Between Flesh and Steel (26 page)

The discovery that microorganisms were responsible for infectious diseases made the advent of antiseptic surgery and the prevention of postoperative infection possible. The idea of antisepsis had been around a long time, but medical practitioners focused on the use of disinfectants in hospital wards. Carl Wilhelm von Scheele had discovered the antiseptic properties of chlorine in 1774, and Bernard Courtois discovered iodine in 1811. Since 1820, chlorine and iodine solutions had been used as “deodorants” along with creosote and turpentine to clean hospital wards and equipment. At the time, a number of published articles suggested using chlorine and iodine solutions as hand rinses for surgeons, but the practice never attracted much attention.
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Carbolic acid, discovered in 1834, had been used to treat sewage in waste plants for some time, and it is likely that Joseph Lister's experience with carbolic acid at the treatment plant in Carlisle, England, led him to use it in his experiments in antisepsis in the 1860s.

Lister was the son of an amateur microscopist and received early training in the use of the microscope. After completing his medical training, Lister was placed in charge of the Male Accident Ward at London Hospital as a professor of surgery. His own experience with amputation showed that the mortality rate in amputation cases ran between 45 and 50 percent from postoperative infection. Lister's interest in microscopy led him to pay attention to Pasteur's work long before its validity had been demonstrated. Believing Pasteur was correct in his assumptions, Lister began the search for a substance that would kill bacteria. In August 1865, Lister used bandages soaked in carbolic acid for dressing a compound fracture of the tibia. In May, he repeated the procedure on another compound fracture of the leg. Both patients recovered.
Lister then developed a systematic procedure for keeping operative wounds wrapped in dressings soaked in carbolic acid. He had hit upon two major medical innovations—
antisepsis
, which involved destroying infective agents that had entered the wound, and
asepsis
, which prevented an infective agent from entering the wound. In March 1867, Lister published his results in the
Lancet.

Although by 1869 the surgical mortality rate from infection had dropped from 45 percent to less than 1.5 percent in his accident ward, the reaction to Lister's innovation remained mixed. To accept Lister's method, one also had to accept Pasteur's theories, and the latter were hardly demonstrated facts at this time. Resistance to Lister's practices remained strong in France, England, and the United States, where, in 1882, the American Surgical Association officially rejected Lister's doctrines and practice. Only in Germany was Lister regarded as a hero, and the German Army was the first to implement his antiseptic surgical procedures on a wide scale. This practice paid off handsomely during the Franco-Prussian War, when German military surgeons saved thousands of lives by using Lister's technique.

The German medical establishment's acceptance of Lister's work provoked further investigations into bacteriology and antisepsis, such as the work of both Edwin Klebs and Robert Koch, who were also Germans. The Germans pioneered the use of steam sterilization of instruments, sterile operating gowns and masks, and rubber gloves.
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They were the first to abandon the crowded surgical amphitheaters for smaller disinfected operating rooms. While other countries gradually adopted these procedures, in no other country were they so widely, systematically, and rapidly adopted as in Germany.

These innovations only slowly seeped into the military medical services of other countries.
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For instance, the American Army made antiseptic surgery part of its official military medical practice in 1877.
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In 1899, the U.S. Army medical officers officially began using rubber gloves and then widely practiced antiseptic surgery in the Spanish-American War. By 1909, 60 percent of all operations in the American military featured rubber gloves, and by World War I, antiseptic surgery with rubber gloves and sterile surgical drapes was standard doctrine.
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The great strides in medical care that were made in the nineteenth century turned upon three major discoveries: anesthesia, bacteriology, and antiseptic surgery. These discoveries revolutionized medical care and opened the door for further research that produced remarkable advances in disease prevention and surgical procedures in the next century. Military medical men were among the first and most
enthusiastic practitioners in adopting the new techniques to their task of caring for the sick and wounded, and most of the innovations of this period found their first large-scale use in the military medical environment. The task of treating the suffering and human wreckage of war has always forced the military medical mind into a more practical than theoretical bent and toward a propensity for utilizing what seems to work regardless of the larger theoretical issues involved. The increased degree of institutional development evident in the military medical institutions of the time positioned them perfectly to recognize and adopt new techniques much faster than the civilian medical establishments could. The nineteenth century, after all, was the period in which, by mid-century, every major army had developed a professional military medical service of some institutional stability and competence.

The armies of revolutionary France were huge for their time and presented a serious problem for their opponents' well-disciplined linear armies. The use of “horde tactics” and frontal assaults produced horrendous casualties. After a poor start, the revolutionary armies succeeded in placing thousands of medical officers in the field. All civilian surgeons and physicians were placed under military conscription and control in August 1793, and in an attempt to abolish privilege, all medical schools were closed and medical practice was opened to anyone who could afford a license. Although the numbers of medical officers were sufficient, the quality of medical care provided to the soldier was often dismal. Inspector General Hercule Sieur of the French medical service called this period “the darkest period of French medicine.”
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When the Revolution suddenly swerved to the right with the fall of Maximilien Robespierre in 1794, the concern for all social welfare services, including military medicine, declined. Although the medical service had lost six hundred officers in the wars between 1794 and 1795, it remained the object of political scorn and interference. By 1795, the French military medical service had been placed under the political control of various ministries, which changed its organizational structure at whim. It no longer had a clear hierarchy of officers, a system of litter bearers, or a medical supply service, and medical personnel were subordinated to political administrators.
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To comprehend the opposition to an established, independent military medical service, it is important to remember that despite the slogans of the Revolution, within the military itself the spirit of privilege and caste was very much alive. The
artillery arm had only recently attained equal status with the infantry and cavalry, and it strongly opposed extending similar status to the engineers and medical corps. By 1796, political authorities assumed control of the military hospitals, removed the mobilization and disposition of the ambulances from the authority of the chief surgeons, and appointed political officers from Paris to whom all medical officers in the field were subordinated. Medical service chiefs in hospitals were forbidden to interact with the administration of the hospitals themselves.
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The one positive effect of these “reforms” was to drive the best physicians and surgeons from the hospitals into the field to treat the wounded, thereby providing an excellent opportunity to develop a corps of experienced battle surgeons. Nonetheless, between 1800 and 1802 the number of military doctors attached to the armies fell by half, and the number of serving surgeons did not reach the original number again until 1809. By that time, however, the armies had doubled in size. In 1800, 210 physicians and 629 surgeons were in the army. By 1802, the number of physicians had fallen to 62 and the number of surgeons to 500.
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Napoleon compounded the disaster in 1803 by reducing the number of military hospitals in France to only thirty while simultaneously closing the military teaching hospitals that had been established during the Revolution.
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Napoleon also refused to make the commissions of military doctors permanent, and despite pleas from Larrey and Percy, he would not establish an independent military medical service.
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The results of these misguided policies made themselves felt in the enormous levels of French battle casualties suffered in the Napoleonic Wars. Of the 4.5 million soldiers who served in the revolutionary and Napoleonic armies, 2.5 million died in hospitals from wounds and disease.
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Another 150,000 were killed in action. During the Egyptian campaign (1798–1800), a force of 30,000 men suffered 4,758 dead in action and 4,157 to disease and infection. The army suffered almost 30,000 cases of ophthalmia, and the death rate from all diseases was 109 men per 1,000.
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When the sick and wounded were transported home, the mortality rate in transit reached 41 percent.
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The Russian campaign (1812) began with 533,000 men in Napoleon's invasion force. By the time the army reached Moscow, disease had shrunk the force to 95,000, even though it had fought only two battles along the way. The retreat from Moscow was even more devastating, with thousands of men abandoned to die of disease and cold.
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Of the total force that began the invasion, only 40,000 lived to reach France. Of these men, fewer than 1,000 were able to return to duty.
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The death rate among military medical officers was equally appalling. At the start of the campaign,
876 medical officers of the Service de Santé (Health Service) attended the army. By the end, only 276 had survived, representing a loss of 551 officers, or 63 percent, to battle, cold, disease, or capture.
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To make matters worse, the quality of military surgeons had fallen so low in the Napoleonic armies that Baron Percy, the chief surgeon of the army, called them
chirurgiens de pacotille,
or “slop-shop surgeons.”
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There were exceptions to this general trend of poor quality, and Larrey, Napoleon's medical director and chief surgeon, was first among them. Larrey took part in twenty-six campaigns, sixty battles, and four hundred engagements and was wounded three times. After Waterloo, the Prussians captured Larrey, but a Prussian surgeon recognized the famous military surgeon and saved him from execution. Marshal Gebhard von Blücher, whose son Larrey had treated before the war, ordered him released. Larrey's memoirs,
Memoires de Chirurgie Militaire et Campagnes
(1812–1817), are the definitive source of information concerning military medicine in this period and make truly adventurous reading. At the Battle of Eylau (1807), Larrey operated for twenty-four hours without rest in weather so cold that his assistants could not hold the instruments. At Borodino (1812), by his own account, he performed no fewer than two hundred amputations in a twenty-four-hour period. His own experience with amputation led him to become an early advocate of the doctrine of primary amputation in contradiction to the then accepted advice of John Hunter. Larrey is recognized as the first military surgeon in Europe to advocate primary amputation. As a student of Desault's, Larrey espoused and practiced debridement of necrotic tissue, and he realized the danger of closing traumatic wounds prematurely. Larrey stipulated basic clinical rules for determining when amputation was required, and these guidelines and the doctrine of primary amputation remained standard military medical practice until after the Russo-Turkish War, when a Russian military surgeon, K. K. Reyer, demonstrated that the majority of gunshot-induced fractures could be salvaged with the aid of antisepsis and early debridement.
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Larrey was also among the first surgeons to recognize the value of immobilization in healing, and he used the starch splint to reduce the pain that casualties suffered during transport.

Larrey had begun his military medical career in the armies of revolutionary France, where he was quick to recognize the poor quality of medical training and knowledge available to the hastily recruited medics of his day. To correct this problem, Larrey established ad hoc training classes in anatomy and surgery at each of his postings no matter the duration. In Egypt, he became aware of the dangers of disease contagion through his experience with infectious ophthalmia. His list of hygiene instructions
to his surgeons was remarkable for its prescience. Larrey prescribed special surgical garments for doctors and nurses made of oiled cloth or rubberized taffeta. If these items were not available, he ordered that gowns should be made of tightly woven linen dipped regularly in vinegar water. He designed special wooden shoes coated with turpentine for use in medical wards. He directed that faces and hands were to be washed regularly in vinegar water, and when undertaking surgery, doctors had to wear linen surgical masks dipped in vinegar water. Larrey's surgeons were required to change the patients' dressings regularly and to minimize physical contact with the patient's wound. Old bandages and bedding were to be burned immediately and instruments washed frequently and kept in an airy place. Before leaving the hospital, surgeons and physicians were required to change their outer clothing and underwear and wash their bodies with vinegar water.
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As contradictory as it seems, however, Larrey remained a believer in the necessary suppuration of wounds and recommended using charpie as a suppurative.
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