The History of Trauma Care

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 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 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 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, 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, possibly, ligated ( Fig. 1.1 ).

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 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 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 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.

Ancient Greece

Ancient Greece provided the theoretical foundations for medicine for the next two millennia. In the epic poem The Iliad , Homer wrote of 213 casualties, with a 90% mortality rate. Long-range weapons such 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 scenes ( Fig. 1.2 ).

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 ).

The Middle Ages

Medicine in the Middle Ages followed the humoralism propagated by the Hippocratic Corpus and Galen. Generalizations across centuries 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, emerged in the literature for the first time as a distinct, educated group of medical providers in the Middle Ages. They held responsibility for managing wounds and diseases affecting the exterior of the body (predominantly contranaturals), whereas physicians focused on internal maladies (naturals). Education for surgeons 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 sites of medical education, the best surgical education slowly moved into these formal curricula.

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, 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 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 ).

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 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 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.

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 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 wounded Christ. Christianity interwove with most aspects of medieval society, including the practice of medicine. Although some tensions between clergy and medical practitioners existed, the two professions largely cooperated, with each healer treating the wounded with their respective, but symbiotic, therapies. Given the urban concentration 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 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 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 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 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 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 of ligating blood vessels after limb amputation instead of applying the standard contemporary therapy: cautery. He invented a new instrument, the bec de corbin, as the first vascular clamp to grasp vessels in preparation for their ligation. However, until Jean Petit's invention of the screw-tourniquet in 1718 to control hemorrhage, ligation remained rare ( Figs. 1.6 and 1.7 ).

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 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 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 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.

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 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 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.

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 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 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.