In order to prevent severe injuries to limbs from becoming gangrenous, amputation was widely considered prudent. However, the nonsterile conditions of the operation introduced its own risks: of infection, of fatal hemorrhage (often days after, when the wound had “sloughed,” that is, become infected), and the shock to the patient, all of which made amputation extremely hazardous. After the battle of Waterloo, 70 percent of amputees died, and during the Crimean War, 63 percent.
²⁶
Even though the German and French armies had embraced Lister’s antiseptic prescriptions with much more enthusiasm than did either the British or American military medical establishments, the losses to amputation during the Franco-Prussian War of 1870–71 were shocking. Georg Friedrich Louis Stromeyer, the most important surgeon in the
Prussian army, lost all of the 36 soldiers whose legs he had amputated. Of the 13,173 amputations (ranging from relatively minor operations to fingers up to major ones to limbs) undertaken by the French, 10,006 (76 percent) died of subsequent infection.
²⁷
During the American Civil War, Union surgeons performed about 30,000 amputations. Of soldiers who had leg amputations, 40 percent died, compared with 12 percent of those who lost arms.
²⁸
For soldiers who had fingers amputated, the death rate was 3 percent; for those who had legs taken off at the hip, it was over 83 percent.
²⁹

Speed was of the essence if the patient was to stand a chance of surviving amputation. In his
Memoir on Amputations
, Larrey reported that prior to his insistence on dealing with the severely wounded as quickly as possible, there was a 90 percent mortality rate. After his reforms (and his own skill—after Borodino he personally performed two hundred amputations), Larrey could boast that “more than three-fourths have recovered after our amputations, some of whom even lost two limbs.”
³⁰

ALTHOUGH ANESTHETICS SUCH
as opium, henbane, Indian hemp, mandragora (mandrake), and, of course, alcohol have been used for millennia, it was not until the first half of the nineteenth century that synthetic anesthesia was more or less generally available to the severely wounded soldier (and even then, many had to withstand terrible ordeals, such as amputation, without its benefit). Ether was first used in 1842 in dental surgery and for an amputation in 1846. Chloroform (preferred over ether because it is not as combustible anywhere near a naked flame) became popular and trusted when it was administered to Queen Victoria during her eighth and her ninth (and final) childbirths.

Although chloroform also had attendant dangers—a deep inhalation might overdose and paralyze the heart muscle—most
soldiers facing the excruciating rigors of amputation would have accepted the risk in the blink of an eye. At the battle of Missionary Ridge on November 25, 1863, a young Confederate soldier, Albert Jernigan, was badly wounded in his right arm and after some days of tormented wandering ended up in a military hospital. He desperately wanted to save his arm, but

Alcohol was used liberally as an anesthetic, but some soldiers displayed a breathtaking sangfroid without it. Joseph Townsend, an American Quaker, observed surgeons working on the British wounded after the battle of Brandywine during the American
War of Independence: “I was disposed to see an operation performed by one of the surgeons, who was preparing to amputate a limb by having a brass clamp or screw [Petit’s tourniquet, invented in 1718, revolutionized amputations by controlling arterial bleeding] fitted thereon a little above the knee joint. He had his knife in his hand … when he recollected that it might be necessary for the wounded man to take something to support him during the operation. He mentioned to some of his attendants to give him a little wine or brandy … to which [the patient] replied, ‘No, doctor, it is not necessary, my spirits are up enough without it.’ ”
³²

The invention of the hypodermic syringe in 1853 by Charles Gabriel Pravaz meant that morphine could now be injected as a fast-acting solution, and the discovery of barbiturates in Germany in 1903 led to intravenously delivered anesthetics.

EXSANGUINATION MAY SOUND
like an arcane rite of the Catholic Church, but it remains the leading killer of soldiers. Loss of blood leads to shock and shock to terminal collapse of the circulatory system. It comes as no surprise that most soldiers who died from their wounds in the pretransfusion era (that is, before World War II) bled to death. But it gives something of a jolt to learn that, according to the US Army Medical Department, hemorrhage is the leading cause of death on the battlefield in modern warfare (over 50 percent) and that “although some soldiers killed on the battlefield are clearly unsalvageable [an interesting if industrial choice of word] and become KIA within minutes of impact … it appears that approximately one-third of KIA would be salvageable with the development and fielding of new methods for early intervention.”
³³
Once a severely bleeding soldier gets to a modern field hospital, his chances of survival are very good indeed, but this was not so for a soldier of, say, the American Civil War,
where over 60 percent died. To save lives, transfusion has to be swift, and the efforts of modern battlefield medicine are focused on getting to the wounded soldier as soon after impact as possible.

Unless blood loss can be replaced, the soldier will die of shock. A British medical officer, Captain Gordon R. Ward, discovered at the end of World War I that replacement with the fluid part of blood, plasma (blood minus the red cells), could restore blood pressure and maintain the basic function of the circulatory system. The wounded would need full blood eventually (either by natural regeneration or transfusion) because it is red blood cells that deliver oxygen to tissue, but as an interim intervention, plasma transfusion revolutionized battlefield medicine. The technique of drying plasma was developed between the world wars, which meant that it could be stored for up to five years and was also easily delivered to the combat zone, where it was mixed with distilled water prior to intravenous injection. By 1943 plasma transfusion was widely available. On Tarawa (November 1943), for example, there were 1,000 plasma transfusions each day, with the average patient receiving 1,200 cubic centimeters. Of the 2,519 American wounded, only 2.7 percent died.

Plasma was important as a stopgap, but exsanguinated soldiers who had plasma transfusions could not withstand the rigors of transportation to rear areas for further medical attention because, starved of oxygen delivered by red blood cells, they were far too fragile. They needed whole-blood transfusion, and as close to the fighting as it could be delivered: “Plasma and albumin work wonders on wounded,” a combat medic writes, “but whole blood is life itself.”
³⁴
From 1943 on there were important advances not only in the collection of blood by Red Cross blood banks but also in preserving it by refrigeration. By war’s end about 388,000 pints of blood had been shipped overseas from America alone.
³⁵

Larrey’s principles of speedy rescue of wounded soldiers as well as immediate battle-line ministration remain as applicable today as
they did two hundred years ago. The modern army has developed highly mobile medical units that can deploy sophisticated facilities close to combat. These forward surgical teams (FSTs), complete with operating tables, ultrasound machines, computerized diagnostics for blood electrolyte count, X-ray machines, and the whole paraphernalia of an intensive care unit, can be operational close to the front line in sixty minutes. In addition, there is a range of devices that might prevent a wounded soldier from bleeding to death: one-handed tourniquets that a wounded soldier can self-administer as well as hemostatic dressings containing the clotting agents fibrogen and thrombin. However, deep intracavity and noncompressible wounds have always been, and are still, intransigent killers of soldiers. Hemostatic foams injected into the cavity to stop bleeding (think fire extinguisher) as well as drugs that would seal the bleeds may one day be successful on the battlefield. But there are problems. The coagulant foams do not distribute themselves within the cavity and reach the centers of bleeding. They also have to fight against the flow of blood that washes them away.

Blood is hard to stanch.

All of us have stood on others’ shoulders in order to see just a little farther. (Through no fault of theirs, although we may see farther we do not necessarily understand what we’re seeing.) To recognize these debts in no way implies that those who are acknowledged would agree with this book in whole or in detail. Nor is it, by some suggestion of affinity, a sneaky co-opting of their genius. Although there are so many to whom a great obligation is owed, the journey of this book could not have happened without certain powerful beacon lights to guide by. Like most people working in this field, I owe a great debt to Sir John Keegan for his brilliant brand of deductive history, illuminating the big picture by the light of the particular. Richard Holmes (who died far too young) has been an inspiration; an enthusiast and scholar whose erudition was always irrigated by a wonderful sympathy and a generous heart. Paul Fussell is a historian and memoirist from a liberal tradition that has been on the defensive since the end of the Vietnam War. He confronts and confounds the flag-wavers and war-boosters with a deeply humane skepticism about the heroics of combat. He learned the truth about the appalling messiness of battle the hard way, as a young infantry officer in Europe in World War II. I would guess that Victor Davis Hanson is not of the same political persuasion as Paul Fussell but he also powerfully evokes the
gut-torn truth of combat, particularly ancient combat, and writes with an intellectual muscularity and audacious sweep that makes one think twice about getting in the same ring. Paddy Griffith is also a military historian, like John Keegan, who focuses on the specifics of combat and tenaciously follows those leads in order to understand what really happens in battle. Always challenging, his work attacks the clogging sediment of received wisdom.

And then there are the memoirists without whom none of this material would have voice, or form, or flesh. It’s a peculiar irony, isn’t it, that the writing about death has to be
alive
. And just to highlight the two world wars, writers such as Graves, Sassoon, Blunden, Coppard, Dunn, Barbusse, Jünger, and Cendrars in the first; Manchester, Sajer, Gantter, Leckie, Bowlby, Fussell, Sledge, Fraser, Verney, Mowat, Litwak, and Douglas in the second, have become companions for whom I feel a deep affection and admiration.