BOOK CHAPTER

The History of Trauma Care  Download PDF

 Justin Barr

  and Dale C. Smith

Skeletal Trauma: Basic Science, Management, and Reconstruction, 1, 2-24

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The views expressed are those of the author and do not reflect the
official position of the Uniformed Services University, the Department
of Defense, or the United States Government.

Introduction
Trauma derives from the Greek word τραῦµα, literally meaning
“wound.” The history of trauma is thus the history of wounds and their
management over time. Wounds provide an unusually pellucid
window into the science, society, and culture of the past. Unlike
medical diseases, they are immediately identifiable and recognized as
pathologic. Although societies managed them differently across both
geography and time, they all applied their highest levels of science and
knowledge in an effort to treat patients. Wounds hurt and kill humans
in three obvious ways: (1) loss of function, (2) bleeding, and (3)
infection. Medical efforts to treat wounds thus focused on managing
these three insults. Relevant to this textbook, trauma care knowledge
predominantly focused on the extremities until quite recently, given
the high mortality rates of wounds to the head, chest, and abdomen
despite surgeons’ efforts to intervene.

The Ancient World

Trauma dates to the earliest records of mankind. Archaeologic
evidence identifies wounds in A. africanus , dating from over 5 million
years ago. Cave art depicts men struck by arrows.   Some of the earliest 1

documented healed fractures derive from the “Iceman,” a mummified

corpse found in an Austrian glacier. Dating back over 5000 years, it
presents clear radiographic evidence of completely healed fractures in
ribs 5 through 9 on the left side, although with unknown etiology or
therapeutic intervention.   Skeletons of early H. sapiens demonstrate
2
arrows lodged in bones, particularly the lumbar vertebrae. The
location of these projectiles raises questions about the presence of
shields that might have protected more superior structures, thus
demonstrating the earliest treatment for trauma:
prevention.   Societies have engaged in a multitude of preventive
1

practices over the millennia, from the shields of Neanderthals to

automatic braking on new cars; for reasons of space, this chapter will
not address preventive medicine.

Ancient Egypt
As one of the world's earliest civilizations, ancient Egypt produced
some of the first medical texts describing systematic approaches to
trauma. The Egyptian medical system combined religion, sorcery, and
science in an effort to explain and treat disease, though efforts to
manage trauma were decidedly more naturalistic.   Healers,
3

called swnw , cared for patients using a variety of spells, medications,

and manual interventions. For snake and scorpion bites, they would
suction out blood and then apply a tourniquet; they treated burns by
applying honey and butter oils.   Bleeding vessels were cauterized or,
4

possibly, ligated   ( Fig. 1.1 ).

5
Open full size image
Fig. 1.1
Medicine in ancient Egypt.
This 20th-century rendition of ancient Egyptian medicine portrays a temple-based healer providing
succor to a patient likely suffering from lockjaw (tetanus). Note the combination of medical
intervention and prayer. Like all modern reproductions, the image suffers from 20th-century
prejudices, such as the lily-white bandages that were uncommon until Florence Nightingale's reforms
in the 1800s.
(Image accessed at https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101651528-img  . Reproduced
courtesy of Pfizer.)
The Edwin Smith Papyrus provides the best description of trauma
management for the era. Written around 1500 BCE and likely
reflecting practice from centuries earlier, it presents 48 wounds
categorized anatomically and describes their diagnosis, treatment, and
prognosis.   The papyrus as it exists today starts with head injuries and
6

moves down the body systematically, abruptly breaking off below the
shoulder. By its nature it is almost surely a compiled teaching or
reference text for young practitioners. It provided examples of what
signs to anticipate, describing a cervical dislocation that presents with
quadriplegia, including priapism and incontinence (case
31).   Although the Papyrus acknowledged the grim outcome in that
7

patient, for others it offered a variety of therapeutic interventions. It

recommended meat to staunch bleeding (case 1), a stratagem used by
Harvey Cushing and others before his development, with William T.
Bovie, of electrocautery. Case 25 clearly instructs the reader on
reducing mandibular fractures, and to treat clavicle fractures the
Edwin Smith Papyrus specifies reduction, realignment, and
immobilization (case 35). Staffs splinted long bone fractures (case 36).
Multiple preserved skeletons from the era reveal well-healed fractures
of various bones, indicating some success—perchance or per design—
in treating them.
Artwork portrays some of these medical interventions, with paintings
suggesting a healer treating the eye injury of a workman and another
setting what appears to be a broken shoulder.   Ancient Greeks
4

certainly knew of and greatly respected ancient Egyptian medicine,

and some scholars have suggested that it influenced the development
of their medical system several centuries later.  8

Ancient Greece
Ancient Greece provided the theoretical foundations for medicine for
the next two millennia.   In the epic poem The Iliad , Homer wrote of
9

213 casualties, with a 90% mortality rate.   Long-range weapons such

10

as spears caused more injuries but were less lethal than swords. Most
warriors who died did so before receiving any medical attention, but
some lived. Homer describes how Machaon, son of Asclepius, treated
Menelaus, husband of Helen, who had been shot with an arrow,
detailing the mechanism of injury, the anatomy afflicted, and the
treatment rendered.   Multiple Greek vase paintings depict similar
11

scenes ( Fig. 1.2 ).

Open full size image
Fig. 1.2
Aeneas having arrowhead removed from thigh.
This first-century fresco from the walls of Pompeii provides one of the few contemporary portrayals
of ancient surgery. Here, a Greek healer uses long-necked forceps to extract an arrow from the thigh
of Aeneas, the mythologic Trojan hero. Although stylized (few patients would tolerate the operation
standing upright), it accurately depicts the role of the ancient surgeon, some of his tools, and the
types of wounds he treated.
(Courtesy of Museo Nazionale, Naples.)
Centuries after Homer, the Hippocratic Corpus came to represent
Greek medicine, constructing a system based on the harmonization of
four humors and defining disease by an imbalance of these humors in
an individual. Medical interventions worked by maintaining or
restoring harmony. This theoretical system did little for trauma.
However, with injuries from war and daily living common, the Corpus
did address surgery as a therapy, recommending multiple means of
reducing dislocated joints and concocting various salves to stem
bleeding and soothe burns. Numerous texts provided instruction on
the splinting of broken limbs, such as Hippocrates’ book Fractures, and
described elaborate contraptions to reduce fractured bones   ( Fig. 1.3 ). 12
Open full size image
Fig. 1.3
Reduction of dislocations.
Illustrations from 11th-century Hippocratic treatise On Joints  demonstrating the reduction of hip and
other dislocations. Although the image heralds from some 15 centuries after the initial publication of
the book, the machinery and techniques remained essentially unchanged. Their persistence into the
1400s demonstrates the lasting influence of the Hippocratic Corpus on the practice of Western
medicine and surgery.
(From Hippocrates, On Joints .)

Ancient Rome
The medical therapies practiced by Roman physicians and the
physiologic theory on which they are based differed little from those of
the Greeks, and much of what we think of as Greek medicine is in fact
the systematic review and consolidation by a Greek-speaking
practitioner in Rome named Galen. Galen described the work of his
predecessors as articulating three broad sources of pathology: the
naturals, or the normal physiology gone awry; the nonnaturals, or
environmental factors such as climate and diet that were not
inherently good or bad but must be managed; and the contranaturals,
or forces that harm the body, such as traumatic injuries. Although
most ancient writings focused on the contranaturals as opportunities
for effective intervention, Galen and others recognized the importance
of total care of the patient for recovery to health.  9

The innovative Roman military medical system emblemized this

dedication to preventive, trauma, and convalescent care through a
remarkable organizational effort to maintain the health of their
soldiers.   All recruits underwent screening physicals to minimize
13

disease at the outset. The praefectus castorum staffed legions as the

second in command and was charged with medical care of the
troops. Medici served with the legion and provided medical care to
soldiers, though with no certification or other educational
requirements before joining. Forts—particularly larger, established
facilities—contained valetudinaria , or hospitals for the sick and
wounded, marking one of the first examples of dedicated spaces for
medical practice. Actual medical care delivered remains poorly
described and likely reflected the variegated traditions from which
the medici came. No notion of triage appears in any text. Although
archaeological expeditions have unearthed contemporary surgical
instruments, few written descriptions of operations exist. 1415
Recent scholarship has challenged prior accounts of a uniform system
of Roman military medicine, but evidence clearly indicates a
concerted, if varied, effort by Rome to care for the legionnaires.   Self-
16

interest motivated the empire more than altruism—they realized the

cost of recruiting and training a new soldier exceeded that of
maintaining those who already served—but the system they created
and implemented nonetheless stands apart as a state-organized,
centrally run effort for taking care of the sick and traumatically
injured.

The Middle Ages

Medicine in the Middle Ages followed the humoralism propagated by
the Hippocratic Corpus and Galen.   Generalizations across centuries
17

and countries are subject to specific exceptions, but scholars agree on

some broad similarities. Notably, medieval medicine argued that even
traumatic injuries resulted in humoral imbalance, requiring treatment
not only for the external wound but also for the internal
pathology.   Surgeons, who had existed informally since antiquity,
18

emerged in the literature for the first time as a distinct, educated

group of medical providers in the Middle Ages.   They held
19

responsibility for managing wounds and diseases affecting the exterior

of the body (predominantly contranaturals), whereas physicians
focused on internal maladies (naturals).   Education for surgeons
20

developed from the apprenticeship model that characterized the

previous two millennia into a text-based curriculum steeped in both
theory and practical application.   As universities became the premier
21
sites of medical education,   the best surgical education slowly moved
22

into these formal curricula.  23

Despite these radical changes in the structure and education of surgery

in the Middle Ages, methods for treating wounds largely paralleled
interventions from the ancient world.   Surgeons would wash wounds,
24

often with wine, and dress them. The types of dressings and salves
applied varied enormously from one practitioner to another, each
convinced his concoction superior. Texts describe various instruments
to help remove foreign bodies from the wound, as well as instructions
on which wounds to sew closed and how, as surgeons dedicated large
portions of their writing to the management of traumatic
injuries.   Recognition of the importance of longitudinal care emerged
25

in the 10th century with debates on the virtues of what we now call
healing by primary and secondary intention, with most surgeons
preferring to allow the wound to granulate in over time ( Fig. 1.4 ).

Open full size image

Fig. 1.4
Operating on the upper arm.
This 13th-century image from Theodoric Borgognoni's text Chirurgia portrays a surgeon cleaning a
traumatic wound to the arm in preparation for dressing it. Theodoric stressed the importance of
approximating the wound edges to ensure proper healing. The long robe worn by the surgeon
connotes formal training and membership in a guild/society.
(From Chirurgia, by Theodoric of Cervia, 13th century.)
The rarity of elective invasive procedures ensured surgical texts
focused on wounds. Documents provide illuminating evidence on
ideas in trauma management but simultaneously problematize our
understanding of actual practice. For example, one novel methodology
involved using a crossbow to remove stuck arrows from
patients.   Crossbows became increasingly common weapons after the
26

11th century, and the arrows fired from them and traditional bows
could lodge in the body with such force that manual removal proved
impossible.   Surgeons could tie the stuck arrow to the bowstring of
27

the crossbow, fire the weapon, and use the force to extract the
offending missile ( Fig. 1.5 ). Although efficacy remains unclear
(particularly for barbed arrows), multiple surgical texts from around
Europe and over several centuries explicate the technique and
reference its common usage. But almost no one describes employing
the technique in practice, leaving actual application undetermined.

Open full size image

Fig. 1.5
Arrow extraction by crossbow.
This 13th-century illustration shows a healer using a crossbow to extract an arrow from a wounded
soldier's thigh. The arrow is tied to the bowstring of the weapon, which, when fired, will vellicate the
foreign body from the wound. Although texts often described and illustrated the technique, actual
utilization is unclear; it promised poor results for barbed arrows.
(From Patijn M. The medical crossbow from Jan Yperman to Isaac Koedijck. In: Kirkham A, Warr C,
eds. Wounds in the Middle Ages. Burlington, VT: Ashgate; 2014:197–211. Image from Guy de
Chauliac, Ars Chirurgica,  Venice, 1546 [manuscript in Leiden University Library, #647 A 24, page
27v].)
The importance and prevalence of wounds in the Middle Ages become
obvious through their depiction in literature at the time. Injury and
death occur frequently to King Arthur's knights, for example, with the
chest and head the most common locations for fatal
trauma.   Although no doctor or surgeon accompanied the knights on
28

their quests, the wounded could receive care at monasteries. Other

paeans praised knights’ ability not only to endure wounds but also to
treat and heal themselves, highlighting the heroism inherent in their
suffering.   This trope parlayed with the broader meme of the
29

wounded Christ. Christianity interwove with most aspects of medieval

society, including the practice of medicine.   Although some tensions
30

between clergy and medical practitioners existed,   the two professions31

largely cooperated, with each healer treating the wounded with their
respective, but symbiotic, therapies.   Given the urban concentration
32

of formally trained healers, priests likely performed basic wound care

on a rural population subject to agricultural trauma of falls, horse
kicks, and so on. Although these injuries and their treatment do not
appear in texts, paleopathology documents a significant number of
healed fractures from this era.   Simple fractures were splinted and
33

generally required bed rest to heal; displaced fractures typically led to

extremity shortening.
Some of the best-studied medieval wounds occurred in those who
fought for the Christian church in the crusades.   Crusaders brought
34

physicians and surgeons along with them from Europe, ensuring

continuity of care. Of the nobility who ventured to the Middle East,
around 15% to 20% died from disease, and another 15% to 20% died
from combat wounds; data for foot soldiers remain unavailable.
Archaeological evidence of skeletons demonstrates the devastating
effect of battlefield trauma and how commonly it afflicted the
crusaders. Spears and lances proved the most fatal instruments,
followed by arrows, which were the most common. Wounds to the
skull, forearm, and lower legs—likely the least armored areas—were
the most frequent. For head wounds without obvious fractures,
surgeons would pour black ink on the skull to try to detect occult
injuries, explore the break, remove bone shards, and dress the wound.
Of note, surgeons who made gross errors in setting bones were
punished with the amputation of their right thumb.

The Early Modern Era (ca. 1450–ca. 1800)

Medicine in the Early Modern era reflected a time of change as the
humoral system of Hippocrates and Galen slowly faded from relevance
and alternative explanations of disease came to the fore.   Andreas
35

Vesalius’ monumental 1543 text De Humani Corporis Fabrica Libri

Septem helped reinvigorate the study of anatomy and demonstrated the
need to rely on personal investigation over textual authority.   After
36

publishing, Vesalius became a military surgeon for Emperor Charles V

and subsequently his son, Phillip II, King of Spain, where he was
called to consult on the case of King Henry II of France, who had been
struck in the head with a lance during a jousting tournament
celebrating the marriage of his son. The case brought in medical
authorities from around Europe who debated whether the brain could
sustain injuries without a skull fracture. Vesalius argued that it could
and prognosticated death. On autopsy, Vesalius identified cerebral
compression, a contracoup injury, and a subdural hemorrhage, clearly
proving the possibility of neurologic injury sans fracture.   A
37

practically experienced military surgeon consulting bedside who had

agreed with Vesalius was the famous Frenchman Ambroise Paré.
Ambroise Paré was born sometime between 1510 and 1517 just outside
of Laval, France. Although never receiving formal, university-based
education in surgery, he gained extensive experience apprenticing to
barber-surgeons and working in the massive French public
hospital Hotel Dieu .   He is perhaps best remembered for his advocacy
38

of ligating blood vessels after limb amputation instead of applying the

standard contemporary therapy: cautery.   He invented a new
39

instrument, the bec de corbin, as the first vascular clamp to grasp

vessels in preparation for their ligation.   However, until Jean Petit's
40

invention of the screw-tourniquet in 1718 to control hemorrhage,

ligation remained rare ( Figs. 1.6 and 1.7 ).
Open full size image
Fig. 1.6
Amputation of leg, 16th century.
This image from Hans von Gersdorff's Feldbuch der Wundartzney shows a leg amputation in 1517.
The patient is apparently passed out from pain with a cloth over his eyes to keep him from
witnessing the event. An assistant holds the leg stable while the surgeon saws through the bone; the
knife for skin incision rests on a pedestal in the foreground. Unlike Fig. 1.4 , this surgeon does not
wear a long robe, connoting his likely status as a barber-surgeon similar to Paré. Although not Paré
himself, the scene accurately captures surgery in his era. Note the arterial hemorrhage—until Petit's
tourniquet, surgeons controlled bleeding after the amputation with cautery or (following Paré)
ligation. The standing figure sports a waterproof animal bladder over the stump of his amputated left
arm; the Greek letter tau  indicates that he suffered from St. Anthony's Fire.
(From Hans von Gersdorff's Feldbuch der Wundartzney ; copyright held by SmithKline Beckman
Corporation Fund, Philadelphia Museum of Art.)
Open full size image
Fig. 1.7
Amputation of leg, early 19th century.
Comparing this preanesthesia 19th-century image by surgeon Charles Bell (of Bell's palsy) of leg
amputation against the previous figure highlights several developments of surgical practice. Most
notably, a Petit-style screw tourniquet controls bleeding until the conclusion of the operation. The
color images portray the circular technique of amputation, which gained popularity in the Napoleonic
Wars but was largely replaced by the flap method in the late 19th century. The line drawing in the
lower corner demonstrates concern for postoperative functionality and possible prosthetics.
(Image accessed
at https://commons.wikimedia.org/wiki/File:Plate_IX,_illustration_of_leg_amputation,_Sir_Charles_B
ell_Wellcome_L0072192.jpg .)
More important than ligation was Paré's treatment of gunshot
wounds. Firearms were not new weapons in the 16th century, having
entered Europe by the 1320s, but they had received little attention in
medical or surgical texts until after the development of
printing.   Gunshot wounds were particularly challenging when
41

fracturing bones. The Hippocratic bench and bed rest were generally
ineffective, and surgical intervention to align bones suffered from
inadequate anatomic knowledge and nearly omnipresent infection.
Military surgeons often resorted to amputation, but even this
procedure had high mortality rates.   French surgeon Jean de Vigo
42

discussed their management in his 1514 book Practica in Arte

Chirurgica Copiosa, which, translated into most European languages,
was the standard surgical text of the era used by Paré and most other
practitioners. Firearms clearly caused devastating wounds, with
posttraumatic sequelae resembling the effects of animal poison bites;
Vigo assumed that some of the pathology resulted from a poisonous
effect of the gunpowder. As such, he recommended pouring boiling oil
into gunshot wounds to neutralize the poison and facilitate healing.
With this instruction at hand, Paré set off on his first military
campaign in 1537, when the French sought to wrest Turin, Italy, from
the Holy Roman Empire. At that time, Paré had never even seen a
patient with a gunshot wound.   In 1537 at the siege of Turin, the
43

number of casualties exhausted his supply of oil.

At last my oil lacked and I was constrained to apply in its place a digestive
made of yolk of eggs, oil of roses and turpentine. That night I could not sleep
at my ease, fearing by lack of cauterization that I should find the wounded on
whom I had failed to put the said oil dead or empoisoned, which made me
rise very early to visit them, where beyond my hope, I found those upon
whom I had put the digestive medicament feeling little pain, and their
wounds without inflammation or swells having rested fairly well throughout
the night; the others to whom I had applied the said boiling oil, I found
feverish, with great pain and swelling about their wounds. Then I resolved
with myself never more to burn thus cruelly poor men wounded with
gunshot. 44

Paré's new treatment of gunshot wounds—avoiding the application of

boiling oil—rapidly spread through contemporary surgical practice
and brought him lasting fame. It also contributed to the general trend
in early modern medicine of reporting and relying on personal,
empirical observation to shape treatment instead of the dogmatic
textual adherence that characterized the tomes of earlier eras.
The early modern era was also significant for the establishment and
organization of formal military medicine. In this era, political states
emerged, and these states required professional armies to expand
their territory and guard against invasion.   States created and funded
45

a medical system to support these armies, evidenced by the

contemporaneous founding of European surgical societies that went
on to establish common standards of training and practice.   Neither
46

needing nor wishing to compensate university-educated, socially elite

practitioners, military medicine often featured apprentice-trained
surgeons who were required to manage a diverse array of medical and
surgical conditions.  47
Economic changes prompted urbanization in the 18th century, which
led to greater opportunities for medical investigation as patients more
often interacted with a formal healthcare system that increasingly
received state funding. Although this new social condition would
support many changes in medical thinking, probably the most
important in the history of trauma was the introduction of the
word shock by John Sparrow in his 1740 translation of
LeDran's Observations in Surgery. Many 18th-century surgeons
commented on the decline suffered by patients after wounding,
whether by trauma or by the surgeon. John Hunter opined that the
body sympathized with the wounded part   ; his student Astley Cooper
48

defined it as a constitutional irritation; and George James Guthrie,

who bridged the 18th and 19th centuries, described a constitutional
alarm. The French surgeon Henri LeDran had said the body suffered a
jar (secousse), which Sparrow translated as shock .   The term was
49

uncommon until the later part of the 19th century, probably related to
Guthrie's adoption of it after the Crimean War. Regardless of the term,
the physiologic changes were real and surgeons would increasingly
work to combat them in their trauma patients.

Trauma Management in the 19th Century

Napoleonic Wars
The Napoleonic Wars (1793–1815) dominated the early decades of the
19th century politically, militarily, and medically. Losses exceeded
three million Europeans; like all previous conflicts, deaths from
disease far outnumbered combat fatalities, but traumatic wounds still
numbered in the hundreds of thousands, caused predominantly by
small arms fire.   Few new therapies emerged, but the impact of the
50

systemization of surgery in the 18th century is obvious from

discussions of postsurgical care. The debility that followed wounding,
whether called shock or something else, was clearly articulated and
surgeons discussed how to prevent and treat it. Clinically, debates
centered on the timing and technique of amputation: whether to
amputate immediately after injury or wait several days for the
unhealthy tissue to demarcate. Supporters of the circular and flap
techniques each maintained the supremacy of their method. Although
the wars ended without substantial agreement of proper technique,
almost all surgeons insisted that early amputation—within 4 hours of
injury—improved patient survival. The prodigious number of
amputations led surgeons to acquire tremendous experience and skill,
with French surgeon Dominique-Jean Larrey allegedly completing
200 amputations in 24 hours after the Battle of Borodino in Russia.  51

Other interventions remained limited. Surgeons occasionally

trephined skull wounds and inserted chest tubes to drain secretions
after thoracic trauma. Anecdotal reports attest to their sporadic
success, but these therapies did not see widespread use, and by the
end of the wars, many leading surgeons discouraged them.   Soft
50

tissue injuries were drained and bandaged; practitioners rarely

sutured wounds closed as healing by secondary intention remained
safer. A great deal of trauma practice (especially outside the military)
involved waiting for nature to heal the wound. Given available
remedies, the gunshot wound, particularly when compounded by long
bone fracture, received the most attention from surgeons both in
written texts and on the wards.
Developments in military medical organization exceeded clinical
advances. The French had a well-established, well-organized military
medical system for much of the 18th century, but the turmoil of the
French Revolution disrupted the medical profession both in and out of
uniform. 5253 After military medical disasters in 1792–1793, the
French strove to create a more effective system.   They insisted on
54

educational standards, instituted warrant rank for at least some

uniformed doctors, and created hospitals both to care for the injured
and to train the next generation of clinicians. Several French
physicians and surgeons played important roles in this reform (and
the establishment of the Paris School of Medicine postbellum), but
none rose to the enduring international fame of Dominique-Jean
Larrey   ( Fig. 1.8 ).
55
Open full size image
Fig. 1.8
Larrey and his flying ambulances.
Larrey is dramatically handed a scalpel as he prepared to operate on the wounded soldier to his
right. The background soldiers firing accurately portray Larrey's proximity to the fighting. A flying
ambulance on the left of the painting stands ready to whisk the wounded rearward.
(Image accessed at http://aqwedc.free.fr/spip2112/spip.php?article183  . Courtesy Académie
Nationale de Médicine, Paris, France.)
From treating revolutionaries struck down storming the Bastille in
1789 to his capture at Waterloo in 1815, Larrey served throughout the
Napoleonic Wars in nearly every theater.   He made many 56

contributions to the organization of medical services, diagnosis of

disease, and care of the injured; he remains best known for his “flying
ambulances,” designed to carry surgeons forward and then spirit
wounded soldiers off the battlefield to the nearest medical facility for
recovery. Larrey recognized that amputation could be avoided in many
cases if the limb was immobilized soon after fracture, and he and
others experimented with stiffening materials, usually starch in one
form or another, during and after the wars. When necessary, forward
surgical amputations made possible by the flying ambulance surgeons
likely contributed to safe convalescence, though any confirmatory data
are lacking. The vehicles certainly made transportation of the patient
more convenient and reduced the pain of transit in an era of minimal
analgesics. As a result of his experiences, his personal association with
Napoleon, and his prodigious postwar writings, Larrey emerged as the
prototypical surgeon of the era, although in Britain Charles Bell and
James Guthrie remained best known.  57

Mid 19th Century

The years after the Napoleonic Wars also marked the coming of the
Industrial Revolution. In this period, the same machines, railroads,
and factories that came to dominate sectors of the economy also
produced a rash of traumatic injuries. Injuries and disease among the
working poor led to voluntary (philanthropic) hospitals in the Anglo-
American world of the 18th and 19th centuries. Other countries had
more organized church and then government sponsorship.   London's
58

Charing Cross hospital, for example, treated over 66,000 traumatic

injuries between 1834 and 1850; other facilities published similar
statistics.   Workers were injured on the job and rushed by their mates
59

to the nearest hospital where a volunteer surgeon was summoned to

provide care. As the century progressed and such injuries increased in
number, surgeons staffed the casualty services on a more routine
basis. An entire specialty of Railway Surgery emerged to care for the
proliferation of trauma from both building and riding the
rails.   Industrial injuries that reached a hospital typically afflicted the
60

extremities, providing surgeons a greater opportunity to intervene

than abdominal or thoracic wounds. The practice of industrial
medicine grew substantially in the 19th century to care for these
patients   ( Fig. 1.9 ). Through the 1840s, many of these clinicians had
61

served in the Napoleonic Wars and brought their wartime experience

to the bedside.   Their surgical expertise proved particularly useful in
62

managing the orthopaedic trauma and crush injuries that afflicted

workers. As the generations changed and war experience became less
common in shaping practice, surgeons began adopting more
conservative principles, such as those of the Hanoverian surgeon
Georg Louis Stromeyer. 6364 Stromeyer argued that even in
compound comminuted fractures the bone would heal if the
suppuration could be avoided, and the rush to amputation slowed.
Practitioners such as Stromeyer commonly used sand—either burying
a limb or surrounding it with sandbags—to immobilize it.
Open full size image
Fig. 1.9
Industrial surgery.
In this 1895 painting titled “A Wounded Workman,” artist Erik Henningsen depicts an industrial
laborer, injured on the job, receiving care from the company surgeon. Note both the proximity of the
“clinic” to the worksite and the limited resources present. The cross in the foreground marks the
grave of an unlucky coworker who apparently succumbed to his injuries.
(Courtesy Statens Museum for Kunst. Image accessed at https://useum.org/artwork/A-Wounded-
Workman-Erik-Henningsen-1895 .)
The other factor that led to a decreased rush to amputate was the
introduction of inhalation (ether) anesthesia in 1846 (chloroform
followed in 1847)   ( Fig. 1.10 ). The focus of anesthesia has largely been
65

on pain control, but ether also gave surgeons the gift of time and a still
patient on whom to operate. The nature and role of pain in the body
was not well understood, and some physicians feared interrupting
normal healing processes. Guthrie, working with John Snow, led
speculation on the role of anesthesia in shock by his follow-up on
patients reported from the Crimean War.   As ether and chloroform
66

came into increasingly common use, the pace of operations slowed,

but the postoperative mortality rate did not, raising questions about
the propriety of elective operations.  67
Open full size image
Fig. 1.10
The introduction of ether anesthesia.
First public demonstration of ether anesthesia, Massachusetts General Hospital, 1846, as John
Collins Warren removes a vascular tumor from a patient's neck while the dentist William Morton
administers ether anesthesia.
(Image accessed
at http://www.massgeneral.org/pathology/training/mgh_case_records_history.aspx  .)
Simultaneously, the late 19th century experienced renewed attention
to anatomy and surgical education. An ongoing effort since the
Renaissance, anatomic studies proved socially distasteful in western
Europe, largely due to the grave robbing (and even murder) involved
in acquiring bodies.   Through the course of the 19th century, society
68

enacted laws permitting dissection, allowing surgeons to study

anatomy freely. 6970 This improved knowledge continued a trend
toward more conservative operations and, later, resection therapy as
the hallmark of surgical care. In orthopaedic trauma, this
conservatism was assisted by the introduction and rapid spread of
plaster of Paris casting. Antonius Mathijsen (1805–1878) was born in
the Netherlands and spent his working life as a medical officer in the
Dutch Army. Building on suggestions in military campaigns of the
Napoleonic era to stiffen bandages, he introduced plaster of Paris
bandaging in 1851. Nikolai Ivanovich Pirogov (1810–1881), a Russian
army doctor and professor of surgery, heard of Mathijsen's work and
applied it in the Crimean War, where it attracted significant attention
and improved the care of closed fractures; open wounds remained
deadly.

American Civil War

In the 1860s the American Civil War again created hundreds of
thousands of trauma patients for surgeons to manage. Anesthesia
spread rapidly such that in the Civil War, only 254 of the documented
80,000 operations on Union soldiers proceeded without
anesthesia.   (Most Confederate medical records burned in Richmond
71

in 1865, limiting analysis of their side.   ) Anesthesia undoubtedly

72

benefited patients by providing them pain-free surgery, but it did not

notably increase either the number or variety of operations.
Intracranial, intrathoracic, and intra-abdominal operations remained
exquisitely rare—and rarely successful. Approximately 62% of patients
with penetrating chest wounds and 89% of patients with abdominal
wounds in the Civil War died.   Therapy again focused on mangled
73

extremities ( Fig. 1.11 ).

Open full size image

Fig. 1.11
Civil War surgery.
Hospital scene at Battle of Antietam (1862) with surgeons operating outdoors, a common practice to
make best use of available light. The bucket in front of the operating table was a likely receptacle for
amputated limbs. Note the line of Letterman's ambulance wagons in the background.
(From Bollet AJ. Civil War Medicine: Challenges and Triumphs. Tucson, AZ: Galen Press, Ltd;
2002:100. Original source in Harper's Weekly  and in public domain.)
Trauma caused by the new minie bullets resulted in devastating
injuries. Claude Etienne Minié (1804–1879) introduced the new
muzzle-loading spin-stabilized rifle, increasing projectile velocity and
tissue destruction significantly. In wounds limited to soft tissue,
surgeons tried to remove the bullet and other foreign bodies. Those
affecting the bone chiefly resulted in amputation, of which there were
approximately 30,000 by Union surgeons, who preferred the flap
technique over circular methods. Again, early amputation proved
superior to delayed operations. Overall, about 26% of amputees died
from their wounds, although the rate differed dramatically by
anatomic location, with hip disarticulations having a nearly 100%
fatality rate.   They also pioneered more conservative operations that
71

removed segments of damaged bone and soft tissue while preserving

the limb. Much death resulted from hospital gangrene and erysipelas.
Although Civil War doctors did not yet recognize the germ theory of
disease, they did come to realize the infectious nature of these septic
(meaning putrid or rotten) conditions and experimented with various
therapies to prevent and treat them, including application of antiseptic
solutions such as bromine.  74

Like Larrey's contributions before, some of the most important

developments in trauma care in the Civil War resulted from
infrastructure improvements, most famously the evacuation system
designed and championed by Jonathan Letterman.   Providing
75

integrated ambulance units and organization of field hospitals, it

established the model for military medical evacuation chains for
American and European armies through the First World War.
Critically, after the war, the US Army published the heralded Medical
and Surgical History of the War of Rebellion .   This document built on
76

the nascent science of medical statistics, pioneered in the early 19th-

century public health movements.   Whereas information from
77

conflicts predating the Napoleonic Wars usually represented

haphazard collections from individual officers, starting in the 1800s
militaries made a concerted effort to track medical data. This practice,
epitomized by the Medical and Surgical History, not only enabled armies
to improve the health of their soldiers but also allowed others to study,
appreciate, and learn the lessons of trauma care.   Its six volumes
78

compiled the most substantial accumulation of medical data ever

before seen. Because literally thousands of American practitioners
contributed to the Medical and Surgical History, it remained widely
popular for a generation and was vigorously mined by European
surgeons. 79

Late 19th Century

Doctors who fought in the Civil War returned home to apply their
knowledge to civilian patients. The US Army had only 114 medical
officers in 1861; by the end of the war, over 12,000 physicians served
Union forces—a substantial portion of America's clinicians.   They
73

brought back anatomic knowledge, skills in surgery, and experience

caring for injured patients; as a result of their service, they elevated
the field in respectability and importance.   Recognizing the benefit of
80

hospitals, they helped establish these institutions as mainstays of

medical and surgical care. Their exposure to contagious diseases in
camps and military hospitals along with the novel efforts to control
suppuration primed the profession to accept the germ theory of
disease in the coming decades.  74

Just 2 years after the US Civil War ended, Joseph Lister, working on
the casualty ward of the Glasgow Royal Infirmary with compound
fracture cases from street accidents, published his now classic article
describing antiseptic surgery, where he applied carbolic acid to
sterilize the wound and prevent infection.   Lister's discovery was part
81

of a gradual acceptance of the germ theory of disease.   Although it

82

took decades for antiseptic (and later aseptic) surgery to become

standard of care,   this development eventually expanded the number
83

and repertoire of operations surgeons could perform   ( Fig. 1.12 ). By

84

1876, when Lister visited America and began to convert leading US

surgeons to his ideas,   there were new hospitals in hundreds of
85

American cities and towns to care for the injuries associated with the
rapidly growing Industrial Revolution.   From the burns of the steel
86

mills to the crush injuries of the rail yards to the thousands of mangled
arms and legs from open gears, trauma was common in the late 19th-
century city and industrial town. The prevalence of trauma prompted
ongoing discussions in new professional organizations such as the
American Surgical Association (founded in 1880) and the Deutsche
Gesellschaft für Chirurgie (1872) that fostered shared knowledge and
experience 8788 ( Fig. 1.13 ). Together now, surgeons and physicians
built on the foundation of scientific investigation to explain disease.
The same germs that caused infectious diseases contaminated wounds
as well, bringing novel technologies such as the thermometer and
sphygmomanometer as well as new notions of pathophysiology to
bear. The care of trauma patients was now studied with the same rigor
and basic sciences as the rest of medicine, spurring progress and
innovation through the 19th and 20th centuries.

Open full size image

Fig. 1.12
Listerism.
In a reenactment of his first published case, Joseph Lister cares for the compound leg fracture of a
young boy by dressing the injury with carbolic acid–soaked guaze to prevent infection, an
intervention that saved both life and limb. Once proven effective for compound fractures, Listerism
expanded to traumatic and elective surgery.
(Courtesy Pfizer; image available from National Library of Medicine
at https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101651506-img  .)
Open full size image
Fig. 1.13
Founding of the Deutsche Gesellschaft für Chirurgie, 1872.
This painting serves as a synechdoche not only for the formation of various surgical organizations
but also for the importance of military surgery to the civilian profession at the time. From left to right:
Richard von Volkmann (secretary), Johann Friedrich August von Esmarch, Heinrich Adolf
Bardeleben, Bernhard Rudolf Conrad von Langenbeck (chairman), Theodor Billroth, Victor von
Bruns, Gustav Simon, and Ernst Julius Gurlt.
(Image accessed at https://upload.wikimedia.org/wikipedia/commons/3/39/Gr
%C3%BCnder_Dt._Ges._Chirurgie.jpg . Public domain.)
One late 19th-century invention further shaped 20th-century
medicine: radiographs. Like anesthesia and antisepsis before it, this
new technology took time to become standard of care.   William 89

Roentgen's discovery of radiographs in 1895 and their deployment to

war from 1896 (Italian-Abyssian War) onward greatly improved the
ability of military surgeons to localize foreign bodies, identify injuries,
and treat the injured.   The US military deployed them to Cuba in the
90

1898 Spanish-American War, but limitations in technology and

interpretive ability rendered them more a curiosity than a valuable
adjunct to care.  91

Other innovations made a significant difference in the Spanish-

American War.   Antiseptic bandages and attempts at aseptic surgery
92

graced the battlefield, reducing infection rates. Amputations made up

approximately 40% of all operations, compared with nearly 75% in the
Civil War, as more conservative interventions on extremities and
surgery on the abdomen and chest became increasingly common.
Although routine wound débridement, fluid resuscitation, and
standard operative fixation of fractures would not arrive until the 20th
century, trauma care improved considerably by the turn of the
century.
Trauma Management in the 20th Century
As operations increasingly expanded into the chest and abdomen in
the 20th century, surgeons experienced, and investigated, a broader
array of complications. Physiologic questions about pressure gradients
across the chest wall, or why bowels stopped moving after laparotomy,
filled the literature. Most disconcertingly, surgeons wondered why a
technically excellent operation still ended with the patient dying of
“shock.” Different surgeons proposed various etiologies, including
blood pressure, blood loss, anesthetics, or sympathetic nervous
responses, but no single explanation sufficed. Microbiology provided
some clues. Paul Friedrich's studies of the late 19th century showed
that it took roughly 6 hours for germs in a wound to enter the
bloodstream and cause systemic detriment   ; this finding contributed
93

to the adoption of débridement in the First World War. In 1897 Carl

Flügge demonstrated the potential importance of droplet transmission
of germs and almost immediately Jan Mikulicz-Radecki began using
and advocating a gauze mask in the operating room.   The steady
94

progress in aseptic technique slowly improved outcomes, but much

remained empirical (and idiosyncratic) in trauma care.

World War I
As the first major, international European war since Napoleon lost at
Waterloo (1815), World War I (WW I) ravaged the continent and its
inhabitants. Like medicine, war had changed substantially in the
intervening century. Machine guns, barbed wire, and rapid-fire
artillery created stagnant, deadly trench warfare, further complicated
by the deployment of poison gases. Submarines stalked the oceans and
airplanes swarmed the skies.   New military technology created
95

casualties in heretofore unseen numbers and magnitude, severely

taxing the successful management of trauma.
Combatant forces responded by expanding and redesigning military
medical systems. They recruited tens of thousands of civilian
physicians who helped provide care, charging these unevenly trained
practitioners to treat massive numbers of horribly wounded patients,
with predictably discrepant outcomes.   Building on the lessons of
96

Larrey and Letterman, countries created evacuation chains that

emphasized early and forward surgery. Disorganized in 1914, by 1915
an effective system was in place. For British and American (after 1917)
forces, the Casualty Clearing Station (CCS) and Mobile Hospital (US)
served as the primary locus for forward care. Functioning sometimes
within enemy artillery range, CCSs expanded to hundreds of beds,
triaging incoming wounded, operating on the injured, and
determining who could return to duty and who required evacuation
for further management   ( Fig. 1.14 ).
97

Open full size image

Fig. 1.14
World War I military surgery.
This busy diorama captures the chaos of a World War I battlefield. In the foreground a team of
surgeons operate in a bunker marked atop by a pitifully drooping red cross. The white clothing and
dressings nod to attempts at sterility, as does the primitive autoclave on the table. Notice, however,
that no members of the team don masks, gloves, or headcoverings. In the background, shellfire
continues as an ambulance either receives or unloads casualties carried by teams of
stretcherbearers over the uneven ground cut by barbed wire and scarred by high explosives.
(Courtesy Science Museum, London. From the Wellcome Collection; available
at https://wellcomecollection.org/works/x7ds6fru?query=great+war+forward+treatment  .)
Surgeons at the CCS confronted two major problems: resuscitation
and wound infection. Despite efforts at early evacuation, the enormous
numbers of casualties (over 60,000 on the first day of the Battle of the
Somme) resulted in patients taking hours or days to reach definitive
medical care, often cold, wet, malnourished, and exhausted.   Those 98

who survived evacuation and triage commonly arrived in shock, a

condition still poorly understood at the time. Contemporary
explanations varied from George Crile's theory of vasomotor
malfunction causing venous dilation to Walter B. Cannon's idea that
acidosis resulted in blood pooling in the abdomen.   In 1917 an Anglo- 49

American conference featuring the world leaders in pathology

convened to discuss the subject but left it unresolved.   Surgeons on 99

the front line noted that “although physiologists have for years past
been trying to define shock for us, we clinicians are fairly well agreed
upon the matter,” diagnosing patients based on tachycardia,
hypotension, tachypnea, and altered mental status.   Treatments 100

varied but centered on keeping the patient warm and dry. Many
doctors attempted fluid resuscitation through saline enemas,
subcutaneous injections, and intravenous boluses of both crystalloid
and colloid solutions, though in volumes (typically less than 1 liter)
that in retrospect explained their relative inefficacy. Toward the end of
the war, blood transfusions became more common with the
establishment of embryonic blood banks ( Fig. 1.15 ).  101

Open full size image

Fig. 1.15
Blood transfusion kit.
This British blood transfusion kit from circa 1917, designed by Geoffrey Keynes, exposes the
challenges of frontline transfusion in the First World War where physicians lacked access to blood
banks. Transfusions were minor surgical procedures, obtaining blood from a willing donor and
directly infusing it into the patient. This kit includes special equipment to regulate the rate of flow.
Keynes went on to found London's blood transfusion service in 1921.
(Courtesy Science Museum, London. From the Wellcome Collection; available
at https://wellcomecollection.org/works/gmz8tngz?query=transfusion+kit+keynes  .)
Patients who survived the initial trauma and shock of their wounds
risked dying from infection. Manure-fertilized fields in France
combined with unsanitary conditions of the trenches where, according
to one military medical manual, “the earth teemed with micro-
organisms” to contaminate wounds.   Despite the acceptance of the
102

germ theory of disease, infection felled thousands of wounded

soldiers, with gas gangrene and tetanus afflicting over 12% of British
cases in 1915, with nearly a 60% mortality rate.   In the first year of
103

the war, an estimated 70% of France's 70,000 amputations resulted

from efforts to control infection.   Before antibiotics, surgeons
104

depended on a combination of débridement and antiseptics.

Hearkening back to Listerian principles, antiseptics included topical
(British and American) or intravenous (German) solutions that killed
cells on contact and included formulas ranging from hyperosmolar
saline to bleach.   The best-known system, the Carrel-Dakin method,
105

included a series of integrated drainage catheters and remained in use

for civilian trauma through World War II (WW II), when penicillin
largely replaced it.   Base hospitals across France had wards filled
106

with Balkan frames to provide traction for fractured limbs

(presumably originating from the Balkan Wars of 1911 and 1912) and
Carrel-Dakin apparatuses for the prolonged process of treating
compound fractures.
These antiseptics buttressed but did not replace effective surgical
débridement. Wounds in the Boer and Russo-Japanese Wars seldom
suppurated, supporting conservative management. 107108 The heavily
contaminated fields of western Europe, and often prolonged
evacuation times, vitiated this doctrine and led surgeons to operate on
almost every penetrating wound, removing dead tissue and foreign
bodies in an effort to prevent infection.   Whereas wound
109

débridement was rare in 1914, by spring 1917 it had become expected

in all armies and has remained a core principle of trauma
surgery.   This strategy of débridement extended to abdominal
103

wounds, as the trauma laparotomy emerged as standard of care by

1916.   A rare example of the military adopting a civilian-initiated
110

therapy, laparotomy dramatically improved outcomes for penetrating

abdominal trauma from mortality rates exceeding 80% in 1914 to
under 40% by 1918.
Later in the war, CCSs began to specialize. Harvey Cushing famously
pioneered modern neurosurgical interventions for head trauma,
although his work had greater historical than clinical
significance.   The advent of gas warfare presented an entirely new
111

type of injury to surgeons who invented ad hoc prophylactic and

treatment regimens that came to include masks, inhaled oxygen,
various emollients for the skin, and venesection.   Surgeons also
112

confronted nonphysical trauma in large numbers, with the label of

“shell-shock” applied to those suffering neuropsychiatric
injuries.   Despite the emergence of various exotic therapies, standard
113

management had surgeons rest patients close to the front lines,

allowing most to return to duty. In orthopaedics, the introduction of
the Thomas splint in 1916 reduced mortality rates from femur
fractures from 80% to nearly 15%   ( Fig. 1.16 ). Operative repair of
114

fractures remained rare, but orthopaedic surgeons parlayed their

success in the Great War into increased professional stature.   The
115

high volume of maimed men catalyzed the growing field of

rehabilitation medicine. 
116

Open full size image

Fig. 1.16
Thomas splint.
One of the original Thomas splints to treat femur fractures that dramatically lowered the mortality
rate from the injury.
(Courtesy Science Museum, London. From the Wellcome Collection; available
at https://wellcomecollection.org/works/mgu6qt9x?query=thomas+splint  .)

Interwar Years
The period between World Wars I and II was notable for several
significant clinical developments. Germans discovered the first
antibiotics in the form of sulfa drugs, which spread throughout the
globe in a continued effort to manage infection. Through most of WW
II, surgeons sprinkled sulfa powder onto open wounds, trying to limit
the bacteria load.   Building on the success in battle, call-in blood
117

donor programs and then civilian blood banks emerged in the 1930s,
first in the Soviet Union and later in the United States and Western
Europe.   In the Spanish Civil War, Joseph Trueta published on the
118

closed treatment of fractures and other wounds, advocating for radical

exposure and débridement, followed by prolonged casting.   For 119

trauma, among the most important contributions was the

demonstration by Alfred Blalock that fluid loss (chiefly blood) was the
primary etiology in shock, and that fluid replacement, in significant
volume, was the first key to immediate therapy.  120

These years are also notable for the first glimmers of organized trauma
care. In 1922 the American College of Surgeons created the Committee
on Trauma (originally the Committee on Fractures), which began to
focus on systemic interventions to improve outcomes for patients with
traumatic injuries both before reaching a hospital and after. The
founding of the American Association for the Surgery of Trauma
(AAST) in 1939 marked an important organizational moment for the
field. The stimulus for the organization came from a 1937 meeting of
the Western Surgical Association, which had only one trauma surgery
paper (on hip fractures) featured on its program. A group of surgeons
recognized the general, national paucity of trauma presentations and
banded together to form a society dedicated to the cross-disciplinary
study and management of trauma.   Composed chiefly of general and
121

orthopaedic surgeons, it met annually and eventually published its

own journal to disseminate both science and practice.   This 122

foundation provided a crucial forum for trauma research, albeit mostly

still anecdotal. Previously a topic of discussion during wars and
frequently ignored in peace, with the AAST and Committee on
Trauma, trauma surgery was starting to emerge as a defined field of
study and practice. But before the society could firmly take root, WW
II broke out.

World War II
Optimal clinical surgery did not change substantially between World
Wars I and II. The operative plan of controlling hemorrhage and wide
débridement remained in place.   Although the CCS that formed the
123

mainstay of operations in WW I did not adapt well to mobile warfare,

the general philosophical and logistical commitment to forward
surgery continued in this conflict through field hospitals and the US
Army Auxiliary Surgery Teams.   The tanks and trucks associated with
124

mobile warfare dramatically increased the number of burn injuries in

combat.   They also combined with airplanes to shorten the time
125

between wounding and definitive surgery. Although aeronautical

evacuation did not extricate men from the front lines, it did transport
them to base hospitals and surgical specialists with an ease and
rapidity heretofore never seen.   It proved particularly valuable for
126

extremity trauma, where prolonged vehicular rides over rugged roads

caused not only suffering but also worsening damage to bone and soft
tissue ( Fig. 1.17 ).
Open full size image
Fig. 1.17
Loading wounded into a C-46 plane for evacuation.
Like blood transfusions, some early attempts at evacuating wounded via airplane occurred in World
War I, but the technology (and military situation) limited its applicability. With the production of more
powerful airframes, aeroevacuation became more common, first in the Spanish Civil War and
especially in World War II. The powerful C-54 enabled transoceanic carriage, bringing injured US
service members to specialists in the United States mere weeks after being wounded. By the end of
the war, almost 1.2 million wounded American soldiers benefited from aeroevacuation.
(From Otis Historical Collection of the National Museum of Health and Medicine. Public domain.)
Building on studies of shock in WW I and the interwar period, military
physicians worked to diagnose the pathology quickly and initially
treated it with large-volume administration of blood plasma, which,
unlike red blood cells, had a long shelf life that facilitated logistics.
However, experience in North Africa quickly demonstrated the
insufficiency of albumin and other colloids.   First the British, then
127

after some delay the Americans recognized the superiority of whole

blood transfusions, prompting a doctrinal shift to prioritize the use of
blood and a major logistical effort to obtain it from donors near and
far   ( Fig. 1.18 ).
128
Open full size image
Fig. 1.18
Blood banking in World War II.
World War II marked a transition to whole blood transfusion for casualty resuscitation. When
demand for blood outstripped local supply, the military and Red Cross coordinated an international
logistical effort to ship American blood overseas. Here, blood collected in the United States makes it
way to the front lines of Belgium in 1944 in specialized refrigerated trucks.
(From Otis Historical Collection of the National Museum of Health and Medicine. Public domain.)
Perhaps most significantly, the United States developed penicillin—at
a cost equal to that of the Manhattan Project.   Widely available to the
129

military by mid-1944, the new “miracle drug” dramatically reduced the

incidence of wound infections. Rapidly replacing the elaborate Carrel-
Dakin method, the medication also permitted more limited
débridement of wounds, enabling conservative surgery to preserve
limbs and tissue. Penicillin epitomized the stimulatory effects of war
on trauma care, marshaling the economic and industrial resources of a
country to address a clear clinical need with evidence of efficacy
demonstrated by controlled hospital trials and broad field experience.

Mid-Century Developments
The war introduced trauma problems that remained for further
research to explain, such as renal failure and burns. The London Blitz
brought the problem of crush syndrome, and its accompanying kidney
injury, to the fore.   Known in Japan and Germany before the war,
130

crush syndrome remained unrecognized in the West until Bywater's

classic description of British civilians suffering from prolonged blunt
trauma after bombings.   Attention to burns also increased in the
131

1940s as a result of military and civilian events. Texts described

attempts at caring for burns since the Egyptian Ebers Papyrus.   For
132

centuries clinicians had recognized that burn patients died from

causes other than the thermal trauma, often attributing deaths to
poisons released by the heat. Frank Underhill's pioneering work in
1920s New Haven demonstrated the critical importance of fluid loss in
patient mortality, prompting a therapeutic turn toward intravenous
rehydration. Later investigators developed specific formulae to
replenish fluid appropriately, accounting for patient weight and burn
size, with E. I. Evans publishing the first in 1952. Multiple variants
followed, including the famous Parkland Formula in the
1960s.   Occlusive dressings, promoted by Harvey Allen in 1942, soon
133

covered burns, although skin grafting, popularized by John Staige's

pinch grafts in 1914, grew more common in the 1940s after the
invention of dermatomes. The disastrous Coconut Grove Fire of 1942
that killed nearly 500 patrons illuminated the importance of these
investigations.   Victims were transported to both the Massachusetts
134

General Hospital (MGH) and Boston City Hospital. Although both

facilities provided modern, efficient care, the MGH focused on fluid
replacement from the new hospital blood bank, as well as pioneering
efforts using penicillin mold.   Whereas about 30% of patients treated
135

at Boston City Hospital perished, none did at MGH. This catastrophe

demonstrated the importance of fluid resuscitation and the possibility
of antibiotics. It also prompted the US Army to create a burn center to
study the pathology and led a young surgeon, Francis Moore, to
research metabolic variables in trauma patients.
By the middle of the 20th century, nations had established markedly
different healthcare systems in terms of specialization, healthcare
access, openness to innovation, and so on. They also experienced
different amounts and proportions (e.g., blunt vs. penetrating) of
trauma. Although trauma pathology is universal, its management in
different healthcare systems varies across the globe. The remainder of
this chapter will concentrate on the United States of America because
of its widespread influence and the import of innovations that
occurred within.

From the Korean War Through the War in Vietnam

Five years after WW II ended, the United States found itself at war
again, this time on the Korean Peninsula. The antibiotic
armamentarium had expanded to included broad-spectrum drugs in
the streptomycin family,   and the military quickly established a trans-
136

Pacific supply chain transporting fresh blood from the United States to
Asia.   Hemodialysis machines, deployed to war for the first time,
137

treated trauma patients in acute renal failure, markedly improving

survival.   By 1953 most combatants wore body armor, increasing
138

survivability and redirecting trauma from the trunk to the

extremities.   Famously, Mobile Army Surgical Hospital (MASH) units
139

provided frontline surgery and supportive care   ( Fig. 1.19 ). Although

140

novel in organization, their conceptual underpinnings date to the work

of Larrey and Letterman. The static nature of the war led to MASH
units functioning as de facto evacuation hospitals; they quickly
captured popular attention, appearing in movies and articles of the
day and ultimately featuring prominently in the television
series M*A*S*H.  141
Open full size image
Fig. 1.19
Mobile Army Surgical Hospital (MASH) unit, Korea.
Surgeons work side-by-side in this undated photo of a MASH unit in Korea. The infrastructure (hung
lights, solid structure with windows) dates it to 1952 or later. Note the glass bottles of blood hanging
from intravenous poles; plastic bags of blood arrived in-country at the end of the war.
(From Otis Historical Collection of the National Museum of Health and Medicine. Public domain.)
At the MASH, wounded service members encountered surgeons
trained far more extensively than in previous conflicts. World Wars I
and II had conclusively demonstrated the benefit of specialized
medicine, but militaries lacked adequate numbers of trained surgeons.
In the United States, residencies in all surgical specialties remained
rare before WW II, educating an elite group of surgeons but leaving
general practitioners to care for the majority of patients. After WW II,
residency positions expanded exponentially.   With the expansion of
142

residencies, specialists (or at least partially trained residents) deployed

to MASH units and other forward hospitals in Korea, providing expert
care. Their difference manifested in vascular surgery. Whereas in
previous conflicts surgeons ligated essentially all damaged arteries, in
Korea they began to repair them with suture and grafts. These efforts
dramatically reduced the amputation rate among the wounded and
helped catalyze the spread of the technique in civilian surgery. 143

Building on experience in the wars, Francis Moore at Harvard

conducted a series of investigations that used radio nucleotides to
establish needed composition of “fluid replacement.”   His studies on
144

the volume of water, nitrogen, potassium, sodium, blood, and other

bodily components and how they changed before, during, and after
surgery resulted in his classic text Metabolic Care of the Surgical
Patient, relied on by a generation of clinicians managing trauma
patients.   Other surgeon-scientists continued Moore's work on burn
145

physiology. With infection now killing the majority of burn patients,

research focused on antimicrobial strategies, including topical agents
such as sulfamylon popularized in the 1950s to parental, broad-
spectrum agents.   The introduction of antibiotics subsequently
146

altered wound pathology. Whereas initially gram-positive bacteria

killed patients, after penicillin, gram-negative rods, and especially
pseudomonas, claimed the greatest number of lives. More recently,
fungi have emerged as the deadliest pathogen.   The persistence of
147

infectious material despite chemotherapy prompted explorations of

effective débridement techniques from baths to surgery, although
interventions on metabolically deranged severely burned patients
carried significant risks. 
148

The characteristics of the Vietnam War distinguished it from other

20th-century conflicts militarily and medically while forecasting
future engagements. Bullets and booby traps replaced artillery as the
primary cause of wounds, with polytrauma becoming the
norm.   Small-unit engagements replaced large-scale battles that had
149

previously swamped military hospitals with thousands of

simultaneous casualties, facilitating evacuation and enabling surgeons
in Vietnam to devote more attention to individual wounded.
Helicopter evacuation, pioneered in WW II and expanded in the
Korean War, became the primary route of evacuation over
uncontrolled, geographically forbidding territory.   Almost 1 million
150

sick and injured service members rode a helicopter to a hospital,

decreasing the time from being wounded to seeing a physician to
around 90 minutes   ( Fig. 1.20 ). This represented a dramatic reduction
151

from prior conflicts, when wounded often lingered for hours on the
field. This speed of evacuation saved lives as the official killed in action
numbers dropped from 21% in Korea to 17% in Vietnam, but it also
brought patients to hospitals who never would have survived to reach
medical care in previous conflicts.   Accordingly, the died-of-wounds
152

rate, a metric that roughly assesses the quality of trauma care, rose
slightly for the first time in over a hundred years ( Table 1.1 ).  153

Open full size image

Fig. 1.20
Helicopter evacuation in Vietnam.
Men rush a wounded American off a UH-1 “Huey” medevac helicopter, which had just extracted him
from a jungle battlefield in Vietnam. Although the US Army used helicopters in World War II and
Korea, the Vietnam War made them an iconic feature of military medicine and demonstrated their
potential for use in civilian trauma systems in the United States.
(Image accessed at http://ausar-web01.inetu.net/publications/ausanews/archives/2016/01/Pages/
AUSAsupportsmedalforVietnamWarDustOffmedicalcrews.aspx  .)
Table 1.1
Died-of-Wounds Rate by War
From Garfield RM, Neugut AI. Epidemiologic analysis of warfare: a historical review. J Am Med
Assoc.  1991;266(5):688–692.
War: Crimean World War World War Korean Vietnam
War I II War War
Died-of-Wounds 20% 6.1% 4.5% 2.5% 2.6%
Rate:
 View full size
Trauma surgery continued with débridement and delayed primary
closure, although whereas in prior wars surgeons closed wounds in-
theater, by Vietnam, with developments in strategic aeromedical
evacuation, they had started evacuating them to base hospitals in the
Pacific rim and even the United States for definitive treatment.
Improved antibiotic armamentarium made destructive exploration for
every foreign body less critical, a trend particularly observed in head
wounds. 154155 Mortality rates for chest and abdominal wounds did
not change significantly between Korea and Vietnam, with advances in
trauma care offset by the severity of patients’ conditions. 156157
Partly due to the nature of warfare and partly from the body armor
worn by soldiers and Marines, extremity injuries were common.
Whereas orthopaedic surgeons previously treated most femur
fractures with splinting or casting, external fixation became standard
of care in Vietnam. They also developed a cast-brace, enabling patients
to ambulate and begin rehabilitation sooner.   Amputations—and
158

especially multiple amputations—increased dramatically in frequency,

with the percentage of amputees losing multiple limbs rising from 5%
in WW II to 19% in Vietnam.   With 75% of amputations traumatic,
159

these number again reflect both the severity of injuries the patients
received and the ability to keep the severely wounded alive long
enough to reach definitive trauma care.  160

Post-Vietnam Trauma Care in the United States and

the Creation of an American Trauma System
Between the 1960s and 1980s, a new standard of trauma care
developed in the United States. Preceding this era, trauma care
consisted mostly of episodic advances in various wars that, in the best
cases, were brought home and applied to civilians. Often, lessons
learned had to be relearned (and re-relearned) with each new war.
Although the AAST and American College of Surgeons (ACS)
Committee on Trauma had started to institutionalize the subject, in
the early 1960s there was still no field of trauma or substantial
infrastructure dedicated to it; by the late 1980s, this had changed. No
single source documents this evolution, and to do so appropriately
would require more space than this format allows, but some broad
outlines and specific examples help convey the magnitude of the
change.   Progress occurred on three broad fronts: (1) the recognition
161

of a major problem that required systemic change in the management

of trauma, (2) clinicians who increasingly focused their efforts on the
management of trauma, and (3) the scientific study of the
pathophysiology and treatment of trauma. The value of the modern
American trauma care system is evident when viewing homicide rates,
which are approaching a half-century nadir despite aggravated
assaults, particularly with firearms, more than tripling in that
period. 162163
Post–WW II America witnessed a dramatic rise in the incidence of
trauma. This increase partly resulted from worsening urban violence,
as assaults, both with and without deadly weapons, grew markedly as
drug wars, mass shootings, and easily available weapons proliferated.
Motor vehicle accidents proved far more epidemiologically significant.
Courtesy of government loans and the GI Bill, America suburbanized
after WW II, prompting a dramatic increase in car ownership and
miles driven.   A “car culture” emerged in the 1950s, with new models
164

applying WW II engineering to create more power, higher speeds, and

faster acceleration.   President Dwight D. Eisenhower designed the
165

interstate system, carrying passengers—and many future trauma

patients—around the country.   Consumer activists such as Ralph
166

Nader warned of the danger in publications such as Unsafe at Any

Speed.   The American medical profession worked with the automobile
167

industry and government regulators to improve the safety profile of

cars, leading to changes such as headrests to prevent cervical injuries
and guardrails on perilous roads; other efforts, such as seatbelts and
drunk-driving legislation, took decades to implement broadly. 168169
As trauma spread through America, so too did its study expand from a
few research and military hospitals to a broader array of facilities.
Burn therapy and investigation, for example, spread nationwide as
Shriners Hospitals opened in the 1960s in cities across the country.
The first International Congress dedicated to burns took place in 1960,
and the American Burn Association was founded in 1968.   These 170

professional movements created an infrastructure that enabled and

enhanced the development of burn care.   The localization of trauma
171

care also resulted from the influence of the “doctor draft,” wherein
physicians learned trauma management in the military and then
applied those lessons back at their civilian institutions.   Curtis Artz,
172

for example, an Army researcher in San Antonio and the Korean War,
brought his investigations to the University of Texas at Galveston as
the Shrine Professor, then the Medical College of South Carolina as
chairman. John Howard, who directed the Army Research Team in
Korea, subsequently chaired departments at Emory Hahnemann and
Toledo. These men and others like them fulfilled a crucial role in
moving physiologic research to trauma units across the nation.
In 1966 the National Academy of Science published its landmark
report, Accidental Death and Disability: The Neglected Disease of American
Society .   It noted that in 1965 alone, 52 million accidental injuries
173

killed 107,000 Americans, disabled 10 million, and cost the economy

roughly $18 billion—an extraordinary burden to society. Moreover,
American society was both unaware of and ill-equipped to manage
trauma. The report noted with bitter irony that American GIs
wounded in the middle of a jungle in Vietnam often received better
care than Americans injured in a major metropolis and urged both
political and medical interventions to address this disparity. This
difference inspired a 1970 trial, Military Assistance to Safety and
Traffic, in which civilian medical authorities in five American cities
used military helicopters equipped with uniformed corpsmen to speed
automobile accident victims to a hospital. The project clearly
demonstrated the feasibility of civilian helicopter evacuation, although
the medical impact was difficult to measure as the quality of trauma
care, pre– and post–emergency department, was still evolving.   The 174

program continued through the mid-1970s, largely at the behest of the

Army's leading advocate of helicopter evacuation, Spurgeon Neel, who
convinced American leaders in medicine and politics that aerial
transport would particularly improve rural medical care. 175176
The creation of effective ambulance systems represented a significant
medical and organizational effort. Despite the attention to early
medical evacuation in wars, in 1966 morticians transported over 50%
of injured Americans in hearses—because those were the only vehicles
communities owned capable of carrying a stretcher.   Accidental Death
177

and Disability catalyzed the US Congress to pass the Highway Safety

Act in 1966, which, along with the National Academy of Science,
provided funding and direction for nascent trauma efforts.
Ambulances themselves changed form, evolving from hearses to the
van and box shapes that allowed paramedics to provide care en route.
R. Adams Cowley extended this concept to air-based ambulances.
Building on the use of military helicopters, in 1969 he established a
state-supported helicopter evacuation system to cover the entire state
of Maryland that enabled the most severely injured to access the most
advanced healthcare facilities rapidly.   This concept eventually
178

spread to cover the United States.  179

Formally trained paramedics began staffing these ambulances. Before

the 1960s, the majority of first responders had little or no training in
treating injured patients. The American Society of Orthopaedic
Surgeons took the lead in trying to solve this issue, sponsoring a
course for paramedics starting in 1964 and publishing the definitive
training textbook in 1971. That same year saw the first certifications,
based on uniformed standards guided by a national registry of
Emergency Medical Technicians.  180

Although the federal government helped guide and fund trauma

systems, ultimately states held responsibility for implementation.
Illinois represented the vanguard of trauma care, with Cook County
Hospital as its headquarters.   Under the direction of David Boyd, it
181

pioneered a systems approach to trauma care that coordinated

prevention, prehospital care, and specialized regional trauma
centers.   Importantly, it also capitalized on intensive care units
182

(ICUs)—relatively new additions to American hospitals—and

demonstrated the value of having dedicated space for trauma patients.
The 1973 Emergency Medical Services Systems Act reinforced this model
and catalyzed its spread around the country.   Education for
161

paramedics continued to expand throughout the 20th and 21st

centuries. A similar training regimen developed for physicians through
the Advanced Trauma Life Support (ATLS) course.   Created when a
183
plane crash transformed orthopaedic surgeon James Styner and his
family into patients deeply dissatisfied with the care they received at a
rural hospital in 1976, by the 1980s ATLS evolved into an international
course run by the ACS to ensure that providers encountering trauma
are well versed in its initial management.
The creation of injury scores helped categorize trauma patients and
facilitated research by enabling interfacility comparisons. Burn
surgeons classified patients based on total body surface area afflicted.
Other surgeons expanded this idea to polytrauma. Susan Baker and
colleagues at Johns Hopkins assessed automobile accident victims
initially using the American Medical Association's Abbreviated Injury
Scale, a metric designed to help car manufacturers develop safety data.
On this foundation, they built the Injury Severity Score (1974) to
define objectively and translationally the gravity of trauma.   Shortly
184

thereafter, the Glasgow Coma Scale emerged, which proved

particularly valuable in an era before rapid, widely available cross-
sectional imaging of the head.   A 1978 multicenter trial confirmed its
185

prognostic accuracy, interhospital applicability, and broad

utility.   Despite these advances, trauma care remained heavily based
185a

on personal experience through the 1970s and early 1980s, epitomized

by the ongoing debate that decade over the utility of Military Anti-
Shock Trousers (MAST) 186187 ; a Cochrane review eventually
demonstrated no benefit to their use. 188

Modern Trauma Physiology and Damage Control

Surgery
Through the 1980s, trauma doctrine, heavily influenced by the
penetrating trauma and blood loss of the Vietnam War, focused on
prompt anatomic repair and blood pressure restoration. Hepatic
trauma simultaneously demonstrated progress since WW II—with the
case fatality rate among the best surgeons dropping from 27% to 20%
—as well as ongoing challenges. 189190 Before WW II, surgeons
managed hepatic trauma almost exclusively with conservative packing,
but leaders of the postwar generation had developed new methods to
control hemorrhage and débride devitalized tissue in an effort to
reduce death rates.   Despite some success with cauterization
191
technologies and diverse techniques such as arterial ligation, blood
loss continued to determine, and often doom, outcomes.   Between
192

1968 and 1973 Charles Lucas in Detroit conducted a prospective trial

to evaluate the results of the various approaches and found that
packing and later surgery had some practical benefits.   The trauma
193

team at Houston's Ben Taub Trauma Center further focused attention

on packing to control hemorrhage and operating to make definitive
repairs later. 
194

Meanwhile, efforts to understand the pathophysiology of trauma

continued. Laboratory investigations documented coagulation
problems specific to the trauma patient. 195196 Kenneth Mattox and
collaborators in Houston focused increasingly on the fact that
maintaining blood pressure at normal levels led to further bleeding
and increased coagulation complications, and they proposed a
doctrine eventually dubbed permissive hypotension. Simultaneously,
physicians recognized other problems associated with massive
transfusion, including significant drops of core temperature despite
novel technologies such as blood warmers.   Recalling the known
197

association of shock and cold patients, surgeons began exploring this

variable among the traumatically injured. 198199 Prospective studies
soon documented both the frequency and high morbidity of
hypothermia in this population. 200201 Resulting from this research,
investigations of penetrating liver trauma introduced a waiting
approach using abdominal packing for patients “in whom
coagulopathies, hypothermia, and acidosis make further surgical
efforts likely to increase hemorrhage.”   Studies such as these
194

identified a so-called lethal triad: how coagulopathy, hypothermia, and

acidosis additively lead to death. 
202

The 1980s witnessed a dramatic increase in penetrating trauma,

especially for urban hospitals. 203204 The proliferation of gunshot
wounds emphasized the importance of exploratory surgery despite
cross-sectional imaging. But the proliferation of laparotomies
reidentified the challenge of hemorrhage control in coagulopathic
trauma patients. Harlan Stone at Emory, perhaps best known for his
burn studies, presented a series of cases that demonstrated survival
benefit of abbreviated initial surgery to tamponade bleeding followed
by resuscitation and subsequent reparative operations.   Other teams
205

soon replicated this experience. 206207 The Western Association

sponsored a multicenter trial and confirmed that the staged approach
was safer for patients with liver trauma.   This stratagem then
208

expanded to encompass nonhepatic injuries as well. 209210 Success

across broad presentations of trauma accelerated a widespread return
to staged surgery,   soon given the military-derived name of damage
211

control surgery by the team at the University of

Pennsylvania.   Surgeons sought to lower mortality rates by returning
212

to a multistep approach: exploration and temporary hemostasis

followed by resuscitation in the ICU, with subsequent definitive
operations when clinically appropriate. Infections remained an
important consideration, particularly with spread of antibiotic
resistance in hospitals and communities. By 2000 damage control
surgery had become standard of care, although recent studies have
since questioned its overuse. 
213

Education and Systems

Applying these advances proved challenging, and for most of the 20th
century hospitals varied enormously in their ability and willingness to
care for trauma. Patient outcomes ranged accordingly. Emergency
medicine as a field evolved in this same era and took over
management of minor injuries.   But significant trauma required
214

expedient, multidisciplinary engagement. It also demanded

competent, trained surgeons. Surgeons who encountered trauma in
the 1960s, 1970s, and 1980s were mainly generalists who spent most
of their clinical time engaged in other, more structured and planned
surgical interventions. Outside a few centers, specialized trauma
surgeons did not exist, and patients suffered. Many Cold War–era
surgeons at least had some exposure to military medicine and thus
trauma indoctrination through the physician draft, but this ceased in
1972. Surveys from the early 1990s clearly showed broad
disenchantment with trauma care among residents.   For various
215

medical, social, and economic factors, trauma fellowships started in

the 1970s and have expanded and regularized, particularly since the
1990s; they frequently incorporate critical care components.   Most
216

major hospitals today benefit from specialized, fellowship-trained

trauma surgeons. As penetrating trauma has decreased in prevalence
since the 1990s 217218 and management of blunt trauma has become
progressively nonoperative,   trauma surgeons have increasingly
219

assumed acute care surgery roles in the past two decades.  220

Effective trauma care also requires expensive, advanced technology

such as computed tomography scanners, ventilators, and ICUs.
Recognizing both the complexity and importance of effective hospital
trauma care, the ACS Committee on Trauma established a trauma
center verification review process in 1987.   Establishing and
221

enforcing standards, it classified hospitals into the now-familiar level

I, II, or III trauma centers. The recently developed injury severity
score demonstrated the survival benefits of patients receiving care at a
trauma center compared with another hospital and helped drive the
expansion of centers   ; the benefits remain apparent today.   Since
222 223

2008 participation in the Committee's National Trauma Database

(founded 1989) has been mandatory for designated trauma centers.
Much like the Medical and Surgical History of the War of Rebellion, this
database crucially avails researchers of data that enable the evaluation
and improvement of trauma care.   When the US military deployed to
224

Iraq and Afghanistan, it built on concepts such as Medical and Surgical

History, Norman Rich's Vietnam Vascular Registry, and the National
Trauma Database to create a similar infrastructure to track, manage,
and improve the care wounded service members received.  225

War on Terror
Since 2001 the United States and its allies have engaged in an ongoing
war with terrorists around the globe, resulting in a new flood of
casualties and concomitant changes in trauma
management.   Organization changed as Forward Surgical Teams and
226

Combat Support Hospitals (CSHs) replaced MASH

units.   Explosions, usually in the form of improvised explosive
162

devices, now caused the vast majority (72%) of casualties, with

gunshot wounds causing 18%.   These statistics do not include
227

traumatic brain injuries, a pathology brought to the fore by the War on

Terror.   They further fail to account for the psychiatric trauma that,
228

although also not immediately apparent, has resulted in significant

morbidity and mortality. Explosions are also more likely to cause
polytrauma and blast injuries, which, combined with the improved
body armor and rapid helicopter evacuation, has been delivering
heretofore unsurvivable injuries to surgeons. 226

Many of the civilian advances of the 1970s to 1990s proved irrelevant

or sometimes even counterproductive in wartime. The 1993 Battle for
Mogadishu demonstrated some challenges physicians faced
integrating military and civilian trauma systems. In particular, the
ATLS protocol seemed less applicable to combat scenarios prompting
the military, led primarily by Frank Butler, to develop a new paradigm
called Tactical Combat Casualty Care (TCCC).   Implemented in
229

Special Operations units in the 1990s and then throughout the US

forces by the mid-2000s, TCCC prioritized hemorrhage control to
minimize preventable death. Among other interventions, TCCC
advocated for tourniquet use. Tourniquets, described since antiquity,
have waxed and waned in popularity over the centuries, fading from
use in trauma almost entirely by the end of the 20th
century.   Accepted doctrine taught that applying tourniquets
230

intrinsically sacrificed the limb; even obtaining effective devices

proved difficult. But in Afghanistan and later Iraq, they quickly proved
effective at controlling hemorrhage, saving lives without costing a
limb.   By 2005 the US Army Surgeon General recommended that
231

every deploying soldier carry one; they have since become common in
ambulances and emergency departments in the United States   ( Fig.
232

1.21 ).
Open full size image
Fig. 1.21
Global War on Terror.
This image of the lower extremities depicts the devastating effects of improvised explosive devices
on service members serving in the Global War on Terror, as well as the importance of tourniquets
(here, the bilaterally placed Combat Application Tourniquet) in preventing exsanguination.
(From Nessen SC et al. War Surgery in Afghanistan and Iraq  . Washington, DC: Borden Institute;
2008:288. Public domain.)
While tourniquets and new hemostatic dressings helped control
bleeding, surgeons in hospitals worked on new methods to replace
that which was lost. In the 1960s large-volume crystalloid
resuscitation supplemented—and in some cases supplanted—whole
blood in trauma cases.   In Iraq, studies showed that 1:1:1 volume
233

replacement with blood, fresh-frozen plasma, and platelets

(mimicking whole blood) led to higher survival rates in trauma
patients.   Moreover, instead of emphasizing arbitrary blood pressure
234

goals, with concomitant high volumes of fluids, surgeons increasingly

practice permissive hypotension. This strategy emphasizes physiologic
goals of critical organ perfusion. Both permissive hypotension and
1:1:1 volume replacement have since spread throughout military and
civilian practice in the care of trauma patients.
 Conclusion
Traumatic wounds have afflicted humans since the emergence of our
species, but human efforts to prevent, control, and treat such
pathology have nearly as long a history. Dating from the first medical
treatises written nearly 3500 years ago to ongoing efforts in military
and civilian hospitals today, healers have identified, classified,
researched, and managed traumatic injuries. Initially centered on
military conflicts, trauma care in the past half-century has seen a more
sustained, scientific, and broader effort than ever previously
marshaled, with correspondingly improved patient outcomes.
Throughout these millennia, advances in trauma have depended on
developments in medicine, surgery, and society. This interdependence
will continue in the future as we continue to care for the wounded
patient.

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