Tourniquet Use on the Battlefield

MILITARY MEDICINE, 171, 5:352, 2006 Tourniquet Use on the Battlefield Guarantor: MAJ Robert L. Mabry, MC USA Contributor: MAJ Robert L. Mabry, MC USA This article examines the history of battlefield tourniquets. The tourniquet, if used properly, is perhaps the leading lifesaving device available to soldiers in the field. However, tourniquet use has been surrounded throughout history by controversy and dogma which continue today. Only after examining the historical context of warfare, weapons, injuries, and medical thought can we gain insight into the proper role of the tourniquet on the modern battlefield. Introduction he tourniquet has been used for the management of extremity hemorrhage for nearly half a millennia. Almost since its T earliest beginnings, however, its use has been surrounded by controversy. This simple lifesaving device has been surrounded throughout history by a wide diversity of strong opinions, myths, and lack of agreement among those who care for injured on the battlefield. Many military surgeons throughout history have recommended abolition of the tourniquet, but the device persists basically unchanged from the original form first used on the battlefield in 1674. Others have praised the tourniquet and recommended that every soldier on the battlefield carry one and be instructed in its use. This debate continues today. 1 Why are there such varying policies and lack of agreement among military medical authorities throughout history? To answer this question, we must understand the historical context of warfare, weapons, and casualties and the prevailing medical thought of the age. Against this backdrop, we gain insight into the difficulties of establishing a comprehensive policy on tourniquet use and an understanding of what unanswered questions remain. Before the American Civil War Before tourniquets were used on the battlefield, tight bandages proximal to wounds were used primarily as an aid to amputation. In 1517, the German surgeon Hans Von Gersdoff of Strasburg published Feldtbuch der Wundtartzney. This book included the first depiction of an amputation and recommended the use of a tourniquet. In 1586, Guy De Chauliac also described using tight bands above and below the amputation site. Ambrose Pare, the legendary French war surgeon, described tying a strong cord around the limb above the amputation site, to hold the muscles retracted with the skin, to limit bleeding, and to reduce sensation. 2 Wilhelm Fabry, the first educated and scientific German surgeon, in 1593 was the first to recommend amputation above the gangrenous parts and to describe a tourniquet using a twisting stick or Spanish windlass. This same technique is still recognizable today, more than four centuries later, in modern military first aid instruction. 3 2nd Battalion, 1st Special Forces Group, Fort Lewis, WA 98433. This manuscript was received for review in September 2004. The revised manuscript was accepted for publication in April 2005. The first military use of a tourniquet as a device to control hemorrhage during battle was in 1674 by Etienne J. Morel, 4 a French Army surgeon, during the Siege of Besançon. Morel introduced a stick into the bandage on the thigh of a wounded soldier and twisted it until the bleeding stopped. John Louis Petit later modified the tourniquet with a mechanical screw and a padded leather strap, to control tension and to make it more comfortable (Fig. 1). From the French verb tourner (to turn), he named the device tourniquet. 5 Petit s tourniquet would be preferred by surgeons well past the American Civil War. Henry LeDran, another French military surgeon and a contemporary of Petit, recommended the tourniquet as standard equipment for military surgery. 6 The device was invaluable in controlling bleeding from massive wounds and during amputation. Furthermore, it allowed for more-efficient use of resources, 7 permitting the surgeon to amputate with less help from assistants, who previously were needed to hold pressure on the wounded extremity until up to 50 ligatures (for the thigh) were applied. It also allowed more time to attend to increasing numbers of battle casualties. Macleod, 8 in his history of the Crimean War, described only 15 cases of injures to larger arteries of 4,434 wounded; he stated, It has been the experience of most wars... that tourniquets are of little use on the battlefield, but he then continues paradoxically, for although it is unquestionable that a large number of the dead sink from hemorrhage... it would be impossible, amid the turmoil and danger of battle, to rescue them in time, the nature of wounds in most cases causing death very rapidly. Macleod further stated that most extremity injuries have small initial hemorrhage that ceases spontaneously, whereas a few casualties rapidly exsanguinate from primary hemorrhage. Macleod was the one of the first surgeons to wonder at the cause of death for those who died on the battlefield not under his observation. Most medical data concerning battle casualties were anecdotal accounts of surgeons caring for the living casualties who reached their aid posts. Comprehensive studies of battlefield injuries that included those killed on the battlefield were generally lacking until World War II, but surgeons like Macleod continued to downplay the role of tourniquets. In that era, patients who survived long enough to be treated likely did not need a tourniquet. 8 American Civil War During the early stages of the American Civil war, surgeons in the service of the Union and Confederacy alike had to rely on the observations and experiences of their European contemporaries, because, in the words of S. D. Gross of Philadelphia, America had never witnessed... such carnage as attended the footsteps of Napoleon at the Bridge of Lodi, at Leipzig, at Dresden, and at Waterloo; or, more recently... the exploits of the English, French and Russian forces in the Crimea; or of the 352

Tourniquet Use on the Battlefield 353 Fig. 1. Petit s tourniquet. French, Italian and Austrian armies in Italy; or of the English soldiers during the rebellion in India. 9 U.S. surgeons naiveté would be short lived. More casualties were sustained during the Battle of Shiloh than in all previous American wars combined, approximately the same number as in the Battle of Waterloo, with many other such battles during that long bloody war. Regimental surgeons came from many different backgrounds and schools, with different levels of skill and training. Most doctors of the period had little experience with trauma. There were no medics or corpsmen. Assistant surgeons would sometimes move about the battlefield and deliver aid when possible. Band members were often trained as litter-bearers. First aid training, when available, was rudimentary at best. The following quotation from Gross s Manuel of Military Surgery is one of the earliest instances in which a physician suggests that soldiers should have some elementary training in hemorrhage control. When the wound is severe, or involving a large artery or vein, or even middle-sized vessels, the bleeding may prove fatal in a few minutes, unless immediate assistance is rendered. Hundreds of persons die on the field of battle from this cause. They allow their life current to run out, as water pours from a hydrant, without an attempt to stop it by thrusting a finger in the wound, or compressing the main artery of the injured limb. They perish simply from their ignorance, because the regimental surgeon has failed to give proper instruction. It is not necessary that the common soldier carry a Petit s tourniquet, but every soldier must put into his pocket a stick of wood, six inches long, and a handkerchief or piece of roller, with a thick compress, and be advised how, where and when they are to be used. 9 The next year, Gross published a textbook on surgery with an entire chapter devoted to injuries of the vessels. In that chapter, he provided an excellent clinical description of hemorrhagic shock and arterial hemorrhage, with some discussion of tourniquets. He wrote, I do not envy the man his feelings who, through ignorance, inattention, or indecision, allows his patient to perish from loss of blood when he ought to have saved him. 10 Thus, early in the war, regimental surgeons on both sides appeared to be very concerned with dangerous primary hemorrhage on the battlefield. Gross described a very simple and effective tourniquet for field practice introduced from Prussia by Mr. George Tiemann [a medical instrument maker from New York City] where it was extensively used in the military service, every orderly sergeant being required to carry one in his pocket. 10 These Prussian service strap-and-buckle tourniquets (Fig. 2) were subsequently supplied to the troops in great numbers, 11 with several being supplied in every army surgeon s case of instruments. 12 Following the wide distribution of tourniquets early in the war, the effects of misuse soon became apparent. Wounded soldiers were cleared from the battlefields after many hours or even days. Given the massive numbers of casualties, previously unprecedented in the U.S. military experience, often many hours passed before all could receive medical attention. With complete constriction of limbs for hours, gangrene was the likely result. Very many of these wounded came into the hospital with extemporaneous tourniquets tightly applied, and their hands and forearms swollen and livid in consequence. This dread of hemorrhage is simply another proof of the inexperience of the troops. 13 Soldiers then and today are reluctant, despite considerable pain, to release a tourniquet once it has been applied for fear of life-threatening hemorrhage. Current U.S. military training instructs soldiers never to loosen or to release a tourniquet once applied, allowing release only by a medical officer. Use of tourniquets and the policy of general distribution to the troops came into question. One physician wrote that he was informed by a brigade-surgeon at Bull s Run, where more than 2000 were wounded, that the use of the field tourniquet was so frequently followed by mortification and loss of the limb, that he had come to the conclusion it was far safer to leave the wound to nature, without any attempts to arrest the flow of blood than depend upon the common army tourniquet. 14 In an effort to avoid circumferential constriction of the entire limb while providing adequate pressure on the bleeding vessels, several tourniquet-like devices were developed. These devices sought to control bleeding while allowing a space that was not constricted, thus permitting collateral blood flow and, it was hoped, avoiding total limb ischemia and thus gangrene. These Fig. 2. Strap-and-buckle tourniquet.

354 Tourniquet Use on the Battlefield devices included Dupuytren s compressor (Fig. 3), the tourniquet of Signori, 12,15 and the elastic or Lambert field tourniquet (Fig. 4). Dupuytren s compressor and the Signori tourniquets were clamp-like devices designed to apply pressure only over the affected artery. Lambert s elastic tourniquet consisted of two concave plates held with wings of wire, connected with an elastic bandage. The wings held the bandage off the skin so that only the metal plates made contact with the affected limb. This version was thought to be simpler and easier to operate than a similar winged tourniquet developed by Valentine Mott. 16 The Lambert tourniquet was enthusiastically endorsed and subsequently issued to troops from Maine, Connecticut, and New Hampshire. 17 Dupuytren s compressor and other similar devices were difficult to position effectively and were eventually abandoned in favor of Petit s tourniquet. Considered the most reliable, that tourniquet remained the most commonly used tourniquet until well after the war. 18 If it were indeed true that many soldiers lost their limbs needlessly to unneeded tourniquets applied during the excitement of battle and left on for extended periods, then one would expect more comment on the subject in the voluminous and very detailed Medical and Surgical History of the War of the Rebellion. No statistics relating to unneeded amputation are found, yet surgical opinion against the tourniquet is very strong in many instances. Julian Chisolm, the Confederate Surgeon General, made the following comments in his Manual of Military Surgery. Should, on the contrary, meddlesome surgery suggest the use of a tourniquet, which cuts off the circulation and especially the venous return, the limb soon swells, tissues become engorged, excessive extravisation in the wound follows, and a train is laid for future mischief. The field tourniquet (strap and buckle), in former days, was so much in vogue that it was considered indispensable on the battlefield, and was, therefore, carried in large numbers, so as to be applied to every limb from which blood was trickling or from which hemorrhage was feared. Now they are nearly discarded from field service, and recent experience, based upon the carelessness with which they are used, recommends their abolition from the field, as doing more harm than good to the wounded. Unless very tightly applied, they Fig. 3. Dupuytren s compressor. Fig. 4. Lambert s field tourniquet. are of no service, as they do not control bleeding, and if firmly applied they act as a general ligature around the extremity, and can be used but for a short time without injury to the limb. 19 In the preface to his book, Chisolm acknowledged using many European sources in his work, basing much of it on observations from the then-recent Crimean War. He stated that severe primary hemorrhage from the extremities is rare, again citing data from Mcleod, but he paradoxically admitted that, when larger arteries are injured, as a rule they either cease bleeding spontaneously or the patient dies so rapidly that art is of little avail. 19 In Gunshot Injuries, Longmore addressed the question of the general distribution of tourniquets, because it was so frequently urged by nonprofessional persons on the occasion of war... who seem to think that every gunshot wound is accompanied with serious loss of blood that life is endangered from this cause alone... although rarely fatal solely from hemorrhage, almost every wound is attended with a slight oozing and loss of blood. But to many uneducated and excited men this bleeding would at once be interpreted as showing the need for a tourniquet: evils... would result... thus a simple wound be converted into a relatively grave one. 14 Others recommended issuing tourniquets only to trained, experienced, noncommissioned officers, as was practiced in the Prussian military, but Longmore correctly recognized the tactical difficulties of such a policy, They could not, without neglecting their own important duties [during the progress of an action]... stop to pay attention to a wounded comrade, even if he were bleeding profusely. 14 Mott, in his essay on hemorrhage, advocated the general introduction of tourniquets among troops, not only because of the advantage in stopping the loss of blood but also because of the moral courage that the possession of the instrument would give to soldiers. 16 Then Surgeon General Longmore disputed Mott s assertion, stating, The arguments of this distinguished surgeon do not, however, appear to me to overrule the practical difficulties and inconveniences which would attend such a general distribution of tourniquets. 14 Several surgeons of high position in the United States, when testifying to the merits of

Tourniquet Use on the Battlefield Lambert s tourniquet, expressed the view that every soldier should have one as a life preserver. Longmore did support the distribution of tourniquets among all trained bearers and hospital attendants for, if properly trained, they will understand what to do and what to avoid in applying the instruments. 14 Because the risk of death from hemorrhage was thought to be slight and the risk of an unneeded tourniquet great, digital pressure was considered by many to be the optimal first aid treatment for extremity hemorrhage. In the words of Julius Chisolm, former Surgeon General of the Confederacy, Unless hemorrhage is very violent, threatening immediate destruction of life, the tourniquet is rarely required. The finger pressure of an intelligent assistant is better than any tourniquet made. 19 Stopping hemorrhage by means of inserting a finger into the wound was taught to soldiers and stretcher-bearers in the Russian army during the Crimean War. Tourniquets were scarcely used. Demme, in his work titled Studies on Military Surgery in the Italian Hospitals in 1859, mentioned that several lives were saved with this method. One young Austrian soldier who was wounded in the thigh tore open his trousers and inserted his thumb into the wound, keeping it there for 4 hours. His femoral artery had been punctured 1 inch below the origin of the profundus branch. 14 The American Civil War appears to be one of the first instances in which some form of tourniquet was issued to U.S. troops in the field and some form of first aid instruction for the control of dangerous hemorrhage given, at least within a few regiments. However, the tourniquet appears to have been overused or used incorrectly in many instances, reflecting a lack of training and the difficulties of timely evacuation and evaluation by a physician. The following quotation from the Medical and Surgical History of the War of the Rebellion summarizes tourniquet use during the Civil War. Early in the war it was recommended that each soldier should have in his possession some simple form of tourniquet, and in many instances the recommendation was carried out; how far they were of use is not known, as no cases are recorded of life being saved by them; but it is probable that they were used little, and it is very doubtful if, in the confusion and excitement of battle, they could have been applied with any efficacy. Later in the war experiences taught the older and more experienced troops to do all they could in an emergency. 20 A pattern was established during the Civil War that was repeated several times in the next century. In the early stages of conflict, there was great concern for severe hemorrhage and tourniquet use was widely accepted, followed by numerous anecdotal instances in which tourniquets were overused or used improperly. As the conflict wore on, the tourniquet fell out of favor and its utility was questioned. However, men still died on the battlefield whose lives could have been saved. After the Civil War to World War I Historian Theodore Ropp 21 described the period between the Civil War and World War I as the Years of Uneasy Peace. Many technological advances in warfare and in battlefield medicine were made. The invention of smokeless gunpowder advanced the development of weapons such as the repeating rifle using 355 individual cartridges and new, high-velocity, small-caliber, conical bullets. In 1883, the Maxim machine gun was introduced. Rapid-fire, long-range, precision artillery was perfected. These advances increased the lethality of the battlefield, thus enlarging it and dispersing its combatants. Military medicine and surgery also advanced during this period. Significant improvements in both asepsis and surgical techniques were made. The practice of exploring wounds with fingers was abandoned. The individual first aid packet or field dressing was developed, and the concept of battlefield first aid was introduced by the German military surgeon Johann Friedrich August von Esmarch in the 1870s. von Esmarch, author of the period s most comprehensive book on battlefield surgery, Handbook of War Surgery Technique, also wrote First Aid on the Battlefield and First Aid to the Injured. He invented the Esmarch dressing, also known as the cravat or triangular bandage. There were few large military engagements of any significance during this period until the outbreak of World War I. Even so, military surgeons of the period thought that the risk of dangerous primary hemorrhage from the newer, small-caliber bullets was slight. This view was based on limited observation and, to some degree, theoretical opinion. Surgeons of the Spanish- American War reported that, of the 1,400 wounded at Santiago in 1898, no deaths from external primary hemorrhage were noted from mostly small-caliber Mauser bullets and no vessels were ligated in the field to control hemorrhage. Similar results were reported by surgeons from the Boer War 22 and the Russo- Japanese War. 23 Praetorius examined the statistics from the Franco-Prussian War (1870 1871) and reported that dangerous hemorrhage occurred in only 5% of gunshot wounds, with 3% dying on the battlefield. 24 Although severe extremity hemorrhage seemed rare, nearly all observers agreed that vessels were injured more often with the newer bullets. La Garde discussed the apparent paradox in wounding patterns with the newer bullets. Formerly when the large leaden bullet with a hemispherical head moving as a comparatively slow rate of speed collided with one of the larger vessels, the latter was pushed aside and if it was cut across or otherwise injured, there was no great tendency to primary hemorrhage because of the irregularity of the wound in the vessel coats. The armored bullets of reduced caliber are more definite in the work which they accomplish; they cut the vessels like a knife because of their superior velocity, smaller caliber and more pointed, ogival heads... There is not time for the vessel to be pushed aside... leaving no lacerated edges. There is in such a wound... every opportunity for fatal external primary hemorrhage... except for the channel of the wound being small, the narrow track is readily obstructed by... muscles, intermuscular septa, fascias, etc. 25 Tourniquet use in civilian surgery advanced during this period as well. It was in 1864 that Joseph Lister described the use of a tourniquet to obtain a bloodless field during the excision of a tuberculous wrist joint. Less than a decade later, in 1873, von Esmarch described his innovative technique for bloodless limb surgery. von Esmarch modified the India rubber emptying ban-

356 Tourniquet Use on the Battlefield dage of Grandesso-Sylvestri. This device, described below, was thought to be more reliable than Petit s tourniquet. We wrap the legs tightly from the toes to above the knees, with elastic bandages made from woven rubber, forcing the blood out of the vessels of the limb by an even compression. Then we apply rubber tubing tightly, four or five times around the upper thigh... where the bandage stops... in such a manner that not one drop of blood can enter the parts below it....thepatient [in the course of operation on the limb] has lost no more than a teaspoonful of blood! 27 In 1875, D. Foulis introduced his improved elastic tourniquet. Consisting of a vulcanized India-rubber cord, the two ends after stretched are joined with a catch. The whole limb is firmly constricted and the circulation stopped. But the very qualities that make it answer this purpose make it dangerous as field tourniquet. Moreover, the pain caused by it in patients with their senses unblunted quickly becomes intolerable. The pressure is the same at every point at the circumference of the limb, and is necessarily very great. It does not admit the amount of adjustment... [allowed by] the Esmarch bandage or common pad and buckle tourniquet. 14 A few years after von Esmarch s technique became popular, Volkmann demonstrated that limb paralysis could result, in his famous article on ischemic muscular paralysis and contractures in 1881. He attributed the cause of the contractures, henceforth know as Volkmann s ischemic contractures, to direct changes in the muscles produced by arterial occlusion from the Esmarch bandage. Because of the increasing concern regarding permanent neuromuscular damage with the Esmarch bandage, Harvey Cushing invented a pneumatic tourniquet in 1904. This device had two advantages over the Esmarch tourniquet, i.e., rapid application and removal and decreased incidence of nerve paralysis. By the turn of the century, however, opinions on the use of tourniquets varied, with some recommending that every soldier know how to apply one and others warning against their use, especially that of elastic constriction devices such as the Esmarch tourniquet. Conclusions August 1914 brought the beginning of the first modern total war, with attendant violence and destruction on a scale the world had never before encountered. The technological advances in transportation, weapons, and munitions of the industrial age far outpaced advances in battlefield tactics, resulting in huge numbers of casualties. By July 1915, 1 year after the war began, 2 million men were dead and nearly 5 million wounded. 28 The historically unprecedented number of casualties presented numerous new challenges. Once again, tourniquets were widely used in the early stages of the war and, once again, debate over their utility continued. In part II, tourniquet use on the modern battlefields of the 20th century will be examined. Many lessons learned in previous conflicts were lost and relearned. Dogma and bias, based on isolated observation and anecdote, would continue to develop and would remain unchallenged, even as lives were lost. Many revolutionary advances in medicine and surgery were made, but questions and uncertainty about this simple device remained. Acknowledgments I thank Alan Hawk, Historical Collections Manager at the National Museum of Health and Medicine, Armed Forces Institutes of Pathology, for providing photographs of tourniquets from the museum s collection. References 1. Husum H, Gilbert M, Wisborg T, Pillgram-Larsen J: Prehospital tourniquets: there should be no controversy. J Trauma 2004; 56: 214 5. 2. Moulin Dd: A History of Surgery. 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