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.
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