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Introduction

Contents

INTRODUCTION

Considering the volume of surgery done during the World War, and the mass of literature resulting from surgical experiences in that war the natural inference is, the developments were many. Each war of magnitude in the recent past, certainly within the period of modern surgery, has advanced to a greater or less degree the boundaries of our knowledge of military surgery; this, in turn, obviously has reacted beneficially on the practice of surgery in general.

To determine how extensively the experiences of the surgeons of the World War have influenced the development of surgery, one must first know what, with the knowledge at hand, it was hoped to accomplish with surgery during that war. The practice of military surgery is inevitably circumscribed. Disregarding its primary purpose-that is, the conservation of combat troops- its scientific purpose is to preserve life, to prevent deformity, and to reconstruct physically. Since in the preservation of the life of the wounded the surgeon has been most concerned with preventing or combating wound infection, it is of present interest to determine not only how successful he was in this direction during the World War, but also to trace briefly the steps which permitted the establishment of the modern principles of surgery along this line. It must be borne in mind also that changes which have been effected in the general treatment of gunshot wounds necessarily have followed changes in armament.

Modern surgery had its beginnings in the sixteenth century, when Paré, no longer in the possession of the hitherto used cauterizing oils, hesitatingly made use of innocuous wound drainings, discovering, thereupon, not only that gunshot wounds were not poisonous in the sense previously held, but also that their healing was dependent upon the body itself. The period from Pare's time to our Civil War witnessed great strides in the technique of operative surgery, thus enabling it to become firmly established as a science; however, little or no improvement was made in respect to the general treatment of wounds. Except in so far as the greater array of surgical instruments and the variety of operations performed are concerned, a perusal of experiences of methods of general wound treatment during Civil War days might just as well apply to the sixteenth century. The inevitable pus of a wound was just as "laudable;"exploring fingers just as dirty. Keen, in comparing old and new war surgery, has this to say concerning his Civil War experiences:

Our dressings in the sixties consisted of simple ointments, often only cold unboiled water followed later by constant poulticing to initiate and promote the abundant flow of pus., Little did we dream that our patients recovered as a result of a kind vis medicatrix naturae, and, as we now know, in spite of our encouragement of infection.
 
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We used only the ordinary marine or toilet sponges. After an operation they were washed in ordinary water to cleanse them of blood and pus, and were used in subsequent operations. In our ignorance of bacteriology we did not know that they harbored multitudes of germs which infected every wound in which they were used. If one fell on the floor it was squeezed two or three times in ordinary water and used at once!

The amazing advances of modern surgery were made possible by the teachings of Lister, which first appeared in printed form only two years after the cessation of our Civil War. Hitherto, unless a wound healed by primary intention, it was considered natural for it to go through the stages of granulation and suppuration. Since the stage of suppuration followed that of inflammation, during which there were the usual signs, including the "surgical fever," and was remarked as representing a relief of the fever, it was looked for as a desirable effect; hence the poultices.

The Franco-German war of 1870-71 was the first war to occur after the beginning of the period of Listerism. At this time, however, antiseptic methods of wound treatment were but little known to many surgeons; they were also quite complicated and especially difficult of application in war time. The French in this war made no use of the new methods; the Germans attempted it and had some satisfactory results. Between this time and the occurrence of the Russo-Turkish War of 1877, greater opportunity had been afforded surgeons in general to try out Listerism and to be convinced of its merits, and in the war of 1877 we find successful though very limited efforts being made to combat surgical infection based on an intelligent conception of its real cause.

In the application of this knowledge in the general treatment of gunshot wounds in the Russo-Turkish War, the surgeons at the front were given thoroughly to understand that there was to be only one line of treatment-to occlude the wound, to lay the wounded part in a suitable position on the litter, and to render it immovable; in other words, to practice conservatism.

Coincident with these strides in the science of surgery, tacticians also were improving armament. In 1866, our slow-firing muzzle-loading rifle became abreechloader. Subsequently, between this date and 1892, improvements were made in the rifle by increasing not only the rapidity of fire but also the effective range. Other advances of the period, seemingly entirely remote from armament, had a great influence on the startling improvements in armament soon to be made. Means of locomotion made it possible more rapidly to concentrate large numbers of troops at weak points. Thus if a greater rapidity of rifle fire were effected than was afforded by the single-firing breechloader of 1866, this with more rapid means of concentrating troops might afford a superiority of rifle fire even to inferior numbers. So, with this in mind the magazine breechloader was devised, and adopted by the great military nations. Our first magazine rifle of reduced caliber was adopted in 1892 under the name of the Krag-Jorgensen, after its two Norwegian inventors. This is the type of rifle with which the opposing forces were armed in the next two wars-Spanish-American (1898) and South African (1899-1901). We now possessed whatwas generally looked upon as a humane military weapon, whose conoidal, jacketed missile when fired into soft tissue caused considerably less contusion and laceration than was true of the older rifle balls; and since there was less devitalization of the tissue surrounding the wound tract, the wound had the appearance of being clean cut, and proved in most cases to be relatively sterile. A suitable first-aid dressing, applied to such an injury on the field and shortly after its inception, effectively occluded it.

First-aid dressings for wounds were used by the British as early as the Crimean War. Since this war occurred prior to the period of Listerism, these dressings made no pretense of accomplishing anything but the prevention of a gross soiling of the wound; they consisted merely of a calico bandage and fourpins carried in the soldier's knapsack. It was not until the Sudan campaignof 1884 that a dressing of surgical utility was used by the British. This dress-ing was made of two pads of carbolized tow, a gauze bandage, pins, and atriangular bandage, all sealed in tin foil covered by parchment. In 1889, cognizance by us was taken of the desirability of having first-aid packets available for front-line dressings, but it was not until 1892 that they were officially adopted. It is interesting to note here the difference in the present meanings of the words aseptic and antiseptic as applied to the treatment of wounds and that which obtained in the latter eighties. The following extract is taken from Smart's Handbook for our Hospital Corps, published in 1889:

The object of aseptic treatment is to destroy germs that are present in a wound, and thereafter to effect their exclusion from its tissues. The object of antiseptic treatment is neither to kill nor exclude, but to suspend their vitality, and prevent fermentative changes.

In 1892, as mentioned above, our Army adopted a first-aid packet comprising two compresses of antiseptic gauze, each wrapped in a piece of waxed paper; an antiseptic roller bandage; a triangular bandage; and two safety pins. In 1896 it was required that each officer and enlisted man of the Army have one of these first-aid packets as a part of his equipment.

Thus when the Spanish-American War began our military surgeons were in the possession of adequate knowledge as to the reasons for the occurrence of infection in gunshot wounds, and means for its mitigation, if not prevention. Experiences in the Spanish-American and South African Wars with wounds that were produced by the small-caliber, steel-jacketed missile and that were treated by the sublimated first-aid packet, showed that the vast majority of them healed by primary intention, thus giving rise to a sense of security as to the treatment of such wounds that was to be thoroughly shaken in the World War.

In both the Spanish-American and South African Wars, injuries caused by the rifle far predominated over those caused by artillery, as had been true of previous wars. This was so to such an extent that in treatises concerning gunshot wounds of these two wars, shell wounds received relatively scant notice since they possessed small surgical interest. It may be noted, however, that they invariably were infected.

Between the two wars just referred to and the World War two things occurred which should have set military surgeons thinking. These were change in the character of the rifle missile and a progressively greater tendency to make use of artillery. Tacticians, ever seeking for a lengthening of the range and an increased accuracy of fire, had in the period in question decreased the weight of the missile and made it pointed instead of ogival, with the view of having it offer less resistance to the air. Its center of gravity being now well back toward its base did away with its former stability when striking structures of even slight resistance; that is to say, resistance offered by such parts of the body as the chest and abdominal walls causes the bullet to turn on its short axis, thus resulting in wounds comparable to those inflicted by an exploding

bullet. With the attendant destruction of tissue, it is easy to see that in such wounds the aseptic and conservative surgery of the beginning of the twentieth century would be totally inadequate. As to the progressive increase in the use of artillery during the period of aseptic surgery: In the Spanish-American and South African Wars shell and shrapnel wounds were between 5 and 10 percent of the total gunshot wounds. In the Russo-Japanese War (1904-5) Lynch reported that in the Japanese First Army, engaged in field operations alone, shell wounds were 14 percent. In the Turko-Balkan War (1912-13) shell and shrapnel wounds averaged about one-third of the whole. It is not the present purpose to give detailed consideration to statistical matter concerning the World War, but the fact remains that, though one would necessarily expect an increase in the proportion of shell wounds in siege warfare-the greater part of the duration of the European war 1914-1918 may be likened to siege warfare-no one evidently was prepared for the preponderant use of heavy projectiles in that war. Thus the ratio of gunshot wounds formerly obtaining, in which the wounds caused by rifle missiles were typical, became reversed and so found surgeons in a state of unpreparedness.

Considering military surgery as a special branch of the science of surgery necessitates a few interpolative words here as to the evolution of the military surgeon himself. To revert to the fifteenth century, it is an incontrovertible fact that the importance of the surgeon to armies then was recognized as being great. Reference already has been made to the work of Pare in this connection, making him an outstanding figure. The poetry of war surgery was again written by the French in the days of Napoleon I when Percy, and especially Larrey, were competent surgeons, as well as exceptionally competent administrative medical officers. Straub mentions, however, that this combination worked badly in our Civil War, as our doctors, unacquainted with war as they were, were all too prone, when charged with important administrative duties such as those of a division surgeon, to devote their energies exclusively to amputations rather than to exercise the supervision essential to their positions. This was all before the dawn of modern sanitation, and for centuries it was the surgeon who held the proscenium in the medicomilitary theater. In our earliest history as a nation the claims of surgery were not overlooked, for we had in the Revolutionary War a surgeon general as well as a physician general. Why the title "surgeon general" persisted is unknown. Perhaps because at that time the importance of surgery was recognized as paramount. Custom and not practice seems later to have dictated the title "military surgeon."As late as our Civil War, however, the surgeon still remained the important medical officer, though now some very competent medicomilitary administrators came to the fore. A change seems to have taken place in the medico-military hierarchy at a later period. With our next war-the Spanish-American-and the subsequent long military occupation of the Tropics, surgery from the military standpoint sank into insignificance and the thoughts in sanitation overshadowed everything else with our Army Medical Department. Nor did our small Regular Army afford much opportunity for specialization in surgery. Some good surgeons have developed therein, but this was not by virtue of but despite the system in vogue. The situation was quite otherwise

in our civilian medical profession. in which knowledge of surgery had advanced by leaps and bounds since the beginning of the antiseptic and finally the a septiceras; operations which would have been truly marvelous to the Army surgeons of preantiseptic days were a matter of everyday occurrence now. These wonderful strides had resulted in a high degree of specialization which had to betaken into consideration in the plans of the Army to use most effectively civilian surgeons. But in this no great difficulty was encountered, since it was the general policy of the Government to secure the best talent available in all lines of activity for the care and welfare of the Army to be used in theWorld War, and committees representative of the many specialities of surgery as well as medicine were appointed by the general medical board of the Councilof National Defense. Such committees were composed of the leaders in the irrespective specialties as well as representatives of the Medical Department, and soon after their organization many were gradually absorbed by the Medical Department, thus permitting them to continue as working components of our military machine. A plan was therefore perfected which enabled American surgeons to work in the Army along the lines of their civil experience, and there came into being the general surgeon, the orthopedic surgeon, and the neuro-surgeon.

It is needless to say that the majority of our civil surgeons, regardless of their qualifications, were needful of adaptation to the practice of military surgery, encompassed, as it inevitably is, by the stress of circumstances, the very masses of material with which it is necessary to deal, and, in the advanced hospitals of the theater of operations, the practical impossibility of securing surgical cleanliness.

Fortunately, when we entered the World War, we could take advantage of  the several years of experiences of our surgical confreres in the allied armies and thus eliminate some of the mistakes which had been made by them. As explained above, prior to the outbreak of the war of 1914-1918, military surgeons still considered the relatively clean wound made by the rifle missile the typical gunshot wound, and that its treatment would consist largely in the early application of a first-aid dressing, plus some means of prophylactically antisepticizing the wound: With this thought in mind the first-aid dressing itself had been for some years prepared in a subliminated form, but a further step had been taken following the discovery of the high antiseptic value of tincture of iodine when applied to the skin and to ordinary wounds. Unfor- tunately, as has been made clear above, the new, pointed missile of the rifle frequently caused a wound whose tract was surrounded with devitalized tissue; also, there was now a preponderance of wounds caused by artillery missiles. Consequently, surgeons in the early part of the war were confronted with an overwhelming amount of wound infection; and since in the years immediately preceding the war prophylactic antisepticizing as a method had become so strongly entrenched among them, it was but natural that their efforts to treat the infected wounds should be directed toward securing efficacious antiseptics. In so far as the prophylactic antisepticizing of wounds in front areas was concerned, all efforts in this direction proved futile, because of the presence of the damaged tissue in which the infecting organisms could readily propagate and where they were inaccessible to antiseptics.

Surgeons now resorted to d ebridement, a practice in vogue centuries ago, consisting of opening up the wound so as to rid it of the foreign contained matter and the products of inflammation, the destroyed tissues being left to a natural process of elimination. This practice, and in conjunction with it, was followed by the use of such substances as the hypochlorites to dissolve the destroyed tissues, and, later, the actual excision of all devitalized tissue. Thus leaving only well-nourished tissues, which of themselves could overcome infection, made it possible now to close the wound either by primary or delayed primary suture. To this practice the name debridement clung, though, as pointed out, it was a radically different procedure.

The excision of gunshot wounds was a firmly established practice by the time we had any great number of wounded in our hospitals in France, so that we now had available to us a means which not only materially reduced the mortality of gunshot wounds but also materially reduced the average length of stay of the injured in hospital because of their wounds.

The applicability to civil surgery of this sound method of treating wounds is measurably slight, perforce, nevertheless it has its field, particularly in industrial surgery; therefore, it represents a distinct contribution on the part of military surgery.

Other advances, such as the treatment of shock, the handling of fractures, and the control of tetanus, will not be touched upon here, since to do so would be but anticipating what is given fully in the following parts of this volume.

It was the policy of our Government to furnish the Army with the very best in the way of surgical personnel and to afford this personnel the opportunity to function best, by making available working facilities. Furthermore, the treatment of the wounded was not to be considered complete, in so far as our Medical Department was concerned, until after the wounded had attained complete recovery, or as complete as it could be, considering the nature of their respective disabilities.