Post-War Speech by Civil War Surgeon W.W. Keen on Military Surgery
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From the St. Louis Post-Dispatch
November 3, 1918
1861 – Military Surgery – 1918
Maj. W.W. Keen, Nestor of American physicians, describes revolution in treating wounded since he was surgeon in Civil War – Antiseptic surgery unknown, and death rate from infection was appalling – Methods that today would seem murderous used by doctors in “ignorant innocence” – Amazing figures on conquest of typhoid – Surgical progress so rapid on battlefield that even 1916 “belonged to another era.”
The “grand old man” of American medicine is Dr. William Williams Keen, who, at the age of 81, is a Major in the Medical Corps of the United States Army and emeritus professor of surgery at the Jefferson Medical College, Philadelphia.
Recently he read before the American Academy of Political and Social Science a most illuminating paper on the wonderful progress that has been made in military surgery since the Civil War. No one is better qualified to draw the immense contrast than Dr. Keen, who served as a surgeon with the Union armies. A summary of the paper is given below, often in Dr. Keen’s own language.
In the Civil War surgeons knew absolutely nothing of “germs.” Bacteriology – the youngest and greatest science to aid in the conquest of death – did not exist! Pasteur’s researches only won gradual assent in the late ‘60s and early ‘70s. Lister’s first paper on antiseptic surgery was not published until 1867, two years after the close of the Civil War, and his views were not generally accepted till the late ‘70s. But the precious gift of anesthesia had been obtained in 1846.
The almost virgin fields of battle in the Civil War held few bacteria, and hence tetanus was not common, though it was deadly, killing nine out of ten victims. In the early days of the present war it was a terrible scourge, and exacted a fearful toll of lives. Few now die of lockjaw, because every wounded man receives an injection of antitoxin at the earliest possible moment.
In the Civil War compound fractures killed two out of every three and amputations averaged more than 50 percent mortality. Only 25 percent of the cases of compound fracture are now fatal. The mortality of amputations in our armies today is low; in some series every patient has recovered.
In one night after Gettysburg, Dr. Keen had five cases of secondary hemorrhage. From 1876, when he adopted the antiseptic method, until today he has not seen five other cases.
The hypodermic syringe was so new in the ‘60s that the number of army surgeons who had them probably did not exceed the number of fingers and toes together.
The ophthalmoscope, first devised in 1851, but few and far between were those who could use it in our army 10 years later. This was even more true of the laryngoscope, first devised in 1858. Instruments for examining all the accessible hollow organs – the ear, the nose, the bronchial tubes in the interior of the lungs, the stomach, bladder, and kidney – were not so much as dreamed of 50 years ago.
Surgeons in 1861-1865, utterly unaware of bacteria and other dangers, in their ignorant innocence committed grievous mistakes which nearly always imperiled life and often actually caused death. They operated in old blood-stained coats, the veterans of a hundred fights. They operated with clean hands in the social sense, but they were not disinfected hands. They used undisinfected instruments from undisinfected plush-lined cases, and, still worse, used marine sponges which had been used in prior cases and had been only washed in tap water.
If a sponge or an instrument fell on the floor it was washed and squeezed in a basin of tap water and used as if it were clean. The silk to tie blood vessels was undisinfected. One end was left hanging out of the wound and after three or four days was duly pulled upon to see if the loop on the blood vessel had rotted loose. When it came away, if a blood clot had formed and closed the blood vessel, well and good; if no such clot had formed, then a dangerous “secondary” hemorrhage followed, and not seldom was fatal.
The silk with which they sewed up all wounds was undisinfected. If there was any difficulty in threading the needle they moistened the silk with bacteria-laden saliva and rolled it between bacteria-infected fingers.
They dressed the wounds with clean but undisinfected sheets, shirts, tablecloths, or other old, soft linen rescued from the family ragbag. They had no sterilized gauze dressing, no gauze sponges.
How utterly different are present methods! So rapid has been the progress even in the last two years that Harvey Cushing, writing to Dr. Keen recently from France, said, “1916 was another world!”
As in civil surgery, the skin in the area of operation is today carefully disinfected; beyond this area everything is covered with disinfected sheets or towels. The surgeon, every assistant and every nurse wear disinfected gowns and disinfected rubber gloves. Every instrument, dressing, needle and silk and catgut used for ligatures to tie blood vessels and to sew upon wounds are sterilized.
All ligatures and blood vessels are now cut off short and in non-infected cases the wound is immediately closed. The ligatures are absorbed and never heard from. Second hemorrhage is almost unknown.
But in this world war the conditions are far more terrible than those of the Civil War. The present war is aged on and in densely infected soil – France and Flanders have been cultivated and manured for w,000 years; the wounds are caused by high explosives which hurl many irregular fragments with unimagined velocity; wounds are often multiple, even up to 100 simultaneous wounds; the tissues are horribly lacerated and devitalized; fragments of the missile and of the dirty, muddy and highly infected clothing are often driven deep into the tissues.
All these elements have conspired to develop an unprecedented rot of infection. Every wound is infected, and with an intensity utterly unknown to 1914 either in civil or military surgery. The efforts to control infection by the means in ordinary use almost entirely failed during the first two years of war. Tetanus, gas gangrene, blood poisoning, and other infections seemed unconquerable for a time.
But research has won the victory. Lister’s surgical principles have been at last even more firmly established than ever. The chemist and the bacteriologist are now constantly associated with the surgeon and together they have often snatched the crown from the brow of death.
Carrel and others have shown that, for, say, the first six, sometimes even for the first 12, hours after a wound has been infected the bacteria – even the most dangerous – are localized on the tissues lining the wound, and especially near any retained clothing or fragment of shell. The wound is “contaminated,” but not yet deeply “infected.” If the wounded can be brought to the surgeon within these few golden hours, even after very severe wounds, two out of three can be saved.
But to effect this first of all the most perfect aseptic care must be given. All missiles, and especially all dirty and infected clothing, must be removed, in finding which the X-rays are of the utmost service. By the knife the wound is opened to all its ultimate pockets and recesses and the tissues lining the entire wound are cut away. With this removal of the tissues covered with bacteria all the adjacent tissues which have been practically killed and devitalized by the fierce impact of the missile must also be removed. Then the wound can be closed at once and will heal immediately. The knife in such cases is by far the best antiseptic. The few bacteria left are destroyed by the cells and fluids of the body.
But in those unfortunates who do not reach surgical aid promptly, even though the foreign bodies and the devitalized tissues be removed, too often the wounds by that time are so deeply infected that primary healing cannot be secured and other means of treatment must be used.
Dakin, an English physiological chemist, now residing in America, by research has found the means of depriving the cheap ordinary bleach powder (sodium-hypochlorite) of its noxious properties, and Carrel, by prior years of work in the Rockefeller institute and in France for four years, has devised a means for distributing this best disinfectant to even the deepest parts of the wound in a constant stream.
The bacteria are rapidly destroyed. Every second day the bacteriologist examines the discharges from the wound and counts the number of bacteria found by his microscope. When they have practically disappeared the surgeon can then close the wound. Out of 400 such wounds closed in Carrel’s hospital in Compiegne – now destroyed by the barbarous Huns – there were only six failures!
Sanitation fifty years ago was crude and unsatisfactory as compared with that of today. The chief reason for this was that bacteriology was utterly unknown and that research had not discovered any of the antitoxins nor the role of the insect world in spreading disease.
In 1861 surgeons were wholly ignorant of the fact that the mosquito, and only the mosquito, spreads yellow fever and malaria; and of the role of the fly in spreading typhoid fever by walking over our food. We did not even suspect that the flea and the rat conspired to spread the bubonic plague and that the louse was responsible for the deadly typhus and that serious and wholly new disease – trench fever.
Research has now provided us with antitoxins against typhoid, diphtheria, tetanus, cerebro-spinal meningitis and other diseases and will provide us with still more.
Typhoid has been banished from our army. When we recall the figures for the Civil War and Spanish-American War in contrast with the present war, the American people should be infinitely grateful to the patient, persistent and much abused research workers in our laboratories for their humane and beneficent work.
The bacillus of typhoid was only discovered in 1880, 15 years after the Civil War. During the Civil War, there were 79,462 cases and 29,336 deaths from typhoid. In the Spanish-American War, out of 107,000 soldiers in our whole army, there were 20,738 cases and 1580 deaths from typhoid. Every fifth man was attacked! Of the entire number of deaths during this short war, including both those from disease and from wounds, 86 percent were due to typhoid alone.
In the present war, as in the case of tetanus, the use of the preventive antitoxin has enormously reduced the number of typhoid cases. The recruiting of our army took place in the autumn of 1917, the very season for typhoid, with men in numbers 15 times as many as in the Spanish-American War, and in a period exceeding in length the whole duration of that war. The following figures have been furnished by Surgeon-General Gorgas:
“IN the entire army, numbering of 1,500,000 men, at the end of December 1917, there had been during the year 242 admissions to hospitals on account of typhoid fever, with 18 deaths. During the corresponding period in 1861, when the Northern army was being mobilized, there were about 9,500 cases of typhoid fever, with less than one-quarter of the strength of the present army, with about 1,800 deaths!”
Had the rate of the Civil War prevailed in 1917, there would have been 38,000 cases and 7,200 deaths instead of 242 cases and 18 deaths! Had the rate of the Spanish-American War prevailed, there would have been more than 311,000 cases and 23,700 deaths. In the
annual reports of the Surgeon-Generals of the army and navy this enormous and happy prevention of typhoid is attributed almost entirely to anti-typhoid vaccination.
During the past year, of the 1,500,000 vaccinated men, about 9,000 were obliged to spend one or two days in hospital on account of a moderate resulting fever following the vaccination. During that same year there was just one death ascribed to anti-typhoid vaccination – one death out of over 1,500,000 men!
Some persons have asserted that the death rate in the army far exceeded that of our large cities. Gen. Gorgas states that, on the contrary, statistics for men from 20 to 30 in our large cities show that the army death rate for July 1918 was only 1/3 of the urban death rate – 1.9 per thousand, instead of 6.7 per thousand.
“The fundamental difference, Dr. Keen sums up, “between surgical conditions in the Civil War and those of the present war is our ignorance in 1861 and the enormous increase in our knowledge since that date. Between these two dates is a veritable chasm of ignorance which we can only appreciate when we peer over its edge and discover how broad and deep it is. Doubtless in another half century our knowledge will have again outstripped our present knowledge as far as our present knowledge exceeds that of 50 years ago.
What has filled up and finally obliterated this chasm? Clinical observation has done much, but research, and chiefly experimental research, has done far more. In chemistry and in physics the chief advances in 50 years have been made by experimental research. In biology and its subdivision – medicine – the same is equally true.”