Is considered ex paramilitary as ex soldiers

Palliative medical care for seriously wounded and dying soldiers in the Wehrmacht medical facilities near the front during World War II

Methods: The article is methodologically based on the review and analysis of the available contemporary military medical literature and military medical regulations of the Wehrmacht with regard to instructions for the care of the dying.

Results: The personal motivation of the individual doctor in the front-line care to look after the dying was certainly inhomogeneous. The care of the dying was based on experience and expert opinion and not according to plan. The expert opinion consisted essentially of an appeal to the ethics of the doctor to even care for the dying. Instructions from the Wehrmacht (medical) leadership were missing.

Conclusions: It can be assumed that the palatal symptom control of the dying was inadequate and that, from today's perspective, these people were undersupplied by palliative medicine. In order to verify this more closely, however, additional extensive source studies are required.

In a further step, the question arises to what extent, in current military medical concepts, for example in the Bundeswehr, palliative care for those wounded in combat is even addressed and, ideally, regulated.

keywords: Palliative medicine, medical service, Wehrmacht, triage, the hopeless, World War II

Palliative care for severely wounded and dying soldiers at frontline Wehrmacht medical treatment facilities during World War II

Summary:Background: Palliative care for incurably wounded (and sick) soldiers is a topic that has received little notice in the history of military medicine. Although military physicians in the Wehrmacht had suitable medicines at their disposal in World War II, their medical knowledge about how to use them for dying patients and concepts for how to care for them beyond administering a pharmacotherapy seem to have been patchy and to have depended on their individual backgrounds. We hardly know anything about plans and professional guidelines and about how they were possibly implemented at frontline medical treatment facilities. The present article is to be seen as a preliminary study for a project in which further research will be done on palliative care in the Medical Service of the Wehrmacht.

Methods: In terms of methods, the article is based on the examination and analysis of contemporary literature and regulations on military medicine of the Wehrmacht for action to be taken in the care of dying patients.

Results: The personal motivation of the physicians who were employed to care for dying patients at a frontline medical treatment facility was probably inhomogeneous. The care they administered to dying patients was based on experience and expert opinions and not on plans. The expert opinions were basically appeals to the ethics of the physicians aimed at getting them to attend to dying patients at all. The Wehrmacht (Medical Service) command did not issue any pertinent instructions.

Conclusions: It can be assumed that the palliative control of dying patients' symptoms was insufficient and that, from today's perspective, these people were not administered adequate palliative care. To verify this more closely, additional extensive basic research must be done.

In a further step, research must be conducted into the question of the degree to which current military medicine concepts, e.g., of the Bundeswehr, address palliative care for combat casualties, if they do so at all, and into the regulations that ideally apply.

Key words: Palliative care, Medical Service, Wehrmacht, triage, hopeless casualties, World War II

background

Wounding and death in combat were and are associated with great individual suffering. The military doctors of the Wehrmacht had - at least theoretically - suitable pharmacological means to alleviate the suffering of the "hopeless", i.e. those who were given no chance of survival under the given conditions and who could not be treated with the aim of restoring their health. It was their fate to wait for death. The implementation of providing medical help to this - not insignificantly large - group of people, however, in reality depended on many factors, first and foremost the doctor's individual knowledge of whether such treatment was deemed necessary. The availability of the pharmaceuticals and the knowledge of their use in the dying as well as the concepts of their care were also decisive. On the one hand, the question arises as to whether the management of the medical service actually had any planning and technical specifications for dealing with seriously wounded soldiers who could no longer be healed. If this was the case, it would also be asked to what extent these specifications were implemented in the treatment facilities, in particular the medical facilities close to the front; In the absence of planning, however, the question of the independent action of the medical officers working there and other groups of people concerned with the care of these soldiers must be asked. In the history of military medicine, hardly any attention has been paid to this complex of issues, just as the palliative care of soldiers of the Bundeswehr on deployment is an important desideratum.

Motivated by this fact, a research project on palliative medicine is currently being prepared in the medical service of the Wehrmacht, which has been applied for in the area of ​​special research by the medical service of the Bundeswehr. The present article is to be understood as a preliminary study for this project, on the basis of which the research problem is presented on the one hand and the methodological approach is to be sharpened on the other.

Methods

For this article, the relevant medical and military medical regulations such as the military medical regulations of the Army [14], the associated leaflets [27] and guidelines [25], and a relevant selection of the contemporary medical specialist literature available were viewed and analyzed: Mentioned here are examples on the one hand for the area of ​​magazines the "Zentralblatt für Chirurgie" [37] and "Der Deutsche Militärarzt" [5]; also the war surgery textbooks by Franz [7], Haberland [8], Käfer [11], Orator [22], Spatz [32], Schörcher [30], Schum [31], Borchard / Schmieden [3], Starlinger [33 , 34], Westhues [36], Zillmer [38], Zimmer [39] and others. The specialist literature available to the doctor at the time, on the one hand, and official technical specifications in the Wehrmacht medical service, on the other, were examined for instructions on how to take care of the dying. Particular attention was paid to the distinction between the ethical and moral appeal and specific professional assistance.

Results

If soldiers are so badly wounded in combat that they ultimately succumb to the injuries, then contrary to popular belief, they often do not suffer immediate, immediate death at the moment of the trauma. Rather, it is a potentially slow process with symptoms such as pain, shortness of breath, and anxiety. This was also true in the fighting of the Wehrmacht during the Second World War.

According to the pioneering study by Rüdiger Overmans, around 5.3 million died of a total of around 18.2 million members of the Wehrmacht (including around 900,000 members of the Waffen SS) and other paramilitary organizations. In the last ten months from July 1944 to the end of the war alone, the fatal losses were about as high as during the entire war period [23].

In contrast to the First World War, there is no medical report for the Second World War and, based on the sources, it will probably not be possible to draw up one, which is why no reliable information can be given on the number of wounded. However, they are certainly many times higher than the death toll. The number of those who were under the care of members of the medical service during the dying process can only be guessed at, but it was without a doubt considerable.

Triage - decide who is allowed to live

Fig. 1: The most important information about the person, the injury pattern and the previous measures should be noted on the “accompanying note for the wounded and other persons to be treated surgically”. The two red stripes could be separated and were used to identify the transport priority. (Source / Photo: Sebastian Schiel)
The forces of the medical service of the Wehrmacht, including the paramedics and doctors, who were not independent but subordinate to the fighting troops (troop dressing station, see below), repeatedly reached the limits of their capabilities in terms of personnel and material when the attack on patients exceeded their own treatment capacities . This phenomenon is also known today in emergency medicine and disaster medicine. This makes it necessary to prioritize patients according to urgency and prognosis. This process, which is known as triage (also known as sighting), is certainly one of the most difficult tasks, both professionally and personally, that can be imposed on a doctor. The decision about who has a chance of survival and who does not, and who is given priority for medical treatment, has always been left to a doctor who is as experienced as possible.

In the Wehrmacht, wounded people were provided with so-called wounded accompanying notes (see Figure 1). The most important medical facts (such as the type of injury, medication administered, the time at which limbs were tied) were recorded on these and the triage result was made clearly visible for everyone in the form of a transport priority. Two red stripes on the left and right on the edges of the map meant “not transportable”, one “transportable” and the removal of both red edges at a perforation led to the marking as “marchable” [15].

Today, as part of the sighting, the hopelessly injured is classified directly into a category which they also define as such and which explicitly names palliative treatment as a consequence. The 6th sighting consensus conference at the Federal Office for Civil Protection and Disaster Assistance agreed for the last time in November 2015 on five triage categories [24]:

I (red): vitally threatened, immediate treatment required,

II (yellow): Seriously injured / ill, urgent treatment necessary,

III (green): Slightly injured / ill, non-urgent treatment and

IV (blue): No chance of survival, palliative care.

Finally there is a category EX (black) for dead people.

Today's triage is based on treatment and not on transport priority. The latter results from the totality of the present situation.

The first aid station

The first place for a medical inspection was the troop formation area in World War II (for the rescue chain, compare the scheme of wounded care in Figure 2). This was operated by the troop doctor of the fighting battalion and was to be erected out of the reach of the enemy infantry; sometimes several troop formation stations were combined to form a regimental formation station (with then several troop doctors). At the troop formation area, the task of the one and only doctor to subject the wounded flowing back or transported from the front, possibly previously treated in the wounded nests of paramedics, to an initial medical examination and only to carry out the most necessary medical measures [16, 20]. This is what it says in a contemporary manual for war surgery from 1941:

"Surgical work in the narrower sense is out of the question at the troop formation area" [26].

Fig. 2: Simplified scheme of the wards for wound care from a textbook on field surgery from 1944 (Source: Hartleben H: The organization of the war medical system and the deployment of the medical troops. In: [11], p. 4)
Only a tracheotomy to prevent asphyxiation, an emergency amputation to get a bleeding under control, or the improvement of the first bandage should serve to ensure that the patient can be transported as quickly as possible. If these measures did not appear promising, the patient was to be classified as "hopeless"; burdening the scarce transport capacities with such a triage was forbidden, as for example a passage in the article by Hermann-Coenen "Principles of transportability, transport and accommodation of the wounded "in the" Textbook of War Surgery "(published by August Borchard and Victor Schmieden), which was first published in 1917 and based on the experiences of the First World War, is still current in 1937 in the third, revised edition:

“It goes without saying that the dying are not transported back. Comrades at the front are also preparing a worthy soldier's grave for the fallen! " [4]

This admission is of course just as unhelpful for the adequate care of this patient group as the advice given elsewhere:

"With brief instructions he [the troop doctor] will see to it that the sight of other wounded people is avoided if possible." [10]

The main dressing station

The next station for the wounded on their way towards definitive care was the main dressing station, the first facility set up autonomously by a medical company [17]. When the main dressing area was full, the medical officers were often supported by dentists and veterinarians who had to assist in the operating theater. This made it possible to create two operating groups per main dressing station and to double the operating room capacity. At the main dressing station, surgical care was calculated for the first time, but by no means every wound that occurred, only selected trauma that required immediate intervention before further transport. These include, for example, relieving a pneumothorax, shooting in the floor of the mouth, jaw or neck that obstructed the airways, stopping bleeding, early amputations, open joint injuries and gunshot fractures.

Triage was and is a dynamic process that has to be carried out repeatedly on the same patient on the timeline of wound care. This was also the case at the main dressing station, the place that had surgical skills, but whose capacity was often unable to meet the demand. So it was here that the dying had to be cared for. “The dying generally stay in the main dressing station”, was the rule [25]. Accordingly, when the main dressing station was set up, a place for accommodating the “dying” [31] was also provided. This is also confirmed by a reference in a contemporary textbook on war surgery:

"Hopeless and obviously dying people are stored in isolation, pain relief is provided and not conveyed." [20]

Example: Shots in the stomach

As an example of the drama behind the decision to have to "give up" a patient for reasons of the special situation in the conservative medical sense, soldiers with stomach shots are particularly well suited: According to the relevant literature, 15-25% of all wounds in combat were stomach shots 40 - 50% of which were fatal on the battlefield [26]. If intra-abdominal structures were injured, such patients could only be saved by an early operation (after a maximum of 6-12 hours); the mortality of the operation itself was up to 50%. The patient with his fragile intestinal suture had to rest for several weeks after the surgical procedure because of the dreaded suture insufficiency; transport was absolutely prohibited. And finally, from a tactical point of view, it was important to consider that an operation of an abdominal shot tied an operating group for at least 2 hours. The following requirement was obvious:

"When there is little time due to a large influx of wounded, only the most promising cases are operated on in principle."[10]

It is therefore not difficult to understand that patients with a shot in the stomach could only be cared for according to peace standards under the most favorable conditions. If the medical service options were limited by the high number of wounded, patients with gunshots in the stomach were classified as "hopeless". So they were doomed to die and from then on needed a special kind of medical (and nursing, pastoral etc.) attention. In today's words, they were provided with palliative care. And not just through a one-time administration of painkillers, but for an indefinite period of time during which the patient's state of health deteriorated, pain increased, fever occurred, nausea, vomiting, and emotional distress tormented the patient. Heinrich Schum wrote in his "Introduction to Defense Surgery" published in 1935 and thus documents the view before the Second World War:

"[It seems] more human, the unfortunate [wounded with shot in the stomach, editor's note. Authors] to ease their last days and hours within the limits of what is possible, since the hope of preserving life is extremely low, even under the strictest regime. [...]. "[31]

Palliation - averting suffering from the dying

Palliative care means, where healing is not possible, using different medical and non-medical means to spare the patient suffering and - ultimately - to enable peaceful death. From a medical point of view, this is essentially about so-called symptom control, that is, about managing physical and mental complaints symptomatically. The most common and central symptoms are pain, restlessness and fear, but possibly also shortness of breath and nausea, to name just the most important. The obligation to stand by the dying soldiers accordingly was also seen in the 1930s:

"[...] it is a human duty to them [the dying patient, editor's note. Authors] to facilitate the last hours with all possible means. "[31]

Fig. 3: Morphine in ampoules of 20 mg each was found in small quantities in the personal equipment of every medical officer (2 ampoules) and in larger quantities in the equipment of the medical facilities. Demand and supplies probably fluctuated considerably (source / photo: Ronny Strauch with kind permission).
If one considers the possibilities of medical palliative care, then, in addition to human attention as a basis, the pharmacological possibilities naturally come to the fore first. But non-medicinal products also have their place. Heinrich Schum once again states in his 1935 “Introduction to Defense Surgery”, which is based on the experiences of the First World War, but is still up-to-date:

"The distribution of tobacco products also works like a miracle on the physical and mental suffering of the wounded."[31]

Pharmacologically, when it comes to controlling the symptoms just mentioned, one group of active substances is at the center today as it was then: opiates. These have an excellent analgesic effect, relieve shortness of breath, and counteract restlessness and fear. They can be administered orally, but also intravenously and subcutaneously if oral administration is no longer possible. The best prerequisites for use in palliative medicine. This was also recognized in World War II, as the following passages show. This is how Hans Käfer writes in his "Field Surgery":

"[...] the seriously injured, for whom any surgical help is certainly futile and for whom fate has determined the soldier's death in a very short time. For them alone, morphine is a benevolent helper. "[12]

And the surgeon Viktor Orator describes the procedure in key words in the "Guide to Field Surgery in War of Movement" published in 1942:

“The obviously irredeemable Moribunds. They are stored as calmly as possible. Pain relief and nursing care. Morphine. " [22]

In the Wehrmacht, the medical officer at the troop first aid station and main first aid station had ampoules with morphine (Morphium hydrochloricum) of 20 mg available (see Figure 3), as well as oxycodone (Eukodal®) in manageable quantities and analgesic scopolamine - Eukodal®-ephedrine (Ephetonin®) ) Mixtures (so-called "SEE"). SEE was particularly popular as a short anesthetic in surgical procedures and existed in two different strengths [1]:

Strength I (weak): Scopolamine 0.0005 + Eukodal® 0.01 + Ephetonin® 0.025;

Strength II (strong): Scopolamine 0.001 + Eukodal® 0.02 + Ephetonin® 0.05.

According to the "Guidelines for the Care of Wounded in the Front Medical Facilities" [25], the troop doctor should "Do not be economical with morphine [...]."

If you summarize the packing order of the material of a troop first aid station with regard to the available strong analgesics (and to be administered parenterally), you get a basic set of 202 ampoules of morphine of 20 mg, 50 ampoules of oxycodone of 10 mg and 30 ampoules of oxycodone of 5 mg, furthermore 10 ampoules “SEE I” and 10 ampoules “SEE II”. At first glance, this is an impressive amount, especially when it comes to morphine. However, if one considers scenarios that assume protracted fighting, a high number of wounded and a poor supply situation, it can be assumed that these quantities were not as abundant as prima Vista seems to be. The doctor at a unit had to take care of his battalion, the strength of a battalion was about 800 men. And of course the opiates were by no means reserved only for the dying, on the contrary: every wounded person should leave the first medical aid with sufficient analgesia.

Fear of overdose as an obstacle?

“And finally, the doctor should and may not carry out euthanasia [...]. But also to spare the dying person any pain and to shape death to slide over weightlessly corresponds to the highest medical ethics. "[33]

This quote from 1944 is as true today as it was then. In the context of palliative medicine, assisting euthanasia expressly does not mean consciously killing the patient. Euthanasia, a term to be avoided anyway for obvious historical reasons, and palliative medicine have nothing to do with each other. The German palliative care physicians deliberately exclude so-called active euthanasia, but still help to die - it is a declared aim to use an image, to pave the way to death, to alleviate agony, to help the dying person Let go and die with as little fear as possible. Today's palliative medicine provides “euthanasia” in the sense of dying care [19].

Then, as now, symptom control has priority over the extension of physical life. It is therefore possible under certain circumstances that the patient may die more quickly as a result of measures to control symptoms. A classic example of this is increasing the dose of morphine while accepting the suppression of the respiratory drive. This is by no means the goal, but a side effect of the symptom-controlling measure, which one accepts after weighing the possible harm to the resulting well-being of the patient. In this context, in our opinion, the greatest inhibition thresholds for the physician inexperienced in palliative care to adequately control symptoms arise time and again.

Moral appeal versus practical relevance

"In order not to lose [...] time in clearing covered body parts, I may inject the medication subcutaneously into the forehead or cheek."[8]

This advice from everyday military medicine during the Second World War is an exception in its practical relevance among the text passages found. The majority of the operating instructions viewed appeal to the medical officer's morality to also take care of the dying, or these sources do mention morphine as a means the choice in the treatment of this frequent group of patients, but there is no concrete help for actual symptom control in those who die from their wounds.

The hint “In principle, one is not reluctant to administer morphine [...]. It is a matter of course that our ethics dictate that the hopelessly irredeemable are only allowed to dawn as gently as possible in a deep morphine-scopolamine intoxication.From a palliative medical point of view, [31] should be supported in principle. What is missing for the inexperienced doctor (and these are usually found at the very front in the medical care of the troops), were more specific instructions regarding the administration of the medication. What do you have to pay attention to? How much, where applied, how often give in to what? Can there be side effects and how do I manage them? The experienced practitioner knows that morphine can and usually does lead to extremely severe nausea. This knowledge is important in order to be able to counter this side effect in a calculated manner. The advice to give enough morphine makes sense in principle, but does not go far enough in practice.

Fig. 4: Seriously wounded Wehrmacht soldier: agony and alone - although under the care of the Red Cross. By holding up the Red Cross flag, a paramedic may signal a wounded collecting nest, where a seriously injured man is already waiting for help. The helplessness of the paramedic is literally palpable. France, summer 1944 (Source: Federal Archives. Photo 1011 - 722 - 0406 - 13A. Photo: Theobald, 1944)
Some of the texts written by experienced and often military superior medical officers, which were used to train surgeons who were first confronted with the peculiarities of war surgery, are likely to have led to confusion and hesitation among these young doctors. Despite a principled advocacy of alleviating the suffering of the hopelessly wounded with the help of opiates, the consultant surgeon senior medical officer Prof. Fritz Starlinger urged caution in 1943 and warned urgently against what we now call "active euthanasia". He, too, fails to provide specific information about the care of the “hopeless” and rather conveys the warning not to violate the medical principle of “nil nocere” by accepting the death of the patient and to give up the patient prematurely. However, depending on the situation, the non-harm principle can also mean courageously taking care of a dying person and thereby doing justice to this principle. Starlinger writes:

“Euthanasia is also a mistake in the field, because one is always surprised at how even dying people who have been held hopelessly lost can recover […]. But the doctor is supposed to make dying easier, may dampen the sometimes hard agony and thus alleviate severe distress. Fixed doses of alkaloids are forbidden and the medication has to be constantly adapted to the individual case. Such a point of view is occasionally resented to the doctor by the seriously injured person who has finished his life and no longer wants to suffer; yes, the doctor himself had to be called "coward". The doctor must nevertheless remain on the correct standpoint, that it is his absolute duty to fight for life as long as there is still a sense that it is not his mission to consciously kill with means that are in his hand for healing purposes were given [...]. " [34]

Starlinger describes an attitude towards “active euthanasia” that is still unconditionally shared today. On the definition of what was to be seen as “hopeless”, however, the various medical officers concerned are likely to have differed opinions, and this conveyed to young doctors in particular that they could violate the oldest medical ethos by resolutely identifying hopeless cases and generous symptom control, and practically become a murderer.

His advice on how to deal with the wounded “psychologically” also reflects the spirit of the times when he gives recommendations on how to save the patient from being confronted with reality. Remarkably, he understands the ability to lie to the patient as a genuine part of the medical art:

“It is not easy to maintain the good and confident mood in a sick room when comrades die day and night in the neighboring camp; Therefore, if possible, a dying room should be set up in every hospital; and questions about the whereabouts of the neighbor who is no longer returning from the dressing room can easily be answered with the unexpectedly possible deportation in the aircraft, which one understandably wanted to allow the seriously injured to benefit from. The doctor must also be able to lie in the field, but no less skillfully than at home [...]. " [34]

Today, from an ethical point of view, one would at least discuss the extent to which the patient is deprived of the opportunity to deal with his situation and that this ultimately deprives him of his maturity and patient autonomy.

Palliative care for the wounded then and now

The author who, as far as we know, has dealt most extensively with the subject, the Berlin police doctor Heinrich Schum, refers in his publication to his experiences in the First World War. The term “palliative emergency operation” to contain agonizing symptoms can also be found - in the sense of our current definition - remarkably in a chapter on abdominal injuries by Victor Schmieden in his work from 1917 mentioned above [29]. Later, one misses not only the term, but also the idea of ​​performing surgical interventions not only for curative purposes, but also to alleviate suffering, even if the overall prognosis is poor. The realization of the need to devote oneself to these patients with no chance of survival was therefore not new in World War II, 20 years later. The quality of the technical discussion was by no means better. Rather the opposite seems to be the case, the problem was hardly discussed in spite of the experiences of the First World War. The reasons for this are still unclear and at best speculative.

Conclusions

It has been shown - this is a result of this preliminary study - in the literature and regulation analyzes that these are by no means sufficient for the historical processing of the topic, but rather that a verification and a detailed examination based on supplementary sources are necessary: ​​This is, for example ego documents such as autobiographies, diaries, reports and letters from people who were involved in the medical care, nursing and pastoral care of the seriously injured and dying. Information and explanations on the topic can also be found in unprinted official sources, such as in protocols, activity and experience reports in the holdings RH 12 - 23 (Army Medical Inspection / Chief of the Wehrmacht Medical Services) of the Federal Archives - Military Archives or other archive holdings that need to be specified in more detail .

In addition, as a further result of this investigation, the question has almost arisen, how it is today, more than 70 years after the end of the Second World War and against the background of a consciousness that has changed and developed in the Federal Republican society in a positive sense in the palliative treatment of dying people, in order to deal with the issue of military medicine?

Symptom control in the dying, i.e. palliative therapy, is a necessary part of the care of seriously wounded soldiers. This begins with the care in the battle and continues into the care at home. Even in the Bundeswehr today, there is a lack of reliable instructions for dealing with those who cannot be rescued. The paramedic, who still has to triage on the spot and treat the incurably wounded, has no instructions for this.

This topic touches on a sensitive point, also from a sociopolitical point of view - that soldiers can also die in combat, in operations. Regardless of this, however, it is imperative to impart relevant knowledge and provide instructions for action. This is justified not only out of concern for the entrusted patients or soldiers, but also in the care for the affected medical officers and members of the health professions, who should not be unprepared for such extreme situations.

The processing of these advanced questions should take place within the framework of a research project that is currently being applied for.

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Citation style:
Schiel S, Vollmuth R: The palliative medical care of seriously wounded and dying soldiers in the Wehrmacht medical facilities near the front during World War II. Military Medical Monthly 2017; 61 (12): 292-299.

Citation:
Schiel S, Vollmuth R: Palliative care for severely wounded and dying soldiers at frontline Wehrmacht medical treatment facilities during World War II. Wehrmedizinische Monatsschrift 2017; 61 (12): 292-299.

For the authors:
Chief Medical Officer d. R. Dr. med. Sebastian Schiel
Specialist in general medicine, palliative medicine, psychotherapy
Falkenburgstrasse 19
97250 Erlabrunn Email: [email protected]

Date: 01.12.2017

Source: Sebastian Schiel, Ralf Vollmuth