In essence, the tourniquet is a very simple bit of kit. It is simply a strip of material tied very tightly around a limb to stop bleeding. But, despite its simplicity, the history of the tourniquet is one of fierce debate and lives lost.
In the recent conflicts in Iraq and Afghanistan the use of tourniquets to treat battlefield casualties was ubiquitous. It is arguably the piece of equipment that saved most lives during those wars. The femoral artery is the main blood vessel carrying blood to the leg and it is frequently severed during traumatic amputations. You can lose up to a litre (just under 2 pints) of blood every minute from a bleeding femoral artery. The human body contains 5 litres of blood and shock occurs when about 20% of this is lost. Bleeding from a femoral artery can therefore send a casualty into shock within 1 minute and death can occur in as little as two minutes. Almost nothing is more important than stopping the bleed.
The success of the tourniquets in these conflicts was due to the fact that all coalition soldiers carried their own tourniquet and, more importantly, all were trained in its proper use. It was for this reason that soldiers routinely survived the loss of two or even three limbs. It is hard now to imagine battlefield medicine without the use of tourniquets but, even though tourniquets have been in use for thousands of years, they have not always enjoyed this glowing reputation.
The earliest attested use of tourniquets is in 6th Century BCE. Sushruta, the Hindu father of Ayurvedic medicine and surgery, wrote about using leather strips to stop arterial bleeding. Hindu physicians are also recorded as using tourniquets to treat soldiers among the invading army of Alexander the Great in 326BCE although, on this occasion, they were used for the treatment of snake bites.
Sushrata
The Romans, ever at the forefront of military innovation, are recorded as using tourniquets, some of which were apparently made of bronze. But it was the most famous of all Roman physicians, Galen, who also levelled early criticism at this life saving tool. He had observed that tourniquets frequently actually make bleeding worse - this is in fact true, a tourniquet applied with insufficient pressure will make an artery bleed more vigorously.
Roman Bronze Thigh Tourniquet
Galen had an enormous influence on the practice of medicine in Europe and the Middle East for over a thousand years and, like many of his ideas, his contempt for the tourniquet was widely shared for many centuries.
Galen
In 1517 Hans von Gersdorff, a Prussian surgeon, published a manual on military medicine that included the use of tourniquets for amputation surgery, but It is not until 1674 that we have evidence of the re-appearance of the tourniquet on the battlefield when the French Surgeon, Morel used one at the siege of Besancon.
Tourniquets continued in use and were developed over the following decades and in 1786 Sir William Blizard lectured at the Maritime School in Chelsea about the importance of battlefield haemorrhage control. He actually began his lecture telling the story of Captain Drinkwater who lost both his legs to cannon shot during the siege of Gibraltar and died due to blood loss because nobody knew how to stop the bleeding before the Captain got to hospital. Blizard also described how the surgeon aboard the Barfleur (a British warship), having seen the terrible wounds caused in naval battles, provided every sailor with a tourniquet and instructed them relentlessly in its use. This presaged the role of medical officers in Iraq and Afghanistan by some 230 years, as they too had to be relentless in the instruction of soldiers about the use of tourniquets.
It is lack of instruction that resulted in the fall from grace of the tourniquet. During the American Civil War Samuel D. Gross, a surgeon on the union side, advised that all soldiers should carry a stick of wood 6 inches long, a handkerchief and a compress with which a tourniquet could be made. Despite the good intentions, training to the soldiers was inadequate and tourniquets caused enormous damage, either by worsening arterial bleeds, or by being left on too long and causing the needless death of limbs.
By the start of WWI, tourniquets were so out of favour that the chief French Surgeon, Tuffier, said that tourniquets caused ‘disasters’ and ‘as soon as a tourniquet is seen in an ambulance it should be taken away’. A Major in the Royal Army Medical Corps wrote in 1916 that, although they were occasionally useful, tourniquets were ‘an invention of the Evil One’. The issues again surrounded improper training as well as prolonged evacuation times during which tourniquets could be left on too long.
During WWII, experience was mixed. Whilst US soldiers were issued with tourniquets, the device they were given was often inadequate and lives were both lost and saved as a result. Use of tourniquets continued to be patchy but the experiences in Korea, Vietnam, the first Iraq War and the US operations in Somalia, were intensely scrutinised and so unequivocal evidence of the usefulness of tourniquets was provided. This eventually led to the provision of high quality tourniquets and high quality training, first amongst special forces units and then to whole armies.
Combat Application Tourniquet
The Combat Application Tourniquet in use today remains a simple piece of kit but, combined with training and highly effective chains of evacuation, it has saved countless lives and will continue to do so in the future.
Adam Staten is the author of the novel Steadfast: Band of Brothers based on his time serving as a medical officer in Helmand Province, Afghanistan.
