# War wounds

Photograph of the wounded treated by the Red Cross  - Private collection, Mr. Roland POLIART ©

Photograph of the wounded treated by the Red Cross - Private collection, Mr. Roland POLIART ©

With this war and its destructive inventions, new injuries also make their appearance. But can one imagine the unimagineable? Has every possible aspect of the horror been envisaged?

The Great War will call into question the established therapeutic principles that were based on the experience from past wars. However, no other conflict will have provided an opportunity to observe so many mutilated bodies and persons suffering from illnesses.

Physicians at the front, far from peacetime theories, will be faced with critical choices: operate or abstain. While the first choice seems perfectly obvious to us, the second will in many cases be the only option available to physicians.

When speaking of injuries, there is also the dehumanization aspect that results for the body. Physical losses are often prolonged by psychological trauma. Over and above the injury, there are the relations with the family that will accentuate the mutilated soldier's suffereing. Wives and children find themselves confronted with a person whom they no longer recognise. This will doubtlessly be the greatest source of difficulty for these soldiers.

Abdominal injuries

Just like all sciences, medicine is based on experimentation in order to draw a certain number of conclusions. Physicians during the First World War will be faced with situations that no one could have imagined. It is through the exchanges, amongst other things, between actors in the field and in the rear that medical knowledge will be developed in line with the realities that will overturn all of the hypotheses imagined before the conflict.

Physicians will distinguish the various types of injuries according to the affected part of the body. Amongst the most serious injuries are the ones to the abdomen. Given their severity, these injuries are often mentioned in the textes written by surgeons during the Great War. Though rare, testimonials by physicians describing their immediate experiences at the front are often eloquent regarding the atrocities represented by the mutilations. They describe not only the nightmarish visions with which they find themselves confronted, but also the odours and screams caused by these injuries.

In her work "Les médecins dans la Grande Guerre 1914-1918", Sophie Delaporte, historian specialising in the history of medicine during the First World War, provides us with the testimonial of the experiences of front line surgeon Joseph Vassal : "I look out over the battlefield. The imagination cannot rival this reality. I would want none of these hours of blood and death to remain in my brain (…) The lugubrious parade of the wounded begins, and will continue until 2 AM. A stoic fellow contemplates his eventration without a gesture; under his shirt, a fluctuation, sticky, liquid, alive and wam, stomach, intestines... A bandage is placed on top, and he's carried off".

As this testimonial indicates, it is most often not the front line physicians who treat abdominal injuries. In most cases, soldiers with abdominal wounds require an operation. The only medical act that could be performed by the "extreme front line" physician is a simple bandage, before sending the soldier off in a surgical ambulance.

According to the statistics by injury type, abdominal wounds are the least numerous when compared with other wartime injuries. These statistics are often compiled in further away hospitals, and certain soldiers with abdominal injuries could not be transported very far from the battlefield, which implies that they are unlikely to make it as far as the hospitals. The findings regarding the proportion of soldiers with abdominal injuries must therefore be put into perspective.

Transportation will be the decisive element for a soldier's life, and treatment will have to begin as soon as possible in order to provide the soldier with the necessary care. The sorting of the wounded according to the severity of the injuries and the multiplication of aid stations will be essential to their survival. Dr. F. Neuman, a colleague of Antoine Depage, stresses this in one of the publications produced by the Océan Hospital:

" It would therefore appear to be indispensable, and we will see that other reasons support this opinion, to distribute the healthcare units in stages with a greater number of beds the further one gets away from the front, while reserving for the front, but close as possible to the line, a certain number of PCA (advanced surgical units) with small capacities reserved only for the treatment of certain categories of seriously wounded soldiers, for whom the tumult of transportation over several kilometres aggravates the condition such that a useful operation is no longer possible. "

The lugubrious parade of the wounded begins, and will continue until 2 AM. A stoic fellow contemplates his eventration without a gesture; under his shirt, a fluctuation, sticky, liquid, alive and wam, stomach, intestines...

From abstention to operation

Most of these injuries result from firearms, very often bullets and to a lesser degree bladed weapons that, for their part, seldom spare the soldier's life. The experiences from previous conflicts or any accumulated during peacetime were often insufficient or approximate. The differences between the injuries from bullets in the Great War and the experience acquired by medical science in this domain result from the increased speed of rotation and propulsion of the bullets, that cause previously unseen damage.

While the power of the weaponry increased strongly in destructive efficiency, the means for annihilating the adversary are much greater in number during the First World War. Most injuries from previous wars resulted from bladed weapons and revolvers. In 14-18, it's not only bullets that will kill, but also, and in much higher proportions, fragments from shell bursts.

In addition to these new factors, there is also the firing distance that will have a crucial impact on the soldier's survival. If the firing is in the immediate vicinity of the organs, the impact from the burst can cause haemorrhaging that results in death without a surgical operation. For its part, medium-distant firing will have less fatal consequences. The importance of a wound can be determined by the perforation of the peritoneum (the abdomen's protective membrane) and the resulting infection. The further the shot, the easier it is for the bullet to lodge in the peritoneum without hitting the viscera, meaning that the peritoneum perfectly fulfills its protective role in this specific case. In addition to the destruction of the body, there also the illnesses that firearms cause to the organism as a result of the debris (clothing, mud, etc.) that they carry.

Any impact on the filled viscera (stomach, liver, etc.) results in a systematic laparotomy (medical name for a surgical operation to the abdomen) given the mortal danger from the lesion. However, there are many debates over performing a surgical operation or abstaining. As such, at the start of the First World War, the arguments in favour of surgical abstention are based on the experiences and dogma acquired by surgeons during previous wars.

During previous conflicts, the few attempts to operate on abdominal wounds often resulted in failures whereas certain of the wounded, for whom no surgery had been performed, "miraculously" healed as indicated by Dr. F. Neuman : "What caused surgeons in previous wars to recommend, and set down as a kind of law, abstention with penetrating wounds to the abdomen was the fact that the vast majority of these patients died on the battlefield, with defective organisation making it absolutely impossible for surgeons to attempt a useful surgical intervention. Some of these patients, most suffering from localized lesions that were often non-visceral, nevertheless managed to reach the rear positions with the healing process already underway, thereby leading one to consider as a rule that which was in reality only an exception: other patients, more severely wounded, only reached the surgeon late in the game and under such conditions that any surgical operation inevitably led to a failure. "

The evacuation conditions that made it impossible to operate under ideal conditions and the lack of knowledge about the various impacts encouraged the decisions not to operate on abdominal wounds.

 

The evacuation conditions that made it impossible to operate under ideal conditions and the lack of knowledge about the various impacts encouraged the decisions not to operate on abdominal wounds.

Acting for better healing

Nevertheless, there is quite a paradox between the actions undertaken in peacetime and the actions undertaken during wartime. Indeed, discussions about abdominal operations outside of armed conflicts were heavily in favour of operations. This finding contributed to the skepticism of many surgeons who would increasingly dispute the abstention theories established during wartime.

As such, as of the end of 1914, such reappraisals prompted physicians to improve the transportation conditions for the wounded, in order to make it possible to attempt an operation. Surgeons undertake a more detailed analysis of the problem, leading to improved knowledge and new theories.

Amongst these theories, the types of wounds are now divided into two categories: non-penetrating abdominal wounds (not reaching the peritoneum) and penetrating wounds. Two further subdivisions of wounds can be added to these two types:

- parietal non-penetrating abdominal wounds (only affecting the parietal layer) and visceral wounds affecting the viscera located outside of the parietal layer

- simple penetrating wounds (extremely rare cases, since they perforate the abdominal protection without affecting any of the viscera) and visceral penetrating wounds (the most common wounds and the most dangerous ones, especially when they affect several organs).

Though medical opinion gradually becomes firm with regard to the need for operations, as quickly as possible, the success of the laparotomy will be dependent on several factors.

Amongst the factors that can influence the operation's success are, in particular, the conditions and speed of the transportation, and the amount of time that the physician can devote to the patient. Given the growing number of patients, the surgeon will be faced with sometimes dramatic choices. As a laparotomy will monopolize the surgeon for quite some time (1 to 2 hours) with limited guarantees, the surgeon will also have to look after other patients who will have better chances of survival with his help.

Improvements with regard to medical knowledge and evacuation of the wounded, but in particular the awareness that operations could stave off death, make it possible to save many lives.

 

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