Shells and Scalpels:
The Development of Military Surgery in the Great War and
The Benefit to Soldiers in the AEF
By Justin Elhoff
The University of South Dakota
AEF Operating Suite at Base Hospital 52
The First World War was fought in a manner in which no one expected nor planned for. The war, envisaged as one of fluidity and mobility, rapidly deteriorated into an internecine stalemate as both sides painfully realized that their stagnant doctrines failed to accommodate changes in warfare. As Europe dug in for a bloody, protracted conflict, military surgeons were compelled to deal with soldiers whose injuries presented new challenges, leading to reforms in the art of military surgery.
The task of the military surgeon in the Great War was no different than it has been throughout history: to salvage as many mutilated bodies as possible from the battlefield and treat them so that they may expediently return to kill more of the enemy. Within this primary objective falls the scientific purpose of the surgeon: to preserve life, prevent deformity, and reconstruct physically. Improvements in technology prior to 1914 made the battlefield an increasingly deadly place, and these changes created new challenges not only for commanders, but surgeons as well. The soldiers' wounds were unfamiliar and grotesque, and initially European surgeons experienced disastrous results in their attempts to heal these wounds using archaic methods. Eventually, surgeons gained greater understanding of wounds and the resultant complications and made significant advances in surgical procedures. The Medical Department of the United States Army was able to discern the early medical calamity and subsequent developments (primarily through first-hand observation). As a result, by the time the United States entered the war in 1917, American military surgeons were aware of proven new techniques, making the experience of wounded American soldiers less horrific than it may otherwise have been.
The history of warfare is filled with technological improvements and the ensuing struggle of the military to assimilate these changes effectively into a nation's conception of war. Several major technological changes strongly affected the nature of the Great War, most of which increased the superiority of defensive over offensive tactics.
Smokeless gunpowder, first introduced during the late 19th century, prompted a necessary reconsideration of tactics. Likewise, revolutionary improvements in small arms produced rifles with increased range, velocity, and firepower as well as enhanced accuracy. The introduction of clip-fed rifles such as the Lee-Enfield used by the British army, accurate up to 400 yards, elongated the battlefield and increased the lethality of an assault. Additionally, failure to understand the potentially awesome destructive power of the machine gun led to massive slaughter on the battlefield, as a relatively small number of soldiers were capable of inflicting massive casualties. One Maxim machine gun could fire approximately 500 rounds per minute, equivalent to 40-80 riflemen.
Moreover, artillery underwent enhancement prior to the Great War. Improvements in metallurgy, powder, and recoil systems resulted in lighter guns capable of firing larger projectiles greater distances with more frequency. Advances in ammunition further maximized lethality. Two of the most common were shrapnel and high-explosive shells. Shrapnel, consisting of a thin-walled shell filled with as many bullets as possible, exploded in flight, launching its bullets and fragments in every direction. High-explosive shells, which became dominant as the war progressed, contained a powerful explosive charge. The intensity of the explosion led to the mutilation of enemy troops. 
At the start of the war, soldiers were slaughtered in alarming numbers as they undertook operations planned in ignorance of the devastating capabilities of these new weapons. Soon, troops began creating a vast network of trenches to protect themselves from the lethal new technology. This led to a static, horrific struggle. Between 1914 and 1918 there was no net change of more than ten miles in the battle lines on the Western Front.  The new weapons and subsequent warfare produced ghastly wounds, provoking adaptation and improvement in military surgery.
Military surgeons entered 1914 unprepared for the challenges on the horizon. The world was on the verge of the most destructive conflict since time immemorial: 60 million men were to be mobilized in all, with 7 million making the ultimate sacrifice and another 19 million wounded.  Previous wars and peacetime surgical practice offered very little pertinent data or experience to surgeons in the World War.  Because of conclusions drawn from previous wars, specifically the Boer War, surgeons entered World War I with conflicting and often erroneous opinions concerning the most effective way to treat the wounded.
By the early 20th century, small arms fire had evolved from low-velocity lead balls to high-velocity, conoidal, jacketed missiles. These more "humane" weapons produced less devitalization of tissue surrounding the wound, resulting in a more clean-cut and sanitary injury.  The relatively sterile, uncultivated terrain and hot, dry weather that predominated during the Boer War gave British military surgeons the false impression that antiseptics and conservative treatments were superior in the new era of humane weapons. The practice of debridement was abandoned, and the lessons learned in South Africa were applied at the outbreak of the First World War, with disastrous results.
The Great War differed in many ways from preceding wars. The supposedly "humane" rifles of the early 20th century were further altered prior to World War I: in an effort to increase range and accuracy, the missile was redesigned from a conoidal to a pointed tip and the center of gravity shifted towards the rear. This diminished the previous stability of the bullet and caused the bullet to tumble upon contact, producing wounds similar to those inflicted by an exploding shell.11 Additionally, the war was fought primarily on heavily cultivated, highly manured soil. As armies entombed themselves into this pathogen-infested medium for infection, it became nearly impossible for a wound to remain sterile.
Another differentiation of the Great War was the increasing dependence upon artillery. The static style of war and the use of entrenchments resulted in warfare in which the most effective way to destroy the enemy was to overwhelm him with a deluge of artillery fire. During the war, 70 percent of battle wounds were caused by secondary missiles and exploding artillery shot. In the American Expeditionary Force (AEF), 20,420 men were treated for wounds inflicted by rifle balls, a combined 51,226 were treated for wounds by either shrapnel or shell and an additional 74,883 were treated for wounds by an unspecified gunshot missile. The Surgeon General's post-war report concluded that, "Taken as a whole, the percentage of wounds from exploding missiles probably varied, from 50 to 80 percent being the highest when battle conditions were most stabilized, as in trench warfare." This differs significantly from previous wars, such as the American Civil War, in which the Minie ball caused 94 percent of all battle wounds and artillery shell and canister approximately six percent.
Wounds from shrapnel and high explosives caused gruesome destruction of tissue and the explosions drove earth, clothing, and shell fragments into the wound. The nature of trench warfare begot mud-soaked (and thereby pathogen-infested) clothing, and therefore all wounds were deeply invaded by pathogens. Gas gangrene was particularly prevalent and a dangerous consequence of these conditions.  In addition to the task of mending pulverized body parts, surgeons now needed to combat massive invasion of pathogenic organisms, an exigency to which they were unaccustomed.
Amid the confusion among military surgeons at the beginning of the war, the policy of conservative treatment and the reliance upon antiseptics emerged as the favored practice. These methods were abandoned as it soon became evident that the Great War was unlike wars of the past. Antisepsis proved to be virtually unattainable in the conditions of the First World War. Nearly all wounds suppurated; in response, surgeons used powerful antiseptics in an attempt to curtail infection. Wounding, especially grotesque wounding such as that from high-explosives, tears blood vessels and disrupts blood flow, leading to devitalized tissue and a prolonged recovery period. An antiseptic drug is essentially a poison which destroys organisms only by direct contact. However, wounds in the Great War tended to be extraordinarily jagged with damage occurring deep within the tissue; consequently, bactericides were ineffective in the treatment of these injuries because infection often proved elusive. Additionally, the poison actively damaged tissues that were already devitalized. 
The failure of antiseptics led surgeons to become more aggressive in their treatment of wounds. Many British and French surgeons began to advocate the practice of debridement. Alexis Carrel, a French surgeon who lived in America, developed a technique that proved particularly efficacious. Through research and experience, Carrel discovered that the bacteria plaguing wounded soldiers in Europe could not subsist on living tissue, but rather fed on dead and decaying flesh. Carrel strongly advocated thorough yet gentle excision of all damaged tissue and careful cleansing of the wound. The second part of the Carrel treatment involved continuous irrigation of the wound. A system of rubber tubing delivered a short-lived antiseptic mixture known as Dakin solution to nearly every inner surface of the wound. The wound was continuously inundated by the solution, destroying any bacteria before the solution itself was neutralized by the lymph. The wound was closed once it was determined to be clean and progressing toward recovery. Patients who received the Carrel treatment typically recovered in less than half the time of patients treated by other methods, and the extensive adoption of this method by the middle of 1915 saved lives and reduced the suffering of millions of men.
By the time the United States entered the war in April of 1917, the techniques utilized by military surgeons had advanced tremendously. Most importantly for the American soldier was that, from the onset of AEF involvement, American surgeons were able to capitalize on the lessons learned from their European counterparts. The United States military assigned members of its medical department to Europe to observe the medical dilemmas and developments in the war; the findings were used to educate the United States Medical Department staff about the injuries occurring, complications, and proven techniques for treatment. Additionally, many American surgeons, specifically orthopedic surgeons, were sent to serve on the medical staffs of the surgeon-deficient Allies such as the British. American surgeons thus gained first-hand experience treating battle wounds and acquired knowledge that allowed them to educate surgeons who would be encountering combat casualties for the first time.
As a result of these experiences, the United States entered the Great War with proven medical doctrine as standard procedure. By the beginning of the Meuse-Argonne Offensive in the fall of 1918, the AEF Medical Corps had a detailed and articulated method for determining treatment of various wounds. Treatment first involved removal of any foreign body present and thorough debridement of the wound. If the wound was fresh and well cleaned, primary suture would follow. If infection seemed likely, suture was delayed and the injury observed and treated until infection was ruled out, or the Carrel treatment was administered.
As a case study of wound treatment by the United States Army Medical Department during the Great War, treatment of injuries to the lower extremities will be considered. These wounds represent the most common injuries treated by AEF medical personnel and provide an accurate representation of the advancement in surgery during the war.
Of the 2,039,329 men the AEF sent to Europe, approximately 784,000 actually engaged in battle. Of these, 75,658 men made the ultimate sacrifice along the Western Front, with 23,937 of these deaths caused by disease and 34,249 men killed in action. In total, 224,089 American soldiers were attended to by military medical personnel, with 13,691 of these eventually perishing from their wounds. These casualties occurred almost exclusively in 1918 and they resulted in a combined 17,491,844 days of hospital stay. Although these statistics may seem trifling compared to the casualties of the other participants in the war, it can be seen that a significant number of American soldiers required and received medical attention during the war.
The most prevalent battle injuries admitted into Medical Corps hospitals involved the lower extremities; 78,032 men were admitted with these injuries, with 5,722 (7.33 percent) eventually succumbing to their wounds. A list of the causes of these injuries, with the concurrent fatality rates listed in parenthesis, shows the emergence of artillery: rifle ball, 10,582 (3.69%), shell, 9,371 (9.10%), shrapnel, 18,182 (5.64%), and not specified, 39,897 (8.65%).
Following initial setbacks, European surgeons developed effective treatment plans for lower extremity wounds. Wounds to the lower extremities could involve multiple scenarios: the wound could be from bullet, shrapnel, or some form of shell. The projectile could pass directly through soft tissue or become lodged, and it was likely to strike bone and cause a fracture. The wound could occur at any section of the leg, including the knee joint, and the time until the soldier was received for treatment varied from four hours under optimal conditions to days during periods of battle activity. There was consensus that any foreign body should be gently and thoroughly removed, if possible with the aid of primitive x-rays to pinpoint the location of the fragment in order to do as little unnecessary damage as possible during excision. Debridement was standard procedure; it was executed by making one or more incisions parallel to the long axis of the limb.  Through this incision the surgeon removed any foreign body present as well as all devitalized tissue. As with other wounds, primary suture was applied if there was little reason to believe that an infection remained. Otherwise, the infection required treatment, such as the Carrel method, and closure of the wound was performed at a later date.
Many of these wounds resulted in broken long bones. The United States Army Medical Department reported 13,523 patients with fractures of the femur, tibia, and/or fibula, the majority incurring from enemy fire. The diversity of these injuries, as well as the almost invariable infection and the difficulties which arose in transportation, provided a constant challenge for the military surgeon. Amputation was a commonly performed procedure, and techniques involved in lower extremity amputation exemplify advancements made in military surgery during World War I. 
At the outbreak of the war, surgeons lacked sound understanding of the principles of amputation. To compound this problem, the use of high-explosive shells and the prevalence of gas gangrene resulted in an increased frequency of amputation. Amputation was performed in order to remove the risk of life-threatening sepsis while concurrently preserving as much of the limb as practical. This was especially a concern in the case of leg amputations, since the stump would later become the base for prosthesis. However, results from amputations conducted early in the war often did not satisfy these goals. Most surgeries resulted in swollen, congested stumps with powerless muscles and serious joint contractures. Many men either lost important segments of their limbs, due to the mistaken notion that a longer stump would be a hindrance, or needed to undergo reamputation because the infection was not eliminated or poor post-operative treatment was administered. 
American orthopedic surgeons serving in France and Great Britain prior to American involvement realized the difficulties associated with amputation. Therefore, the AEF created an amputation service to deal with the injuries. The amputation service had three primary functions. First, the service strove to provide proper surgical, physiotherapeutic, and prosthetic treatment for amputation cases. Second, the service was to compile information regarding proper methods of treatment. Third, amputation cases were to be prepared for evacuation to the United States.
Amputation techniques were affected by the military situation at hand. During relatively quiet periods when injuries were less frequent, post-operative care could be more thorough. During times of heavy activity, on the other hand, soldiers experienced more delay before being treated and hospital space was at a premium. Therefore, every case was treated knowing that the soldier would be evacuated almost immediately, which necessitated the utilization of different methods.
Amputation was generally performed due to heavy sepsis, compound comminuted fractures in which it was apparent that greater functionality would be achieved from an artificial limb than the injured member, or secondary hemorrhage due to burrowing sepsis. Amputation was generally conducted with the soldier under nitrous oxide-oxygen anesthesia. The extremity was elevated to reduce blood flow. Under ideal conditions, ample strips of healthy skin were conserved to be used later as flaps to cover the stump.  Soft-tissue surrounding the amputation site was removed, the periosteum was peeled from the bone, and the bone was sawn through. As with other procedures, careful debridement was practiced to remove devitalized tissue. The wound was not closed immediately, but monitored for 24-48 hours. If after this time wound conditions seemed favorable, the flaps were drawn together and sutured. Conversely, if there was suggestion of sepsis, Carrel-Dakin treatment was initiated until the risk of infection was abolished.
During times of heavy battle when soldiers waited longer to be treated and amputees were quickly transported to base hospitals, this method was found to result in high post-operation infection rates. In these circumstances, a flapless amputation, known as a guillotine amputation, was often performed. This technique was accomplished by dividing the skin and deep fascia in a circular manner and allowing them to retract. As this occurred, the muscles were divided at the level of the retracted skin and allowed to concurrently retract. While the procedure was being conducted, blood vessels were ligated and nerves shortened. The bone was sawn off flush with the muscle, and the stump became somewhat convex as the tissue retracted slightly more. These cases were generally observed for 48 hours, at which point the soldier could be safely evacuated. This method preserved the maximum length of the stump, could be done relatively quickly, and was well drained, leading to a lower risk of infection during evacuation.
Surgeons strove to maximize stump length, but when deciding on the point of amputation it was vital, especially in cases of gangrene, to ensure that infection was eliminated. A simple method was used in order to decide the best point at which to make the amputation. It called for blood circulation to be minimized to the legs via elevation and constriction. After five to six minutes, the constriction was removed from both legs and they were placed side by side horizontally and carefully observed. The amputation was to be made at the point directly above where the skin no longer had the normal pink appearance of the rest of the extremity, as this indicated defective circulation due to damage or infection. Overall, the effective modern treatments of wound infection and bone lesion by AEF surgeons resulted in the salvage of many limbs in World War I which may have been amputated in previous wars.
Military surgeons entered 1914 in the same way as the rest of Europe: totally unprepared for the protracted, macabre stalemate that would ensue. At the start of the war, surgeons disastrously applied antiquated methods to treat soldiers who were fighting a war in which modern technology imposed a new style of warfare and led to horrific injuries. As millions of European soldiers entrenched themselves into heavily manured, pathogen-infested soil, the military surgeon needed to learn to deal with unfamiliar, invariably septic wounds. Wound mortality neared 28 percent in 1915, and amputation rates were as high as 40 percent for wounds of the extremities involving injuries to the bone.
The medical community responded to the challenge, however, and soon injured soldiers were receiving more appropriate treatment. American surgeons were able to capitalize on the experience of their European counterparts, primarily due to first-hand observation and practice in the battlefield. When the US entered the struggle in 1917, the United States Medical Department possessed knowledge and took the necessary steps that precluded their surgeons from administering the same abominable care that was experienced in the early period of the war. Extraordinary improvements were attained, and the increased understanding of the human body led to significant advancements in both the military and civil medical community. By the end of the war, overall wound mortality was eight percent (compared to over 13 percent in the American Civil War), and the amputation rate dropped to below ten percent. The development of new, felicitous treatments of wounds resulted in less suffering and death of soldiers, as well as more expedient return to service. The United States, by means of its delayed entrance and assimilation of knowledge from the European experience, averted several of the wound treatment problems that occurred early in the war and was able to provide higher quality care for its wounded.
1 United States Surgeon Generals Office, The Medical Department of the United States Army in the World War, 17 vols. (Washington: Government Printing Office, 1921-1929), vol. XI, part 1, XXIX. (Hereafter cited as Surgeon General Report).
2 Spencer C. Tucker, The Great War - 1914-1918 (Bloomington, IN: Indiana University Press, 1998), 11-12.
3 Benedict Cromwell, America's Munitions: 1917-1918 (Washington: Government Printing Office, 1919), 158-159.
4 Surgeon General Report, vol. XI, part I, 14-24.
5 Tucker, The Great War, 37.
6 Richard A. Gabriel and Karen S. Metz, A History of Military Medicine (New York: Greenwood Press, 1992), 239.
7 Surgeon General Report, vol. XI, part I, 9.
8 devitalized: Devoid of life; dead. Thomas L Steadman, Stedman's Medical Dictionary, 27th Edition. (Philadelphia: Lippincott Williams and Wilkins, 2000), 488; Surgeon General Report, vol. XI, part I, XXX.
9 Surgeons in the United States also took note of the medical results of the Boer War. The 1912 handbook used by the hospital corps advocated conservative treatment of wounds due to their general cleanliness and the wound's natural tendency to heal without infection; Charles Field Mason, A Complete Handbook for the Hospital Corps of the U.S. Army and Navy, 3rd edition (New York: William Word and Company, 1912), 74.
10 debridement: Excision of devitalized tissue and foreign matter from a wound. Steadman, Stedman's Medical Dictionary, 460; Gabriel and Metz, A History of Military Medicine, 220-221.
11 Ibid., XXXI-XXXII.
12 Frederick F. Cartwright, The Development of Modern Surgery (New York: Thomas Crowley Company, 1967), 109.
13 Gabriel and Metz, A History of Military Medicine, 239-240.
14 Surgeon General Report, vol. XV, part 2, 1019; It should be emphasized that these statistics reflect soldiers who were admitted to a hospital for treatment. Deaths that occurred on the battlefield, many of which would have been caused by the violent explosion of artillery shell, are not accounted for here.
15 Surgeon General Report, vol. XI, part I, 54.
16 Gabriel and Metz, A History of Military Medicine, 181.
17 Cartwright, The Development of Modern Surgery, 110.
18 gas gangrene: occurring in a wound infected with various anaerobic sporeforming bacteria...which cause rapidly advancing crepitation of the surrounding tissues, due to gas liberated by bacterial fermentation.... Steadman, Stedman's Medical Dictionary, 729; Great Britain Army Medical Services, Manual of Injuries and Diseases of War (London: His Majesty's Stationary Office, 1918), 31-40.
19 antisepsis: Prevention of infection by inhibiting the growth of infectious agents. Steadman, Stedman's Medical Dictionary, 105.
20 suppurate: To form pus. Steadman, Stedman's Medical Dictionary, 1731.
21 Cartwright, The Development of Modern Surgery, 110-111.
22 Ibid., 111.
23 Woods Hutchinson, The Doctor in War (London: Cassell, 1919), 83.
24 Ibid., 87-93; lymph is defined as: A clear...fluid that is collected from the tissues throughout the body, flows in the lymphatic vessels, and is eventually added to the venous blood circulation. Steadman, Stedman's Medical Dictionary, 1038.
25 Woods, The Doctor in War, 86.
26 For example, in 1915 the United States Government published a first-hand account of a surgeon who had been sent to observe the Allied Armies. A.M. Fauntleroy, Report on the Medico-Military Aspects of the European War (Washington: Government Printing Office, 1915). The United States also learned from the well-organized Germans. Although the United States had no medical observers in the German Army, civilian hospital units were sent to the Central Powers prior to the United States official entrance and their findings were also utilized. John R. McDrill, Medical War Manual #5: Lessons from the Enemy - How Germany Cares for Her War Disabled (Philadelphia: Lea and Febiger, 1918).
27 Surgeon General Report, vol. XI, part I, 584-585.
28 Ibid., 299-314.
29 H.H.M. Lyle, "The Principles of the Surgery, Hospitalization and Evacuation of the Wounded in the Meuse-Argonne Offensive," Military Surgeon 84 (June 1939): 580-586.
30 Gabriel and Metz, A History of Military Medicine, 249.
31 Surgeon General Report, vol. XV, part 2, 1017.
32 Ibid., 1023.
33 Approximate casualty (fatality) statistics for some of the most significant participants in the Great War are as follows: Germany, 1.7 million, Russia, over 700,000, Great Britain, 700,000, France, at least 1 million. Gabriel and Metz, A History of Military Medicine, 243-249.
34 Surgeon General Report, vol. XV, part 2, 1024; These statistics show a very large percentage of wounds with an unspecified cause. This may have been the result of the frantic condition in which reports were often written and/or extensive mutilation of the injured body part, among other reasons. However, the similarity in fatality rates between high-explosive shell and not specified may suggest that many of the unspecified injuries resulted from shell explosions.
35 Surgeon General Report, vol. XI, part 1, 294-304.
36 Primary suture was typically only completed when the time between injury and operation was minimal (36-48 hours). If primary suture was not practical, the wound was treated and bacteria levels were quantitatively measured using a smear and culture. Once the wound had been closed (up to five days after the surgery was considered delayed primary suture; after that closure was referred to as secondary suture) the injured area was immobilized before the soldier was transported. Surgeon General Report, vol. XI, part 1, 295-314.
37 Surgeon General Report, vol. XI, part 1, 499,602.
38 Ibid., 713.
39 sepsis: The presence of various pathogenic organisms, or their toxins, in the blood or tissues. Steadman, Stedman's Medical Dictionary, 1619.
40 Surgeon General Report, vol. XI, part 1, 687-688.
41 This paper will focus on the surgical aspects of amputation, but tremendous progress was also made in rehabilitation and in the field of prosthetics. These advancements led to a much better prognosis for soldiers who underwent amputation. An overview of these improvements can be found in the records of the US Army Medical Department; Surgeon General Report , vol. XI, part 1, 701-747.
42 Surgeon General Report, vol. XI, part 1, 688.
43 Ibid., 690-691.
44 compound fracture: Fracture in which the skin is perforated and there is an open wound down to the site of the fracture; comminuted fracture: Fracture in which the bone is broken into more than two fragments. Steadman, Stedman's Medical Dictionary, 711-712; Albert J. Ochsner and Nelson M. Percy, A New Manual of Surgery - Civil and Military, 6th edition (Chicago: Cleveland Press, 1917), 767-769.
45 Surgeon General Report, vol. XI, part 1, 166, 180-181.
46 Ochsner and Percy, A New Manual of Surgery, 730.
47 periosteum: The thick fibrous membrane covering the entire surface of a bone except its articular cartilage. Steadman, Stedman's Medical Dictionary, 1351; Ochsner and Percy, A New Manual of Surgery, 730.
48 Surgeon General Report, vol. XI, part 1, 690-693.
49 Ibid., 690-691.
50 ligature: A thread, wire, fillet, or the like, tied tightly around a blood vessel...to constrict it. Steadman, Stedman's Medical Dictionary, 1010.
51 Ochsner and Percy, A New Manual of Surgery, 769.
52 Surgeon General Report, vol. XI, part 1, 691.
53 Ochsner and Percy, A New Manual of Surgery, 731.
54 Ibid., 766.
55 Gabriel and Metz, A History of Military Medicine, 240.
56 Ibid., 240-241.
Originally Written For: Dr. Kurt Hackemer's HIST 492: European Military History
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