War burns: the blow and the cure

Abstract

War burns have been described throughout the past 5,000 years of written human history, and fire was probably utilized as a weapon long before that. The invention of gunpowder and sophisticated explosives turned the battlefield into a burning inferno and changed for the worse the odds against protective measures. The textbook of military medicine1 has analyzed the development of weapons as the cause of the trends of changes in the nature of injuries during war. The majority of casualties in the First and Second World Wars suffered one—or only a few—relatively large, penetrating injuries. The anti-materiel munitions that were introduced during World War II with the American-made Bazooka—a shaped-charge warhead propelled by a rocket as its first representative—changed the nature of injuries to multiple, penetrating wounds and deep burns caused by small particles of burning aluminum. High-kinetic-energy munitions that penetrated armored vehicles, buildings, and fortifications created a spall (a cloud of blown-out fragmentation debris) that caused similar injuries. The introduction of these new munitions added more burns to the casualty case mix. War burns can be classified as those that are caused by incinerating materials (such as fuel-air bombs, napalms, phosphorous munitions, etc.), flash injuries due to exposure to the high temperatures of explosives, flame burns (mostly secondary to burning fuel, vehicles, buildings, or shelters that were ignited by explosives), contact burns from hot objects in the battlefield hostile environment, scalds from steam or hot fluids that were released by a direct hit or damaged machinery, chemical burns from blistering warfare agents or leakage of chemicals used or stored in the immediate environment of the injured, accidental electrical burns or burns that were caused by laser beams, and—last but not least—radiation burns due to exposure to nuclear weapons. Many times these burns are accompanied by blast, blunt, or penetrating injuries and sometimes by drowning or high-altitude sickness, frostbite, dehydration, or hypothermia. Almost all of these injuries are inflicted in the battlefield, far away from advanced medical services, where evacuation to a rear hospital or even a basic medical echelon might be significantly delayed due to battle conditions, while the medical teams work in life-threatening surroundings and under the emotional stress of the fighting zone. The load on the medical system is at the extreme in the mass-casualty situation. All of these characteristics make war burns more extensive, deeper, more complicated, and undertreated compared with the “normal” case mix of accidental burns in our everyday life. This situation could worsen the prognosis of war burn casualties unless this challenge was met by the entire medical system, from the medic and the battalion surgeon in the field to the rear hospital echelon. In the preface to The Treatment of Burns: Oxford War Manuals by A. B. Wallace, published in l94l during the Second World War, the general editor writes: “If any good is to emerge from the evil which confronts us today, it will be salvaged in the form of medical progress accelerated through intensity of experience.”2 Perhaps the only true benefit of war is the higher standards of trauma care it forces us to develop and to pass on to the succeeding generation. Medicine and surgery have always been professions made of a solid mixture of tradition and craftsmanship. The heavy burden of responsibility for life and death forced physicians to rely almost entirely on what they were taught and on what was considered and accepted as dogma. Some theories, policies, and traditions became almost sacred, to the degree that they were incorporated into the moral code of various religions. This can pose a moral problem for the physician, because doing something different that contradicts the great teachers could be considered a sin, by both themselves and society. It is therefore understandable why many times, during the history of medicine, it had to take wars, revolutions, or disasters to change deep-rooted concepts. Only in the apocalyptic atmosphere of a large-scale catastrophe would it be acceptable to question conventions. Only under the overwhelming demands for medical services could the failures of an old method be demonstrated, and surgeons could gain sufficient experience, courage, and conviction to effect a change. It took crises to change—and wars were always available.