“War is cruelty and you can not refine it”, was what one of America’s foremost experts on war, Union General William Tecumseh Sherman, told the mayor of Atlanta in 1864 after ordering all civilians expelled from the occupied city. Human nature periodically compels us to revisit this terrible caveat, most recently when the American combat death total in Iraq reached 3000, the largest casualty figure since the Vietnam War. Yet, General Sherman’s observation was not completely accurate. The brutal cruelty of war has indeed been refined - because the same human ingenuity that creates weapons of combat and the capacity to kill simultaneously discovers ways to heal and save lives.

Although weapons of war grow more destructive, the Iraq War has been accompanied by evolving medical advances that reduce the likelihood of soldiers dying in combat. These advances, as well as the refinement of Kevlar body armor and helmets, have kept the harrowing figure of 3000 deaths from being much higher. In World War II, 30 percent of all Americans seriously injured in combat died. In Vietnam, 24 percent of all serious wounds proved fatal. The current figure for Iraq is between 10 and 15 percent. Given equivalent injuries, today’s soldier in Iraq is 50 percent less likely to die than his Vietnam counterpart 40 years ago.

Traditionally, war has been the impetus for medical progress. The ancient Romans created sophisticated field stations behind battle lines to treat wounded foot soldiers. In the Middle Ages, surgeons routinely perfected their craft at “schools for surgery”, the battlefield, where gunpowder caused injuries unknown outside combat. The practice of nursing was revolutionized and dignified by Florence Nightingale during the Crimean War in the mid 1850’s. A decade later the status and esteem of British nurses was realized by American Civil War nurses. Many medical innovations can be traced to specific conflicts –the widespread use of antiseptics to treat wounds in the Franco-Prussian War, storage and transfusion of blood during the Spanish Civil War, the use of antibiotics in World War II and the treatment of hemorrhage and shock in Korea, later refined in Vietnam.

The Iraq War has accelerated the pace of medical miracles. Formerly, the guiding philosophy of military surgeons was definitive wound repair as quickly as possible. Now, more lives can be saved by emphasizing rapid control of bleeding in the field, then stabilizing and moving patients for definitive surgery to larger support hospitals in Iraq or, back to the United States in the case of more complex injuries. In the field, small, mobile medical teams are equipped with sophisticated equipment and drugs undreamt of in previous wars, including chemically treated bandages that stop bleeding, genetically engineered drugs to promote clotting and portable diagnostic ultrasound equipment. Once a severely injured patient is stabilized, the average time from battlefield to a U.S. facility is now four days compared to 45 days in Vietnam. Soon, paramedics on highways will treat trauma with similar tools.

The nature of injury in Iraq is different than in the past. Suicide bombers and roadside bombs (known in military parlance as IEDs, improvised explosive devices) have increased the number of blast injuries, a frightening amalgam of blunt and penetrating trauma, burns and shrapnel composed of dirt, nails and ball bearings, frequently accompanied by clothing and bone from attackers. Besides massive bleeding, blindness and life-threatening infections, blast injuries often cause limb damage necessitating amputation. Here again, military medicine has responded to the challenge. Once back in the U.S., amputee soldiers can be fitted with state-of-the-art prosthetics made from high-tech plastics and metal alloys. Using microprocessors and hydraulics, these sophisticated prosthetics employ sensors that react to electronic impulses from intact muscles. Under the supervision of highly trained staff, the soldier with a prosthetic can actually return to combat in some cases. All these innovations will be coming soon to a neighborhood medical center near you.

It is reassuring to realize that, just as in past conflicts, the knowledge gained and techniques perfected in battlefield care will soon spread to civilian medicine. Notwithstanding, Sherman’s caution about war should be heeded; the Vietnam-era adage “War is unhealthy for children and other living things”, remains truer today than ever. While far preferable to the alternative of “toe tags and body bags”, lifesaving medical advances result in greater numbers of unfortunate soldiers surviving with severe brain injuries, paralyzing spinal cord damage or devastating psychological trauma. These casualties create a debt we are obliged to repay with care, compassion, counseling, employment and most importantly, our understanding and appreciation. No matter what the political outcome of the war, all Americans benefit from the sacrifice of these men and women.

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