Extremity Injury and War: A Historical Reflection.

Medical research and science in the 20th century have transformed the gruesome realities of war: Whereas before, a battlefield injury was associated with a high likelihood of death, most injured combatants now survive their injuries. However, even as advances in orthopaedic surgery have improved the lives of those injured in war, it is fair to say that the necessities of war have advanced the specialty. David LeVay, the prominent British orthopaedic surgeon and historian of orthopaedics, has argued that, ‘‘Orthopaedics was initially the surgery of war, fostered by war and the province of general surgeons’’ [13]. In fact, so many surgical advances seem to be associated with wars that some even compile a medical balance sheet of war [7], weighing its costs and benefits in a bizarre social calculus. War is a horrible failure of social and political responsibility and a social disaster of the first magnitude. As terrible as it is, however, war often serves as a sort of forcing function in medicine, accelerating changes already in queue because of the number of sick and injured as well as the number of medical personnel involved in similar war-related activities. The great 19th century Russian military surgeon, Nikolai Pirogov, is credited with calling war ‘‘an epidemic of trauma’’ [21]. Pirogov is correct. Historians often note that the practice of medicine and/ or standard of care at the beginning of a war is different from the practice of medicine and/or standard of care at the end of the war [1, 4, 8, 10, 14, 18, 20, 22, 26]. By reflecting on the key wars from before the 20 century to the war in Vietnam, we can potentially gain a better understanding of this transformative process.