Tourniquet Use on the Battlefield

Military Medicine, May 2006 by Mabry, Robert L

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

The tourniquet has been used for the management of extremity hemorrhage for nearly half a millennia. Almost since its 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 modem military first aid instruction.3

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 Petits 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