THE GERMAN MEDICAL ESTABLISHMENT *
The first limitations imposed on any account purporting to assess the German medical establishment are time and place. That is to say, observers no matter how qualified cannot judge the standards of German medical practice in 1939, for instance, in the light of what they found to exist in May 1945, after the total enemy collapse; nor can they judge the quality of practice elsewhere in Europe in the light of what they found in Italy. Immediately following the Allied victory in Italy, the Fifth Army Surgeon directed several qualified officers to tour the German medical installations, and survey as completely as they could the techniques and facilities utilized by the German medical service. These officers were: Col Hugh R. Gilmore, Jr., MC, Chief of Preventive Medicine, Fifth Army; Col Howard E. Snyder, MC, Surgical Consultant, Fifth Army; Col Eldridge Campbell, MC, Acting Neurosurgical Consultant, MTOUSA; Lt Col Paul Sanger, MC, Chief of Surgical Service, 38th Evacuation Hospital; Lt Col Manuel E. Lichtenstein, MC, Chief of Surgical Service, 16th Evacuation Hospital; Lt Col Douglas Donald, MC, Medical Consultant, Fifth Army; LtCol Marcel H. Mial, SnC, Medical Supply Officer, Fifth Army; and Captain Carroll H. Ward, MAC, Assistant Medical Supply Officer, Fifth Army. From their reports to the Army Surgeon, most of the material in this chapter is derived.
This, then, was the German medical establishment as it existed in Italy just after the German collapse. How it existed in, say, Russia in 1942, cannot be assumed from the material set down here. Nor can the various social, or political, or economic factors which doubtless affected all German medical practice, including the military, under National Socialism, be truly or fully evaluated. For while many of the German medical officers interviewed volunteered opinions concerning the effect of political or racial discrimination on sound medical practice in Germany, and those opinions will be set down here, it must be remembered that such opinions are hardly objective: after the German collapse all elements of the German army were busy negating their part in the Nazi regime, forswearing their allegiance to the Nazi party, and condemning such fanatical groups as the loyal party members, the Gestapo and the SS formations of the Wehrmacht. In other words, if saying "the German medical service was degraded by National
* Reproduced from the Annual Rpt of the Surg, Fifth U.S. Army, MTO, 1945, pp. 191-209.
Socialism" would indicate that a German doctor was not a Nazi, he would not hesitate for a moment to say just that.
With these limitations in mind, it is safe to view the German medical establishment in Italy after the military defeat of May 1945, as seen through the eyes of qualified American observers.
2. HOSPITALIZATION AND EVACUATION
The chain of evacuation of German wounded was found to be very similar to that utilized by the US Army, but triage, that is sorting of patients for specialized hospitalization, differed in several important aspects. First aid to the wounded was rendered in a Verwun detennest by a medical non-commissioned officer, in an extreme forward position. This treatment can be said to compare in echelon to that given by a US company aid man on the field of battle. Here the first dressing, improvised splinting for transportation ease, traction splinting, pressure bandages and tourniquets were applied. The wounded were evacuated from the Verwundetennest to the Truppenverbandplatz, which corresponded to the American battalion aid station, and where the first medical officer, corresponding to the US battalion surgeon, practiced. Treatment given at this station included: checking of the dressing (unless there was some indication the dressing was not to be disturbed) ; tracheotomy; application of occlusive dressings to open chest wounds; relief of pain; preparation for further evacuation to the rear; shock therapy in the forms of peristone, physiological salt solution, coramine, and external heat by electric heaters; prevention of infection, by injection of tetanus antitoxin and gas gangrene antitoxin, administration of sulfapyridine by mouth, insufflation of sulfanilamide powder into wound at time of first dressing, pressure bandage, and arrest of hemorrhage by application of tourniquet (rarely by hemostat or ligature);and catheterization.
From the Truppenverbandplatzall the wounded were evacuated to the Hauptverbandplatz, which was established about four miles to the rear of the combat line by the Sanitaets Kompanie of the division. This unit was staffed to perform the functions of both clearing and hospitalization. Its Tables of Organization provided for two operating surgeons, but in times of stress six or eight more surgeons might be added. The unit was designed to hospitalize two hundred patients, but often expanded to three or four hundred. When the flow of casualties was not heavy, all those patients with abdominal wounds and other non-transportable cases were given primary surgery at this installation. In addition, primary surgery was performed on minor wound cases here as well. All cases with major compound fractures, brain wounds, and chest wounds were evacuated to the Feldlazarett or to a Kriegslazarett, where they were treated with more definitive care. In the German medical field manuals the functions of a Hauptverbandplatz are listed as: tracheotomy; closure of open chest wounds; aspiration of the
pericardium in cardiac tamponade; emergency amputations; final arrest of hemorrhage; administration of blood and blood substitutes; surgery on the non-transportables; and suprapubiccystostomy.
The Feldlazarettwas the next unit in the chain of evacuation. It was an Army unit designed to care for two hundred patients. Ordinarily patients with head wounds and transportable chest wounds, severe muscle wounds, buttock wounds, and major compound fractures received primary surgery in the Feldlazarett. While it was attempted to perform intra-abdominal surgery as far forward as possible, such cases were often evacuated to the Feldlazarett for surgery whenever the Hauptverbandplatz was too busy. The Feldlazarett was staffed with only two surgeons, but in periods of pressure, it was often augmented by surgeons from other units.
The Kriegslazarett, or General Hospital, was usually assigned to the German Army Group. In Italy most of these installations were grouped at Merano and Cortina d`Ampezzo. It was their function to hospitalize all patients who were not returned to duty from the more forward units. In addition, certain groups of the wounded received primary surgery at the Kriegslazarett, such as penetrating head wounds complicated by involvement of the eye or ear, and maxillofacial wounds. In very busy periods, all patients with major wounds might be evacuated to the Kriegslazarett for surgery while the more forward units confined their surgery to men with wounds of such a nature that they would be able to return to their units and full duty within reasonable short periods of time after surgery. Also, as frequently occurred during heavy attack periods, abdominal and head wound cases were given no surgical care.
In addition to those units already mentioned, there were hospitals for the lightly sick, lightly wounded, and convalescent patients. In each German division was the Ersatz company which served as a replacement depot and reconditioning unit for lightly wounded who had received primary surgery at the Hauptverbandplatz. The wounded sent to this Ersatz company were given light exercise under the direction of a doctor, and were ordinarily returned to duty after one week. There were usually between fifty and one hundred lightly wounded in the Ersatz company, in addition to the replacements sent from Germany, who only stayed long enough to be equipped before being sent into combat. The officers and the doctor of the Ersatz company were limited service personnel by nature of previous wounds or illness.
In the army areas and in the general hospital centers, hospitals for the lightly sick and wounded were established by elements of transport units (Kranken transportabteilungen).They received their patients from Feldlazaretten in the Army area and from Kriegslazaretten in the Army Group area or hospital centers. Most patients sent to these particular hospitals stayed for two or three weeks. One such hospital was located at Bolzano not far from the hospital center at Merano. At the time this hospital was
visited on 6 May 1945 there were 1600 patients. The commanding officer reported that 500 would be able to return to duty in two weeks, 600 in one month, 300 in two months, 100 in three months and the remaining 100 in six months.
At the beginning of the war in Europe, all divisions had two Sanitaets Kompanies. At the end only the armored and mountain divisions had two each, but the Corps Surgeon had under his control one Sanitaets Kompanie for use where needed.When two Sanitaets Kompanies were available, two Hauptverbandplatzen were often established. In the beginning of an offensive, one Sanitaets Kompanie, horse-drawn, was placed only three or four kilometers behind the battle line to receive casualties. The other Kompanie, motorized, was held in reserve to be used after substantial gains had been made. Then, if further gains were made and the Hauptverbandplatz was required farther forward, the motorized Kompanie moved, leaving its patients to be taken over by the animal-drawn Kompanie. The patients of the animal-drawn Kompanie were left to be taken over by a Feldlazarett. Thus there were often two divisional units performing surgery ahead of the Army`s most forward Feldlazarett. With a large-scale offensive division, army, and army group hospitals might all perform primary surgery only on the less seriously wounded, putting aside the intra-abdominal and intra-cranial wounds in favor of those who were more likely to live and return to full duty.
There were no Auxiliary Surgical Groups, but the German Army Surgeon learned to use personnel from reserve or less active units to augment the staffs of heavily-pressed units. Most American observers felt that the German system of hospitalization and evacuation was certainly extremely flexible, but its very flexibility tended to favor the lightly wounded at the expense, and often the expense of death, of the more seriously wounded, the group which US surgical practice terms "first priority" wounded.
3. THE SURGICAL SERVICE
Infection of wounds was found by one observer to be the most incomprehensible facet of the German surgical service. He subtitled his report to the Army Surgeon "The Story of a Finger", to illustrate the status of asepsis, antisepsis, wound contamination, and cross infection. In one hospital visited, the German surgeon made "rounds" looking at patients, examining clinical records and viewing X-ray films. Extremities with soiled bandages were examined and bandages were handled without gloves. The surgeon made readjustments of mechanical supports and traction apparatus. Some wounds were exposed in the wards and examined. At one bed inquiry was made concerning the hydration and nutrition of the patient. The condition of the tongue was noted and its wetness was determined by the unwashed finger of the surgeon stroked across the tongue surface. This finger
was wiped on the surgeons coat and the remark was made that the moisture on the finger indicated that the patient was not too dry. During the course of "rounds" the chief of the hospital entered the ward, and was first greeted in military fashion by the surgeon, and then by a handshake. Several cases were selected for further examination in the septic dressing room. This dressing room had three tables, each occupied by a patient with large wounds from which all dressings were removed. In this room no one wore a mask over the nose and mouth. Conversations were conducted over each wound and traffic through the doors, closing and opening, was active. A staircase just off the dressing room was being dry-swept and clouds of dust filled the hallway and the entrance to the dressing room.
The surgeon soon proceeded to examine one of the wounded men, and without washing his hands or donning gloves, he felt of the extremity from which the pus-soaked bandages were recently removed. After dressing the wound, the surgeon placed the used instruments on a tabletop, and proceeded to the next case without washing his hands. The American observer left the dressing room without shaking hands with the German surgeon. In later discussing the matter of infected wounds with a German medical officer, the observer learned that the Germans assumed automatically that all penetrating wounds received in combat would become infected, and that pus was anticipated. Perforating wounds were rarely disturbed, but instead were simply covered with dressings. The German medical officer claimed that most perforating wounds did exceedingly well except that occasionally an aneurysm developed which required treatment. All wounds due to penetrating missiles, shell or bomb fragments, became infected and healed by granulation following infection.
When the US observer discussed the problem of infected wounds with another German medical officer, it was brought out that primary surgery done immediately was most essential. Lacking this, wounds became infected and the following reasons were given for lack of immediate care:
(1) Inadequate medical personnel were available to the German medical service. Many medical men were driven out of Germany during a seven-year period from 1933 to 1939, for reasons unrelated to their medical practice. Medical schools were depleted of teaching personnel and the number of graduating physicians gradually diminished. Early in the Russian Campaign, many medical men, acting as company officers, took up positions with the infantry in the front lines. `The gradually increasing number of patients requiring surgical care increased the number of patients for each medical officer. As a result, this disproportion was equivalent to a decrease in medical personnel.
(2) Large numbers of battle casualties admitted to field hospitals in short periods of time made adequate surgery impossible. One German surgeon interviewed pointed out that when acting as a surgeon in the city of Naples in September 1943,it was not unusual for him to care for fresh
wounds by complete excision and primary suture. The infection rate was approximately 4% in these fresh cases and approached favorably the infection rate to which he was accustomed in civilian practice. However, he said, operative procedures which would require an hour had to be done in less than one minute when he was active on the Russian front. In one three-day period in Russia 1,000 battle casualties were admitted to a field hospital whose medical personnel consisted of two doctors, no nurses, and considerable number of enlisted men. To devote more than a few minutes to each case was, he attested, impossible. Aside from an incision for decompression of tissues and application of a dressing, bandages and splint, nothing else could be done. He was aware that these steps would not prevent infection in a wound. Perforating wounds were rarely bothered with; dressings were applied and patients frequently returned to duty.
(3) Speaking again of the Russian Campaigns, in comparison to the closing phases of the Italian Campaign, this German medical officer stated that during the advance on Stalingrad the German Armies progressed at the rate of forty to sixty kilometers a day. Patients could not be kept in any hospital for any length of time. Frequently patients had to be evacuated to the rear without any sort of initial treatment and days were required before the patient arrived at an installation where surgery could be accomplished. During the winter months long trips in the icy cold of Russia made travel hazardous and for many patients, fatal. Not only were patients frozen to death because of inadequate covering but also many arrived in such poor condition that many hours or days were required to resuscitate them so that they could tolerate even a small degree of surgery. On the Italian front travel by day forwounded patients was extremely hazardous because of the narrow roads over mountain passes, and the constant presence of Allied airplanes over German lines of communications. Transportation of the wounded to the rear could be accomplished only at night, and the long trips in the mountains were time-consuming and exhausting to the patients.
(4) Lack of adequate supplies and equipment was also given by this German medical officer as a reason for the deterioration of the Wehrmacht`s medical service. Many patients died from exsanguination because neither blood nor a blood substitute was available at the field hospitals. Many patients with small wounds developed infection because of the precarious condition in which they arrived at the base hospital after a long journey, without proper dressings or immobilization of the wounds. There were no blood banks to furnish blood for the restoration of blood volume. With the decreasing number of medical personnel and the increasing hunger of the Wehrmacht for more manpower the obtaining of blood for transfusions became more and more difficult. Plasma was unobtainable. Penicillin was unknown. Sulfonamides were used but were felt by the Germans to be most useful only in acute infections, and to have no particular value
in the treatment of patients from whose wounds flowed large amounts of purulent material. No new discoveries in chemotherapy had been made, and while patients received large amounts of drugs, ineffectiveness had been noted in patients who had had inadequate wound surgery.
(5) Finally, this medical officer felt that one of the greatest reasons for lack of immediate care was the general deterioration in German medical officers. The mental status of the average medical officer, and his morale, were low for many reasons, each resulting in deteriorating care for patients. Among these factors was the large number of infected wounds, leading doctors to feel that all wounds were automatically infected; the inadequate number of personnel; the lack of care possible because of constant evacuation; the lack of liaison, there being no uniform treatment plan throughout the German medical service; the entrance into the service of young, poorly-trained surgeons, "graduate wonders" who knew little or nothing of the principles of surgery; the class distinction favoring the Luftwaffe, SS and high-ranking officers; and the placement of medical officers in high positions by political rather than professional standards. All of these points weighed heavily on the mind of the conscientious surgeon and succeeded in wearing down professional morale.
This had been a discussion of wound infections, which, according to the German consultant, were just as frequent in this war in the German army as in World War I.As such, it has reported generally most of the negative aspects of German surgery and surgical practice. There are, however, many positive aspects, which somewhat redeem the German practices in the eyes of an American observer. Therefore, a brief description of certain German techniques, such as treatment for shock and hemorrhage, extremity wounds, head wounds, intrathoracic wounds, and abdominal wounds, is felt to be in order here.
Wounds received in shock were treated by the use of external heat, stimulants, infusion of peristone and direct blood transfusion. Peristone had not been available in all German installations. The medical units in the divisional area were given first priority on peristone, but it was frequently not available to them. German medical officers claimed that peristone was a good plasma substitute, and that its osmotic properties were such that it was retained in the vascular system from twelve to fourteen hours. It was furnished in 500 cc. units. Usually one and never more than two units were used in the treatment of one patient. All blood transfusions were accomplished by the direct method. Blood was transfused in amounts of 200 cc, 300 cc, 500 cc, 800 cc, and never more than 1000 cc. Hence the most a patient in shock might receive would be 1,000 cc of peristone and 1,000 cc of blood. The general German belief seemed to be that if the pulse volume did not approach normal, after such treatment no surgery was to be performed. Some German surgeons interviewed were opposed to using more than 200 to 300cc of blood at one time. The extreme
pallor of many and moderate pall or of most of the wounded seen in German hospitals were further evidence that little blood was administered.
This type management of shock and hemorrhage was in sharp contrast to American methods whereby plasma is made available and used in quantities sufficient for the needs in all forward medical units of a division; and whereby banked blood is available in adequate quantities in all army hospitals including field hospitals adjacent to division clearing stations.
The bulk of extremity wounds suffered in the Wehrmacht were given primary surgical treatment in the Hauptverbandplatz or the Feldlazarett. In rush periods this surgery consisted of no more than incision of skin and fascial planes, the removal of gross debris and devitalized tissue, and usually trimming of devitalized edges of the skin wound. The careful wound excision practiced by Allied surgeons was done in German hospitals only in rare instances. One German surgeon reported that he had performed only four or five such operations in as many years of war surgery. In these he had done a primary wound closure. It was evident in many of the patients seen that practically no wound excision had been accomplished, since much devitalized tissue was left behind, and frequently wounds were primarily drained after no more than a fasciotomy. Perforating wounds from small arms missiles or small high explosive shell fragments had no surgery performed. This applied to wounds of joints and wounds involving bone unless there was a large wound of exit. Splinting of extremities after surgery varied. In several hospitals visited, surgeons stated that temporary wooden or wire ladder splints were applied for three to five days, following which treatment the limbs were put in plaster if infection did not develop. Most of the other hospitals reported that plaster was applied immediately after surgery. In either instance, the plaster was always padded and windows were cut over the wounds to permit inspection and dressing.
Compound fractures of the femur were put up in skeletal traction in both field and general hospitals. Kirchner wires were used in applying skeletal traction. When infection developed, the limb was incorporated in plaster, but some traction was usually continued. An ingenious apparatus made of perforated metal pipes served as a substitute for the ordinary Balkan frame. It was capable of many combinations to secure, easily and simply, pulley wheels in the desired position for any sort of traction. In some instances a complete Balkan frame was fashioned. In most cases, however, one pipe, which clamped to the metal hospital bed, sufficed to support sufficient side arms to provide the necessary number of pulley wheels in the proper positions. Walking, unpadded plaster spicas, after the method of Boehler, were used in the management of some of the simple fractures of the femur, and in some compound fractures after the soft tissue wounds had healed. They were not used early in the management of fresh compound fractures from bullet or shell fragment wounds as Truetta used them in the Spanish Civil War. In badly damaged heels, one surgeon was
practising excision of the talus, calcaneus, and one half of the scaphoid and cuboid, then placing the foot in a drop position and anchoring it there with a Steinman pin. He said that one-quarter to one-third of the cases so treated got functional results, but the remainder required amputation. Those getting a "functional result" were fitted with a below the knee prosthesis.
Two surgeons were found who had been using the Kuntscher nail in the treatment of certain fractures of the long bones. It was reported by two surgical consultants that for a time many surgeons attempted the use of this intramedullary nail with poor results, including osteomyelitis and death from shock. Following this experimentation, a few surgeons were designated who might use the method when they thought it indicated. The original work in Germany on this intramedullary nail was done by Kuntscher at the University at Kiel beginning in 1937. It was first tried on animals. Examination of the bones histologically at various periods after nailing led to the conclusion that approximately one-third of the marrow is destroyed and that small fat emboliare nearly always dislodged. One surgeon who participated in the original study at Kiel stated that he had records of 550 cases, not all his own, in which the Kuntscher nail had been used. Fat embolism had occurred in a few of these cases but in no instance did it lead to a fatality. This surgeon felt that its usefulness was chiefly in closed fractures of the middle third of the femur, in which the fracture line was transverse or nearly so. Such patients could walk without any splinting eight to fourteen days after the operation. This surgeon did not feel it an advisable procedure in tibial fractures and rarely used it in fractures of the humerus, radius, or ulna. It could be used in compound transverse fractures of the femoral shaft after the wound had healed or when infection was absent. One surgeon had used it in a few infected compound fractures of the humerus and femur when the desirability of fixation seemed to outweigh the danger of using it in the presence of infection.
In the field of head surgery, only a few intracranial wounds were found in the hospitals visited. One hospital at Merano and one at Gardone Riviera held the largest concentrations of head wounds. Of a sample of forty head cases, at least thirty needed further neurosurgery. There were also approximately twelve with wounds of the spinal cord, a similar proportion of which needed further surgery. Neurosurgical techniques in practice among the German hospitals visited were generally barely adequate, and often under the standards se tin Allied armies.
Nearly all of the patients seen in German hospitals with intrathoracic wounds had empyema. Of course, most of those seen had incurred their wounds months or even as long as two years before. Opinion expressed by German surgeons concerning the management of chest wounds varied in some particulars, but regarding major policies were in unanimity. No
facilities were available for gas anesthesia or for positive pressure delivered by anesthetic machine. A good oxygen therapy machine was available, but according to statements of the Germans, it was seldom if ever used for expanding the lungs during the course of intrathoracic surgery. No endotracheal tubes were seen nor was the use of endotracheal anesthesia mentioned in a hospital. Local, evipan, or ether by open drop was the anesthetic employed in what chest surgery was accomplished. Opinions concerning the indications for and time of aspiration of hemothoraces varied considerably. Some surgeons stated that aspiration was never performed except to relieve dyspnea arising from a large hemothorax or hemopneumothorax. Others stated that it was performed during the first five days after wounding. One consulting surgeon stated that early in the war aspiration was performed after five days unless dyspnea made it mandatory earlier, but that more recently aspiration was performed after the patient reacted from shock, which was usually two days after wounding. It was obvious that the policy of early, repeated aspiration of hemothorax was not practiced as in the Allied armies.
The incidence of empyema was reported at one hospital as 60% in shell fragment wounds of the chest and 30% in bullet wounds of the chest. In another hospital, an incidence of 50% in all intrathoracic wounds was reported. The treatment of empyema seemed uniform in all the hospitals. Closed intercostal drainage was instituted as soon as the presence of pus or infection in the pleura was demonstrated. The catheter was attached to a water seal bottle which in most instances was in turn connected with a pair of bottles providing suction after the Wangenstein method. This procedure was continued until the cavity was obliterated or until after six months the empyema was adjudged chronic and a thoracoplasty and decortication were performed. Rib resection for drainage was rarely employed.
Only a very few patients with thoraco-abdominal wounds were seen. These few had not had extensive wounds and their surgical care had consisted of laparotomy and simple closure of the chest wall wound. No cases were seen in which transdiaphragmatic surgery had been accomplished at thoracotomy. Lacking the facilities for positive pressure ether-oxygen anesthesia and well-trained anesthetists, it seemed obvious that modern intrathoracic and transdiaphragmatic surgery were not available to the German wounded.
Only a few patients with abdominal wounds were found in the German hospitals which were captured or which fell into Allied hands with the collapse of the Wehrmacht. This was not surprising, if the tactical situation of the preceding month was viewed in relation to the German policy concerning the care of the seriously wounded which was outlined in the hospitalization and evacuation section of this chapter. With the confusion and heavy casualty load of their crushing defeat in the German stand against the Allies last push, it was probable that few with abdominal wounds
were fortunate enough to receive any surgical attention. In one hospital two patients were found who had had abdominal surgery. One of these had had a negative exploratory laparotomy and had developed a huge incisional hernia. The other had a wound of the small intestine and was making a satisfactory recovery.
In interviews with German surgeons and in studying their Army manual on surgery, it became apparent that the Germans had been impressed with the advantage of early surgery in forward installations for those casualties with intra-abdominal wounds. General principles in this surgery were found to be quite similar to those in practice among the US Forces. Wounds of the stomach and small intestine were repaired and usually a proximal cecostomy done. Large or severe wounds of the colon were exteriorized. Wounds of the liver were drained. Those who did not respond to shock therapy were not given the benefit of emergency surgery unless it was felt that there was a continuing severe hemorrhage. Lacking whole blood in adequate amounts and using only direct transfusions in amounts never totaling more than 1000 cc, it is probable that the Germans would not have bettered their mortality rate by attempting surgery on the abdominally wounded. What the Fifth Army accomplished in this type surgery was dependent not only on the skill of the surgeons, but as well upon the skill and superior equipment of anesthetists, the judicious use of available banked blood, oxygen and all the other facilities provided to insure the best possible care of every wounded man.
This was the surgical service of the German army as it existed at the conclusion of hostilities in Italy. Its negative aspects, viewed objectively and dispassionately, seemed certainly to outweigh its positive. One of the American observers seemed to express the unanimous opinion of all when he stated: "My reaction to this visit is not one of condemnation for the type of surgery and surgical care that the German soldier receives from medical officers in German installations. Rather it is one of high praise for the excellence of the American medical service. . . . To see and discuss the German wounded offers the contrast by which to bring into better view what has actually been accomplished in our own medical service."
4. PREVENTIVE MEDICINE AND MEDICAL CARE
Militarily, preventive medicine is far more important to the combat effectiveness of any command, Allied or German, than the surgical or medical services. To the German Army, surgically understaffed and underequipped, and seemingly with a lower moral conception of the medical mission than our own, a seriously wounded man who could not fight again, even if his life were saved, was not worth bothering with, or expending precious time and supplies upon. But if, by means of preventive medicine, even one man could be spared an infectious disease which would incapacitate
him for only three days, then preventive medicine was the field upon which the harshly realistic Wehrmacht would concentrate its efforts. This helps to explain why preventive medicine was under rigid military control in the German Army, and at the same time why German standards of preventive medicine, considering the equipment available for their enforcement, compared more favorably with preventive medicine as instituted in the United States Army than did German surgical standards with our own.
Mess sanitation in the Wehrmacht was limited by the type of mess served. Food was prepared in mobile ranges, and generally consisted of a stew, bread, tea or coffee. No attempt was made to screen field kitchens, but if troops were situated in buildings and screening was available, the kitchen was screened. However, one directive published by German headquarters in 1945 prohibited the use of screening except for buildings in malarious areas. There was no system of mess kit washing similar to that practised in the US Army. Usually the German soldier washed his mess kit in a stream, or at a well or cold water tap. Sometimes hot water was supplied from the field ranges, or occasionally it was heated in a bucket or can over a wood fire, but such procedures were the exception. Provisions for hot water depended on the interest insanitation evidenced by the company commander, which ordinarily was slight. No soap was issued for mess gear washing, and the allowance of soap for bathing and washing clothing was so small that very few soldiers ever used part of their soap ration for washing mess kits. Instead sand or gravel was used to remove the grease from the mess kits. Soap and washing soda were available for use in the kitchens, in small amounts.
Bread was transported without any protective covering from the field bakeries to unit messes. Fruits and vegetables to be eaten uncooked were washed first in raw water and then in boiled water. In areas where amoebic dysentery was prevalent, directives were issued ordering fruits and vegetables to be soaked in a 1-5000 solution of potassium permanganate; in practice, however, this procedure was reported to be seldom followed. Chlorine washing of fruits and vegetables was unheard of in the German Army in Italy. Garbage was usually disposed of to civilians. In the last months of the campaign, many units kept hogs to which they fed food scraps. Some garbage was burned. Directives were issued requiring soakage pits for waste water, but in actuality these pits were seldom constructed. Since there were no mess kit washing facilities, German kitchens had less waste water than normally found in US kitchens. German food handlers were inspected weekly and stool examinations were conducted four times a year. Consumption of raw milk or cheese made from raw milk was forbidden.
In rear areas, the Germans used box-type latrines similar to US box latrines. A squat-type latrine with lid was also used frequently. In forward areas, straddle trenches were dug, or each man was required to cover his own excrement by digging a small hole with a spade, similar to US "cat-
holes". Latrine pits were treated with lime, never with oil of any sort. There was never a sufficient supply of pyrethreum spray for use in latrines.
Provisions for water supply in the German Army were grossly inadequate. In forward areas, the German soldier was given boiled tea or coffee rather than water; he had no "GI" drinking water whatsoever. The supply of tea and coffee depended on the tactical situation. If kitchens were far enough forward, the supply was sufficient, but otherwise the soldier was forced to resort to local water sources to allay his thirst. The supply of tea and coffee even in bivouac areas was never unlimited: there the soldier received a rationed quantity of one or two liters and no more. Nothing existed in the German Army similar to the US water sterilizing bag, to which an American soldier in rear areas can go at all times for additional fluids. Water sterilizing tablets, comparable to our Halazone, and thiosulphate tablets, such as the British use, were used only to a limited extent in the German Army and were never popularized. In rear areas, troops ordinarily used the town water supply, which was tested by the corps or army hygiene officer. If four samples taken the same day at different points in the town were reported as bacteriologically potable, the water was approved for drinking. In the field water was transported to kitchens in cans similar to the US five-gallon water can. Sanitary companies and motorized field hospitals had water trailers.
A few water purification units operated in the German Army, but no attempt was made to furnish all troops with water from these units. Basically, these units consisted of three tanks mounted on a large lorry. Water was pumped from one tank to another through all three, each of which contained lime and iron chloride. From the third tank the water passed through a Seitz type filter which rendered it bacteriologically potable. The output of this unit was normally 5000 liters a day, but it could be increased to 8000-12000 liters for short periods. (The US portable unit delivers about 3600 liters an hour and the US mobile unit 21,160 liters an hour). These German units were operated by the Medical Department. The chief objection to such units was that the Seitz filter discs soon became clogged and had to be replaced. The water from these units was not chlorinated, the Germans using chlorine only where necessary to treat city supplies. Another type of water filter used by the Germans was a portable apparatus carried on the back and capable of producing 200 liters a day. One such filter was issued for each battalion, or one for each separate company if the company had a medical officer attached. The apparatus was issued to and operated by the Medical Department. These filters were never popular and were seldom used except to clear up turbid water. The filter discs had to be replaced frequently and were always difficult to obtain.
German malaria control in Italy was centralized in an antimalaria staff at Army Group Headquarters. This staff consisted of a major in charge assisted by two entomologists and one clerk. Operating directly under this
staff were two or three malaria stations(comparable to US Malaria Survey Units), each consisting of one entomologist and two drivers, one clerk and one technician. These stations operated in malarious areas, effecting surveys and advising on malaria control procedures. Each German division had a sanitary officer in charge of malaria control, who was assisted by six or eight enlisted men. If more labor was needed, civilians or prisoners were used, and if necessary, help was given by engineer troops. In general, malaria control measures were carried out by troop units themselves, and no malaria control units as such were available. Division malaria control officers rendered monthly reports to the Army Group malaria staff.
Paris green or calcium arsenite was used for larviciding since oil was seldom available for such uses. A very limited amount of DDT was available to the Germans, however, due to the scarcity of screening, as has been pointed out, its use was restricted to buildings used as quarters in malarious areas. Mosquito bed nets were used, and in heavily malarious areas, guards used head nets and gloves. Short trousers and rolled shirt sleeves were forbidden in malarious areas.
The 1945 German malaria directive called for atabrine prophylaxis to begin in Italy on 15 April, south of a line from Trieste, through Gorizia, Udine, Vicenza, Verona, Brescia, Bergamo, Novarro, Turin and Cuneo. The dosage was .06 grams daily, and it was to be given by roster (US dosage has been .10 grams daily). If the malaria rate became unduly high in any unit, the surgeon was to consult with the anti-malaria staff on the advisability of giving all troops a therapeutic course of atabrine and then resuming the prophylactic dosage. The therapeutic dosage of atabrine was .10 grams three times a day for seven days, followed by .01 grams of plasmochin three times a day for three days. In severe cases in the German army, an intramuscular dose of .3 grams of plasmochin might be administered, or the daily dose of at a brine could be increased up to .9 grams, or quinine could be given up to 1 gram daily. Another routine treatment consisted of one tablet of a combination of quinine or plasmochin given three times a day for twenty-one days. The use of thick smears was urged in making the diagnosis of malaria, and smears were to be forwarded with transferred patients. All malaria patients were required to be treated as near the front as possible, and evacuation to Germany was forbidden except in the presence of severe complications. A hospital specializing in tropical disease was located at Cortina d`Ampezzo, and malarial cases presenting special problems were transferred there.
For louse control, the Germans used several louse powders called Delicia, LouseEX and Lauscto. Delicia is thought to have had a cresol base, but the ingredients of the other powders are not known. Another powder, "Russle", is said to have contained horse "sweat" extracted from horse blankets, but later this substance was synthesized. It had been noted that horse blankets never became lousy, and that lice would leave an infested person if he
slept in a blanket which had been used to cover a horse. This latter powder was never popular--it had a bad odor and caused skin eruptions in the troops. The other three powders mentioned above were moderately effective. For the most part, the Germans depended on hot air sterilization of clothing and blankets to kill lice. Every month, battalions were required to have the clothing and blankets of their personnel disinfested, and troops returning from the front were bathed and disinfested routinely. A small amount of DDT powder (called by the Germans "Gix") was available for dusting men found to be infested with lice. Steam disinfestation of clothing was not practical because it damaged the cellulose fibers of German ersatz fabrics. Methyl bromide was not used, but formalin in glass ampules was available for disinfesting blankets. Impregnation of clothing with a liquid preparation of Delicia was effective for from ten to twenty days.
A few bath units were available for front line troops, set up in connection with hot air sterilization units, but for the most part German soldiers had to seek out their own bathing facilities. Since they usually occupied buildings, this was not a great problem, except for the important fact that soap was always short.
Two types of typhus vaccine were used, the Cox type similar to US vaccine, and the Weigl type prepared from lice. A Roumanian type vaccine prepared from mouse lungs was tried out, but was found to be not very effective. Only sufficient vaccine was available for vaccination of medical personnel and key personnel over forty years of age.
The German Army in Italy had considerable trench foot in the Apennines during the winter of 1944-45 (when US rates were remarkably low), and this was attributed by German medical officers to the wet, cold, but not freezing weather, and to the failure of troops to guard against trench foot. Many of the soldiers had come from the Russian front where it was generally far colder, and they did not expect trench foot in the comparatively mild climate of Italy. Prevention of trench foot in the German military depended on the individuals taking proper care of his feet, and having a supply of warm and dry socks and shoes. Medical officers were responsible for seeing that the troops were properly instructed and that the instructions were carried out. This was of course entirely contrary to US practice where the command elements are responsible that anti-trench foot precautions are properly carried out. German medical officers were also responsible for checking shoes and socks of troops. Leather shoes were worn in temperatures above freezing, and in Russia felt boots were worn in lower temperatures. A sock exchange system operated in some units, where civilian women were hired to launder the socks. Paper and straw were often used for extra warm thin boots. A salicin ointment was used as an anti-frost bite cream.
The German army emphasized abstinence as its strongest venereal disease control measure, but at the same time it operated controlled brothels. The prostitutes in these brothels were examined daily by a German doctor
or by an Italian physician. Smears were taken and serological tests were made weekly. Civilians were not admitted to army brothels. Upon entering a brothel the soldier was given a form in duplicate on which was recorded his name and unit, the date, the designation of the brothel and the name of the prostitute. He was examined for the presence of pests or venereal disease and was given a condom. Both the prostitute and the soldier were subject to punishment if the condom was not used. A prophylactic treatment was administered before the soldier left the brothel. Prophylaxis consisted of a wash with soap and water and bichloride of mercury, followed by an intraurethral injection of 2% protargol and the application of calomel ointment. Sulfa drugs were not used since in Russia sulfa drug prophylaxis had resulted in strains of gonococci resistant to treatment with sulfa drugs. Chemical prophylactic kits containing calomel ointment were available to the German soldier but were not much used.
The simple facts of the matter are that in the German Army, controlled prostitution was not successful in the prevention of venereal diseases. That it was not successful was probably due in main to the fact that the average German soldier did not choose to frequent an Army-operated house of prostitution, for two inter-related reasons: he objected morally to having sexual intercourse with a woman whom he knew just previous to him had entertained other soldiers; and, following traditional male instincts, he preferred the chase and the conquest of a clandestine to the easy procurement of an admitted prostitute, even though he probably knew that the clandestine was quite as sexually experienced as the woman in the Army-controlled house. That this was the case is not evident from German statistics concerning venereal disease, but all German medical officers interviewed readily admitted the inaccuracy of their statistical procedures and records. It is evident, however, from the following portion of a letter to all troops from Field Marshal Albert Kesselring, Commander in Chief Army Group "C," dated 11 January 1945, where in it can readily be seen that the majority of German soldiers did not patronize Army-operated brothels:
The attitude towards illegitimate sexual intercourse is a matter of personal ethics and world philosophy, a subject which is not to be discussed at this time. But since such intercourse causes widespread VD in the Army, the High Command is compelled to adopt special measures.
It has been proven that the ordered treatment and the prescribed prophylaxis are protections against the disease. 69% of the infected soldiers, admitted to the hospitals of the Army Group during November did not undergo the ordered preventive treatment.
This fact proves that during the past year the troops did not exercise the proper attention towards these diseases which endanger the health, the total defense potential and also the future generations of the German people.
The non-compliance with the ordered preventive treatments is a violation of
discipline and punishable as such. In addition, a six months furlough suspension is enforced against the infected soldier.
If the soldier conceals the disease and takes own treatments, he is charged with self-mutilation.1
The German army had always seemed unwilling to admit that psychoneurosis existed in the members of the master race. Their statistics, even though of unreliable accuracy, have never even allotted space to neuropsychiatric disorders of any nature. For this reason, it was extremely difficult, even after the German collapse of May 1945, to obtain an adequate picture of either the prevention or treatment of psychoneurosis in the German army, or to assess what little material was gathered. During the winter of 1944-45, a captured manual for the use of German medical officers in the field fell into US hands. The sections on "pure" psychiatry were brief and gave little insight into the extent of the problem of combat reactions. The section of gastric complaints, however, was quite explicit in its discussion of the psychogenic aspects. A single careful examination, including hospitalization if necessary, was advocated, but once a man had been returned to duty, further examinations were forbidden and disciplinary measures (including deprivation of tobacco and alcohol) were prescribed if complaints continued.
After the German surrender on 2 May, an opportunity arose to question a captured medical officer with psychiatric training. Although he had not been primarily a psychiatrist in the German army, he had had two years training in the specialty at Frankfurt as a civilian, and consequently he was interested in psychiatric problems. This officer declared outright that German neuropsychiatric statistics were completely inaccurate, and he confessed that he could not give a valid estimate of the actual incidence within the army. He quoted a report of the previous year which had claimed only 4000 cases in the entire German army during a certain period. Since a single Bavarian division had had half that many during a similar period of World War I, he pointed out that present figures were absurd. Apparently there were no written directives which limited the making of psychiatric diagnoses, but there was a definite tendency to mislabel them. Obviously, cases did occur, and this captured medical officer attested that at one time German Army Group "C" had a small hospital located near Verona, which was devoted entirely to the treatment of hysterical reactions. Typically, however, this German officer stated that Wehrmacht troops were so well trained that casualties of a psychiatric type did not increase greatly with heavy combat action.
In discussing German handling of neuropsychiatric cases, the German officer said there was some variation in different commands. Chemical hypnosis, induced by pentothal sodium in US psychiatric procedures, was not
1 Translated by G-2, Headquarters, Fifth Army.
utilized in the German establishment. Shock treatments were employed only to render patients fit for transportation. Psychotics were removed from the Army as soon as possible to reduce the chances of the Army`s being held responsible for complications in the course of treatment.
An inspection during June of medical treatment standards in practice among German medical officers at Merano, showed an adequacy of knowledge, methods, and diagnostic procedures, although deficient by American standards. Of the approximately 12,000 patients hospitalized at Merano at the time, about 20% were medical patients, mostly of the same types observed in US general hospitals--patients severely ill or with protracted illness. The Chiefs of Medical Service and the consultants were apparently men of attainment, and the ward officers showed evidence of fairly good training. Records were in excellent condition. Laboratory facilities including X-ray and electrocardiography were available and were used intelligently. Drugs and other therapeutic agents seined sufficient, although penicillin and sulfadiazine were not available.
Numerous cases of infectious hepatitis were found in this inspection. Their stay in the hospital averaged from fifty to sixty days. High carbohydrate-low fat diets were instituted, but protein was not emphasized as in US hepatitis treatment. Such tests as the liver function, cephalin flocculation and bromosulfale in tests were not used. The Germans considered serum Vilirubin and TakataAva tests best regarding liver functions. In severe early cases of hepatitis, plasma and glucose were not given intravenously, and the patient was given no exercise tolerance before leaving the hospital.
Field nephritis constituted an amazingly large problem in the German army. There were 180 cases in the hospitals visited, and a consulting German "nephritis specialist" stated that he had observed over three thousand cases on the Russian front. This incidence in the German Army was hard to explain, since there has been so little nephritis observed among Allied soldiers. The exact pathology or etiology was undetermined, but it seemed probable that this incidence represented a true glomerular nephritis. Treatment consisted of the Karell diet in the early stages and later, a low protein, salt-free diet. Protracted bed rest was necessary in all cases, none of whom were returned to duty before at least six months.
Several cases of bacillary dysentery were observed, but since no sulfadiazine was available, they were treated with a preparation called Cibison Elcudron, actually a sulfathiazol derivative. Results were good in most cases. Three cases of amoebic liver abscess were seen, being treated by a dosage of .065 grams Emetine daily for from ten to twelve days. No operations were performed, although in one case, the abscess was drained with a needle. These patients were improving satisfactorily.
No cases of atypical pneumonia were encountered. The Germans had only recently become familiar with this disease, and first learned of it from Allied medical literature obtained through Switzerland. At no time
had it been as prevalent among German troops as in the US Army, and the Germans had seen no explosive outbreaks comparable to those experienced in Fifth Army early in 1945. Four cases of post-diphtheritic polyneuritis were seen, and the German medical officers stated that about 4% of their diphtheria cases developed polyneuritis. This high rate was felt to be due to two factors: first, it was usually three or four days after the onset of the disease before the patient was hospitalized; and second, standard treatment consisted only of 25,000 units of antitoxin, and many cases received only 15,000 units. Several duodenal ulcers were also encountered, diagnosis having been established by X-ray. Treatment consisted of bed rest and a diet similar to the American Sippy diet. Alkalies were not given. Hospitalization for duodenal ulcer lasted approximately thirty days, at the end of which time patients were discharged to one of the "Magen battalions", or "Stomach" battalions, a field organization absolutely unique in the German army, where soldiers performed light work and were fed special diets. Duodenal ulcer cases were not discharged from the army.
5. MEDICAL SUPPLY
The German medical establishment in Italy was almost completely self-sufficient, as it had to be, with the Brenner rail route to Germany under constant Allied air attack. On 4 May, two days after the German surrender, Fifth Army assumed control of the Base Medical Depot at Merano, along with a large factory equipped to manufacture many items such as cotton, bandages, drugs and narcotics. Included in the factory was a well-equipped laboratory capable of performing biochemical and physio-chemical procedures. The equipment was extremely modern in design, and apparently expensive and valuable. This factory employed approximately nine hundred German military workers. A few civilian men and women were employed by the Germans, hut for the most part this factory was run by German WACs and enlisted technicians.
The Merano medical depot, as apart from the factory, contained approximately 2000 tons of medical supplies when it was captured; with consolidation of other north Italy depots into this one, the stock levels were built up to 9000 tons within a few weeks. The depot did not employ civilians, and operated with a complement of three hundred enlisted men and forty WACs. This depot operated in similar fashion to a US base section depot, with the exception that platoons organized from its basic complement were attached to the various armies of Army Group "C". Thus, each army had no depot unit solely its own, as is the case in the US army.
The medical supplies stocked at this depot were generally of an inferior quality. A certain cheapness, typical in many ways of the entire German medical service, was noticeable in almost all items of expendable supply. A paper material, somewhat like crepe, was used as a substitute for gauze
in the dressing of wounds. Also, a still thinner paper was placed under casts as a substitute for cotton batting. Many of the medications found in this depot were of Italian manufacture, and not of a very high quality. The medical equipment generally was substantial and well-made, however, but more suited for a civilian general hospital than for issue to a field medical service. Surgical and dental instrument sets were far too elaborate to insure a rapid replacement. X-ray equipment, including dental X-ray sets, was good, and especially designed chests were provided to aid in proper handling. Chests of a standard size and design were provided for mobile medical supply platoons. These chests were an admirable item, hinged on opposite edges, top and bottom, so that the chest could be opened from the top or the front, and when set up one on top of the other, provided an efficient and orderly establishment.
Liquid medicines were dispensed from large demijohns, and requisitioning units were required to furnish their own containers. When a sufficient supply of demijohns was lacking, bottles of all shapes and sizes were used. The general appearance of the pharmacy at the Merano depot was not one of orderly and neat management.
Thus German medical supply and equipment seem to summarize actually the entire German medical establishment: a service of great potential ability and technique, hampered by paucity of material and bogged down in the morass of politico-military interference over a long period of time.