Between Flesh and Steel (25 page)

The greatest killer of soldiers at the beginning of the century was still disease, and it routinely carried off eight soldiers for each one felled by an enemy bullet. The
advances of bacteriology, nutrition, and military and public sanitation, along with antiseptic surgery, finally made it possible for an army to kill more of the enemy with hostile fire than were killed by deadly infectious microbes. The Franco-Prussian War was the first war of any magnitude in which the number of soldiers lost to hostile fire was greater than to disease.

At the start of the nineteenth century, no army had established an independent military medical service under the control of medical officers for treating the sick and wounded. No nation could provide a trained medical staff, supply structure, transport, and medical personnel adequate to handle the usual casualty loads. By the end of the century, every major army had an independent, professionally trained, and sufficiently manned military medical service complete with an ambulance corps for reaching and evacuating the huge numbers of casualties that had never before been seen on the battlefield. If war finally reached modern proportions in all its respects in the nineteenth century, it is also fair to say that military medicine achieved a similar stature.

Effective and safe anesthesia was introduced to military medicine in the nineteenth century. The term “anesthesia” is generally credited to Oliver Wendell Holmes Sr. (1809–1894), to describe the effects of ether.
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Prior to the discovery of ether and chloroform as anesthetics, the most commonly used agent against pain was opium administered in liquid or powdered form. Other methods of rendering a patient unconscious or semiconscious for surgery were to reduce the blood supply to the brain either by compressing the carotid artery until the patient passed out or by bleeding the patient to a state of near total unconsciousness. Immediately prior to the introduction of ether anesthesia, some surgeons, including the famous English surgeon Sir Robert Liston (1794–1847), used hypnotic suggestion to induce sleep.
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All of these methods produced semiconscious states of only short duration, requiring the surgeon to complete the surgical procedure quickly.

The first gas recognized as having anesthetic properties was nitrous oxide, which Joseph Priestley (1733–1804) identified in 1772 as part of his experiments with oxygen. For several years the gas was thought to be deadly. In 1795, the chemist Humphry Davy (1778–1829) inhaled nitrous oxide and, noting its pleasant effects, named the mixture “laughing gas.” In 1800, Davy published a monograph in which he described the use of nitrous oxide to relieve the pain of an inflamed gum. More
important, he suggested its use as a surgical anesthetic. Eighteen years later, Davy's student, Michael Faraday, noticed the anesthetic effects of sulfuric ether and compared them to the effects of nitrous oxide. In 1842, Henry Hill Hickman, a member of the Royal College of Surgeons of London, performed the first operation with an anesthetic on animals.

None of these experiments evoked any serious interest. Although nitrous oxide and ether were well known by mid-century, the medical community still showed no systematic interest in using it for surgery, perhaps because of the widespread belief that pain was natural to illness. Medical students were aware of the anesthetic properties of both nitrous oxide and sulfuric ether, and they commonly used them at university parties to induce silly behavior. In January 1842, William E. Clarke, a student of chemistry, convinced Elijah Pope to extract a tooth from a patient anesthetized by ether. Two months later a Georgia dentist, Crawford Long, removed a tumor from the neck of a patient who was anesthetized by ether. After William T. G. Morton, a Boston dentist, extracted a tooth from a patient to whom he had administered ether in 1846, he published the results of his work in the
Boston Journal.
Morton was heretofore regarded as the discoverer of ether as a surgical anesthetic. In October 1846, Morton administered anesthesia while Dr. John Collins Warren removed a tumor from a patient's jaw. The use of ether as a surgical anesthetic quickly spread to Paris and to London, where, in December 1846, Sir Liston performed a thigh amputation on an etherized patient and publicly proclaimed the new anesthetic a major medical innovation.

The U.S. Army was the first to formally issue ether for anesthetic purposes, having allotted supplies to the physicians and battle surgeons who accompanied Maj. Gen. Winfield Scott's men in the 1847 landing at Veracruz during the Mexican War. That March or early April, Edward H. Barton, surgeon of the Third Dragoons, Cavalry Brigade, Twiggs's Division, anesthetized a teamster of the U.S. Army's logistics train to amputate his leg, which had been shattered by an accidental musket blast. The operation marks a military field surgeon's first use of the ether anesthetic.
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Samuel Guthrie in the United States, Eugène Soubeiran in France, and Justus von Liebig in Germany almost simultaneously discovered chloroform in 1831.
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Chloroform was not used as an anesthetic, however, until 1847.
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Chloroform had a number of advantages over ether for military applications. The simple “rag and bottle method” of administering chloroform was easier to use since it did not require an inhaler. Smaller quantities were required to induce anesthesia, and chloroform could
be more easily stored and transported in the battle surgeon's pocket while in the field. Most important, unlike ether, chloroform was not explosive, an important consideration in a time when most operations were performed by candle or lantern light in close quarters. Given these advantages, it is difficult to explain why chloroform was so slow to catch on, especially among English military surgeons. From 1847 to the early days of the Crimean War in 1853, there was not a single documented instance of a British military surgeon using chloroform for anesthesia.
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John Snow (1813–1858) was the first physician to calculate specific doses for ether and chloroform as surgical anesthetics. He personally administered chloroform to Queen Victoria (1819–1901) during the births of the last two of her nine children, leading to the widespread acceptance of the use of anesthetics among English physicians. Although the French military had used it as early as the Paris revolt of 1848 and the Prussians likely used it in the Danish-Prussian War of 1848–1851, British military medical doctors did not begin to use chloroform until the first few months of the Crimean War. A British naval surgeon aboard the HMS
Arethusa
was the first to administer chloroform at sea in 1854.
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Anesthesia revolutionized military surgery, especially in the area of battlefield amputation. Without anesthesia, speed was the surgeon's primary qualification. Sir Liston, the famous English surgeon, reportedly could amputate a leg in twenty-eight seconds. Even less skilled military surgeons could accomplish the task in less than a minute. Moreover, the doctrine of primary amputation advanced early in the century by Dominique-Jean Larrey, Baron Pierre-François Percy (1754–1825), and George James Guthrie (1785–1856) was gradually accepted as the century wore on, and under the influence of Sir Thomas Longmore (1816–1895) and George H. B. MacLeod in the Crimean War, it became established practice for military surgeons. Anesthesia made it possible to operate more slowly, to take the time to effect more complete hemostasis (stopping blood flow), and to prepare the stump for prosthesis. Although early in the century surgeons maintained that the pain associated with surgery was actually beneficial in that it kept the body's systems fighting to survive, in fact the use of anesthesia greatly reduced the incidence of death by surgical shock.

The problem of hemostasis remained a serious obstacle to battlefield surgery, however. A common method of hemostasis during amputation was to put pressure on the femoral artery. Liston preferred this technique to the tourniquet. Ligature
gained more acceptance as surgeons trained in battlefield surgery gradually learned how to accomplish it. At the beginning of the century, surgeons found that a ligatured artery formed a clot within the ligature. Military surgeons often left the ligatures long so that the suture could act as a drain outside the wound. A common practice until after the Civil War, this technique allowed the exposed suture to act as a wick along which infection could be transferred deep within the wound, provoking a secondary hemorrhage that was often fatal. Since the ligature material was not sterile, even a short ligature left in the wound provoked infection and secondary hemorrhage. Philip Physick (1768–1837), a Philadelphia surgeon, made some progress in this area. He experimented with ligatures made of buckskin and parchment to make them absorbable. Horatio Jameson (1778–1855) of Baltimore continued the work and, in 1824, introduced absorbable ligatures made of kid and chamois.
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The medical community, however, was slow to accept both advances. Until after the Civil War, most ligatures were still made of harnessmaker's silk, horsehair, and catgut. Dr. Joseph Lister experimented with treating catgut with carbolic and tannic acid to make it sterile, but using these materials produced high rates of tetanus, anthrax, and gas gangrene in amputated limbs.
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Meanwhile, some advances in hemostasis were achieved. In 1829, Karl Ferdinand van Gräfe developed a lock to hold the hemostat closed, and more technical advances were made along the way until William Steward Halsted invented the modern hemostat in 1879.
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Spencer Wells contributed greatly to the introduction of bloodless surgery in 1872 when he used small arterial clips to close off blood flow temporarily during surgical procedures. In 1873, the German military surgeon Friedrich von Esmarch invented the Esmarch elastic bandage, which served as a battlefield tourniquet and promised the possibility, although unrealized, of bloodless surgery.

The large numbers of experienced surgeons on the battlefield over the course of the century generally improved the overall competence of surgical procedures and stimulated solutions to problems that they had commonly encountered. Thus, the French surgeon Charles Pravaz, searching for a way to administer drugs more efficiently, developed the hypodermic syringe in 1853. René Laennec, another military surgeon, carried out experiments with the stethoscope (published in 1819) and introduced this vital piece of diagnostic equipment for use on the battlefield.
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Wilhelm Röntgen's discovery of the X-ray in 1895 became a revolutionary way of determining the position of projectiles buried deeply inside the body.
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Unknown military staff physicians in the Seminole War (1841) discovered that regular doses of quinine
were a safe and effective preventive for malarial fever.
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In 1900, the U.S. Army Yellow Fever Commission, consisting of Walter Reed, James Carroll, and contract surgeons Jesse Lasaer and Aristide Agramonte, proved experimentally that yellow fever was transmitted by the bite of a mosquito. In 1898 American Army physician William Gorgas was assigned to eradicate Cuba of yellow fever, and his efforts later made the building of the Panama Canal possible.
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As important as these advances were, though, little progress in the field of military surgery and hygiene would have been possible without the discoveries in the field of bacteriology, which, for the first time, made it possible to prevent infection, the primary killer of wounded soldiers.

By 1830, improvements in the microscope began to open up the microbial world to medical investigation. Even so, by mid-century no one had made a systematic investigation into microbes as agents responsible for disease, although medical thought had already started to move in the direction of specificity of disease analysis. The most commonly held theory of disease causation at the time was that all sorts of foul matter, or miasmas, transmitted by air and water caused diseases. While medicine at least had abandoned the idea that evil spirits produced illness, conceptions of disease agents had not moved much beyond those of the Roman engineer Marcus Terentius Varro (177 BCE–27 BCE), who speculated that little animals too small to see invaded the body by respiration and breaks in the skin to cause diseases. It was the specific nature of these “little animals” that continued to elude scientific investigation.

Disease and infection continued to kill thousands of soldiers, especially those who succumbed to postoperative infection. In the early 1860s, Joseph Lister found that infection carried off 80 percent of the patients who underwent amputation of the femur and 50 percent who underwent amputation of the tibia in the Male Accident Ward at London Hospital.
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During the Crimean War, infection produced a mortality rate for thigh amputations of 62 percent, a scant improvement on the 70 percent mortality rate for similar operations during the Battle of Waterloo (1815).
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Until bacteriology was able to determine the specific cause of infection and disease, no serious attempt at preventing surgical infection was likely to succeed.

Between 1857 and 1863, French chemist Louis Pasteur (1822–1895) conducted a series of experiments on fermentation and putrefaction, successfully demonstrating that different microbe agents caused fermentation in different substances. Pasteur also proved that these agents were not spontaneously generated, a view that enjoyed
wide currency at the time, but entered the substance from outside. Pasteur became the most forthright proponent of the germ theory of infection and, in 1878, presented a paper asserting that microorganisms were responsible for disease and infection. Because Pasteur's results were hardly convincing, his new theory was not readily accepted.

After the Franco-Prussian War, Edwin Klebs (1834–1913) furnished convincing proof of the role of microorganisms in surgical sepsis. The most important evidence came with the publication of Robert Koch's
Investigations into the Etiology of Traumatic Infective Diseases
(1879). Not only did Koch (1843–1910) establish through studies of the anthrax bacillus that microorganisms caused specific diseases, but equally important for future investigation, he established the methodology for testing the causative nature of disease-specific agents, one still in use today.
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