The fact French army surgeons had better luck saving shot-up arms than shattered legs might seem like one of the medical mysteries of World War I, the bloodiest conflict in history until World War II.
It was not because leg wounds were almost always more severe than arm wounds.
“The statistics of the French army show that the relation of loss of the lower extremity to that of the upper extremity is three to two,” the late Fred Houdlett Albee, MD, said in Orthopedic and Reconstruction Surgery: Industrial and Civilian, a book published in Philadelphia in 1921. Albee was a colonel in the Army Medical Corps and the director of the Department of Orthopedic Surgery at the New York Post-Graduate Medical School.
“The proportion of disabling injuries not resulting in amputation is the reverse of this,” Albee continued. “The reason for this has been found to lie in the fact that when a man received even a very severe mangling injury to the arm he was able to walk back to the dressing station where he received treatment which prevented infection and saved his arm.”
A long, bloody battle
One hundred years ago in February, weary, blood-spattered French and German military physicians were risking their own lives — often braving heavy enemy shellfire — treating desperately wounded soldiers at Verdun, on the Meuse River in France.
On Feb. 21, 1916, 140,000 German troops hurled themselves at massive French fortifications that were part of the Western Front, a killing zone of British, French and German trenches that stretched for more than 400 miles from the North Sea, through Belgium and France, to the border of neutral Switzerland.
The 30,000 French troops at Verdun held fast, adopting the motto On ne passe pas, “They shall not pass.” The attackers never did.
In the months that followed, both armies sent tens of thousands of reinforcements. The Germans spent almost 10 months attacking Verdun, firing more than 21 million artillery shells at their foe. The French replied with more than 23 million rounds and finally succeeded in pushing the invaders back on Dec. 18, 1916.
All told, attackers and defenders suffered 700,000 men killed, wounded or missing. Among the wounded were thousands of amputees.
The Great War — now called World War I because of World War II — continued for nearly 2 more years. The Germans did not give up until Nov. 11, 1918.
Deadly weapons, lifesaving medicine
World War I ushered in the use of new and deadlier weapons such as tanks, poison gas, machine guns, war planes and submarines. But with the global conflict came improvements in military medical science, notably in surgery, artificial limb technology and in the rehabilitation of amputee veterans. Dozens of articles and books, including Albee’s, were written about the hard lessons army physicians, limb makers and rehabilitation specialists learned from the war that was supposed to end war but did not.
At the time Albee’s book was published, the population of France alone included some 50,000 amputees, he wrote. There were considerably fewer American amputee veterans because the United States did not join the war on the side of Britain and France until 1917.
In his book, Albee included a frank report from the Army’s Office of Surgeon General (OSG), which admitted that surgeons had paid little attention to artificial limbs and how they were fitted.
“As a rule, the surgeon rarely sees his patient after the healing of the wound, but turns him over, usually without supervision, to the care of the artificial limb maker,” he quoted from the report.
Thus, according to the OSG, “the surgeon loses one of the most valuable means of control in the perfection of his technique and frequently errs in comparatively simple details which a knowledge of the fundamental points of the artificial limb maker’s art would enable him to avoid.” Therefore it seemed prudent “to call attention to those points in the technic [sic] of amputations which have a direct bearing on the fitting and wearing of a substitute.”
The report conceded that amputations were more trying for surgeons and patients under combat conditions than in a sanitary hospital in peacetime. Often, candidates for amputation also were suffering from shock and exhaustion, which made them even more vulnerable to infection. Thus the medical staff had to act quickly, the SGO advised: “The questions of when to amputate, at what point it should be done, what type of amputation should be chosen and whether the incision can with safety be closed are obviously matters of the most vital importance to the individual and also determine whether his after-care and the fitting of the artificial limb are to be easy or difficult.” The SGO admitted that early in World War I, “when conditions were particularly unfavorable and infection ran rampant, amputations were sometimes performed carelessly and [residual limbs] left open that could with safety have been closed.”
The report concluded, “The question of amputation is, therefore, one of the most serious problems the army surgeon must face and one that calls particularly for calmness under stress and for the exercise of the most sound surgical judgment. When the requirements necessary to conserve the safety of the patient have been met, the sole remaining consideration is to be given to securing the [residual limb] which will best meet the demands made upon it by the artificial limb.”
Repercussions of war
Long after the war ended in 1918, scores of armless and legless veterans were visible in the combatant countries. “One of the most graphic reminders of the destructiveness of war is the amputee. Every major conflict in the 20th century has seen large numbers of amputee veterans as the result of battle,” wrote Lt. Col. Paul J. Dougherty of the Army Medical Corps in a 2002 Veterans Administration publication. Approximately 2,300 major amputee veterans came home to America from France in World War I, according to Dougherty, who defined a “major amputation” as “one which is proximal to the wrist or ankle.”
He explained that transfemoral amputations (1,145) were the most common, followed by transhumeral (556), transtibial (335), forearm (215) and multiple (44). The data excluded 95 knee disarticulations, he said.
During the conflict, 25.5% of amputations resulted from the direct effects of trauma, such as small arms, mortar or artillery fire or bombing from airplanes. The rest — 74.5% — were necessitated by infection, Dougherty wrote.
- Albee F. Orthopedic and Reconstruction Surgery: Industrial and Civilian. Philadelphia: W.B. Saunders Company, 1921.
- Dougherty P. Traumatic amputations during military service (including issues of surgical revision and limb salvage). Traumatic Amputations and Prosthetics. Department of Veterans Affairs, 2002, p. 3-26. Available www.publichealth.va.gov/docs/vhi/traumatic_amputation.pdf. Accessed Jan. 4, 2016.