With a short leap of over 20,000 years, we learn that by the time of the siege of Troy, it was considered essential for all educated Greeks to understand simple medical care.5
The other information that we have of the Trojan siege is derived mainly from Homer’s Iliad in which the author gives detailed accounts of the wounds. Frolich has analysed Homer’s work and demonstrated that there was a variation in the number of wounds (shown in red in Figure 2) caused by each weapon and the percentage of fatalities (in purple).
It is interesting to note that the chance of actually hitting the enemy was greatest with the spear, and with a fatality of 80 percent, it was the best of the weapons. The swordsman was more accurate, with 100 percent fatality. He was much less likely to hit his opponent, however, who in turn would be close enough to offer a—possibly fatal—response. Slingshots and arrows had a very low hit rate and medium fatality with arrows at the worst. This is a startling contrast with the success of the mediaeval English bowmen at Crécy and Agincourt. It surely indicates that technological progress and tactics, as well as the English attention to obligatory training, played a large part in the development of the bow before explosive weapons replaced it.
This primitive—though bloody—form of warfare was changed completely by the invention of explosive devices. Although these were initially an inaccurate and relatively weak form of weaponry, they soon developed to combine high-hitting potential with lethal precision.
The science of all weapons, and in fact of all injuries, is to direct sufficient energy into biological tissues to disrupt them. All moving particles are possessed of a certain amount of energy, and when they are stopped or slowed by an object, that energy is transferred to the object and distorts or destroys it. Soft animal tissue is particularly vulnerable and severe wounds occur.
Physics tells us that the amount of energy (E) within a moving object depends on the combined effect of its mass (M) and the velocity (V). This applies to a wounding object whether it is a car, a bullet or a fragments of a mine.
The actual equation is:
Energy (E) = Mass (M)/2 x Velocity (V)2/2 or E= M/2 x V2/2
By and large, the smaller the injuring object in war, the more accurate its path. Therefore, anti-personnel weapons were designed to be smaller but to travel at a greatly increased speed—hence the effectiveness of a sniper’s bullet. The simple mathematics show that with an object of 10 grams travelling at 10 kilometres per minute, to double the mass will multiply the energy by 20 times (10x2 = 20). But to double the velocity will increase the energy by 400 times (202= 20x20 = 400). Velocity is, therefore, the major factor in determining the energy content of a moving particle
These forms of injuries are designated “High Energy Transfer Wounds,”6 and can occur from any object that moves with sufficient energy. There are particular properties of such injuries apart from the initial severe wound. These should be considered in detail because they demonstrate why there is a high complication rate even after good initial treatment, namely the following eight reasons:
1. Massive tissue destruction is characteristic of such wounds, and often the limb cannot be preserved. The missile, whether it is a bullet or a piece of a mine or shell, will fragment further and spread violently through the tissues.
2. The high speed of the missile causes cavities to form, destroying local tissue beyond the site of the track and creating a vacuum that sucks in infected air and contaminated material from clothes, etc.
3. The wounds are always infected, both from the debris of shell or mine fragments and from the material sucked in behind the fast-moving particles or bullet.
4. The tissues are literally torn apart from the energy that is released by the particles slowing down, and this is independent of the direct effect of the missile debris.
5. Injuries to nerves and large blood vessels are 10 times more frequent than in peacetime wounds.
6. The patients are usually shocked from blood loss, and delay in treatment is often fatal.
7. Complex “shattered bone” fractures usually occur.
8. Multiple sites of injury will occur.
The Situation in Besieged Sarajevo 1992–1996
The siege of Sarajevo was the longest in modern times. It was an example of a method of warfare as old as recorded history, in which attrition is focused on the civilian population with the ultimate aim of attacking the citizens psychologically and physically. As well as wounding and killing, the weapons used are those of fear, uncertainty and deprivation. All will suffer, but the sick and elderly, the unborn children and infants, and the wounded are particularly vulnerable to starvation and loss of basic amenities. That every one in Sarajevo was effectively in the front line is reflected in the distribution of wounded between military and civilians (Figure 3).
In the summer of 1993, the new non-governmental organization (NGO) HMD Response International asked for volunteers from British Orthopaedic and Trauma Surgeons to assist their Sarajevo colleagues. As with all wars, nothing went entirely according to plan, but it began a presence of this NGO in Bosnia that still continues.
By August 1993, the devastation of over a year of war was obvious in the destroyed buildings and the hospital wards filled with patients suffering from complex wounds. Surprisingly, considering the terrible circumstances in which the surgeons had worked, the level of infection was much lower than expected. This was soon to change.
The succeeding months demonstrated the problems from the blockade of food convoys and the effects of a freezing winter. In Sarajevo, the temperature ranges from as high as 40o C in summer to –15o in winter. The city is set on a high plateau surrounded by mountains that inhibit air transport, and the poor roads, already militarily blockaded, were obstructed by heavy snowfalls.
Medical supplies soon failed, and in particular, the devices for fixing fractures were exhausted within weeks of the beginning of hostilities. Undeterred, a local external fixator was designed by an engineer and two surgeons and produced in Sarajevo throughout the war. This device—the Sarafix—was used in all Bosnia on over 3,000 patients. HMD Response International provided a critical component of the fixture—its surgical steel pins—as part of its support programme for the surgical development.
Management of the Soft Tissue Component of High-Energy Wounds
The majority of the wounds treated in the Sarajevo siege were from shell and bullet wounds. Because the population was confined so severely, reaching mined areas was in itself hazardous. Nevertheless, because of the similarity of high energy transfer wounds, the principles of treatment and the complications that occur are entirely relevant to a study of mine injuries.
War wounds are complex and inevitably get infected. In the early months of the first World War, British Army Medical Officers were inexperienced in treating such terrible wounds, and a massive number of lethal infections occurred. In 1915,7 orders were given to remove all dead and foreign material and to never primarily close wounds. The technique is known as debridement, from the French to unsaddle or release.
This tested method was employed in Sarajevo with great success with the addition of an anti-tetanus toxin and antibiotics. Injuries near the buttocks were particularly at risk of such infection.
Management of Fractures in High-Energy Wounds
Stabilising fractures resulting from such injuries is both imperative and difficult. The fractures are often multiple and very unstable, with considerable implanted debris. They must be managed without closure of the wound and must be stabilised to allow treatment of other injuries of the arteries and viscera. External fixation is the first choice, but Coupland states8 that devices can be too complex for adverse war situations. The reliability and simplicity of Sarafix proved ideal for this work.
The device was used at many sites including complex pelvic injuries with bowel and vascular damage.
Despite the overall success of the Sarafix device (76.97 percent of a studied cohort), there were inevitable complications, as shown in Figure 4.
There are no simple complications of these wounds, and all cause considerable persistent symptoms that are often permanent. Osteomyelitis (6.67 percent) has a particularly sinister recurrent and debilitating effect over many years. An estimate suggests that 15,000 Bosnians suffer from this crippling disease.
Gavrankapetanovic and Beavis reported the results of radical treatment of chronic osteomyelitis following Bosnian war injuries and found that after an initial improvement, the incidence began to increase considerably after two years (Figure 5).
Nutritional Problems in a Siege Situation
For patients with massive injuries from bullets, shells and mines, the effects of starvation and winter cold increased the incidence of infection. A study between September 1993 and January 1994 showed a massive rise in wound infection.
It was considered that the injured patient in Sarajevo was at risk from malnutrition for several reasons:
It is easy to envisage a situation in which a severely injured patient—with a 10 percent increase in nutritional requirement from the effects of trauma, lying in a ward at 10o with a pyrexia of, say, 39o and suffering from anorexia for many physical and emotional reasons—becomes a victim of malnutrition.
HMD instituted a survey of the relationship between malnutrition and wound infection in Sarajevo between August 1993 and January 1994.9 Assessment by Zec, Harper and Beavis in 1994 of food delivery in the winter months of the survey (November–January) demonstrated that no more than 60 percent of the required food would reach the city due to roadblocks and weather preventing air support. As well as blockade, there was inevitable loss of food by theft, reducing the food to a little over 40 percent of the required amount. Finally, the rejection of food by patients in all hospitals in peaceful circumstances is well-recognised as a major problem,9 reducing the final amount to 25 percent. In the Sarajevo hospitals in winter, the circumstances of the injured were, despite the best efforts of the staff, truly terrible. It is not surprising, therefore, that depression, anorexia and rejection of unpalatable food contributed to the malnutrition. A graphical scheme of such a scenario is represented in Figure 6.
A further HMD study demonstrated that the nutritional requirements of the patients were not satisfied and that this became more obvious as the autumn progressed (Figure 7). It can be seen that the pre-war nutritional status was in excess of the recommended levels and body weight was also higher than optimum.10 It is tempting to speculate that the excess of body fat in the Sarajevans protected them from malnutrition during the first severe winter.
Very significantly, dietary micronutrients such as vitamins greatly decreased during the early winter months of 1993/9411 (Figure 8).
As can be seen in Figure 8, there are serious deficiencies in the intake of Vitamins C, B12, B6 and Folate, which are essential in tissue repair. Although no cases of scurvy were recorded, the potential for it to occur is obvious.
It was important to try to quantify the relationship between the care of patients and the change in nutritional status during the early winter months of 1993/94; the obvious parameter to review was infection. A direct relationship was observed between the reduction in food supplies and an increase in wound infection when the pin track sites of the Sarafix device were inspected.11
Unfortunately, extra food could not be brought in by aircraft, despite the obvious case that was made for considering the wounded patients as vulnerable.
Sarajevo was besieged for nearly four years, and during this time, the population was subjected to all the terrors of modern warfare and massive deprivation. Demoralising the civilian population by depriving them of their basic needs has always been the aim of besieging armies throughout history, and Sarajevo was no exception.
Modern weapons primarily have an anti-personnel role in civil wars of this nature, and the incidence in Sarajevo of high energy transfer wounds in the civilian population reflects this fact. The well-tried immediate treatment of wound toilet and adequate debridement, along with stable fracture fixation, proved once again to be effective in producing a satisfactory cohort of results.
The nutritional deprivation was objectively shown to be important in the wounded patients by a significant rise in the infection rate during winter months when the food supply fell well below the required levels. In a war situation where evacuation is not possible and food supplies are precarious, the injured patients must be considered a vulnerable group. Aid agencies should concentrate on relieving this problem as part of their overall medical aid strategy.
Mine injuries were not common among the citizens of Sarajevo because enemy snipers and artillery confined them to a very localised life. Military personnel were most likely to be injured by mines during frontline service. Those civilians who were injured by mines had usually left the city for various reasons such as collecting wood for fuel.
The risks that these unfortunate individuals were prepared to take just to warm their families or obtain meagre amounts of food are an indication of the terrible effects of siege warfare on ordinary people.
* All graphics courtesy of the authors.