How were gunshot wounds treated in World War I.

WAR INJURIES AND THEIR TREATMENT DURING THE FIRST WORLD WAR BASED ON PREPARATIONS FROM THE DEVELOPMENTAL PATHOLOGY COLLECTION OF THE BUNDESWEHR

War surgery was scientifically supported by systematic anatomical-pathological examinations. Initially at the army level, field prosecutions were set up for this purpose, in which sections were carried out, reports were written and war-pathological collections were compiled. The preserved preparations of the Munich professor Dr. Max Borst, who set up the first field prosecution of the Bavarian army, today form the basis of the military pathological collection of the medical academy of the Bundeswehr and are unique evidence of the war injuries of the First World War. Examples of such wound patterns and their treatment in the overall context are presented using individual preparations.

Keywords: First World War, wounding, war injury, war surgery, war pathology, field prosecution

Summary

In WW I more than 4.5 million German soldiers were wounded in action. The medical officers were facing new patterns of tremendous war injuries caused by modern weapon systems and special conditions of trench warfare. New surgical skills were developed to manage these wounding’s under difficult conditions. An active hands-on procedure took over the conservative awaiting of war surgery, which was typical for the time before WW I. Dreaded wound infections inquired fast surgical operations. Academically the war surgery was supported by systematically carried out anatomical-pathological investigations. Special battlefield prosection theaters were established to investigate fatal injuries and to sample typical anatomical preparations. The war pathology collection of Munich university and field pathologist, Prof. Dr. Max Borst, is preserved and today basis of the war pathology collection of the German Bundeswehr Medical Service. There unique anatomic specimens demonstrate the variation of challenching war injuries. This article presents some examples of typical preparates and discusses the chance of surgical methods in WW I.
Keywords: Great War, WW I, war injury, war surgery, trench warfare, treatment of wounded, medical service, battlefield prosection theater

Surgery at the start of the war in 1914

Only a few weeks after the start of the war, the Leipzig poet and junior physician Dr. Wilhelm Klemm (1881 - 1968), employed as a surgical assistant in the 3rd field hospital of the 19th century. Saxon Army Corps in front of Ypres, on November 5, 1914 to his wife:
“I now have 3 halls where there are 82 wounded today. We get mostly leg shots, hip shots, neck, head, face and chest shots. The large smashes, tears in the abdomen, and the shooting of body parts constantly die outside, since the wounded can only be taken out at night and often only after several nights. ... The most hideous are the so-called gas phlegmons, which develop most frequently on the forearm and calf. This kind of infection is not known in peacetime. "[1, p. 80]

In fact, German surgery was surprised by the effectiveness of new weapons and projectiles and the number and type of wounds they caused at the beginning of the war. Not only the lay press like the "Freiburger Tageblatt" tried to reassure the readership at the beginning of the war on August 5, 1914: "The wounds are getting less and less severe and the new artillery weapons are nowhere near as dangerous as the [...] foot troops."[2, p. 40] At the beginning of the war, the head of the medical officer corps of the Imperial Army also looked to the coming conflicts with confidence in terms of wounds and surgical care. For years, the German medical service had sent experienced surgeons as observers as part of official support missions in almost all regional wars. Their experiences, especially with regard to the effects of bullets in the organism, had been published and discussed [3, 4]. Last but not least, they had meticulously carried out their own scientific shooting tests and drawn some conclusions from them [5]. Like Carl Franz (1870-1946), people spoke of the new one "Humanity of the small-caliber infantry projectile"[6, p. 5] compared to the coarser projectiles of earlier wars. The theory of “primary sterility of the gunshot wound” had also won some supporters within the surgeon. In the first "Field Medical Supplement" of the Münchner Medizinischen Wochenschrift on August 11, 1914, the Munich surgery professor Ottmar von Angerer (1850-1918) postulated that the modern infantry bullets "Metals themselves would have a certain bactericidal power" [7, p. 1794], and thus it for the "It would be more advantageous for the wounded to take a more conservative standpoint and curb the desire to operate."[7, p. 1794] Finally, people liked to rely on the postulates of the luminaries of German surgery, especially Ernst von Bergmanns (1836-1907) and Mikulicz's successor Hermann Küttner (1870-1932), based on their experience in war surgery previous wars and the significant advances in anti- and asepsis which had advocated conservative treatment of gunshot fractures and even abdominal injuries. Even more cautious were the English or French armies, which with the traditions of Larreys (1766 - 1842) and Percy (1754 - 1825), the founders of the modern "Médecine de l’avant", such. B. the rapid amputation while still on the battlefield.
All in all, the German medical service believed that it was well prepared for the treatment of such injuries, as field medical officer Otto von Schjerning (1853 - 1921) put it at the 30th Congress of the German Surgical Society in 1901:
“If the wounded come from the battlefield alive, they have a better chance of being healed than before, this is due to the favorable nature of the wounds; but we owe it to a large extent to the advances in medical art and the excellent organization of the medical service. "[8, p. 307] Of course, at the beginning of the war, all of this weighed on operational discipline like a dogma. Perhaps it should have been thought that the last basic war surgery textbook written before 1914 was from 1877. Although it was written by one of the old masters of German military surgery, Friedrich von Esmarch (1823-1908), it was based only on his experiences in the Franco-German War of 1870/71 [9].

Weapon effect

After just a few days, the German troops advancing in the attack, who had hardly any cover, were caught in massive fire ("steel thunderstorms") from machine guns, shrapnel and fragmentation grenades of all calibres. Later, people liked to talk about the disproportion between the military tactics of the 19th century and the modern weapons effects of the 20th century that hit the troops. Both the cadence of machine guns and their penetration had improved significantly compared to previous wars, as had the firepower, accuracy and range of the artillery. Barely four weeks after the start of the war, the first hospital trains arrived back home. On August 23 and 25, 1914, numerous seriously wounded men were unloaded in Munich and alarming observations were made:
“Such severe shrapnel injuries will of course be much more common in the first place than in the hospitals. At the sight of them, the opinion so often expressed about the humane effect of modern projectiles disappears. " [10, p. 1950] A few days later the basic German operational planning, the Schlieffen Plan, failed in the Battle of the Marne. The medical service assumptions and principles on which this was based had also become outdated. Werner Steuber, corps doctor in the von Arnim corps with the 1st Army (von Kluck) and responsible for the evacuation of the field hospitals south of the Marne, later described soberly: "The care for the innumerable wounded was fully geared towards the expected victory, a failure of the operational action would have to be fatal for the wounded."[11, p. 214] The already mentioned Wilhelm Klemm experienced the fiasco directly at the front. He worked in a field hospital with 200 wounded who were housed in a church.
“In the evening we were back in Maisons. I was sewing up a face when suddenly it was said, everything back in a hurry ... The baggage and ammunition columns moved away immediately, but we had to take the wounded with us first! On every car, on top of the tarpaulin. We invited them in between boxes and crates. ... The wounded of course noticed this and all crawled to the street. You saw people with shot (sic) hips and thighs pulling themselves forward on tufts of grass. When the church was emptied, I dragged the last one out on my back after the illumination, drove off the hospital, at the end of the columns. ... The misery of the wounded is terrible. "[1, pp. 33-41]

Types of wound and their treatment

The highest number of bloody losses actually occurred in the first year of the war, long before the notorious material battles off Verdun, on the Somme or on the Chemin des Dames. There, a well-developed system of positions and an organized rescue chain offered the soldiers comparatively better protection against injuries than was possible during attack or retreat operations in warfare on the move. Infantry projectiles mainly caused wounds to the head and neck, the upper arms and the torso during trench warfare.

While in the first two years of the war the rifle gunshot wounds received for treatment were even more numerous than those caused by artillery projectiles, by this time more soldiers had been killed by grenade wounds. From 1917 onwards more than 75% of all wounds resulted from artillery explosive projectiles.

General principles of treatment
The operational activity, primarily in the field hospitals, turned out to be much more extensive, both qualitatively and quantitatively, than expected at the beginning of the war. Originally, the main focus was on bandaging and immobilizing the wounded limbs. Occasionally, emergency interventions such as ligatures of large vessels or tracheotomies should be performed. But already the first skirmishes led to a large number "Severe tissue fragmentation and decomposition. ... Such effects were known from the shooting attempts by Schjerning and Bruns, but the tears in the living were much more terrible and, due to the infection that had occurred, far more disastrous. "[12, p. 31]
The unforeseen combination of complicated gunshot fractures and infected problem wounds developed into a major challenge for field surgery. The Leipzig professor for surgery and general practitioner à la suite Erwin Payr (1871-1946), who worked at the front, estimated the percentage of infected shrapnel injuries to be 60 - 70%, and of grenade injuries to 90 - 95%. [13, p. 529]
Even wounds with bone involvement from infantry projectiles were, according to observations by Georg Perthes (1869 - 1927), full professor of surgery in Tübingen and advisory surgeon of the XIII. (K.W.) Army Corps, 60 - 70% infected, which was due to the pollution from contaminated soil components, wood splinters, pieces of uniform or scraps of leather in combination with inadequate initial treatment and long transport times.
The resulting operating "Under streams of pus and manure"[14, XVIII] was - shaped by the long peacetime with its modern aseptic working clinics - already in 1914 no longer common property of the operative field.
It was therefore quickly determined that the wound excision according to Friedrich with its primary suture of gunshot wounds, carried out within 6 hours, was not suitable for the conditions of the war. Rather, primary surgical wound care has developed into the method of choice for outwardly small gunshot wounds from infantry projectiles as well as for more extensive soft tissue wounds from shrapnel. The Bonn professor for surgery, general physician Prof. Dr. Carl Garrè (1857 - 1928), recommended as early as 1915:
"Every grenade wound in the field hospital should therefore be uncovered in all its corners as soon as possible, all pockets and hiding spots made accessible through further incisions, hematomas split, tissues disturbed in the diet (muscle and fascia fragments, bone fragments, brain parts, etc.) removed or cut away . The wound must be wiped thoroughly (dry or with an antiseptic), then the wound secretion must be drained off with careful, loose tamponade or drainage. "[13, p. 411]
In order to reduce the incidence of infection in the wounds, it was also postulated that the wounded person should be removed as quickly as possible and that surgical treatment should be carried out as quickly as possible within 12 hours.

Limb injuries

Between 60 and 70% of all wounds were to the limbs. Their character had changed significantly due to the frequent splinters from artillery shells with their extensive tissue and bone destruction. Traumatic amputation injuries with bleeding, death in shock or from fat embolism resulted.
As with many war injuries, when the extremities were wounded, the first on-site treatment was often decisive for the further prognosis. For this reason, recommendations were made for optimal, gentle first aid for limb injuries at the site of the wound, for transport and for the first medical treatment until reaching the operational facility Legion. The aim was to prevent immediate bleeding by means of effective ligatures or a pressure bandage without provoking further tissue damage, to cover the wound with an aseptic bandage and to enable a reasonably stable movement backwards by means of strict splinting.
There was a struggle for the optimal treatment of the approx. 20% shot fractures with their high mortality and the 7% joint shots. The surgeons treated with soft tissue cuts, bone splinters removed, the application of fenestrated transport plaster to the extension treatment in the back hospitals. As far as possible, limbs were not amputated. In addition, the first approaches to standardized surgical procedures in special hospitals, such as B. carried out by Lorenz Böhler (1885 - 1973) with the systematization of bone fracture injuries and their treatment methods.
Of the limb injuries, those of the thigh were the most important. Large bone splinters caused extensive muscle damage. All forms of fracture up to the most severe fragmentation fractures occurred. While the primary amputation of thigh gunshot fractures, in which the periosteum still held the splinters together, was carried out more and more cautiously in the course of the war, the large splinter fractures with often more than a hand-sized entry and exit were almost completely amputated because of the inevitable infection.
In terms of numbers, gunshot wounds to the knee joint were the most common injuries with joint involvement in the First World War and presented the surgeons with special challenges due to the difficult anatomical conditions. In earlier wars, the prognosis was extremely unfavorable, but modern war surgery procedures were able to reduce the risk, especially for simple injuries from infantry projectiles "Significantly improve sad results". [15, p. 775] However, the increased effects of the grenade weapon with its displacing gunshot fractures, splinters and soft tissue and vascular involvement almost inevitably led to infection. Active wound care, rinsing, drainage and immobilization up to lengthy follow-up treatments were the rule.
In particular, the sensitive soft tissue compartment of the popliteal fossa with its large ducts in the lower leg was relatively easy to injure. Grenade fragments penetrated there with injuries to the popliteal vessels and simultaneous intra-articular fractures led to extensive bleeding and were an indication for primary amputation. In the case of hand injuries, left-sided wounds were observed much more frequently and these were explained with movement patterns typical of combat. In the hand injuries, varied bone fractures, primarily the metacarpal, played an important role. If several metacarpals were affected, it was mostly a matter of more severe shattering, which after surgery and successful healing led to extensive functional disorders. If such gunshot fractures occurred as a result of infections, soft tissue changes with tendon-bone adhesions, the surgeons usually decided to amputate the hand.

Stomach shots

Surprising for war surgery was actually the comparatively low number of brain, chest and stomach shots, even if these showed a significantly higher lethality. The medical services calculated only about 4% of all wounds for abdominal and pelvic injuries, significantly less than the 6.2% share of thoracic injuries. While at the beginning of the war as well as on the part of the French and English the doctrine of v.Bergmann intended a conservative approach, the need for a rapid laparotomy in such cases was quickly recognized.
Since the end of the first year of the war, surgeons have performed laparotomies regularly in German field hospitals and even in main dressing stations, which was also favored by the special infrastructural conditions of the trench warfare. For example, special laparotomy stations had been set up in medical companies and field hospitals. The aim was to have the abdominal injured undergo an operation as quickly as possible. "The earlier you can operate on stomach shots, the more successful you are." [6, p. 443] The so-called 12-hour rule, according to which an operation could avoid peritonitis within this period with a high probability, was also viewed pragmatically by experienced war surgeons. "But you shouldn't be too anxious to commit yourself to the time, but in each case carefully weigh the pros and cons."[6, p. 443] Viktor Schmieden (1874 - 1945), professor in Halle and consulting surgeon of the IV Army Corps, later formulated self-critically:
“We all went into this war with particularly high expectations about the course of the stomach shots; Should it really be true that about half of all gunshot wounds penetrating the abdominal cavity will heal if they wait and see? Should the conservative treatment, almost unanimously praised by the surgeons of earlier wars, really recover from such severe damage that we are accustomed to regard in peacetime as an absolute indication for an abdominal incision? Well, we have been severely disappointed by our own experiences. ... We absolutely do not understand how previous observers were able to get such a favorable picture of the shot in the stomach, such as For example, a war surgeon as successful as Goldammer could describe the conservative path as the absolutely correct one, because he was able to heal 27 of 30 abdominal injuries in the Greco-Turkish war without surgery. "[15, pp. 511-512]
Nevertheless, the mortality rate after surgery for abdominal injuries in World War I was still very high. According to English, French and Austrian reports, it was between 50 and 60% [16, p. 9].
Solitary organ injuries such as those to the liver only played a minor role in the hospitals. Most of the wounded barely reached the treatment facilities. Close-range shots and shrapnel often resulted in severe bursts that were incompatible with life due to the tight encapsulation of the organ. In contrast, the bleeding and infection of the gunshot duct determined the further prognosis in the case of smooth hepatic plug-in or penetration.

Chest shots

In relation to the total number of injuries, the frequency of bullets in the chest during World War I was very high. Ferdinand Sauerbruch (1875 - 1951), during the war still professor of surgery in Zurich and consultant surgeon of the XV. Army Corps, examined the dead on a battlefield in the Vosges for their injuries. In 300 casualties he found 112 chest gunshot wounds. The course of the chest shots was very different. Once they were adequately treated surgically, there were fewer late complications and deaths in the rear facilities. Nevertheless, an exorbitantly high mortality of up to 50% must be assumed, since seriously injured people hardly ever reached the first surgical facilities [17, p. 696]. For all chest injuries, the focus was on bleeding and infection.
Injuries to the heart and large vessels usually resulted in death on the battlefield. In particular in the case of perforating heart shots, cases of combinations of simple penetration effects with simultaneous hydrodynamic explosion rupture have been described, all of which "4 heart sections, which were apparently in diastole, opened explosively wide and pieces were torn out of the anterior wall and the septum ..."[18, p. 465].

The Munich pathologist Prof. Max Borst (1869-1946) made extremely interesting findings in cardiac injuries. He reported on embolic spread of projectiles that had penetrated the heart into the pulmonary veins or even into the great circulation to the iliac artery [17, pp. 699-701].

Head injuries

About 15% of all wounds concerned the head, 50% of those killed died of such injuries. This underlines the eminent importance of cranio-cerebral gunshot wounds. The war surgeons dealt in particular with the hydrodynamic explosive effect and mechanics of the projectile effect on the skull and brain, the underlying physical properties of the tissue, the classification of the shots and the resulting therapeutic procedures. Even if many bone injuries with brain injuries were observed at the front, only relatively few of the dreaded brain shots actually appeared in the treatment facilities. Penetrating wounds, ventricular perforations, cranio-cerebral perforations and those with a massive skull fracture mostly ended fatally at the site of the wound due to the severity of the injury. Apart from that, all transitions from splinters, infractions, cracks, isolated fissures, impressions up to coarse explosive fractures were observed in the skull injuries. During the initial treatment of the skull injured, an aseptic bandage had to be put on and the rapid transfer to a field hospital for definitive care had to be organized. It was observed that the untreated brain injured tolerated the transport better than the operated one. As a result, the patients mostly stayed in the surgical facility for a longer period of time. Special centers for the treatment of craniocerebral injuries emerged in all parties during the course of the war.
According to the relationship between the firing trajectory and the skull, a distinction was made between soft tissue and bone shots, of which the tangential shots with a groove or furrow were often survived and in the hospital "The main contingent for medical treatment"[6, p. 355]. The treatment was carried out by rapid surgical revision with trepanation, removal of bone splinters and projectile parts as well as infection prevention. Compression fractures with epidural, subdural or intracerebral bleeding also required immediate surgery.
The number and severity of craniocerebral injuries only fell significantly on the German side after the use of the steel helmet, which was introduced in 1916. Above all, the skull injuries without involvement of the brain as well as the maxillary injuries were reduced. At the same time, however, the number of lower jaw injuries that came for treatment increased. The main reason for this was the frequent use of explosive projectiles, which, with great explosiveness and high speed, caused the fragments to have a destructive effect in the event of war injuries to the face. The protective effect of the steel helmet mainly affected the brain and the upper half of the head, so that lower jaw wounds mostly appeared solitary and were survived, whereas before the helmet was introduced they were associated with other head injuries and were mostly fatal.
In fact, the injuries to the face and lower jaw aroused an increased interest and special interest, including pity, among the public and medical officers. The wounded suffered from severe disfigurement, the following psychological trauma and were often unable to feed themselves. The initial surgical treatment of anterior jaw injuries should be kept as conservative as possible, special interdisciplinary dental treatment procedures were necessary afterwards and established the specialty of maxillofacial surgery [19].

Final consideration

A large number of publications have appeared in the context of commemorating the beginning of the First World War, covering causes, characteristics, operational-tactical procedures through to individual war experience and war perception by contemporary witnesses. They contain numerous references to the living conditions of soldiers on the battlefield, their medical services and the resulting suffering of hundreds of thousands. Personal memories such as letters or diary entries are still movingly to be reflected on today, as well as numerous photographic evidence from the archives that document the violence and its effects on people and the environment.
Death and wounding were not only constant companions of the soldier at the front, but were also the focus of precise scientific investigations by the medical services involved. In addition to standardizing surgical procedures on the basis of wartime experience, at the suggestion of the advising army pathologist, the field medical officer, Freiburg professor Dr. Ludwig Aschoff (1866 - 1942), also set up field prosecutions. The scientists, who were initially institutionalized at the army level, carried out sections from the fallen using uniform criteria and impressively documented the type and severity of the war injuries. They also created numerous specimens for war pathology collections for research and study purposes [20]. The largest such collection with over 7,000 specimens and tens of thousands of dissection protocols and medical histories was set up at the Kaisers-Wilhelms-Akademie in Berlin. Her whereabouts have not been clarified since 1945. The military pathological collection of the medical service of the Bundeswehr is based on the collection of the Munich pathologist Professor Dr. Max Borst, who set up the first field prosecution in the Bavarian army.
With the help of the pathological specimens prepared by Borst and preserved to this day, the various forms of injuries that occurred during World War I can be impressively studied. Furthermore, they are still shattering evidence of a time in which the great dying, in which death and suffering afflicted a whole generation of Europeans and which has left its mark up to the present day.

Image sources:
Unless otherwise noted in the caption, the images come from exhibits in the Bundeswehr's Wehpathological Teaching Collection.

Photographer: Fig. 1 Thomas Wilke, Munich

Date: 13.02.2015