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Diagnosing historic American military medical innovations.

The U.S. Navy hospital ship Comfort steamed toward Port-au-Prince, Haiti, days after the devastating January earthquake that killed more than 200,000 people. A fully equipped floating hospital and one of the largest trauma facilities in the United States, with the capacity of holding more than 1,200 military medical personnel and 1,000 hospital beds, the Comfort was launched in 1987 as a treatment facility for combat casualties and to support disaster relief and humanitarian operations. In a country that lacked adequate medical facilities even before the earthquake, the Comfort provided definitive care on its seven-week mission, treating 871 patients (540 critically injured) and performing 843 surgeries, according to the Navy.

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In one of the first medical procedures of her mission to Haiti, a young man who had sustained blunt head trauma was whisked to the radiology department and slid into the center of the donut-shaped, state-of-the-art CT scanner for diagnosis. The help provided him echoes critical antecedents in American military medical history. For it was in these same waters near Haiti, surrounding the Greater Antilles, during the 1898 Spanish-American War that the x-ray was first used by the American Medical Corps in wartime. As Haitians received vital treatment aboard the Comfort earlier this year, soldiers and civilians benefited from crucial cutting-edge U.S. military medical practices more than 100 years ago.

The period between the late 19,h and early 20"' century was marked by a radical transformation of medicine, especially in biomedicine, technology, specialization and rehabilitation. Wartime medical practice saved lives and served as a training ground and experimental laboratory, substantively influencing military and civilian medicine. New technologies like radiographic imaging saved soldiers in the field. The evolution of others such as prosthetics, coupled with the rise of medical specialization such as orthopedics and plastic surgery, also helped the wounded reclaim their lives and reintegrate into society.

X-ray developments marked the spot

X-rays were discovered late in 1895. Their usefulness in pinpointing the location of bullets within the body was immediately recognized and soon x-ray photographs were used by Italian, British and German military doctors in late 19Ih-century conflicts. By the time of the Spanish-American War less than three years after their discovery, practical diagnostic use of radiographs to treat wounded soldiers was conducted at permanent hospitals in the United States and on U.S. Army hospital ships such as the Relief. Dr. William Gray served as a photomicroscopist and roentgenologist (a specialist in imaging technology like the x-ray) aboard the Relief, which was characterized as the best-equipped vessel of her kind in the world. Gray, of the Army Medical Museum in Washington, D.C., had experimented with x-rays there as early as June 1896.

The shadows from x-rays revolutionized the diagnosis of war injuries by revealing fractured bones as well as locating bullets and shrapnel that often ripped haphazardly through the body. Before the introduction of the x-ray, military surgeons investigated wounds "by feel" with their finger, probe or other instrument. This was an inexact exploratory process that, even with antiseptic procedures, routinely compounded the projectiles' destructive effect and led to infection and other complications. In fact, seven soldiers died of infectious disease for each one who died from wounds sustained in battle. As a result of following a "do not touch" policy of limited surgical intervention when appropriate, 95 percent of those wounded in the Spanish-American war recovered, and x-rays factored into this success rate considerably.

Despite the technological revolution it helped introduce into the practice of military surgery, radiological progress in the Army Medical Department languished after the conclusion of the Spanish-American War. But veterans, who had gained an appreciation for this pain-free technology during wartime, called for x-ray diagnoses after returning home.

One was a retired colonel shot while campaigning for political office in Milwaukee in 1912. He was literally saved by his speech, the notes to which, folded and placed in his breast pocket along with his spectacle case, absorbed the impact and deflected the bullet. X-rays confirmed its location. A decision was made not to operate and the bullet remained harmlessly within his chest wall for the next seven years until he died. This former soldier, celebrated for the charge up San Juan Hill as leader of the Rough Riders during the Spanish-American War, was former President Theodore Roosevelt. He was again running for the highest office in the land, this time on the Progressive ticket, after having served as commander in chief from 1901 to '09 as a Republican.

World War I, which began in 1914 although American involvement was not to commence until 1917, played a pivotal role in legitimizing and popularizing the use of x-rays. Half of all American doughboys hospitalized in France were x-rayed. Improved materials and better techniques, and the relatively inexpensive manufacture of portable units, allowed for large-scale production of radiographs close to battle lines. Because of complex injuries and high casualty rates in the Great War, radiologists became indispensible to military surgeons. After the Treaty of Versailles in 1919, radiologists professionalized their discipline and the use of x-rays attained sound footing within the practice of military and civilian medicine.

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Reconstructive surgery began In WWI

The medical response to devastating wounds unique to the Great War also gave rise to radical reconstructive surgical techniques and innovative treatments to improve healing. Machine guns, heavy artillery, armored tanks, and gas warfare leveled casualties on a massive scale. While numbers vary by source, more than 110,000 American soldiers died and almost 206,000 were wounded, and 24 percent of all American physicians served in the Army. Engaged in trench warfare, thousands of soldiers sustained horrific facial wounds. Harold Gillies, a London otolaryngologist (ear, nose and throat specialist) serving in the Royal Army Medical Corps, pioneered the treatment of surgery of the face, taking into account not only the repair of damage but also the patient's post-operative appearance. He is regarded as the father of plastic surgery, a specialty that stemmed from injuries unique to the war.

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An estimated 20,000 patients from the war had brutalized, mutilated faces: gaping cheek wounds, severed ears, empty eye sockets and missing jaws. The work of plastic and maxillofacial (facial and jaw) surgeons attempted to balance functional as well as cosmetic results. Reconstructive surgery was undertaken in a regimen of multiple tedious procedures. Flaps of skin, bone grafts and improvised appliances constructed of wire, leather, plaster and metal were creatively manipulated in the kind of work that civilian surgeons and dentists would seldom if ever experience. Oculists, speech instructors, engineers, and sculptors might join a reconstructive team. For example, an American sculptor, Anna Coleman Ladd, travelled to Parrs in 1917 to craft facial masks for French soldiers at the American Red Cross Studio for Portrait Masks. She produced approximately 185 custom-made facial masks for soldiers, concealing disfigurement with thin pieces of painted metal. The soldiers with irreparable traumatic damage to their faces were able to return to their families and workplaces under concealment.

Meanwhile, Vilray Blair, head of the Armed Forces plastic surgery section during World War i and a leader in post-traumatic facial reconstruction, learned techniques from Gillies before returning to the United States at the end of the war. Blair set up teams of surgeons and dentists to treat complex maxillofacial injuries and went on to form one of the largest multidisciplinary teams in the specialty at Walter Reed (Army) Hospital, in Washington, D.C., with additional facilities at Jefferson Barracks, Mo., and Ft. McHenry, Md.

Prosthetics supported the wounded

Artificial limbs merit attention here. Even though the recorded history of the use of artificial limbs is long, in American military medicine the Civil War was the first period in which masses of soldiers were outfitted with rudimentary artificial limbs due to amputations. During World War I, improvements in prosthetics occurred: greater standardization in the manufacturing process that made possible high-quality, mass-produced units for a range of functional options.

Alongside these functional improvements, reconstructive and rehabilitative programs were initiated by the military. Focused on rebuilding individual soldiers' lives, these programs offered customized workshops extending from physiotherapy to vocational training such as welding, drafting, painting, and even the crafting of artificial limbs. These programs served the dual aim of rehabilitating the disabled and addressing wartime labor shortages through preparation for reentering the job market. These reconstructive and rehabilitative programs also fostered the establishment of the new medical professions of orthopedics and occupational therapy.

More wartime injuries need addressing

The demands of war have elevated the efficiency of emergency and long-term medical care. Much has changed through successive waves of medical technological innovation, adaptation and adoption in the past 100-plus years. Today, wars in Iraq and Afghanistan bring new challenges to military medicine. Soldiers are experiencing traumatic brain injury, polytrauma and massive blood loss. Emerging technologies, coupled with the skills of military medical personnel, continue to save lives on the battlefield and assist wounded and disabled service members--not to mention injured others in troubled lands like Haiti--in returning to a life of health and dignity.

Editor's note: The National Museum of Health and Medicine, which provided the photos for this article, was founded in 1862 as the Army Medical Museum. For more information, go online to nmhm.washingtonde.museum.

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James Curley is a collections manager in the Historical Collections Division of the National Museum of Health and Medicine, Armed Forces Institute of Pathology. After earning a psychology degree from St. Louis University, he has accrued more than 15 years of experience working with special collections in medical historical museums, libraries and archives including at the Wangensteen Historical Library of Biology and Medicine at University of Minnesota and the archives and rare books section of the Bernard Becker Medical Library, Washington University in St. Louis. He is vice president of the Medical Museums Association. Email him at james.curley@afip.osd.mil.
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Author:Curley, James
Publication:Phi Kappa Phi Forum
Geographic Code:1USA
Date:Jun 22, 2010
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