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Chapter XVI - C

Contents

Section III. The German Medical Service in Italy

GENERAL CONSIDERATIONS

    Practically all of the prisoners whom Allied medical services were called upon to treat in Italy were Germans. Since the Italians surrendered to the Allied forces as the invasion of Italy was in progress in 1943, very few became

36 See footnote 10, p.361.
37
See footnote 19, p.398.


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FIGURE 76. - German prisoners of war in Po Valley, May 1945.

prisoners. When Italian troops fought with Allied troops in the south of Italy, their wounded were cared for in their own hospitals. Italians who fought with German troops were treated in German hospitals; a few of them were encountered in these hospitals after the surrender that ended the war in Italy.

    As for German prisoners of war, the first trickle of captured troops in the Po Valley (fig.76) after the breakthrough there in April 1945 furnished a hint of what was soon to become a major problem. After 29 April 1945, there were few Allied casualties, and U.S. Army medical facilities became, in effect, depositories for the sick and wounded remnants of the Wehrmacht. On 3 May 1945, an Allied forces headquarters directive made captured German prisoners who were wounded or ill time responsibility of the Fifth U.S. Army medical service. Eventually, over half a million prisoners were taken, 20,000 of whom were either already in hospitals or required immediate hospitalization (fig.77). Most German wounded were in German hospitals, and after the surrender they continued to be cared for by their own medical officers, under the supervision of U.S. medical personnel assigned to the hospitals in a supervisory capacity

    From mid-April 1945 on, as more and more territory was taken and more and more troops surrendered, there were unusual opportunities to study the management of battle casualties in German hospitals. Immediately after the final surrender, on 2 May 1945, General Martin directed a number of medical officers, among them the army consultant in surgery, to visit the German medical installations and survey them as completely as possible. These observa-


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FIGURE 77. - Care of enemy wounded. A. Care of wounded German soldier by officer of 11th Armored Infantry Battalion in Silla area, Italy, October 1944. B. Care of wounded German by American medic of 10th Mountain Division in Castel d'Aiano area, March 1945. Dead German lies nearby.


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FIGURE 77. - Continued. C. Wounded German being carried into hospital which had surrendered to U.S. troops in Verona area, April 1945. D. American soldier, injured in motorcycle crash, being cared for by German medics until the arrival of American ambulance, in Maresca area, Italy, May 1945.


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tions, supplemented by interviews with German medical officers in hospitals and hospital groups and with others who held staff positions in German armies and army groups,38 yielded much information of interest.

    While it is impossible to judge the standards of German military practice by the conditions found in hospitals operated by a beaten enemy after 6 years of war, there is no doubt that, since 1933, both time quantity and quality of German physicians had steadily deteriorated. By U.S. standards, observations in German hospitals showed their food and their medical and surgical supplies to be inferior and their medical and surgical practices no more than mediocre.

ECHELONS OF MEDICAL CARE

    The chain of evacuation of German wounded was basically similar to that employed in the U.S. Army, although triage differed in a number of respects. The system was as follows:

    1. First aid was rendered by a noncommissioned officer in an installation (Verwundetennest) located very far forward. The measures employed were limited to dressing the wound; the application of transportation splinting, traction splinting, or pressure bandages; and the application of tourniquets. Care at this level corresponded to the care given U.S. Army casualties on the battlefield by company aidmen.

    2. The wounded were then evacuated to an installation (Truppenverbandplatz) which corresponded to the U.S. battalion aid station. All care at this level, as in the similar U.S. battalion aid station, was directed to preparing the casualty for evacuation farther to the rear.

      A medical officer who corresponded to the U.S. Army battalion surgeon carried out much the same functions as his U.S. counterpart. The dressing over the wound was checked, but it was not disturbed unless there was some indication for the interference. An occlusive dressing was applied to an open chest wound. Tracheotomy was performed if necessary. Hemorrhage was arrested by pressure bandages, the application of a tourniquet, or, less often, by hemostat or ligature. If he required it, the patient was catheterized. Pain was relieved by standard methods. Shock therapy (physiologic salt solution, external heat by electric heaters, 
Periston, or Nikethamide (Coramine)) was instituted.

    3. The wounded were next evacuated to an installation (Hauptverbandplatz) set up by the sanitäts company of the division about 4 miles behind the frontline. It was staffed to perform functions similar to those of a U.S. Army clearing station, but it also was equipped to hospitalize patients (fig.78). It could care for 200 routinely, and in times of stress the bed capacity could be expanded to care for from 300 to 400 casualties. The table of organization

38 Brig. Gen. Prof. H. Burkhe de la Camp, M.D., Advisory Surgeon to the Officer in charge of the Medical Service of the Army of the Southwest. Subject: Report of experience gained during the entire work of the Medical Service from 1939 to 1945. Reference: Oral order issued by the Officer in Charge of the Medical Service of the Army of the Southwest to prepare a report on the experience acquired, for submission to the American Occupation Authorities. Merano, June 1945.


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FIGURE 78. - Captured German hospital and equipment. A. Complete German field hospital captured with all its equipment and personnel, April 1945. The trucks are driven by Germans and German nurses and medics are riding in them. B. Ambulances captured with the 334th German Hospital in the Florence area, April 1945.


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provided for two operating surgeons, but, when a push was on, six or eight additional surgeons might be attached.

    Primary surgery was performed on minor wounds at this installation. When the flow of casualties was light, those with abdominal wounds and other injuries which made them nontransportable also received initial wound surgery here. Casualties with craniocerebral injuries, chest wounds, and major compound fractures were evacuated farther to the rear. According to the German medical field manual, the functions of the Hauptverbandplatz included tracheotomy; closure of open chest wounds; aspiration of the pericardium in cardiac tamponade; emergency amputations; definitive arrest of hemorrhage; suprapubic cystostomy; surgery on nontransportable casualties; and administration of blood and blood substitutes.

    At the beginning of the war, all army divisions had two sanitäts companies. At the end, only armored divisions and mountain divisions had two companies, though each corps surgeon had one under his control to use at his discretion. When two sanitäts companies were available to each division, two Hauptverbandplatzen were often set up.

    At the beginning of an offensive, a horsedrawn sanitäts company was placed 3 or 4 kilometers behind the line, ready to receive casualties. The other company, which was motorized, was held in reserve, to be used after substantial gains had been made. If the gains were extensive and the Hauptverbandplatz was required farther forward, the motorized company moved forward, leaving its patients to be taken over by the horsedrawn unit, which left its patients, in turn, to be taken over by a Feldlazarett.

    4. Next in the chain of evacuation was a unit (Feldlazarett), corresponding, in general, to a U.S. Army evacuation hospital (fig. 79). It was designed to care for 200 patients, and its table of organization provided for only 2 operating surgeons. In times of stress, however, the intrinsic staff was augmented by surgeons from other units.

    Ordinarily, the Feldlazarett provided primary surgery for head wounds, transportable chest wounds, severe muscle wounds, wounds of the buttocks, and major compound fractures. When the Hauptverbandplatz was rushed, patients with abdominal injuries were evacuated for care here, though the preference was to care for them farther forward.

    As this description has indicated, there were often two divisional units performing surgery ahead of the most forward field hospital. When, however, a major offensive had been launched, division, army, and army group hospitals might all perform primary surgery only on the less seriously wounded, casualties with intra-abdominal and intracranial wounds being put aside in favor of those more likely to survive and to be returned to full duty. Generally speaking, the German Army system of medical care was extremely flexible, but its flexibility tended to favor the lightly wounded at the expense of the seriously wounded, the group which U.S. Army medical officers considered first priority patients.


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FIGURE 79. - Feldhazarett. In the German medical service, this installation corresponded to a U.S. evacuation hospital.

    5. General hospitals (Kriegslazaretten) were usually assigned to an army group. In Italy, most of these installations were grouped at Merano and Cortina d'Ampezzo.
    The major function of these hospitals was to care for patients who had been operated on at more forward units and who could not be returned to duty. In addition, certain casualties received primary surgery here, including those with penetrating head wounds complicated by involvement of the eyes or ears and those with maxillofacial wounds. In very busy times, such as occurred during the frequent offensives launched by both sides, all patients requiring major surgery might be evacuated to these general hospitals for it, the units farther forward being engaged in caring for men who could return to their units within a reasonable time after operation. It was not at all unusual at such times for patients with abdominal injuries, head injuries, and other serious wounds to receive no surgery at all.

   6. In addition to these units, other medical installations cared for casualties with slight wounds and illnesses and for convalescents, as follows:

    In each German division was an ersatz company which served as a replacement depot and reconditioning unit for lightly wounded casualties who had


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received primary surgery in the Hauptverbandplatz. Patients were ordinarily held here for a week. During this time, a medical officer directed their reconditioning, which was chiefly accomplished by exercises. There were usually between 50 and 100 of these patients in an ersatz company at a single time. The staff usually consisted of medical officers who had been injured or who were on limited service for some other reason.

    Hospitals for patients with slight injuries and mild illnesses were established in army areas and general hospital centers by elements of transport units (Krankentransportabteilungen). These units received their patients from the Feldlazaretten in the army area or from the Kriegslazaretten in the army group area or hospital centers. Most patients remained 2 or 3 weeks.

    7. The German Army medical service had no auxiliary surgical groups. The army surgeon used personnel from reserve units or less active units to augment the staff of busy units.

    Administration. - For control purposes, medical units of 100 beds were incorporated into larger units, and these units into still larger units. Hospitals found better staffed and equipped than others were invariably those designated to treat elite casualties, such as Luftwaffe and SS troops.

CONSULTANT SYSTEM

    Each army group had two consulting surgeons and one consulting physician. Each army had the same number. The army group also had consultants in ophthalmology, otology, and psychiatry. Their surgical assistants were physicians who had had 3 or 4 years of surgical training after graduation from medical school.

    Consultants were selected from medical schools or civilian clinics. If they had served 6 weeks in the army before the outbreak of the war, they had the rank of major; otherwise, they entered as lieutenants. Promotions were granted to officers with the civilian rank of professor, regardless of their primary grade, after they had served half the usual time requirement. A major thus became a lieutenant colonel after 18 months and a lieutenant colonel a full colonel after 3 years.

    The duties of the German consultants were in general much the same as those of consultants in surgery in the U.S. Army. There was, however, one exception. When a consultant visited a hospital, he took along his assistant and a noncommissioned officer, together with a full set of instruments, because he was frequently called upon to operate, or decided for himself to operate, in special cases. The relative paucity of skilled surgeons in the German Army made the operating function of the consultant extremely important; many hospitals had no surgeons on their staffs capable of performing difficult major surgery.


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INSPECTIONS OF GERMAN HOSPITALS

    During the first week of May 1945, Colonel Snyder visited a number of German hospitals in all echelons of medical care, making notes on the administrative aspects of these installations and examining numerous casualties.  Some of these patients had had primary surgery within the past 48 hours to 21 days, but others had been wounded a year or more earlier.

    All along the roads traversed in reaching these hospitals, rail lines, railroad bridges, and other rail installations were largely demolished because of the excellent work of the U.S. Army Air Forces on the Brenner Pass and its approaches. Bombing damage was practically always confined to the areas near these targets, and transportation along the roads had therefore not been interfered with. Numerous groups of German soldiers were observed marching along the highway to the rear, without guards, although they were still armed. Convoys of troops, also without guards, were also proceeding to the rear. They were all orderly and well-behaved, and the absence of guards apparently did not move them to attempt to escape.

    The following notes on special hospitals are representative of the conditions found in all of the hospitals inspected:

    A Luftwaffe hospital, set up at Villa d'Este at Cernobbio on Lake Como, was operated chiefly as an orthopedic surgery center. The Germans had added a magnificent operating room to this luxury hotel, and the equipment was excellent. A small prosthetic shop was operated by three mechanics, and the patients for whom prostheses were being prepared were serving as their assistants. All parts, including metal joints, were made from raw materials in the shop. Some prostheses were constructed of wood and others of a plastic material which could be softened with acetone for molding and fitting.

    The surgical standards in this hospital seemed much higher than in many others inspected. Even so, the U.S. medical officer who had been attached to it to check on the professional work done by the German staff reported that the aseptic technique here, as in most other hospitals, was far from optimum. Surgeons did not wear masks, even when performing elective major abdominal surgery or orthopedic surgery, and the incidence of wound infection was high.

    At Feltre, the hospital staff consisted of 11 medical officers, 2 medical administrative officers, 1 dentist, and 5 chaplains. When this hospital was inspected on 5 May 1944, it had only 295 patients; 84 had been evacuated within the previous 24 hours.

    At Feldlazarett No. 200, at Primeiro, there were 3 medical officers and 80 patients. At this hospital, as at the hospital at Feltre, the surgery was of poor quality.

    At a group of three other hospitals visited the same day, the bed capacity was 1,200, and there were 860 patients. Each hospital occupied three or four hotels; one of the installations was entirely for paratroopers and another for Luftwaffe patients. The surgery in these hospitals, all of which housed high-


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ranking officers and other special patients, seemed of a higher quality than in some of the hospitals which had been inspected earlier, but wound infection and gas bacillus infections were widely prevalent.

    At this installation, Colonel Snyder was told of a new drug, still secret, which was being used by injection for clostridial myositis. It did not impress him as being as good as penicillin, and, since nothing more has been heard of it, his impression was probably correct.

    The hospital center at Merano consisted of 14 hospitals, each occupying several hotels or other buildings. Near it, on the outskirts of Bolzano, was a hospital for the lightly wounded, with its bed capacity of 3,000 little more than half occupied. It was said that this was an unusually large number of patients for this installation. The staff consisted of 12 medical officers, 3 administrative officers, 200 enlisted men, 44 German nurses, 7 Italian nurses, and 3 Russian and 3 Italian Red Cross Sisters. The commanding officer had plans to discharge 500 of his approximately 1,600 patients within 2 weeks, 600 within 4 weeks, 300 within 2 months, 100 within 3 months, and the remainder within 6 months.

    At the center at Merano, 42 Allied wounded were in process of evacuation under the supervision of Maj. (later Lt. Col.) Claude E. Welch, MC, who had been detailed from temporary duty with the 8th Evacuation Hospital for this purpose. According to the Germans, four of these patients were nontransportable.

    One of this group was a U.S. Thunderbolt pilot, who had been shot down in February 1945 and badly burned. He was still very ill, little more than skin and bones, and the Germans had allowed him to become very anemic. One eye had been enucleated 2 days before Colonel Snyder's visit, because of sepsis, and the cornea of the other was white. The German plan was to give him 200 to 250 cc. of blood by direct transfusion every second day. He was given 4 pints of blood and large doses of penicillin at once and was moved to a U.S. Army hospital 48 hours later.

    The ranking officer among Allied wounded in this center was a British major who had been captured in December 1944 and had undergone a mid thigh amputation. He reported that the food he had received was as good as was available and that his treatment had been generally good, though the Germans were very domineering, particularly to the Italian staff of the hospital. An Italian physician had worked in the hospital along with German medical officers, in preference to being sent to a concentration camp, and this patient reported that he had been extremely kind to all the Allied prisoners.

GENERAL CLINICAL CONSIDERATIONS

    The outstanding impression gained from a survey of these and other German hospitals in Italy was that infection was many times more frequent than in U.S. Army hospitals. The generally pale and anemic appearance of the patients was in contrast to the healthy appearance of most patients in


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U.S. Army hospitals. Clinical practices in the German Army medical service explained these observations. Blood was used in little more than homeopathic amounts, and an almost complete lack of aseptic technique accounted for the prevalence of wound infection, the extent of which was almost incomprehensible in the year 1945, regardless of military circumstances.

    Colonel Lichtenstein, who subtitled his report to the Fifth U.S. Army surgeon "The Story of a Finger," described the ward rounds and other activities of a German surgeon substantially as follows:

    He examined clinical records, X-ray films, and soiled bandages. He determined the patient's state of hydration by running his finger across his tongue. He then readjusted several mechanical supports. He shook hands with the superintendent of the hospital and other visitors on the ward. With his assistants, he examined draining extremity wounds without gloves or a mask, using the same instruments throughout and proceeding from one case to another without washing his hands. In fact, he did not wash his hands during the entire morning. Conversation over open wounds was completely uninhibited. The American observer noted that he himself did not offer to shake hands with him when the so-called rounds were over.

    Under these conditions, which were of the same order though perhaps somewhat less extreme in most of the hospitals inspected, infection was practically inevitable, and interviews with many German surgeons indicated that they had come to regard it as such. A German consultant who had seen service in World War I, as well as on the Russian front in World War II, stated that infection was just as much a problem in World War II as in World War I.

    Shock and hemorrhage. - German wounded received in shock were treated by external heat, stimulants, Periston when it was available, and direct blood transfusions.

    The Germans regarded Periston as an excellent substitute for plasma and of such high osmotic properties that it was retained in the blood stream for 12 or 14 hours. It was furnished in 500-cc. units, and the dosage did not exceed 2 units.39 Supplies, however, were limited, and it was not available in all German medical installations, even in units in the division area, which had prior claims on it.

    All blood transfusions were done by the direct technique, in amounts of 200, 300, 500, or 800 cc. Occasionally, a casualty was given 1,000 cc., but larger amounts were never used, and most of the German surgeons questioned were opposed to giving more than 200 to 300 cc. of blood at any one time. As already noted, the extreme pallor of many patients seen in German hospitals, and the moderate pallor of most of them, supported the surgeon's statement that blood was used only in small quantities and in selected patients.

39 Periston has never been popular in the United States and was regarded in 1958 as a poor plasma substitute. It has been determined that it is not all excreted, a certain amount being deposited in some of the organs of the body. U.S. medical officers were in agreement with German medical officers that a maximum dosage of 1,000 cc. should never be exceeded.


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    At the best, it seemed that a German casualty, no matter how serious his wound or how deep his shock, would not ever receive more than 1,000 cc. of Periston and 1,000 cc. of blood. If the pulse did not return in a patient with an abdominal or other serious wound in response to this type of resuscitation, he was simply not operated on. The impression was gained that satisfactory restoration of the pulse volume was the criterion of successful resuscitation and that, surgery was seldom performed if this was not achieved.

    This method of treating shock and loss of blood was in sharp contrast to U.S. Army methods. In the U.S. Army, plasma was available in all forward medical units in the division and was used in large enough quantities to make casualties transportable to field hospitals, in which banked blood was available. By the end of the war, U.S. battle casualties in the Mediterranean theater were receiving an average of 1 pint of blood each. Furthermore, casualties who did not respond promptly to vigorous shock therapy were operated on immediately and thus given their chance of life. This bold policy saved many lives.

REGIONAL INJURIES

    Head injuries. - Most of the German casualties with intracranial wounds who were observed at the hospitals visited in May 1945 needed additional surgery. At the hospital center at Gardone Riviera, which Colonel Campbell surveyed on 6 May 1945, there were 40 patients with head injuries, 30 of whom needed further surgery. About a dozen patients with wounds of the spinal cord were examined, about the same proportion of whom needed operation. At this hospital, a general surgeon was in charge of neurosurgery. Maj. (later Lt. Col.) Henry L. Hoffman, MC, was assigned to it as professional supervisor.

    Chest wounds. - Most of the patients with chest wounds observed in German hospitals had been wounded weeks and months earlier. About 60 percent of them had empyema. Colonel Snyder was informed that empyema could be expected to develop in about this proportion of shell-fragment wounds and that it could also be expected in about 30 percent of all bullet wounds. In the U.S. Army in World War II, empyema came to be a very uncommon complication.

    Opinions expressed by German surgeons concerning the management of chest injuries varied widely in details but were fairly unanimous in respect to most principles. It was agreed that shock of some degree was present in most chest wounds and that its management must take precedence over management of the wound unless there was a wide open pneumothorax or a severe and menacing hemorrhage. When there was serious internal bleeding, or an increasing hemothorax, the patient needed constant attention; otherwise, shock might pass on to collapse, and the patient would bleed to death. When a large number of wounded men were received at the same time and the surgeons were busy in the operating room, a junior officer or intern or whoever else was available was employed to make so-called collapse examinations, to make certain that a failing circulation and serious bleeding would be reported before they became irreversible.


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    No surgery was done in perforating chest wounds unless there were indriven rib fragments. The policy of early, repeated aspiration in hemothorax, which was routine in U.S. Army hospitals, was not employed in German hospitals, and there seemed no general policy for the management of this complication. Some surgeons stated that aspiration was never employed unless it became necessary to relieve dyspnea associated with a large hemothorax or hemopneumothorax. Others said that aspiration was performed within the first 5 days after wounding. One consulting surgeon said that this had been the practice early in the war unless respiratory difficulties required interference earlier but that it had recently become the practice to perform aspiration as soon as the casualty had reacted from shock, usually within 48 hours after wounding.

    The treatment of empyema seemed rather more uniform. Closed intercostal (Bülau) drainage was instituted as soon as infection or pus was evident. The catheter was attached to a water-seal bottle, which was usually converted into a Wangensteen-like suction apparatus by the use of two additional bottles. Drainage was continued until the cavity was obliterated. If this had not occurred at the end of 6 months, the empyema was considered to have become chronic, and thoracoplasty and decortication were employed by the modified Schede's technique. Rib resection was seldom employed.

    No facilities were provided for gas anesthesia or for positive pressure delivered by an anesthetic machine. A good machine was available for oxygen therapy, but it was apparently seldom or never used for expanding the lungs during intrathoracic surgery. Endotracheal tubes were not observed in any hospital, and no chest surgeon or anesthesiologist mentioned this technique. Most chest surgery was performed under open-drop ether anesthesia or local analgesia supplemented by Pentothal sodium given intravenously.

    Thoracoabdominal wounds. - Only a small number of patients were observed with thoracoabdominal wounds. None was extensive, and, in all instances, surgery had consisted of laparotomy and simple closure of the wound in the chest wall. No patients were seen who had been treated by the transdiaphragmatic surgery which was regarded so favorably by U.S. Army chest surgeons. When inquiries were made about this technique, the replies were rather vague. One surgeon stated that the thoracic approach might be used if the chest wound was large and the intra-abdominal wound small.

    In the absence of facilities for positive pressure at operation, and without well-trained anesthesiologists experienced in anesthesia for chest surgery, it was concluded that the German wounded could not have had the advantages of modern intrathoracic and transdiaphragmatic techniques.

    Abdominal wounds. - Only a small number of patients with abdominal injuries were found in the German hospitals which were captured and in those which fell into U.S. Army hands when the mass surrender occurred. This is not surprising if one considers the tactical situation during the preceding weeks and the German policy of care of casualties. which favored the less seriously


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wounded. It seems doubtful, in the confusion of the final weeks of fighting and the heavy casualties associated with the crushing German defeat in the last push, that many casualties with abdominal injuries were fortunate enough to undergo any surgery at all. In the combined hospitals at Merano, in which 6,917 casualties had been collected by 6 June 1945, there were only 264 patients with abdominal, thoracoabdominal, or combined thoracic and abdominal wounds, and 112 of these were listed as superficial wounds.

    Only two patients who had undergone abdominal surgery were observed by Colonel Snyder, both of them in the same installation. One of them had had a negative exploration and had developed a huge incisional hernia. The other was making a satisfactory recovery after surgery on the small intestine.

    It was evident, in spite of these observations, that the Germans were impressed with the advantages of early surgery in forward installations for intra-abdominal wounds. The army manual of surgery recommended it, and German surgeons stressed it in interviews held with them.

    One surgeon described a Hauptverbandplatz on the Russian front in which 37 operations for abdominal injuries had been performed over a 2-month period. There were eight deaths. The timelag was usually 2 hours; when it rose to 6 or 8 hours, results were less good. This hospital was located close to the frontline, which was well stabilized, and the Germans were well dug in. Also, the casualty load was not heavy. Surgery could therefore be performed in the division area on almost all patients; not more than six or seven were evacuated, for various reasons, to the Feldlazarett farther to the rear.

    Even when conditions were favorable, however, it was clear that patients with abdominal injuries who did not respond to shock therapy did not have emergency surgery unless there was reason to believe that shock was produced by intra-abdominal hemorrhage. It was not clear, from the replies to questions, how the distinction was made between shock due to intra-abdominal hemorrhage and shock due to massive peritoneal contamination.

    Techniques of abdominal surgery, when it was employed, seemed much the same as those used in U.S. Army hospitals. Wounds of the liver were drained. Wounds of the stomach and small intestine were repaired unless the wound was so extensive that resection was necessary. Small wounds of the colon were usually repaired, after which proximal cecostomy was usually done. Large wounds of the colon were exteriorized.

    It is doubtful that the Germans, without whole blood in adequate amounts and using only the direct technique of transfusion, could have improved their results in wounds of the abdomen even if they had attempted surgery on these desperately wounded casualties. What U.S. Army surgeons accomplished in this group was due not only to their own skill but also to the skill and superior equipment of their anesthesiologists, the judicious use of banked whole blood, and the use of oxygen and all the other facilities and equipment which the U.S. Army provided to insure the best possible care for every wounded man.


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    Wounds of the extremities. - Most wounds of the extremities were treated primarily in the Hauptverbandplatz or the Feldlazarett. The careful wound excision practiced by U.S. Army surgeons was practically unknown. One German surgeon stated that he had done only five or six such operations during the entire war; he had performed primary wound closure in all of them.

    Many of the patients seen in German hospitals had had little or no excisional surgery. Treatment seemed to have been limited to incision of the skin and fascial planes, excision of devitalized edges of skin wounds, and removal of gross debris and devitalized tissue. Whether the devitalized tissue present in many of the wounds examined had been left in situ or had developed after inadequate debridement it was not possible to say. Unless the wound was large, perforating wounds associated with fractures were often treated without surgery, as were all bullet wounds. As a result of these practices, infection was frequent and extensive, and there was a great deal of gas edema and actual gas gangrene.

    One surgeon described the management of badly damaged heels by excision of the talus, calcaneus, and half the scaphoid and the cuboid. He then put the foot in the drop position in which it was anchored with Steinmann's extension pin. The patients were then fitted with below-the-knee prostheses, which they wore most of the time. He reported good functional results in a quarter or a third of the patients treated by this method; amputation was necessary in the remaining cases.

    Wounds of the joints. - Perforating joint wounds from small arms or high explosive shell fragments were frequently treated without surgery unless there was a large wound of exit. When infection developed in knee joints in which fractures had occurred into the joint, drainage was sometimes tried tentatively, but more often resection was resorted to at once. Resection of the elbow, wrist, and shoulder joints was also sometimes done to control infection. Most patients observed in German hospitals after joint resections were still septic. Infected wounds and resected joints were often treated with irrigations of Dakin's solution.

    Splinting and traction. - Compound fractures of the femur were put up in skeletal traction, with Kirschner wires, whether they were treated in field or general hospitals. When infection developed, the limb was incorporated in plaster, but some traction was usually continued. In fractures of the head of the femur caused by shell fragments, the femoral neck and head were usually resected at initial wound surgery.

    Techniques of splinting varied. In some simple fractures of the femur, unpadded walking plaster spicas were used after the method of Böhher. Similar spicas were used in some compound fractures after the soft-tissue wounds had healed. These walking spicas were not used in the early management of fresh compound fractures from bullet or shell fragments as Trueta had used them in the Spanish Civil war.


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    Some surgeons favored the use of wooden or wire ladder splints for several days after operation; then plaster casts, which were always padded, were applied. Other surgeons used plaster immediately after operation. Windows were cut into the cast to provide for dressing the wound and for the management of infection, the anticipation of which seemed to be routine.

    An ingenious apparatus made of perforated metal pipes served as an excellent substitute for the Balkan frame. It was capable of many combinations, since the pulley wheels could be adjusted to the desired position for any sort of traction. Sometimes a complete Balkan frame was constructed from these pipes, but more often a single pipe clamped to the metal hospital or hotel bed was used to support sidearms which provided the necessary number of pulley wheels in the desired position.

    In the hospital at Cernobbio, Colonel Snyder encountered two German surgeons who had been using the nail devised by Küntscher for the management of fractures of the femur and other long bones. One of them, the chief of surgery at the hospital, had participated in the original work at the University of Kiel in 1937. He had the records of 550 clinical cases in which this method had been used and in many of which he had done the operation. There were no fatalities in this group, but there were some instances of fat embolism. The original experimental work on animals carried out at various periods after nailing showed that about a third of the bone marrow is destroyed when the nail is inserted and that small fat emboli are nearly always dislodged.

    The German Army had prepared a booklet describing in detail the technique and the indications for this method of fixation. In fractures of the femur, a straight, rigid nail was used; it was driven down through the trochanter and into the distal fragment under fluoroscopic control. The nails used for the other bones were flexible and slightly curved.

    The surgeons interviewed at Cernobbio stated that for a time many surgeons had attempted to use the Küntscher nail, with disastrous results. Osteomyelitis had developed, and there were some deaths from shock. After the original wave of enthusiasm had thus been quenched, a few qualified surgeons were designated to use the technique when they considered it indicated. In the opinion of the surgeon who had worked with Küntscher, the intramedullary nail should be used only on strictly limited indications, chiefly in closed fractures of the middle third of the femur, in which the fracture line was transverse or almost transverse. These patients could walk without additional splinting in from 8 to 10 days after nailing. Küntscher's former associate did not consider the nail indicated in fractures of the tibia, humerus, radius, or ulna, though he did use it in compound fractures of the femoral shaft after wound healing or when healing was occurring without infection.

    The other surgeon at Cernobbio had used the technique in a few infected compound fractures of the femur and the humerus when the desirability of fixation seemed to outweigh the risks of introducing a nail in the presence of infection.