MILITARY MEDICINE, 164, 4:243, 1999

MILITARY MEDICINE

ORIGINAL ARTICLES

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In Days Gone By Downloaded from https://academic.oup.com/milmed/article/164/4/243/4832094 by guest on 27 September 2021

Dale C. Smith, PhD

Nicholas Senn and the Origins oj the Association ojMilitary Surgeons oj the

n 1891, Dr.Nicholas Senn,SurgeonGeneral ofthe mately 2-hour meeting following the opening dinner I National Guard,invited his colleagues, the SurgeonsGeneral (8:30-10:30 p.m., September 17,1891, with Dr. Woodward of ofthe National Guardin otherstates, and theirassociatestojoin Michigan in the chair), CPT W.W. Wilson (Indiana National him for a day of intellectual exchange and discussion about Guard) moved to name the organization the Association ofMil­ establishing an organization of National Guard surgeons. Dr. itarySurgeonsofthe National Guardofthe United States. Com­ Senn was a leader of American , a professor at Rush mitteeswere appointed todrafta constitutionand bylaws and to Medical College and the Polyclinic Medical School. His designa badge; Senn'sprearrangedprogram waspresentedand colleagues were not as eminentin American surgerybut were, adopted as well. Senn's invitations outlined the purpose he forthe mostpart, committed to providing the best carehumanly envisioned: "The advancement ofmilitary and accidentsurgery possible for their militia patients. Six state Surgeons General and allthingspertainingto the health and welfare ofthe civilian attended, and 15 guard organizations were represented; soldier." At the Chicago Polyclinic meeting on the afternoon of the total attendance approached 50 part-time military medical the 18th, a constitution and bylaws were adopted that estab­ officers. lished those objectives. The program ofthat organizational meeting includeda lot of Things "pertaining to the health and welfare of the civilian informal fellowship time: an opening banquet at the Leland soldier" were in a state of flux in 1891. Two members of the Hotel, a luncheon at the Union Club of Chicago, and a closing constitution committee at the meeting fully understood that reception at the Dearborne Avenue home of Dr. Senne The in­ sanitaryreform wasrapidly becoming scientific preventive med­ tellectual content included a morning clinic at Rush Medical icine. COL CharlesAlden, MC USA, was medical director ofthe College "illustrating gunshotwoundsand osteomyelitis" and an Department of Dakota and fully understood that disease was afternoon ofpapers that included J.D. Bryant's"Concerning the the great waster of armies. In 1893, when Surgeon General Organization ofthe National Guard" and C.M. Woodward's "The George Sternburg,MC USA, opened a newArmy Medical School Civilian Soldier: HisDiseases and Hygiene." in Washington, DC, he selected COL Alden as the president of The invitations were extended about September 1 for the the faculty. (Alden wasoneofmanyregularmedical officers who September 17 and 18 gathering, but it seems likely that Dr. participated in AMSUS between 1891 and 1893, whenmember­ Senn had been working with others for sometime to bring the ship was officially opened to regular officers.) Also on the com­ meeting together. Bryantwas SurgeonGeneral ofthe New York mitteewas Dr. C.A. Wheaton, the health officer for the state of National Guard and the only other attendee who, retrospec­ Minnesota and Surgeon General of the Minnesota National tively, approached Senn in stature. Woodward was the Acting Guard. UnderWheaton's direction, a public health laboratory Surgeon General of the Michigan National Guard. Both were wasestablishedbythe state and a regularprogram oflaboratory busy men, and it is reasonable to assume that they had more service and research was begun. Over time, disease and all than 3 weeks notice of Senn's intentions. Dr. Horace Brown aspects of military health care would be important parts of recalled that Senn begandiscussingthe need forsuch an orga­ AMSUS programs, but the verylack ofspecificity suggeststhat nization the previous spring. 2 theywere not Nicholas Senn's primarymotivation in calling the The business of the meeting was carried forward with dis­ meeting; changesin military and accidentsurgery, i.e., trauma patch, further suggesting previous planning. In an approxi- surgery, wereSenn's primaryconcern.

243 Military Medicine, Vol. 164, April 1999 244 Nicholas Senn and the Origins of AMSUS

In 1891, trauma surgerywasin the earlystagesofa phenom­ ideas on surgical pathology and bacteriology, the techniques of enal transformation. Senior members of the National Guard modemsurgeryfrom American and Europeanclinics were dis­ medical service had practice memories of Civil War surgery, cussed at ASA meetings. Improvements in anesthesia, antisep­ whereas the younger members had been trained in the new sis and asepsis, and anatomical knowledge led to an increas­ antisepticand asepticsurgerybased on a knowledge ofspecific ingly radical American school of surgery that believed in the germs that were the etiological agents ofwound infection. The power ofthe knife to heal.Inthe mid 1880s, this enthusiasmfor recently completed Medical and Surgical History oftheWarofthe surgical therapy led to a reevaluation of surgery in trauma, Rebellion documented the real limitations ofthe expectantcon­ particularly gunshotwoundsofthe abdomen. Thereportsin the servatism that wasthe best that pre-germ-theory surgeryhad to u.S. medical journal literature illustrate this interest. In 1881, offer. Although the regular army surgeons had obtained some there was 1 reportofabdominal sectionaftergunshotwounds; limited experience in military trauma in the campaigns against in 1884, therewas another; in 1885, therewere 6; and in 1886, there were 24. the Native Americans, the majority ofmilitia surgeonshad not Downloaded from https://academic.oup.com/milmed/article/164/4/243/4832094 by guest on 27 September 2021 been mobilized sincethe end ofthe Civil War, a quarter century In 1886, Nicholas SennwasChairmanofthe Surgical Section earlier. How were the newideasand trauma surgeryexperiences ofthe AMA and gave his address from the chairon the status of to be communicated to those whomightneed them?ToSenn, abdominal surgery. He noted the changing status of surgical and to most other physicians of the later 19th century, the therapy: "During the last few years surgery has assumed a answerwas a medical society. decidedly progressive and aggressive character." In his exten­ Medical societies beganin North America as an effort to both sive discussion ofthe recentworkongunshotwounds, he noted, ensure quality and provide for professional exchange and con­ "Procrastination and transportation are dangerous factors in tinuing education. Local and colonial/state societies were sel­ the treatmentofthis classofinjuries." Henotedthat the natural dom able to meet fully all oftheir objectives in the antebellum historyofgunshot woundswas not well understood and called period, and the nationalsociety-the American Medical Associ­ for careful experimentation and clinical reporting to settle the ation (AMA)-founded in 1847 had only moral suasion to proper therapy for different groups of patients. Similarly for achieve its goals. In the last third of the century, the general wounds ofthe liver, he believed "thatwithpropersurgicaltreat­ societies were joined by specialist societies with more limited ment injuries ofthe liver would not be attended by such great objectives." mortality as has been the case on the expectantplan of treat­ The earliest specialty societies were limited associations of merit." self-selected experts, most of whom limited their practices or TheASA meeting of1887featured a discussionofthe surgical wished to do so. Medical school appointments were common treatment ofgunshot wounds, prompting a series ofpapers by among these practitioners. Ophthalmologists ledthe way, form­ Charles Nanarede of Philadelphia, R.A. Kinloch of Charleston, ingthe American Ophthalmological Society in 1864, and others and W.W. Keen ofPhiladelphia. Kinloch reported only onecase, followed as there were enough proto-specialists to sustain an notingthat "the present attitude oflaparotomy fortraumatism organization: the American Otological Society (1868), American is such that it should be regarded as imperative with the pro­ Neurological Society (1875), American Dermatological Associa­ fession to report every case occurring in practice." The discus­ tion (1876), American Gynecological Society (1876), etc. These sion illustrated the realization that simple penetrating trauma groups met annually to exchange specialized knowledge and was usuallyself-limited. T.G. Richardson ofCharity Hospital in techniques, to discuss common problems, and to enjoy the New Orleans noted that 24 of 31 patients with knife wounds fellowship of like-mind practitioners. All were initially small, recovered, whereas only 13of33 patientswithgunshotwounds usually fewer than 50 practitioners, mostly from the several recovered. Theincreasedpossibility ofvisceral injuryin gunshot largercitiesin the nation.Although self-selected and limited in wounds was the key difference, and the diagnostic challenge membership, theywere relatively inclusive becauseofthe small was identified as determining which patients had sustained number ofpractitioners choosing to limittheir practicesin the visceral injury. Moses Gunn of Chicago caught the essence of third quarter ofthe 19th century. the issue: "How shallwemakethe diagnosis? I confess that I do In 1879, SamuelD. Gross, the professor ofsurgeryat Jeffer­ not know absolutely. I, however, decidedly incline toward the son Medical College and the generally acknowledged dean of use ofdtagnostical laparotomy." American surgeons, invited several of his colleagues to meet Surgery could, at least in the hands of the best surgeons, with him at the annual AMA meeting to discuss forming an make a difference. Death in penetratingtrauma resulted from American Surgical Society. Nicholas Senn became a member of bothhemorrhage and infection. Thesurgeoncouldligate vessels the new group, soon renamed the American Surgical Associa­ and repairorgans. Drainage afterlaparotomy reducedinfection. tion (ASA), in 1822. New members were elected by their fellow But laparotomy was still dangerous, particularly in less well­ surgeons, and the membership was cautiously limited to the trained hands. Patients, and general practitioners, feared sur­ leaders of the field. Like the surgical subspecialty groups gical therapyand would neitherrecommend nor submit unless founded in the earlieryears, the ASA held an annual meeting there was no other choice. and published annual transactions. The reports of the ASA Death at the hands of the surgeon was a real issue. In his meetings were followed with great interest because surgical 1887 paper, Charles Nanarede referred to the 1881 defense therapy, in the last quarter ofthe 19th century,was morefre­ mountedforPresident Garfield's murderer, which"assertedthat quently provided by nonsurgeons than by the relatively few the examination of the track of the ball by a probe in a pene­ limited-practice specialists. trating gunshot wound of the abdomen, had turned the scale From early debates on listerism through the discussion of toward a fatal issue." Themurder was, by this theory, a simple

Military Medicine, Vol. 164, April 1999 Nicholas Senn and the Origins of AMSUS 245 assault; death was the result ofmedical interference. Nicholas By 1891, Senn had witnessed dramaticchangesin the stan­ Senn addressedthis problem witha series ofdiagnostic papers dards of care for gunshot wounds and the redevelopment of that used insufflation ofhydrogen gas to assist in dtagnosis.?" systemsoftransportation ofthe wounded. AsSurgeonGeneral Senn applied all of scientific medicine to his effort; beginning of the Wisconsin National Guard, he knew that much of this withanimaland cadaverexperiments, he studiedwoundballis­ information was not readily available to his Badger State col­ tics and "discovered" that a "bulletpassingthrough the abdom­ leagues. His call for a meeting to organize a new society for inalcavity doesnot producevisceral injuriesas constantlyas we National Guard surgeonswas thus a natural solutionto a per­ havebeen taught to believe."Enthusiasm forlaparotomy, both ceived problem. Specialization was not at all fixed in the 1890s; diagnostic and therapeutic,grew in the 1890sas moresurgeons in additionto the medical societies weremember forpioneering enjoyed greater success with the operation. In 1891, it was their specialties, there were associations dedicated to railway essential that trauma surgeons knowofthe diagnostic difficul­ surgery and electrotherapeutics. In fact, any special medical ties and the therapeutic progress ofthe previous decade. Large interest seemed to callforan association and proceedings. The Downloaded from https://academic.oup.com/milmed/article/164/4/243/4832094 by guest on 27 September 2021 surgicalorganizations such as the Surgical Section ofthe AMA recognition by Dr.Senn ofa unique set ofissues facing military and elitesurgicalsocieties such as the ASA werevaluable, but surgeons led almostnaturally to a specialassociation. they were not focused on military medical issues. LTC Senn articulated the problems ofmilttarysurgeons in the Duringthe same period, largely as a result ofCivil Warexpe­ 1890s in his presidential addressat the St. Louis meeting ofthe rience, American hospitalswere developing ambulancesystems association in 1892.9 TheNational Guardwasheavily usedbothin to bring trauma victims to the surgeon. Senn's concern with warand duringthe "many strikesand riotswhich have menaced "procrastination and transportation" was widely shared. The thepeace andpersonal andpublic property for a numberofyears." experience ofNew York City was typical. When the Metropolitan Thephysicians who served intheguardwere, Sennbelieved, "good BoardofHealthwascharteredafterthe Civil War, Dr.Edward B. physicians," but he felt that "few of them possess the requisite Dalton was appointed as a sanitary superintendent.Dr. Dalton qualifications and training to satisfactorily perform the manifold had served in the Union Army as a volunteer, completing his dutiesofa mtlitarysurgeon." Thesolution was"concerted action." wartime service as Medical Director ofthe 9th Corpsin theArmy Hethoughtthe prospects good because 200 ofthe 500 National of the Potomac. As corps surgeon, Dr. Daltonwas responsible Guardmedical officers hadjoined the association. forthe functioning ofthe Letterman systemwithinhis unit and Senn outlined several areas in which the new association fully appreciated the role of prehospital care and dedicated should work to improve the military medical situation. First, transport. In May 1869, a military-like ambulancesystemwas comparatively few members would attend the annual meeting, establishedin New York City at his suggestion. Aunit ofBelle­ so state associations were needed. These state associations vue Hospital, the ambulanceswere posted in different areas of should meet "at least three times a year, one of them shortly the cityto take patients to eitherBellevue or a receiving hospital before encampment, at whichthe workduringcamplife should established to support the ambulance system. In the decade be thoroughly planned." Senn was equally concerned that the that followed, other New York City hospitalsestablishedambu­ lance service: New York Hospital (1871), Roosevelt Hospital new association be involved in original research, noting "the (1877), St. Vincent's Hospital (1879), and Presbyterian Hospital bulletwoundsthat will come under the treatmentofthe military (1880). Theutilization ofthe systemsuggested somemeasureof surgeonoffuture wars will present an entirely different aspect, success: in 1870, Bellevue ambulances responded to 1,812 and will call for different treatment than those inflicted by the calls; in 1881, there were 7,765 calls in the city. oldweapons." Henoted the need fornewideas and methodsin Urban ambulances frequently depended on interns to provide the treatment offracturesand penetratingtrauma, as well as in prehospital care; the ambulance driver only didthe driving. How­ the areas offield dressings, transportationofthe wounded, and ever, many physicians recalled the massive epidemic of trauma field medical facilities. Therewere the educational functions of that occurred on Civil Warbattlefields, and otherslearned ofthe any medical society in the 1890s, and AMSUS nowhas a long need for prehospital providers based on the European mtlltary historyofmeeting its goals. experience. The development of Red Cross organizations and a The majority of Senn's address was devoted to questions of system offirstaid were documented in Friedrich Von Esmarch's standards in the medical service of the National Guard. He 1882 classic DieersteHulfe bieplutzlichen Unglucksfallen (FirstAid arguedeloquently fora military medical school forpostgraduate tothe Injured). Senn frequently quoted the German dictum, 'The education in military medicine. Such a school was needed for fate ofthewounded rests in the hands ofonewho applies the first both regular and militia medical officers, all of whom were or dressing." In 1887, the regular armyestablished a hospital corps, shouldbe "asa matterofcourse,a good doctor, but [who] knows based on the Civil Warexperience, to provide dedicated enlisted nothing of military life and discipline." He called for medical medical soldiers. In 1888, MAl Charles Heizman wrote a manual assignments based on the needs of the services rather than ofinstruction that included bothevacuation and firstaidfor early attachment to a particularmilitia unit, and forappointments to stabilization ofpatients. the National Guard Medical Service to be based on competitive In 1889, Senn published Surgical Bacteriology, in which he examinations. noted F. Fehleisen's experiments on the timerequiredto estab­ Senn's concernwith standards was driven by a need for the lish the septic process after contamination of a wound with medical service to enjoy the confidence ofthe lineifits members bacteria.Transportation ofthe injuredand the timedelay before wereto dotheirjob. "I haveoftenheard the complaint madethat surgery were issues with quantitative differences sufficient to the line officers do not show proper respect for the military make qualitative differences in military surgery. surgeon," he wrote. Thejob ofthe association was then, in the

Military Medicine, Vol. 164, April 1999 246 Nich olas Senn and the Origins of AMSUS

final analysis. "education in the duties of the military surgeon References and in elevating the position ofthe medical staffin the estima­ tion ofthe line officers." I. Hume EE: The Golden Jubilee of the Association of Military Surgeons of the United States. Washin gton. DC. Association of Military Surgeons of the United National policy in the 1990s. like the 1890s. makes the military States. 194 1. establishment dependent on supplements. reserve and National 2. Brown: The founding of the as sociation and its founder as I knew him. Milit Surg Guard, to the regularforces.There is increasedconcern regarding 1920: 46: 549-63. the readiness ofthe medical assets ofthese supplemental forces. 3. Smith DC: Medical institutions. In Oxford Companion to Medicine.Vol I. pp The world of military medicine has changed dramatically: in the 740- 6. New York. Oxford University Press . 1986. 1890s. there were only the Medical Corps and Hospital Corps; 4. Senn N: Diagnostic and operative treatment of gunshot wounds of the stomach now, there are many professional traditions. Still, theoriginal mis­ and intestines. JAMA 1890: 15: 3 11-20. 352-63. 389 -95. 5. Trans ASA 1887. sions ofAMSUS remainimportant. AMSUS has done, and contin­ 6. Senn N: Rectal insuffiation of hydrogen gas an infallible test in the diagnosis of ues todo. thevaluablework ofsupporting local activitiesbymeans visceral inju ry of the gastro-intestinal canal in penetrating wound s of the abdo­ ofits chapters. Discussing original investigations and the impact men. J AMA 1888: 10: 767- 77. Downloaded from https://academic.oup.com/milmed/article/164/4/243/4832094 by guest on 27 September 2021 ofchangingmedicalknowledge on practice. and the publication of 7. Senn N: Two cases of gunshot wound s of the abdomen illustrating the use of researchand educational material initsjournaland at the annual rectal lnsufflation with hydrogen gas as a diagnostic measure. Medical News meeting, remains an important focal point of the organization. 1888: 53: 528-30. 8. Senn N: The present status of abdominal su rgery. JAMA 1886: 6: 589 -98 . 6 17­ Perhaps it is time to revisit the issue ofstandards, the education 26. and certification ofpractitioners in military medicine. even if it will 9. Senn N:The mission of the Association of Military Surgeons of the National Guard not be as easy as it was in Senn'sday. of the United States. J AMA 1892: 18: 546-5 0.

Photos from San Antonio, the 105th Annual Meeting

1998 AMSUS President ADM David Satcher, USPHS delivers the Keynote Address at the opening ceremony of the 105th Annual meeting while VADM Richard A. Nelson , MG. USN, Lt Gen Charles H. Roadrnan , II. USAF, MC and USUHS President VAMD James A. Zimble, MG, USN, Ret. listen .

Military Medicine, Vol. 164, April 1999