Between Flesh and Steel (43 page)

The Spanish Civil War, which ended six months before World War II began, was a testing ground for new weapons and tactics that the Germans and Soviets supplied to the respective sides. It also became a testing ground for military medical advances. Gaston Ramon (1886–1963) introduced a new tetanus vaccine at the Pasteur Institute in 1931 that received its first large-scale field test in the Spanish Civil War. For the first time that the new sulfonamides—sulfa drugs, or a new group of antibacterial drugs working by bacteriostatic action—were used in war. Both sides generally adopted the German methods of antiseptic and aseptic surgery, leading to the widespread use of antibiotics and new antiseptics. The war saw the medical services widely utilize mobile surgical teams, which the Allies later perfected in World War II, and combat blood transfusion using stored blood for the first time.
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Overall these innovations in military medical care resulted in a drastic decline in the wound infection and amputation rates. Despite often primitive surgical conditions, only 342 of 42,000 wounded soldiers underwent amputations in the Spanish Civil War.
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During World War II, the British medical service treated 5 million patients, of whom 104,076 died of their wounds. Another 239,457 were wounded but survived.
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More than a thousand British medical units were mobilized for the war, including 148 field and general hospitals in the overseas theaters and 88 at home, 36 casualty clearing stations, 141 field ambulances, 49 ambulance trains, 34 hospital ships, 42 medical supply depots, 50 surgical field units, 36 blood transfusion teams, 64 field dressing stations, 27 convalescent centers, 122 field hygiene units and sanitary sections, 71 antimalarial control units, and an unknown number of mobile laboratories and other specialized units.
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The British went to war with a medical structure essentially unchanged since World War I, but the new mobile tactics and distances that it had to cover during casualty evacuation required more mobile medical facilities. To solve the problem, they adopted the American idea of equipping the entire medical structure with motorized transport. They reduced the size of the casualty clearing stations and made the field ambulance units lighter but gave them more vehicles, created field dressing stations and mobile surgical teams and equipped them with enough surgical supplies to conduct a hundred operations without replenishment. They also introduced mobile neurosurgical, maxillofacial, and field transfusion teams. The Blood Transfusion Service quickly became an integral part of forward surgical units.

The British experience at the start of the war demonstrated that a casualty had to be transported 133 miles from the forward aid station to the casualty clearing station and another 236 miles to the general hospital.
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This situation led to the creation of the advanced surgical center (ASC), which was located forward in the combat zone and designed to provide and rapid surgical care. Attached to a casualty clearing station or field dressing station, the unit was totally self-sufficient with complete facilities, personnel, and transport, including a field transfusion unit. The center could be quickly attached or detached from its parent unit and rushed to the point of greatest casualties. The advanced surgical centers dealt with all shock, penetrating abdominal wounds, chest wounds, amputations, femoral fractures, and major arterial injuries. They serviced approximately 15 percent of the total casualty load.
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New tactical units, such as airborne and commando outfits, required their own independent medical support, so the British developed special commando and airborne medical units. They trained twenty-five thousand special medical personnel for these sections, and the first air-droppable division medical component was used at Arnhem (1944).
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The long distances that the casualty transports traveled placed a premium upon limb immobilization. At the Battle of Tobruk (1942), the British used the Tobruk splint with great success. Essentially an adaptation of the Thomas splint of World War I, the Tobruk splint incorporated a plaster shell with a traction pulley anchored to the splint's heel to allow constant traction on the fracture. Meanwhile, the first large-scale use of tanks and other armored fighting vehicles resulted in a high proportion of burn casualties. The early use of tannic acid for burn treatment proved ineffective and even damaging. Armored vehicle crews were later issued wound dressings made of sheets of gauze, which were impregnated with surgical jelly to which sulfanilamide had been added, and loose gloves made of waterproof silk that sealed at the wrist for hand burns. These efforts drastically reduced pain and infection from burns.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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The Germans had not discovered the secret of storing blood and still administered almost all blood transfusions from donor to recipient.
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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.
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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.
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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.

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.
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Of the wounded, only 1,957 men died, for a wound mortality rate of only 2.5 percent.
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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.
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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.
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A total of 89,974 surgical operations were performed, an average of 1.2 operations per wounded soldier.
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