Navy Medicine in Support of Civilian Authorities

In the past, I’ve published a couple of articles on the Navy’s support to civilian medical authorities during the 1918 influenza epidemic, when civil facilities and personnel were overwhelmed by the sheer volume of sick people who needed care. In another article , I added a “what of today” piece in which I discussed civil-military lessons learned from the Hurricane Katrina disaster, and  then-current directives directing or permitting military installations and their personnel to support civil authorities in planning and responding to medical and natural disasters. I also pointed out that such arrangements, at the time, were based pretty much on “handshake” agreements between local military bases and surrounding civilian health and disaster planning agencies.

Late last week, Captain James Bloom, MC, USN (Ret), who regularly emails short naval historical vignettes under the rubric “Today in Naval History”, posted this piece on a Navy diving medicine response, to wit (with Captain Bloom’s permission):

28 JULY 2002

TRAPPED MINERS

The evening of 24 July 2002 was unremarkable for 18 miners working the Quecreek deep shaft coal mine near Somerset, Pennsylvania; that is until they accidentally broke through a thin wall separating them from the nearby Saxon mine. The abandoned, flooded Saxon shaft was errantly shown on maps to be several thousand feet away, but in seconds 150 million gallons water poured into the Quecreek shaft. Nine miners scurried to safety; nine more struggled to reach the highest point within their subterranean tomb. Here the rising water compressed the residual air into a bubble just large enough to keep the nine from drowning. Within hours a six-inch pipe reached the miners through which heated, pressurized air was pumped to hold the chilly, rising water at bay.

Breathing pressurized air at their position 240 feet below the surface made the miners effectively divers, equivalent to an air-saturation dive 40 feet below the sea. Experience with even shallow water marine rescues had taught that the sudden decompression of rescue was likely to result in death or serious injury from “the bends.” The Navy was called and within hours CAPT Dale Molé from the Bureau of Medicine and CAPT Henry Schwartz from Naval Sea Systems Command joined emergency physician LCDR Nick Colovos and 60 Navy personnel from eight commands at the scene. Recompression chambers were quickly flown in–nine multi-place chambers and five transportable “Hyperlite” chambers. Set up in a nearby barn, the assemblage represented the first time so much recompression capability had been assembled in one location.

A special drilling rig had to be transported from West Virginia to sink a 32″ rescue shaft. It would be used to lower a cylindrical basket through which the nine could be raised one-by-one. A steel cap, the “iron maiden,” was built over the site to maintain air pressure in the shaft while the rescue proceeded. At the mine entrance over a mile away high-volume pumps strained to drain as much water as possible from the flooded mine. This paced removal of water proved very helpful as it lowered the pressure in the miner’s air bubble about one foot of seawater each hour–the perfect rate for decompression. But nothing more had been heard from the miners. For two torturous days Navy personnel worked, sympathized with families, and rehearsed their rescue scenarios.

Finally at 2215 on the 27th the rescue shaft reached the trapped miners. Video equipment borrowed from the Navy-Marine Corps News crew and attached to the first rescue basket recorded all nine alive! CAPT Schwartz escorted the first rescued miner to a nearby trauma center, where one of the recompression chambers proved necessary and helpful. By 0245 all nine had been rescued.

Watch for more “Today in Naval History” 1 AUG 19

CAPT James Bloom, Ret.
Molè, Dale, “Steaming to Assist at the Quecreek Mine Disaster.” Navy Medicine, Vol 93 (5), September/October 2002, pp. 18-29.

Oral History, CAPT Dale Molè, MC/USN, August 2002.

ADDITIONAL NOTES: This rescue was the first in the 20-year experience of Pennsylvania Bureau of Deep Mine Safety representative Jeffrey Stancheck in which all the trapped miners were rescued safely. The assistance of the US Navy proved invaluable. Indeed, when the first miner was brought to the surface it quickly be came apparent that some visual screening would be necessary to preserve the privacy of the miners being transported from the shaft opening to the decontamination station. Initially Navy personnel on the scene formed a 70-foot “human shield” until within 15 minutes the SeaBees had constructed a 12′ barrier of wood and “cumshawed” tarpaulins.

Though we usually associate “the bends” with diving activities, the disease was originally described in the 19th century in underground constructions workers building the massive caissons that support the Brooklyn Bridge. It was originally called “caisson’s disease.”

Ironically the site of this Quecreek mine disaster and miraculous rescue is only 15 miles from the crash site of the September 11th, 2001, highjacked United Airlines Flight 93.

I think this is a terrific example of the special expertise the Navy and the other military medical services can bring to bear in emergencies. (I also wrote a short piece on the Army’s medical response to the San Francisco earthquake and fires of 1906 here.)

(You can subscribe to Captain Bloom’s vignettes by emailing him at navalist@aol.com; put Subscribe to “Today in Naval History” in your subject line.)

©2019 Thomas L Snyder

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USNS Mercy Completes Mission in Perú

Today, the hospital ship Mercy completed a 6 day visit to the Peruvian port of Callao. While there, according to U.S. Embassy and U.S. Southern Command reports, the medical staff worked in partnership with other Western Hemisphere personnel. They provided health care – including an average of 20 surgeries a day – for more than 4,000 people in “vulnerable populations”, including, explicitly, refugees from the humanitarian disaster in Venezuela. Reportedly, Perú currently harbors about a million Venezuelans who’ve escaped hardship in their home country.

Mercy has made 7 visits to the region since 2007. Over this time, her people have helped build and equip emergency treatment centers in 15 Peruvian locations, and assisted in training the local health professionals who would staff them.

I’ve written about medical diplomacy before. Such activities seek to build friendly relationships with other nations. They can also play interesting propaganda roles, as in this case, where the explicit mention of care for Venezuelan refugees is intended to embarrass the Venezuelan government and help strengthen the coalition of nations opposing that regime.

Perú was the second stop in the ship’s five month mission to visit 12 nations in Latin America and the Caribbean.

(C)2019 Thomas L Snyder

Independence Day

Today we celebrate the birth of this magnificent experiment in self-governance. May it continue to thrive, and ever be a beacon of hope to oppressed people everywhere.

A Memorial Day Reflection

 

As you enjoy the Memorial Day weekend, please take time to remember someone you know who gave his or her life in service to our country. 

 

Search as I might, I couldn’t find any data on medical personnel who’ve died in war time. But we know many have. Those who care also die.

 

On Monday, I’ll have the honor of giving my city’s Memorial Day speech. Here’s my peroration:

 

In conclusion, I ask you – no, I task you:
–every day, to try to memorialize – perhaps by putting on a special pin or necklace, or by saying, out loud, the name or names of someone who died in our nation’s service – our nation’s fallen ones.
–when you do that, give a thought to those who still suffer the ravages of war time experience, and seek advice – the VFW would be a good source – about how you can support their care. Be sure our legislators know that you favor generous medical and psychological benefits for veterans, especially including the homeless and addicted men and women who’ve served.
–finally, hold in your thoughts those who now face danger on our behalf.

Let us be thankful, every day, that we live in this great country, and, let us be especially thankful for the people who defended her then and defend her now. Let us remember them – and thereby preserve them from falling completely out of memory.

(c)2019 Thomas L Snyder

From a Naval Perspective: The Parts of Medicine That Are Like Convoy Work

Before we start: today marks the 148th anniversary of the founding of the U.S. Navy Medical Corps, in which physicians automatically receive Commissions as naval officers. Prior to that time, doctors received their Commissions from individual ship commanders as they saw fit.

Now, back to our original program. In medicine, as in naval operations, the least dramatic undertakings often produce the most dramatic results. Look, for instance, at convoy operations in both World War I and World War II. Despite devastating losses due to submarine attacks on merchant shipping (Britain was only months from suing for peace in World War I due to impending starvation), senior naval officers resisted the use of convoys protected by antisubmarine-enabled escorts, because such prosaic (and both boring and dangerous) work didn’t fit the idea of dashing naval battles. Yet when the convoy system was instituted, in each war, merchant ship losses plummeted.

The story is similar in medicine. It is almost cliché to say that non-combat deaths (from contagion and, interestingly, scurvy) in land war exceeded combat deaths until the Franco-Prussian War (1871), when German attention to hygiene – and vaccination against smallpox – reversed this proportion for the first time in history. This relation held (with the notable exception of the American experience in the Spanish American War) through both World Wars, the Korean War and Vietnam. Only in the recent wars in the Middle East and Afghanistan have advanced combat casualty care and the wide use of body armor brought the proportion of combat to non-combat deaths to near parity, with accidents, not disease causing the largest number of non-combat deaths.

I’m soon to be giving a talk on what I thought would be mostly about combat casualty care – the surgeons’ work in the cockpit – in Nelson’s navy around the time of Trafalgar. As I began to research the matter, it became pretty clear, pretty quickly, that the most significant benefits from the Royal Navy’s medical establishment in the quarter century leading up to that battle were the most pedestrian imaginable, and most definitely not dramatic advances in the surgical art. Pushed by naval physicians and surgeons, and some enlightened line officers, the Royal Navy reformed its victualling to include regular supplies of sauerkraut (a fair source of vitamin C), fresh vegetables whenever possible, and citrus fruits and juices. This reduced the incidence of scurvy to almost non-existent. Surgeons and commanding officers began to demand cleanliness among the sailors (a general issue of soap to ships of the fleet was instituted only after 1795), their clothing and bedding, and of cooking and eating utensils. This reduced the incidence of fever and the fluxes* significantly.

The data are stunning: during the period of the American Revolution, prior to the institution of the reforms victualling and hygiene, non-combat deaths outnumbered KIAs by 18:1. By contrast, for the period between the Glorious First Of June battle (1794) and Trafalgar (1805), the ratio was closer to 3:1. Like boring convoy operations, boring public health measures yield outsized benefits.(1)

 

 *In an era before the causes of most diseases had been elucidated, “fever” was a catch-all diagnosis for any febrile illness. The most significant ones for sailors were

–“putrid” (or ship) fever – epidemic typhus – caused by rickettsia prowasecksii, spread by the bites body lice; and yellow fever and malaria, for men serving in the tropics, and

–“flux” and “bloody flux” – gastroenteritis or dysentery – caused by a variety of bacteria that grow in spoiled food and unclean cooking and eating utensils.

 

(1) Care is warranted in noting these numbers, as naval operations during the American Revolution ranged from the tropical Caribbean to Newfoundland. In the later period, most battles occurred in the northern latitudes. Nevertheless, the beneficial effects of good nutrition and basic cleanliness were significant. This post is based on preliminary research for my lecture project and are drawn from the classic and epic four volume medical history of the Royal Navy started by John J Keevil (Vols 1 & 2), and, following his untimely death in his mid-50s, completed by Christopher Lloyd and Jack Coulter. The material that informed this post is in: Lloyd, Christopher and Jack L. S. Coulter, Medicine and the Navy, 1200-1900, Volume III 1714-1815. London, Livingstone, 1961. Several more sources await my attention.

(c)2019 Thomas L Snyder

Surgical Suite Aboard a Small Ship

Around mid-January, there was a flutter of news that the Spanish frigate ESPS Méndez Núñez (F-104) was in Norfolk and will be integrated into the USS Abraham Lincoln (CVN-72) Carrier Strike Group until November of this year. A review of the ship’s history on Wikipedia shows that since her commissioning in 2006, she has been quite active in international anti-terrorism and anti-piratical activities.

What’s medically interesting about the ship (which, according to an article in USNI News, is being showcased by Spanish shipbuider Navantia to the U.S. Navy, presumably as a possible candidate for its FF(X) future frigate program) is that it has what looks to be a basic surgical suite instead of a simple sick bay.

Sickbay / Operating Suite Aboard ESPS Méndez Núñez (F-104). (USNI News photo)

The ship also has a separate space to accommodate four sick or injured sailors. She typically carries a physician and a nurse when deployed, according to the USNI News article.

This kind of medical space is pretty unusual in a small unit like a Frigate. I recall that the sickbay in my Adams Class guided missile destroyer – I was the staff medical officer for Destroyer Squadron 15 – was no larger than a large closet. Sure, one could evaluate sick sailors there (physical diagnosis only; no Xray or lab) and perhaps do minor surgical procedures such as suturing wounds or draining abscesses, but there was no room to do something as basic as an appendectomy (the crew’s mess deck, a much larger space,  could be fitted out for surgery, but this was intended for combat casualty care, and doing even simple appendectomies was officially discouraged). Most U.S. small units don’t rate medical officers unless they are squadron flagships (and I’m not sure even these ships rate a physician these days). Independent duty corpsmen, specially trained to be the sole “Medical Department Representative” serve on these smaller ships, and have proven to be most capable for tending to the minor surgical and medical needs of the crew. Sailors with more serious problems are typically medically evacuated to an amphibious ship, aircraft carrier, hospital ship (all of which carry qualified surgeons, or would in a potential combat situation) or a facility ashore.

So I’m not sure the operating room in Méndez Núñez would be all that useful. Surely, for instance, there is no way laparoscopic work (the clear trend in abdominal and chest surgery not related to trauma) could be performed in that space. It would be interesting to learn what the Spanish experience has been.

©2019 Thomas L Snyder

A Medical Hero Celebrated

It’s not so often that we see a military medico publicly recognized for life sustaining work in combat. “It’s our job, after all” would be a common rejoinder. It was good, therefore, to read about Royal Navy Surgeon Captain Rick Jolly, who was named OBE for his surgical and leadership exertions in the Falkland War. Jolly recently passed over the bar at age 71. At the time, he was the senior medical officer of 3 Commando Brigade. He and his crew set up a field hospital in an abandoned slaughterhouse at Ajax Bay. There, Jolly and his colleagues treated more than 500 British wounded soldiers and Marines, and about 200 Argentine troops. Only 3 of those wounded died, none while under his care. The Argentine government awarded him the Orden de Mayo for his work.

I remember reading that Argentine surgeons often mismanaged soldiers’ wounds, which, under typically filthy combat situations, were grossly contaminated with dirt, clothing fragments and shrapnel. Already loaded with bacteria, these wounds became terribly infected, so when the Brit surgeons “inherited” the patients, their work was often that of managing these serious infections – truly life-saving work.

Jolly was an outspoken guy. See his interesting comments (and facial expressions) in a two-segment (~4 mins each) interview for Sky News here. I like this quote: “We had only one motto in War – that the wounded MUST survive”. Military medicine at its simple best.

(Hat tip: Cdr Salamander)

(C)2019 Thomas L Snyder

Surgical Specialties Emerging from World War II (Part Two of Two)

Last week I posted the first half – on the development of neurosurgery – of a paper on the surgical specialties that emerged from the Great War I was to give at a symposium at Cal State Channel Islands in late October. The symposium was cancelled as the Woolsey Fire approached. Fortunately, no damage was done to the campus or its wider environs, but the paper “hung fire”, so to speak. So, I post it for a wider audience.

Herewith, the second half. It looks like the footnotes transferred this time (they didn’t last week when I used my iPad), but if you want a copy of the complete paper with footnotes, let me know and I’ll send you a copy.

Trench warfare also saw a huge increase in facial wounds, compared with previous wars. The lore of plastic surgery has Hindu surgeons performing nose reconstructions for men who’ve had their noses cut off as punishment. But the reality is that “[w]hen we entered World War I, there was a total ignorance of plastic surgery in the army, but it must be said, that even in civil hospitals and medical schools of that time, 1917, the appreciation of this branch of surgery as a special subject was also lacking.”[1] Interestingly, the first major influx of facial wounds on the British side came from the Royal Navy after the Battle of Jutland. Up to this point, any reconstructive surgery of the face was in the bailiwick of the otolaryngologists (ear, nose, throat specialists) and dental surgeons, and both Germany and France had put together teams of dentists and surgeons to deal with these problems. As fate would have it, another “great man” of his surgical art, Harold Gillies, a New Zealander trained in ear, nose and throat surgery, serendipitously fell in with August Valadier, a French-American dentist in France in 1915. Valadier had set up a unit to care for soldiers with jaw injuries, and Gillies, intrigued by the challenges of facial reconstructive surgery, went back to England to lobby for a hospital dedicated to these cases.[2] Once granted, Gillies and a team of surgeons, dentists, anesthetists, and technicians he gathered around him, set out – initially “by trial and error”[3] – to work out techniques of reconstruction that gave grievously wounded men – men with noses and jaws blown off – functional and cosmetically satisfactory results. Like Cushing, Gillies acknowledged that when he set out to repair the horribly wounded faces he saw, “…the principles laid down by the fathers of surgery [were] found to be of general application… But our work [was] original in that all of it had to be built up again de novo. …The earlier months, then, were spent in a very thorough trial of the then known methods. It has been illuminating to discover the impracticability of many of these, which would appear to have been put forward on the study of only one case, or even on purely theoretical grounds.”[4] Major accomplishments by Gillies and his team included the successful use of “tube grafts”, by which skin can, in stages, be transferred from, say, the chest to fill large facial defects; and the transplant of cartilage from the ribs into the face to rebuild noses, and more. By the time America came into the war, Gillies and his team had such an extensive experience that our medical officers who spent time with them were prepared to provide knowledgeable care to American doughboys wounded in combat. The U.S. Army set up several centers in France specifically for the care of men with facial wounds. The Army also established Plastic Surgery Centers in 9 hospitals stateside where these men received definitive care, being retained in the Army until they had received “maximal benefit” from the surgeons’ hands.[5] After the war, interest in plastic surgery varied. In England, just four men continued with development and practice of the specialty and these same four were the only experienced plastic surgeons available to British military forces at the outset of World War II. [6] In the U.S. on the other hand, interest was greater, promoted at least in part by increasing numbers of automobile accident victims needing skin grafting and other specialized care. One result was that the U.S. could provide 60 well experienced specialists to the army and the navy prior to our entry into the war. [7] As in the Great War, the Army established a series of short training courses to bring other surgeons up to speed in assessment and technique, and so well did the program work in providing needed talent, that the “short course” system was discontinued before war’s end.[8]

When peace finally came, the value of plastic and reconstructive surgery had been nearly universally appreciated, and training programs found their way into almost all medical schools in the west. Plastic surgery in the Soviet Union languished and was generally performed by general surgeons. Specialty practice existed only in Moscow and Leningrad, and access there limited largely to the political elite, movie stars and the security services.[9] Plastic surgery as a distinct specialty was recognized in Russia only in 2008, and specialty training centers established the same year.[10] China, on the other hand, established training programs in plastic / reconstructive surgery after World War II, and the profession has flourished, especially in the 21^st century as the nation has become more wealthy, and demand for aesthetic surgery has grown. The International Society of Aesthetic Plastic Surgery estimates that more than 23,000,000 cosmetic procedures were performed world-wide in 2016.[11] Nearly 6,000,000 reconstructive surgical operations were performed in the United States in 2017.[12]

Conclusion

Two surgical specialties, for which there had been virtually no antecedent experience, emerged from the unique injuries soldiers in the Great War experienced in high numbers due to their exposure in trench warfare. The experience gained from treating these patients permitted surgeons to lay down principles of practice that inform the practice of neurosurgery and plastic / reconstructive surgery even today. Acceptance of these as separate surgical specialties was not universal until experience in World War II confirmed their value. Every major nation except the Soviet Union saw their advancement in the later 20th century. This progress and acceptance has only expanded in the 21st century.

Copyright 2018 Thomas L Snyder

[1] John Staige Davis, “Plastic Surgery in World War I and in World War II,” Annals of Surgery 123, no. 4 (April 1946): 610-621.

[2] Andrew Bamji, “Sir Harold Gillies: Surgical Pioneer,” Trauma 2006 8, http://www.gilliesarchives.org.uk/traumahdg.pdf (accessed 18October2018).

[3] John Staige Davis, op. cit.

[4] Harold Delf Gillies, Plastic Surgery of the Face Based on Selected Cases of War Injuries of the Face Including Burns, with Original Illustrations (London: Oxford University Press, 1920), reprint by Andesite Press / Creative Media Partners 2015

[5] Davis, op.cit.

[6] Richard Battle, “Plastic Surgery in the Two World Wars and in the Years Between,” Journal of the Royal Medical Society 71 (November 1978), http://journals.sagepub.com/doi/pdf/10.1177/014107687807101115 (accessed 21 October 2018).

[7] Lihani du Plessis, The Influence of World War I on the Development of Reconstructive Plastic Surgery. 2016. Honors Baccalaureate of Science thesis, Oregon State University.

[8] Davis, op. cit.

[9] “Soviet Plastic Surgery: When the USSR Went Under the Scalpel,” The Calvert Journal (22 March 2017), https://www.calvertjournal.com/articles/show/7971/soviet-plastic-surgery-ussr-under-scalpel (accessed 22 October 2018).

[10] Alexander V Melerzanov, “Plastic Surgery in Russia,” Prime – International Journal of Aesthetic and Anti-Aging Medicine (17 January 2014), https://www.prime-journal.com/plastic-surgery-in-russia/ (accessed 22 October 2018).

[11] International Society of Aesthetic Plastic Surgery, “International Study of Aesthetic / Cosmetic Procedures Performed in 2016 (Summary),”

https://www.isaps.org/wp-content/uploads/2017/10/GlobalStatistics.WorldWide.Summary2016s-1.pdf (accessed 22 October 2018).

[12] American Society of Plastic Surgeons, “2017 Plastic Surgery Statistics Report ‘ 2017 Reconstructive Surgery Statistics,” https://www.plasticsurgery.org/documents/News/Statistics/2017/reconstructive-procedure-trends-2017.pdf (accessed 22 October 2018).

Surgical Specialties Emerging from World War I (Part One of Two)

Around mid-November, I was to give the paper captioned above at a World War I Symposium entitled “Imperial Implosions: World War One and Its Implications” at California State University Channel Islands in Camarillo. About an hour before I was to go on, the campus was evacuated because of the advancing Woolsey Fire. The university was physically safe, but continued smoke forced symposium sponsors to cancel, and the campus didn’t reopen until the Monday after Thanksgiving.

Here is that paper, presented in two parts, the next part next week. I could not get the footnotes to transfer, so if you want to see them, let me know and I’ll send you a copy of the paper.

At the very worst, this should help you fall asleep tonight!

Echoes of World War One in the Surgical World

Thomas L Snyder

The Hippocratic admonition that “a man who would become a surgeon should join an army and follow it” has long been cliché in medical circles. The ancients generally attributed disease to the anger of unappeased gods. But they took a distinctly practical view when it came to the injuries of combat: sword and arrow wounds were visibly the result of human agency, and called for active human intervention instead of appeals to distant deities. The desire to help their comrades eventually saw the emergence of men who “specialized” in handling the wounds of war. The Sumerian / Akkadian (4000-1000 BCE) Asu was an empirical operator who wielded sharp (surgical) instruments, in contradistinction to the more spiritual sorcerer (Baru) and priestly (Ashipu) healers of disease. The Assyrians (900-600 BCE) formalized the Asu’s role as a military official, responsible for wound care, field hygiene (including burial of the dead), and health assessment of prisoners of war (who were prospective slaves). The Egyptian swnw was similarly appointed to serve in the army in war and peace; he was expected to be skilled in the management of war wounds and other injuries. In ancient India, Hindu men who practiced surgery were given the sobriquet shalyahara – remover of arrows. Similarly, the ancient Greek word for “physician”, iatros, translates as “arrow extractor” from Ionian Greek. While physicians may have been contracted by their Generals, Roman legionaries received field treatment from men called capsarii, binders of wounds. Roman military hospitals – an innovation that arose from the need to care for soldiers at the frontiers of the empire and a long, hazardous distance from home – were sophisticated permanent structures that featured an elaborate surgical set-up and protected interior “pulse” space designed for the care of an influx of fresh combat injuries should local battles break out.

Not much in the way of surgical advances occurred in the 5th through the 15th centuries after the Roman era. The Byzantines, military and medical successors to the Romans, who referred to themselves as Romanoi (“Romans”, but in Greek) merely perpetuated the Roman way of combat casualty care. Medieval Arabs produced advances in eye surgery and translated ancient Greek and Roman writings in medicine and surgery. Being a largely nomadic people, they also developed a form of mobile hospital for use in military and civil settings. The teaching of surgery was dropped from the curricula of French universities of the early Renaissance (the notion being that surgeons, who worked with their hands, were “laborers”, and not worthy of the scholarly tradition of medicine), though the Italians maintained a robust academic surgical tradition. Once the Catholic Church’s abhorrence for the shedding of blood in surgery (especially by educated priests), and of dissection of cadavers for the study of anatomy was overcome, and once the rigid conservatism of the Scholastic tradition yielded to the humanism of the Renaissance, surgery began to make advances in both theory and practice. Even so, until the advent of effective anesthesia in the mid-19th Century, major surgery of any type was a fraught affair, undertaken by brave surgeons for desperate patients and done as rapidly as possible so as to finish the operation before the patient went into shock because of the pain and blood loss. European surgeons led the way, and 19th century doctors from America and other nations typically toured the famous hospitals of England, Scotland, France, Germany, Austria and Italy to learn the most up-to-date techniques. Finally, once the bacterial cause of surgical infections was elucidated, techniques to check the infections (“antiseptic surgery”) and, later, to prevent infection (“aseptic surgery”) finally made the major kinds of surgery we think of today, particularly orthopedic and abdominal operations safe. Surgery on chest organs came much later. Meanwhile, advances in medicine, especially in vaccination (especially against smallpox), but also in nutrition (for instance, scurvy was a major cause of death among siege armies in the 13th through the 15th centuries) and hygiene (for instance, the understanding that cholera, an often-fatal infection of the digestive tract, came from water contaminated by excrement provided scientific justification for careful regulation of field latrines in relation to water supplies) meant that by the time of the Franco-Prussian War, for the first time in human history, deaths from combat injuries actually outnumbered those caused by disease and contagion. By the outbreak of World War I, the only apparent significant gaps in our understanding or tools of combat casualty care involved the prevention and treatment of shock, and the treatment of infection in contaminated wounds.

In the Great War, artillery barrages and mass infantry attacks produced the expected extremity, chest and abdominal wounds. But the unique aspect of trench warfare saw men standing in trenches peering out at the enemy with just heads showing. These men suffered brain and facial injuries in unexpected numbers. Wounds of the head and neck accounted for 15 – 20% of all combat wounds during the Great War. Grievous wounds of the brain and of the face resulted in the evolution of two new surgical specialties – neurosurgery and plastic reconstructive surgery. This is necessarily an example of “great man” history, because almost no one had practice (and certainly no one was trained) in these areas of the surgical art prior to the war. Necessarily then, brave pioneering surgeons played an outsized role in wading in where no man had gone before, to establish principles of practice that largely persist until today.

As regards neurosurgery, the great man is the American Harvey Cushing. Up until the advent of good anesthesia and aseptic (infection-preventing) surgical technique, few men had ventured into the cranium, and when they did, the complications of hemorrhage and infection, almost invariably fatal, discouraged further efforts. Cushing undertook to study and practice brain surgery at Harvard starting around 1908. While individual surgeons had written about their pioneering forays into neurosurgery , it was by no means an established specialty, and no formal training programs existed. As Cushing himself put it, “[a]nything classified as neurological is looked upon by many of us as baffling and difficult, and a feeling prevails that the ultimate functional results after recovery from serious cranial injuries are, to say the least, forlorn. Few medical officers had received training in the surgery of the central nervous system before the war, no organized instruction has been given in the subject since; and the tools provided for the work have been inadequate and antiquated.” Thus it was that, when Cushing arrived in Europe as a volunteer in 1915, he had opportunity to observe the work of just a few individuals who were making pioneering efforts to respond to the wounds that modern warfare had wrought. The wounds sustained by soldiers in Europe carried special risks because of the fields in which they fought had for centuries been well fertilized with manure and therefore bore a rich variety of bacteria, many of which were carried by projectiles or shrapnel into the brain, along with fragments of filthy clothing. The combination of the physical damage and contamination demanded a vigorous surgical response. Early in the war, individual French, German, Austrian, Russian and British surgeons took up the gauntlet. They gradually, through experience, established guidelines and techniques that improved outcomes, but much of this work was unpublished. When Cushing returned to Europe with a Harvard team of fourteen surgeons and four nurses in March, 1917, as director of American Base Hospital #5, he soon was detached to a BEF receiving hospital, where he and his team operated full time on neurosurgical cases. By late April, they started the work of consolidating the experiences of their European predecessors by carefully and systematically utilizing, then adjusting their techniques to lay down principles of traumatic brain surgery. As he and his associates gained experience, their results steadily improved so that by war’s end, the survivorship of brain surgery for war wounds had increased from around 45% to 71%. One of his earliest learnings was that sticking a finger into the brain to find a bullet or fragment was a bad idea (he referred to this as “Little Jack Horner” surgery); rather, Cushing adopted the use of soft rubber tubes snaked into the wound track. By applying gentle suction, he could remove damaged brain tissue, bone fragments and other wound debris. He even adopted a technique using a magnetized steel nail to extract metal fragments from deep inside the brain. One other surgical innovation that Cushing adopted was to layer Dichloramine T, referred to as a chlorine antiseptic at the time, but really an early sulfa antibiotic precursor, into the brain wounds. Combined with careful surgical technique and an insistence on operation as soon after wounding as possible, this approach reduced the rate of brain infections to near zero by war’s end.

Cushing’s Illustration of the Use of a Soft Catheter and Gentle Suction to Debride and Irrigate Brain Wounds

Before the U.S. entered the war, and based on Allied experience, Army Surgeon General Gorgas concluded that we would need something like 200 neurosurgeons. In response to a national survey, about 50 men stepped forward, claiming experience. At this point, Gorgas established crash 70-day programs in Philadelphia, Chicago, New York, St. Louis and Camp Greenleaf, GA to train selected surgeons in the art of brain surgery. Ultimately, about 190 neurosurgeons served in Europe. Only a few of them continued in the specialty after the war. Cushing returned to Harvard after the war. He published his learnings and expanded a training program in neurosurgery that he had started before the war. Perhaps in part because of an ongoing debate between non-surgeon neurologists and neurosurgeons over their respective bailiwicks, training of the surgical specialists seemed to languish in the United States, and an official certifying body, the American Board of Neurological Surgeons didn’t even come into existence until 1940. Only a few training programs, in New York, Virginia, San Francisco, St Louis, Cleveland the Mayo Clinic in Rochester, Minnesota, the Johns Hopkins Hospital in Baltimore and at the University of Pennsylvania, and perhaps a few others operated in the interwar period. A similarly desultory effort at neurosurgical training appears to have obtained in France and Britain, while the dictatorial regimes of German and the Soviet Union seem to have done a better job of planning for the contingencies of war. As a result of this dearth of residency programs, the Army could count on a pool of only about 200 trained neurosurgeons at the beginning of World War II. Once again, short training programs were established to teach the rudiments of brain surgery to promising young general surgeons. These programs produced about 250 brain surgeons and went far to meet the demand. By war’s end, there had been nearly 61,000 neurosurgical admissions to U.S. Army hospitals. After the war, training programs proliferated both in the United States (110 in 2018) and abroad so that today, most major medical schools train neurosurgeons, of whom about 3500 practice in the United States. Postwar neurosurgery in a divided Germany presents an interesting story, as robust development in Western Germany produced a growth in neurosurgical centers from 18 in 1950 to 85 by the early 21st century; on the other hand, in Eastern Germany, a struggling economy and regressive regime limited neurosurgical progress to just a few talented individuals who gained worldwide notoriety. By 2006, 1200 fully trained neurosurgeons were serving the entire German population, performing nearly a quarter million neurological surgeries yearly. Many advances in the years since World War I, including antibiotics, CT scanning, electrocautery for control of bleeding, and the use of medications to reduce the brain swelling that accompanies brain injuries have led to ever safer and more successful brain surgery. Today, surgery for traumatic brain injuries represents about 18% of all brain operations in the U.S. (2011 statistics, the most recent year for which statistics are available). 18% of traumatic brain injuries are caused by firearms (the majority being suicides); of those, 90% are fatal, the patients dying usually even before reaching hospital. Cancer surgery, such as that offered to the late Senator McCain, represents another 21% of brain surgery.

Next week, Part II, the story of plastic / reconstructive surgery.

(C)2018 Thomas L Snyder

Navy Medical Diplomacy “a la Salamander”

I’ve written before about the role of Navy medicine as a tool in service of our nation’s larger geostrategic / geopolitical interests. Today I purloin, in its entirety (lightly edited…), a post from “Commander Salamander”, a sometimes ascerbic commentator on our Navy’s leadership and policies. On Monday, he commented on the U.S. hospital ship USNS Comfort, which is now on a medical mission to South America. As is his wont, Salamander notes the geopolitical impact in  the region – and much farther afield.

Then, check his closing line.

Commander Salamander

Monday, November 19, 2018

A Hospital Ship’s Soft Powers Sharp Elbow

As we’ve discussed here through the years, hospital ships are one of the best “soft power” assets we have. The green eye-shade types, warheads-on-forehead silo-dwellers, and the medical OCD narrow-casters will throw spitballs, but in my book look at two things:

1. Are your competitors building them too? Yes, look at the Chinese catch-up efforts.

2. Do they upset the right people? Well …lookie here:

A U.S. Navy hospital ship moored off Colombia has started giving free medical care to Venezuelan refugees, in a move likely to rile officials in Caracas who deny the existence of a humanitarian crisis in their own country. I
…
The USNS Comfort, which is on a three-month mission that has already taken in Ecuador and Peru and will end next month in Honduras, arrived at Colombia’s northwestern port city Turbo on Wednesday.

Patients in Turbo and Riohacha, where the ship will dock next week, will receive medical assistance from the crew of more than 900 doctors, nurses, military technicians and volunteers, with medical facilities on board the hospital ship as well as on shore.
…
But it has stoked tensions in the region, with China — one of Venezuela’s few allies — hastily dispatching its own hospital ship to Venezuela in September ahead of the U.S. mission.

“This is how you undertake diplomacy in the world,” Venezuelan defense minister Vladimir Padrino said at the time. “With concrete actions of co-operation and not stoking the false voices of those who beat the drum of war.”

Even here in the USA, the deployment is making all the right kind of enemies:

“It’s pretty brilliant PR, isn’t it?” Adam Isacson, a security analyst at the Washington Office on Latin America, a think tank, said in response to the deployment. “We could just as easily, at similar cost, send a huge contingent of civilian doctors, working on land where the people are, to help tend to the Venezuelan population. But sending a military ship — even though it’s white with a big red cross on it — sends more of a message about projecting U.S. power.”

…….

Judge something by the enemies they make.

Conclusion: we need 4 new, modern hospital ships. Get cracking.