The Italian Mobile Surgical Units in the Great War: the Modernity of the Past
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Updates in Surgery (2020) 72:565–572 https://doi.org/10.1007/s13304-020-00873-9 HISTORICAL ARTICLE The Italian mobile surgical units in the Great War: the modernity of the past Contardo Vergani1,2 · Marco Venturi2 Received: 11 June 2020 / Accepted: 25 August 2020 / Published online: 2 September 2020 © The Author(s) 2020 Abstract Medical services in WWI had to face enormous new problems: masses of wounded, most with devastating wounds from artillery splinters, often involving body cavities, and always contaminated. Tetanus, gas gangrene, wound infections were common and often fatal. Abdominal wounds were especially a problem: upon entering the war the commanders of all medical services ordered to avoid surgery, based on dismal experiences of previous wars. Surgical community divided into non-operative and operative treatment supporters. The problem seemed mainly organizational, as the wounded were rescued after many hours and treated by non-specialist doctors, in inadequate frontline settings or evacuated back with further delay of treatment. During initial neutrality, Italian Academics closely followed the debate, with diferent positions. Many courses and publications on war surgery fourished. Among the interventionists, Baldo Rossi, to provide a setting adequate to major operations close to the frontline, with trained surgeons and adequate instruments, realized for the Milano Red Cross three fully equipped, mobile surgical hospitals mounted on trucks, with an operating cabin-tent, with warming, illumination and sterilizing devices, post-operative tents and a radiological unit. Chiefs of the army approved the project and implemented seven similar units, called army surgical ambulances, each run by a distinguished surgeon. Epic history and challenges of the mobile units at the frontline, brilliant results achieved on war wounds and epidemics are described. After the war they were considered among the most signifcant novelties of military medical services. Parallels with present scenarios in war and peace are outlined. Keywords World War I · Mobile health units · Ambulances · Wound and injuries · Disease outbreaks · Surgery The new war attack turned into carnage. The wounded in No Man’s Land were rescued at nightfall, several hours after injury. The The outbreak of World War I, in August 1914, found all Sezioni di Sanità (comparable to the British Field ambu- Armies unprepared. Army medical services were still ori- lances) were fooded with wounded to be triaged, dressed ented to past trends: military doctors had a general medical and sent back to action if lightly wounded. Those who could training, and the organization, following a hasty dressing in be moved were evacuated to the rear feld hospitals, while the feld, aimed mainly at rapidly evacuating the wounded. those who could not were treated on the spot. As a rule, no Soon the confict turned into a horrifc war of position. surgical operation should have been performed at the Sezioni Thousands of men holed up in the trenches awaiting to go di Sanità [1, 2]. “over the top” to attempt breaking through enemy lines, Bayonet wounds were relatively infrequent, and gunshot despite barbed wire fences and machine-gun fre. Every wounds were a minority; the vast majority were devastating lacerations from artillery splinters or machine gun blasts. The onset of infection, tetanus or gas gangrene was often * Contardo Vergani [email protected] fatal [3]. 1 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy 2 Day Surgery Unit, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Pad. Zonda, 20122 Milan, Italy Vol.:(0123456789)1 3 566 Updates in Surgery (2020) 72:565–572 Do not operate on abdominal wounds! The mobile surgical hospitals Skull, chest and particularly abdominal wounds were a spe- He returned with the intent of developing a fully equipped cial challenge. Initially, all army medical services recom- Ospedale Chirurgico Mobile (Mobile Surgical Hospital) mended not to operate on abdominal wounds, due to the where experienced surgeons with their own teams could dismal outcome of laparotomies during the Anglo-Boer war carry out major surgical operations [18]. The unit would [4–7]. The famous British surgeon, Sir William MacCormac, be self-sufcient, producing warming, energy, illumina- had coined an aphorism which held true: “A man wounded tion, sterilization. As post-operative care was considered as in the abdomen dies if he is operated on, and remains alive important as the operation itself, tents allowed the patients if he is left in peace” [8]. Standard management consisted in to be followed by the same operating team. The unit was nil per mouth, opiates to alleviate pain and reduce intestinal designed to act in proximity with a Sezione di Sanità, which movements and semi-seated position to promote pelvic col- would triage patients and treat common wounds, but would lection of pus for possible suprapubic drainage [4–6]. As this refer head, chest, and abdomen injuries to the specialized was not done in civil practice, the surgical community soon Mobile Surgical Hospital [18]. divided into abstainers and interventionists, who attributed Rossi and co-workers developed an operating cabin- poor results to delayed treatment carried out in hostile and tent that could be assembled rapidly, had wooden walls to inadequate settings by poorly trained and poorly equipped improve wind resistance and sterility, wide windows (at that general doctors. This debate raged for the frst 2 years [7, 8]. time operations were preferably performed at the natural Italian surgeons, not yet involved in war, carefully daylight), and was covered by a double-layer tarpaulin to observed the solutions adopted by the Germans and the maintain temperature [19]. All the components were trans- Anglo-French. The Germans, who had penetrated far in ported on a Fiat 15-ter truck. Once installed, the cabin was heavily destroyed French territory, opted for building connected to two tents for the patient and surgeons’ prepa- wooden surgical citadels at ten to ffteen kilometres from ration and for preoperative X-rays (Fig. 1). The “theatre” the frontline. The French privileged a quick evacuation net- truck engine remained connected to the deployable theatre work back to the nearest towns, but the wounded who could to provide energy for gas illumination and for sterilization not be evacuated remained a problem. To reduce the time Heating was achieved with portable radiators. The tents for to intervention, the French developed the Ambulances Chi- personnel and for accommodating one hundred patients, rurgicales Automobiles: true surgical theatres mounted on together with the rest of the equipment were transported by trucks that could be located close to the front. The idea was six Fiat 15-ter [20]. An additional truck carried the radio- good, but they soon became mammoth structures surrounded logic apparatus. Once the hospital was in place, the lorries by a huge number of barracks that precluded mobility and turned into ambulances to transport the wounded from the even retreat under attack [9, 10]. lines. The Fiat 15-ter was a slow but reliable truck that could be loaded on a standard rail car, to improve long-distance Italian surgeons prepare for war Italian academic surgeons prepared the medical community to imminent involvement. Every University organized crash courses of war medicine and surgery, which were attended by crowds of junior and senior doctors unseen in time of peace [11]. Publications fourished [12–14]. Many Aca- demics wrote pocket manuals on war medicine. A series of booklets “Problemi sanitari di guerra” (Health War Problems) published by Ravà & C. were sold at 10 Cents each at newspaper kiosks [11, 15]. Eminent medical lead- ers actively intervened in medical and political debate [16]. Among them was Baldo Rossi, the chief surgeon of Ponti and Zonda pavilions at the Ospedale Maggiore in Milano and vice-president of the local Red Cross. Taking advan- Fig. 1 tage of Italian neutrality, he visited the French and German The core of the Mobile Surgical Hospital “Città di Milano”. The operating cabin-tent, connected with the two preparation tents medical frontline installations, observing everything “he was and sided by the Fiat 15-ter truck that transported it and whose allowed to observe” [17]. engine, once the cabin was installed, remained connected to the oper- ating tent to provide energy for warming and illumination 1 3 Updates in Surgery (2020) 72:565–572 567 mobility [21]. The entire unit could be deployed in 6 h and repacked in four [22]. Baldo Rossi would direct the hospital with his own team from Zonda Pavilion. The hospital would be positioned right behind the lines during ofensives, leaving limited person- nel in Milano to cover the duties of the surgeons posted to the front-line. During pauses in the war, the proportion of personnel at home would be reversed. This was important, as mobilization of the doctors to the front line had already greatly impoverished civil medical assistance at home. The fund‑raising campaign Fig. 2 An Army Surgical Ambulance deployed in the courtyard of Back from the western front, Rossi carried out a veritable Caserma Masino in Bologna in May 1916 before departing for the communication campaign, holding conferences to medical frontline. The long rectangular tent hosted the theatre and X-rays and lay audiences and writing articles in specialized and apparatus common press, to sensitize citizens and administrators of Milano [23–25]. He was well introduced at the Military Headquarter, and presented his detailed project to general Porro, who was Cadorna’s second in command [20, 22]. The project was approved. Rossi set up a “Committee for Mobile Surgical Hospitals” with many infuent personalities and launched a fundraising campaign on the columns of the Secolo and Corriere della Sera at the end of December 1915. Bank- ers, entrepreneurs, merchants and professionals, as well as common people, responded generously.