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WASHINGTON, Feb. 7 (UPI) -- As medical teams across the country prepare for a possible war with Iraq, the American Academy of Orthopaedic Surgeons -- meeting this week in New Orleans -- is looking back to the experiences of surgeons who served in World War II, during which many of the medical treatments and procedures used today originated.
World War II changed orthopaedics from a "strap and buckle" specialty that treated deformities in children to trauma surgery. "Ninety percent of war problems were surgical, and 90 percent of the 90 percent were orthopaedic," said Dr. Nathaniel Gould, who spent 46 months overseas during the conflict.
Gould is quoted in a book of first-person narratives the academy prepared as part of its "Legacy of Heroes" project. In the documentary film "Wounded in Action," surgeons reflect on their war experiences and how those experiences changed their lives. The project also includes a traveling multimedia exhibit and a Web site, legacyofheroes.aaos.org, showcasing these vivid accounts and historic medical advancements -- from the use of antibiotics, to the development of such subspecialties as hand surgery, burn units, artificial limbs and bone fusion.
Hippocrates, the Greek physician and father of modern medicine, said: "If one wants to become a surgeon, follow the army."
During World War II, orthopaedists re-learned the principle of leaving fracture wounds open (after excising dead tissue) to prevent infection, a practice developed by Napoleonic army surgeon Dominique Larrey. They also learned to use refrigerated anesthesia to prevent the absorption of toxins from wounded limbs.
Dr. William W. Tipton, executive vice president of the American Academy of Orthopaedic Surgeons, said in a phone interview that the academy plans to bring the exhibit to the meetings of the American Medical Association in June and the American College of Surgeons in October, both in Chicago. Orthopaedists in France, where much of the fighting took place, have expressed an interest in bringing the exhibit there.
Projects such as "Legacy of Heroes," produced by successor generations, are important because war veterans fear being seen as bores.
"You know, if I bring World War II to the attention of a young resident, I think he would present shut ears to me," Dr. Zachary B. Friedenberg says in the video. "I dare say that of the hundreds of residents I have trained, I don't think any of them know of my experience in the war."
Friedenberg, who will be 88 in April, graduated from Columbia medical school in 1939. He no longer performs surgery but has an office practice in Philadelphia, continues to teach medical students and residents, and maintains an administrative involvement with the Orthopaedics Department at the University of Pennsylvania Medical School. He also conducts research and writes on the history of medicine.
Friedenberg finished a two-year surgical internship at King's County Hospital in Brooklyn in 1941 and was assigned to an artillery battalion at Fort Benning, Ga. "Believe it or not, when I came down there, they were still horse-drawn," he told United Press International in a phone interview. He volunteered for overseas duty and was assigned to the 95th Evacuation Hospital. After a few months in North Africa, the unit participated in the brutal invasion of Salerno, southern Italy, on Sept. 9, 1943. Friedenberg reflected on the experience he never shared with his students in the book the academy prepared.
The Germans were waiting, and the troops could not advance beyond the beach. Stuka dive bombers pounded the ships in the bay, and the decision was made to land the hospital units, ready or not.
"The front ramp was lowered just as another air raid started. The two British sailors manning the craft glanced overhead and shouted, 'Out with you Yanks, we're leaving.' By the time the last of us was hip-deep in the water, the landing craft was reversing out to sea. Four ME-109s swooped down and strafed us. At full speed I hurtled over a dead soldier, dodged around a fallen plane and dug in about 20 yards from the water's edge."
On the third day the 95th set up the first Allied hospital in continental Europe near a Greek temple about 300 yards from the beach. Friedenberg was in charge of the "shock tent" set up for triage and emergency surgery for casualties -- military and civilian -- so seriously wounded they could not survive evacuation.
Most soldiers wounded in the first few days of the invasion had been treated and sent back to the hospital ships. Those left were soldiers who had been overlooked in trenches, gullies or hedgerows and injured civilians lying under the hot Italian sun, some for several days.
Sixty years later, Friedenberg has recurring nightmares about a night that seemed never to end. Forty mortally wounded people were lined up on litters along both sides of the cavernous tent, lit by two naked light bulbs. The moans of the dying -- men, women, children and babies -- could be heard above the distant firing. Friedenberg and his medics knelt beside each patient, using a flashlight to dress their wounds, provide morphine and start infusions. They had no blood, no oxygen, no penicillin, no anesthetics.
"I remember kneeling down by one man, examining his leg and feeling and hearing the crackling sound of gas (gangrene) in the tissues. Now it was to the level of his thigh, but it advanced unremittingly during the night, finally bloating the abdomen and ending his life. Then from patient to patient the same bloated purplish mottling of limbs and trunks was seen."
The night seemed endless.
"I listened with a helpless feeling to their cries for help. There was nothing ever so welcome as the first streams of daylight filtering through the tent."
Anzio, in 1944, was even more intense. In tents, surgeons operated in the pandemonium of Luftwaffe attacks. "The screaming planes overhead, the ground reverberating with the explosions. ... Your first reflex is to hit the ground. But you know if you do that, so will everyone else, and the patient on the table will die," Friedenberg told UPI.
"Our hospital was bombed. A Messerschmitt-109 was being chased by two British Spitfires. He was about tent level. It was about 3 o'clock in the afternoon." Friedenberg had just stepped out for the first mail delivery since the landing, about a month previously. "The German plane was loaded with fragmentation bombs on both wings, and in an effort to get away from the Spitfires, he dropped the whole thing on the hospital. ...
"Twenty-two of our personnel were killed, including three nurses and two doctors. There were about 50 wounded among the staff."
Friedenberg had a favorite sergeant, from Chicago, who wanted to go to medical school after the war. "I ran back to the hospital, which was in flames, and there were just charred blankets lying over the patients, rivulets of blood dripping to the ground.
"The first person I encountered was my sergeant. There was a big gaping hole in his chest. I knelt down beside him, trying to take his pulse. He looked up into my eyes and said: 'I'm fine. Now that you are here, I'm fine.' I wish I had that confidence in myself. He gave me divine grace. Anyway, I stopped his bleeding and plugged the hole in his chest." Friedenberg never learned whether the sergeant survived.
The doctor's third invasion was in southern France in August 1944. By the time the German counterattack at "The Bulge," the hospital was at Mutzig, about 12 miles west of Strasbourg.
Friedenberg was in Augsburg, Germany, when the war in Europe ended on May 8, 1945. He witnessed "an event I think the world has never seen before" -- millions of displaced persons, wandering on foot in all directions, trying to find their way home and hoping their homes were still there.
Dr. Paul W. Brown, 83, had a degree in zoology from the University of Michigan before he was drafted in 1942. "I was supposed to go to Officers Candidate School," he said in a phone interview from Connecticut, "but they were mounting the North African invasion, so they were grabbing everybody indiscriminately, and they put me in a port battalion and trained me to be a stevedore for the invasion of North Africa in Casablanca. And then in the invasion of Sicily, we were still unloading things, but I was on a .50-caliber machine gun. Our medic was killed by the Luftwaffe on the beach, so I saw an opportunity to get rid of the machine gun and volunteered to be a medic. I didn't know a damn thing about it."
He worked as a medic intermittently during the Anzio campaign.
After the war, he went to medical school on the GI Bill and returned to the Army for an internship on the day the Korean War broke out. While treating casualties at Letterman Army Hospital near San Francisco, he become interested in orthopaedics, stayed in for an orthopaedic residency and took a regular commission. He retired from the Army in 1970 with the rank of colonel and then taught at Yale and the University of Colorado.
"The lessons we have learned about wound management have come at great price. With every war, we've learned a bit more," Brown said.
One of the most important orthopaedic advances to come out of World War II -- the insertion of nails into the marrow cavity of thigh bones -- was first mistaken for a Nazi atrocity. Brown said Gerhard Kuntscher demonstrated his technique of nailing femurs in 1940. German surgeons used the procedure to treat captured Allied flyers, and American doctors became aware of it when the POWs were repatriated in 1945.
Friedenberg recalled his thoughts the first time he looked at an X-ray and saw the hardware: "These bastardly Germans. They're experimenting on American prisoners, putting in this big rod. They're destroying the intramedullary canal.
"We equated that with their cold experiments on concentration camp victims. Yet these former prisoners were walking around without a limp, happy, and the bone was healed."
Nailing quickly became the standard of care.
http://www.upi.com/view.cfm?StoryID=20030207-050709-3380r
WASHINGTON, Feb. 7 (UPI) -- As medical teams across the country prepare for a possible war with Iraq, the American Academy of Orthopaedic Surgeons -- meeting this week in New Orleans -- is looking back to the experiences of surgeons who served in World War II, during which many of the medical treatments and procedures used today originated.
World War II changed orthopaedics from a "strap and buckle" specialty that treated deformities in children to trauma surgery. "Ninety percent of war problems were surgical, and 90 percent of the 90 percent were orthopaedic," said Dr. Nathaniel Gould, who spent 46 months overseas during the conflict.
Gould is quoted in a book of first-person narratives the academy prepared as part of its "Legacy of Heroes" project. In the documentary film "Wounded in Action," surgeons reflect on their war experiences and how those experiences changed their lives. The project also includes a traveling multimedia exhibit and a Web site, legacyofheroes.aaos.org, showcasing these vivid accounts and historic medical advancements -- from the use of antibiotics, to the development of such subspecialties as hand surgery, burn units, artificial limbs and bone fusion.
Hippocrates, the Greek physician and father of modern medicine, said: "If one wants to become a surgeon, follow the army."
During World War II, orthopaedists re-learned the principle of leaving fracture wounds open (after excising dead tissue) to prevent infection, a practice developed by Napoleonic army surgeon Dominique Larrey. They also learned to use refrigerated anesthesia to prevent the absorption of toxins from wounded limbs.
Dr. William W. Tipton, executive vice president of the American Academy of Orthopaedic Surgeons, said in a phone interview that the academy plans to bring the exhibit to the meetings of the American Medical Association in June and the American College of Surgeons in October, both in Chicago. Orthopaedists in France, where much of the fighting took place, have expressed an interest in bringing the exhibit there.
Projects such as "Legacy of Heroes," produced by successor generations, are important because war veterans fear being seen as bores.
"You know, if I bring World War II to the attention of a young resident, I think he would present shut ears to me," Dr. Zachary B. Friedenberg says in the video. "I dare say that of the hundreds of residents I have trained, I don't think any of them know of my experience in the war."
Friedenberg, who will be 88 in April, graduated from Columbia medical school in 1939. He no longer performs surgery but has an office practice in Philadelphia, continues to teach medical students and residents, and maintains an administrative involvement with the Orthopaedics Department at the University of Pennsylvania Medical School. He also conducts research and writes on the history of medicine.
Friedenberg finished a two-year surgical internship at King's County Hospital in Brooklyn in 1941 and was assigned to an artillery battalion at Fort Benning, Ga. "Believe it or not, when I came down there, they were still horse-drawn," he told United Press International in a phone interview. He volunteered for overseas duty and was assigned to the 95th Evacuation Hospital. After a few months in North Africa, the unit participated in the brutal invasion of Salerno, southern Italy, on Sept. 9, 1943. Friedenberg reflected on the experience he never shared with his students in the book the academy prepared.
The Germans were waiting, and the troops could not advance beyond the beach. Stuka dive bombers pounded the ships in the bay, and the decision was made to land the hospital units, ready or not.
"The front ramp was lowered just as another air raid started. The two British sailors manning the craft glanced overhead and shouted, 'Out with you Yanks, we're leaving.' By the time the last of us was hip-deep in the water, the landing craft was reversing out to sea. Four ME-109s swooped down and strafed us. At full speed I hurtled over a dead soldier, dodged around a fallen plane and dug in about 20 yards from the water's edge."
On the third day the 95th set up the first Allied hospital in continental Europe near a Greek temple about 300 yards from the beach. Friedenberg was in charge of the "shock tent" set up for triage and emergency surgery for casualties -- military and civilian -- so seriously wounded they could not survive evacuation.
Most soldiers wounded in the first few days of the invasion had been treated and sent back to the hospital ships. Those left were soldiers who had been overlooked in trenches, gullies or hedgerows and injured civilians lying under the hot Italian sun, some for several days.
Sixty years later, Friedenberg has recurring nightmares about a night that seemed never to end. Forty mortally wounded people were lined up on litters along both sides of the cavernous tent, lit by two naked light bulbs. The moans of the dying -- men, women, children and babies -- could be heard above the distant firing. Friedenberg and his medics knelt beside each patient, using a flashlight to dress their wounds, provide morphine and start infusions. They had no blood, no oxygen, no penicillin, no anesthetics.
"I remember kneeling down by one man, examining his leg and feeling and hearing the crackling sound of gas (gangrene) in the tissues. Now it was to the level of his thigh, but it advanced unremittingly during the night, finally bloating the abdomen and ending his life. Then from patient to patient the same bloated purplish mottling of limbs and trunks was seen."
The night seemed endless.
"I listened with a helpless feeling to their cries for help. There was nothing ever so welcome as the first streams of daylight filtering through the tent."
Anzio, in 1944, was even more intense. In tents, surgeons operated in the pandemonium of Luftwaffe attacks. "The screaming planes overhead, the ground reverberating with the explosions. ... Your first reflex is to hit the ground. But you know if you do that, so will everyone else, and the patient on the table will die," Friedenberg told UPI.
"Our hospital was bombed. A Messerschmitt-109 was being chased by two British Spitfires. He was about tent level. It was about 3 o'clock in the afternoon." Friedenberg had just stepped out for the first mail delivery since the landing, about a month previously. "The German plane was loaded with fragmentation bombs on both wings, and in an effort to get away from the Spitfires, he dropped the whole thing on the hospital. ...
"Twenty-two of our personnel were killed, including three nurses and two doctors. There were about 50 wounded among the staff."
Friedenberg had a favorite sergeant, from Chicago, who wanted to go to medical school after the war. "I ran back to the hospital, which was in flames, and there were just charred blankets lying over the patients, rivulets of blood dripping to the ground.
"The first person I encountered was my sergeant. There was a big gaping hole in his chest. I knelt down beside him, trying to take his pulse. He looked up into my eyes and said: 'I'm fine. Now that you are here, I'm fine.' I wish I had that confidence in myself. He gave me divine grace. Anyway, I stopped his bleeding and plugged the hole in his chest." Friedenberg never learned whether the sergeant survived.
The doctor's third invasion was in southern France in August 1944. By the time the German counterattack at "The Bulge," the hospital was at Mutzig, about 12 miles west of Strasbourg.
Friedenberg was in Augsburg, Germany, when the war in Europe ended on May 8, 1945. He witnessed "an event I think the world has never seen before" -- millions of displaced persons, wandering on foot in all directions, trying to find their way home and hoping their homes were still there.
Dr. Paul W. Brown, 83, had a degree in zoology from the University of Michigan before he was drafted in 1942. "I was supposed to go to Officers Candidate School," he said in a phone interview from Connecticut, "but they were mounting the North African invasion, so they were grabbing everybody indiscriminately, and they put me in a port battalion and trained me to be a stevedore for the invasion of North Africa in Casablanca. And then in the invasion of Sicily, we were still unloading things, but I was on a .50-caliber machine gun. Our medic was killed by the Luftwaffe on the beach, so I saw an opportunity to get rid of the machine gun and volunteered to be a medic. I didn't know a damn thing about it."
He worked as a medic intermittently during the Anzio campaign.
After the war, he went to medical school on the GI Bill and returned to the Army for an internship on the day the Korean War broke out. While treating casualties at Letterman Army Hospital near San Francisco, he become interested in orthopaedics, stayed in for an orthopaedic residency and took a regular commission. He retired from the Army in 1970 with the rank of colonel and then taught at Yale and the University of Colorado.
"The lessons we have learned about wound management have come at great price. With every war, we've learned a bit more," Brown said.
One of the most important orthopaedic advances to come out of World War II -- the insertion of nails into the marrow cavity of thigh bones -- was first mistaken for a Nazi atrocity. Brown said Gerhard Kuntscher demonstrated his technique of nailing femurs in 1940. German surgeons used the procedure to treat captured Allied flyers, and American doctors became aware of it when the POWs were repatriated in 1945.
Friedenberg recalled his thoughts the first time he looked at an X-ray and saw the hardware: "These bastardly Germans. They're experimenting on American prisoners, putting in this big rod. They're destroying the intramedullary canal.
"We equated that with their cold experiments on concentration camp victims. Yet these former prisoners were walking around without a limp, happy, and the bone was healed."
Nailing quickly became the standard of care.
http://www.upi.com/view.cfm?StoryID=20030207-050709-3380r