Battlefield medicine, also known as field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. With the advent of advanced procedures and medical technology, even polytrauma can be survivable in modern wars. Battlefield medicine is a category of military medicine.
History Antiquity
During the 4th century BC, Alexander the Great (July 356 BC – June 323 BC) ran a lengthy military campaign, creating one the largest empires in history. During his military campaigns, tourniquets were used to slow the bleeding of wounded soldiers. Romans used them to control bleeding, especially during amputations. These tourniquets were narrow straps made of bronze, using leather only for comfort. In the 1st century BC, the Roman army used spider webs and honey-soaked bandages as field dressings. Wounds were packed with webs before being wrapped in honey-soaked bandages. The webs served as a natural fungicide while the honey staved off bacterial infection. Field healers provided wounded soldiers with amulets associated with their circumstances. This appears to have been effective for the combatant's mental health.
In 3rd century China, bamboo slips from the Han dynasty (202 BC – 9 AD) list injuries sustained by soldiers on the front line and from infighting. Illnesses related to the digestive and respiratory systems were also included. Medical treatment was limited and comprised such treatments as acupuncture, applications of plaster, and drugs, the latter being the most common. The practice of cranioplasty, or skull repair surgery, may have originated in pre-Incan Peru. Skulls with evidence of cranioplasty have been found more commonly in military burial grounds than residential ones, and primarily in male skeletons, suggesting the practice was mainly performed as a result of traumatic battle-related injury. Various materials were used to graft skull injuries, including non-natural and organic materials, such as gold and silver plates, shells and coconut.
Middle Ages
The Middle Ages saw further developments in battlefield medicine. The Crusades allowed for significant development of trauma surgery and military medicine. In 1112, the first king of the Crusaders ordered a hospital to be built. This hospital was shown to have military medicine uses after 750 patients were admitted in a 24-hour period after a battle in November 1177. This hospital utilized medicinal traditions from Schola Medica Salernitana, a prominent medieval medical school located in Salerno, such as examining the urine. The practices at the hospital were also influenced by Byzantine and Islamic methods. Despite these hospital systems and the recent invention of the tourniquet, most soldier fatalities on the battlefield were due to a fatal loss of blood. In order to return deceased crusaders' bodies home, practices like boiling the body to remove the bones, dissecting out important organs like the heart, and packing the body with salt were all common practices. This practice of dismemberment for transport occurred across Europe until a decree banning it was issued in 1299 by Pope Boniface III. However, it continued illegally after. Notably, crusaders performing such preservations learned a significantly better anatomical knowledge of the human body. As more soldiers were brought into the Crusades, more medical interventions for fatal blood loss were introduced. For example, texts from Islamic Spain describe an early cauterization method to stop arterial bleeding. This method involves using a hot olive cautery, a metal rod with an olive-shaped tip, to burn the artery shut. Performance of this procedure would be complicated by blood filling the site and making both the vessel and instruments slippery. Other evidence of surgical technology included an unspecified, specially designed surgical instrument for John Bradmore's removal of an arrow from Prince Henry's face after he was wounded in 1403 during the Battle of Shrewsbury. Another notable innovation with a modern counterpart is an early stretcher, likely made from wicker over a frame. This stretcher appears in a manuscript from . Simple stretchers were commonly used in militaries through the middle of the 20th century. Ambulances as well were first used by Spanish soldiers during the Siege of Málaga in 1487, a part of the campaigns to seize control of southern Spain. Authorized by Isabella I of Castile, the ambulances were largely ineffective, though they were perceived as critical to Spanish morale.
Battlefield medicine also appears in classical medieval texts such as Wolfram von Eschenbach's (1160/80 – c. 1220) Parzival, first published in 1210. Wolfram von Eschenbach was a German knight, poet and composer, regarded as one of the greatest German writers in national history. A scene in the book describes a wounded soldier with internal bleeding in his chest. The book explains that the soldier was thrown from his mount after being struck by a lance that pierced his shield. After, a procedure similar to a modern-day thoracostomy, inserting a tube into the chest to release blood or fluid, is described. A similar procedure done for an accumulation of pus in the chest was described as early as 460 BC, by Hippocrates, (460 BC – 370 BC) an influential medical figure from Kos. Galen (129 – 216 AD), another influential medical figure, describes the procedure roughly 500 years later again for pus and not blood.
Early modern period The early modern period brought several large changes to the conduction of warfare, which in turn brought major developments to medicine. For one, political changes like the formation of nation-states meant that armies were now national institutions, and military medicine became an established professional field. Political conflict between emerging nation-states meant more organized warfare and larger conquests, both in duration and number of soldiers, thus requiring more surgeons and physicians to accompany. Social and cultural trends also impacted medicine and medical advancements. At the beginning of the 16th century, it was generally not socially accepted to alter the human body away from its natural form, even if that meant danger, or even death. Amputation was only accepted in cases of necrosis. Over the course of the 16th and 17th centuries, this convention gradually faded, allowing for more and more alterations to the body for the sake of health, including a gradual accepting of amputation as a lifesaving practice. Organized armies brought army surgeons along on their conquests; these surgeons were more specialized and more highly respected than civilian barber-surgeons, and they were trained to the same battle standards as soldiers, but better paid. Surgeons' social status grew significantly during this time, as the practical skills and handiness with tools was far more useful than a physician's knowledge of internal ailments in situations of dire injury. This rise in reputation was also seen as a result of surgeons treating noblemen and royalty in battle, then developing a lasting rapport with them.
Triage Though the early modern period in general was associated with new military centralization, The Napoleonic Wars (1803–1815) brought never-before-seen centralization to battlefield medicine, as armies grew to large sizes of 100,000 or more. The practice of triage was pioneered by Dominique Jean Larrey, Napoleon Bonaparte's surgeon-in-chief of the Imperial Guard during the Napoleonic Wars. He also pioneered the use of ambulances in the midst of combat, called ('flying ambulances'). Prior to this, military ambulances had waited for combat to cease before collecting the wounded by which time many casualties had succumbed to their injuries. Despite his valuable advances in treatment for the wounded, the conquest Larrey accompanied was an enormous failure for the French Empire, as factors outside of his control, starvation, epidemic disease, cold, caused unavoidably high casualties
Gunshot injuries Warfare with gunpowder was rapidly becoming commonplace beginning in the early 16th century, a development that had many consequences for medicine. Prior to gunpowder weaponry, any injuries sustained in battle were caused by weapons driven by human force, and thus only caused simple fractures easily treated with non-invasive setting techniques. Newer, more powerful weapons brought more complex fractures and injuries involving projectile artillery debris that easily caused infections when removed from wounds without sterile technique. Further, guns enabled soldiers to become more accurate shots in shorter training times, leading to an increase in head injuries as soldiers aimed to cause maximal damage to their enemies' forces. In 1497, German surgeon Hieronymous Brunschwig (1450–1512) published the first known book discussing treatment of gunshot wounds and advocating for cauterization to stop bleeding, which at the time was performed with boiling oil. This practice was effective but painful, and also destroyed healthy tissue that would be necessary for forming amputation stumps. In the early 18th century, new developments like the invention of the screw-type tourniquet (Jean Louis Petit, 1718), forceps as means of removing bullets, and wound debridement meant even safer treatment of critical battlefield wounds.
Amputation and prosthetic limbs Given the changes described above, conversations amongst surgeons on nuances of amputation, such as methods of stopping bleeding, grew. French military surgeon Ambroise Paré (1510–1590) pioneered modern battlefield wound treatment and mainly contributed to the use of dressing to treat wounds and the use of ligature to stop bleeding during amputation. His advocation for ligature, as well as his invention of a precursor to the modern hemostat, was critical for enabling amputation to become commonplace, as before it was not possible to create stumps without risk of hemorrhage. When he first began his career as a military doctor, he did follow the tradition of cauterization, but eventually ran out of oil, leading him to turn to more experimental techniques. He developed an experimental medication to treat wounds with a solution of egg yolk, rose oil, and turpentine, and noted his surprise to find that it (along with ligature) reduced pain and inflammation in his soldiers.
Paré's strong defense of ligature over cauterization contested Brunschwig's doctrine, but also re-ignited ideas first proposed by much older medical authorities like Galen and Gui de Chauliac, both proponents of ligature for stopping bleeding of all wounds. Prior to Paré's interventions, it was believed that gunpowder was poisonous and that cauterization was necessary to burn the poison away, but Paré proposed, controversially, that people who died of gunshot wounds in fact died because of tissue death and wound severity, not poison, thus any method of stopping bleeding (i.e. ligature) would be sufficient. Paré also made contributions to neuroscience; in his 1545 publication on wounds, "The Method of Curing Wounds Caused by Arquebus and Firearms", he pays special attention to head wounds, and he was also one of the first documented medics to comment on concussion.