Shortly after the German surrender in World War II, a physician named Captain James Fulton Neil in the British Royal Army Medical Corps inspected a German military hospital and encountered a young soldier being treated for a pressure injury with a suspension apparatus. Captain Neil published a photograph of the device (Figure 1) and its description in the British Medical Journal.1 His recording of this suspension device employed by National Socialist (Nazi) physicians provides an important perspective on contemporary techniques for pressure injury prevention and treatment and serves as a reminder of how far the healthcare profession has come with regard to ethical practices.
This commentary will discuss the suspension device and its historical context and use the term “bed-sore” interchangeably with “pressure injury” because this was the term used within the original publication. This author notes that this device is not approved by the FDA for any purpose and is not available or labeled for current use under any circumstance.
James Fulton Neil was born September 30, 1917, in the historic city of Nottingham in the East Midlands of England.2 His father was a general surgeon who practiced at Nottingham General Hospital, and he had two sisters, one of whom became a medical doctor, and the other, a pharmacist. James graduated medical school in the midst of World War II, receiving his Member of the Royal Colleges of Surgeons degree in 1942.3 Soon after graduating, he married Tess Dawe, a nurse with whom he trained at Middlesex Hospital in London, and shortly thereafter his life was swept up in the maelstrom of the World War.4
On March 20, 1943, James Neil was commissioned as lieutenant in the Royal Army Medical Corps and soon thereafter promoted to captain. His photograph taken during military service is presented in Figure 2. Within a year, he took part in the amphibious landing by British and American forces at Anzio, on the western shore of Italy behind German lines. Also known as Operation Shingle, the battle began on January 22, 1944, and ended with the capture of Rome 4 months later on June 8, 1944.5 He cared for soldiers who fought in the Anzio campaign that left more than 10,000 allied soldiers dead or missing.6 He later took part in the landing of Operation Overlord, the code name for the Battle of Normandy, where he again cared for wounded soldiers.
At the time Captain Neil observed the suspension method for treating bed-sores, he was stationed in Eckernförde in north Germany on the Baltic Sea, not far from Denmark.7 According to his war diary, he served as medical officer for the occupying British forces and had the opportunity to care for patients who incurred typhus and malnutrition in a concentration camp. Captain Neil submitted his case report shortly after the German surrender on May 8, 1945, and before the full scope of medical involvement in Nazi atrocities was revealed to the world through the Doctors Trial in Nuremberg.
THE CASE REPORT
The title of the report was Apparatus for Treating Bed-Sores,1 and it appeared in a section entitled Preparations and Appliances. Captain Neil encountered the suspension method as medical officer for the occupying British forces in Eckernförde, Germany, on July 26, 1945, only a few months after the German surrender on May 8—bed-sore treatment by suspension of the patient by pins driven into superior iliac spines of the pelvic bones.
The patient was a young German soldier who was wounded in the left knee by a shell fragment on May 4, 1944, a year before the end of the war. The joint became infected, leading to sepsis, anemia, and a bed-sore of the sacral region that failed to respond to pressure relief cushions. Because the leg was splinted, his mobility and ability to turn were limited. The bed-sore was deep and involved the medial half of both buttocks with exposed sacral bone in the center.
Ten days prior to Dr Neil’s inspection, the surgeons had placed a thin wire (also called a Kirschner wire or K-wire) through each anterior superior iliac spine under local anesthesia and attached the wire to a stirrup connected to a system of pulleys and counter-weights attached to a Balkan frame that suspended the patient 3 inches above the bed. A schematic key to the device appears in Figure 3. The patient’s legs were supported with Kramer wire splints, padded, and suspended in similar fashion. The head and shoulders rested on air cushions. The patient’s only complaint was that he could not move around much, but Captain Neil reports that the sore was improving, and the nursing was easy.1
In a comment, Captain Neil informs us that the German surgeons had used this suspension device in several other cases and that 6 weeks was the maximum length of time a patient could be left in this position. The reasons for this time limitation and complications of this therapy were not provided. He also notes that wires were sometimes passed through the tibial tuberosity if bed-sores appeared on the legs.
Components of the Suspension Device. Captain Neil described the use of Kirschner wires, also called K-wires, inserted into the anterior superior iliac spines. The K-wire was developed in the early 20th century by Martin Kirschner (1879-–1942) and is still used today by orthopedic surgeons for skeletal traction and other applications.8 It was originally a thin pin, which evolved over the years into a stainless-steel wire that was either hammered into bone or inserted through a predrilled hole. Complications of the K-wire include wire migration, skin necrosis, and pin-track infections.
Another component of the suspension device was the Balkan frame, also called the Balkan beam. This was an elevated support attached to the hospital bed that served as a fixation point for slings to elevate injured extremities. The device was invented by a Croatian surgeon, Vatroslav Florschütz (1879-–1967), for extremity bone fractures and adapted by military physicians on both sides during the first World War.9
The Kramer splint (also called the Cramer splint) is constructed of a metal lattice that has the advantage of flexibility in that it can be bent into any shape and fit over any dressing. Still in use today, it was described in 1887 in Berliner Klinische Wochenschrift, a German journal that was one of the oldest and most prestigious in Europe.10,11
Air cushions were described in the orthopedic literature of the 19th century.12 Nursing texts from World War I recognized the value of air cushions for prevention of bed-sores. They were constructed of rubber and inflated by air pumps or bellows.13
POTENTIAL COMPLICATIONS OF SUSPENSION WITH TRACTION PINS
Captain Neil did not discuss the complications of suspension therapy, but it is possible to speculate that they were severe and involved both physical and psychological consequences. As previously stated, traction pins are commonly used in orthopedic surgery to manage fractures and dislocations. The complications of this treatment have been well described and include thermal damage to the bone during drilling; pin loosening; loss of alignment; skin necrosis around the pin; foreign body reaction; damage to neurovascular structures; fracture; and infections including cellulitis, abscess, and osteomyelitis.14 Insertion is painful and requires local anesthesia, sedation, and sterile conditions.15 Once inserted, meticulous care must be administered around the pin site that includes frequent dressings with aseptic technique and local antibacterials.16
A patient subjected to prolonged bed rest in a suspension device with traction pins would likely suffer a variety of complications from immobility. Aside from local pain and discomfort from the pins, one would expect muscle atrophy, contractures, accelerated sarcopenia, insulin resistance, hypercalcemia, osteoporosis, urinary tract infections, cardiac deconditioning, deep vein thrombosis, orthostatic hypotension, atelectasis, pneumonia, kidney stones, and constipation.17–19 Bone failure with fractures from mechanical stress, particularly in light of immobilization-related osteoporosis, would be another expected complication. Psychological complications could include sensory deprivation, behavior disorders, anxiety, depression, altered sleep patterns, anorexia, and symptoms similar to ICU psychosis.20
If a suspension technique with traction pins were used today for pressure injury prevention or treatment, informed consent would require that all of these complications be discussed with the patient and/or healthcare proxy. In light of modern medical knowledge, nursing strategies, and numerous alternative devices for pressure redistribution, the use of suspension with traction pins would be considered invasive, overly restrictive, fraught with unnecessary complications, and unethical.
HISTORICAL CONTEXT OF THE SUSPENSION DEVICE
Throughout civilization, many advances in wound care were closely related to war and human conflict.21 Ambrose Pare, a 16th-century physician considered to be the father of modern surgery, earned his reputation on the battlefield with soothing dressings instead of boiling oil for wounds and also wrote in his diaries about curing a nobleman who incurred a pressure injury while recovering from a war injury.22 In the 19th century, Florence Nightingale applied statistical analysis to mortality and morbidity of soldiers wounded in the Crimean War, laying the groundwork for public health principles in the healthcare environment.23 Henry Dakin perfected his antiseptic wound cleansing solution on wounded soldiers in World War I.24
This case report from the close of World War II presents a suspension method for treating a pressure injury using materials that had been in use by the medical and nursing professions for decades. Suspension for both prevention and treatment of pressure injuries had been described previously, although suspension was performed not with traction pins but with a hammock attached to the bed frame.25,26 This technology elevated the patient off of the bed but did not provide pressure relief. An example of this suspension device is presented in Figure 4. Although suspension treatment using traction pins makes theoretical sense because it completely relieves pressure, serious complications must be considered. In addition, the report cannot be taken out of context of medical history in Germany under the Nazi movement.
In the 19th and early 20th centuries, Germany’s medical community was considered the best in the world, and its universities and hospitals were a center for research and scientific advancement.27 The 1930s brought increasing involvement by the German government in medical care and research, with implementation of racial hygiene laws that incorporated principles of eugenics.28 Nazi ideology became an integral component of healthcare education and services, including both the medical and nursing professions. Practices such as forcible abortion, sterilization, and euthanasia of children with disabilities and persons with mental illness became routine in the political-medical complex of Nazi Germany.
In concentration camps, physicians participated in murder and gruesome medical experiments, some of which involved wound care. In the Ravensbrück camp, for example, experiments took place in which contaminated material was inserted into the legs of prisoners to observe the development of infection and gangrene.29 Many inhumane experiments were performed with the express purpose of saving German soldiers on the battlefield, in the air, and at sea.
Captain Neil reported this case shortly after the war’s end, but before the full extent of Nazi medical atrocities was revealed in the Nuremberg trials. The trials of Nazi leaders began on November 20, 1945, but the Doctors Trial, officially called United States of America v Karl Brandt et al, began a year later on December 9, 1946. A major outcome of this trial was the Nuremberg Code—considered the first international ethical standard for human experimentation.30 This code formed the basis for modern themes of protection of patient rights and the welfare of human research participants. The Nuremberg Code includes 10 principles based on three concepts, the first of which is informed consent.31 Research participants must be volunteers in the absence of coercion and informed of any risks. Second, the experiment must be designed and based on the results of animal experimentation and the knowledge of the natural history of the disease. Third, the experiments must be conducted by scientifically qualified persons who are prepared to terminate the experiment if deemed harmful to participants.
The photograph illustrating this case report depicts a seriously ill, immobilized young man, his hips and groin exposed, looking directly into the camera. Publication of such an image today would be inconceivable and certainly deemed a violation of patient rights. However, the ethical principles of privacy in healthcare that became prominent in the late 20th century are not referenced in the Nuremburg Code. These principles are defined by the American Medical Association as encompassing physical, informational, and associational privacy that includes personal relationships with family members and other intimates.32 Privacy in healthcare was formally signed into law by President Clinton on August 21, 1996, with the Healthcare Insurance Portability and Accountability Act.33
Following World War II, the German treatment for pressure injuries remained unknown and thankfully unduplicated despite Captain Neil’s case report. Physician-novelist Robin Cook described a suspension method for pressure injury prevention in his 1977 thriller, Coma, which spawned a hit movie the following year.34 In the book, comatose patients were stored in a warehouse for sale of their organs by a company run by evil healthcare providers. Bed-sores were prevented by suspension from wires drilled into bones, but Dr Cook had no knowledge of the German suspension method from World War II. Instead, he had heard about this technique applied to severe burn patients.35
Dr Cook was accurate in his knowledge of burn patients treated by total body suspension. In the same year his book was turned into a movie, there was a published case report presenting two children with burns treated with total body suspension using pins and screws inserted into their bones to facilitate skin grafting and prevent pressure injuries.36 The authors of this report were also unaware of the German suspension methods, and they explicitly state that they did not know of prior reports of complete body suspension.36
Captain Neil was released from army service in 1946 and went on to specialize in laryngology, practicing in the same hospital his father had practiced in Nottingham. Dr Neil enjoyed a distinguished career as a physician and accomplished cellist, becoming a clinical teacher, receiving many honors and awards, and playing in a local orchestra. He retired in 1982 and spent his remaining years playing the cello, gardening, and cooking.37 At the time of his death at the age of 93 in 2012, he had three children and seven grandchildren.
Dr James Fulton Neil was a model physician who served his country and his profession, devoting his life to patient care, medical education, music, and raising a family. One could speculate that his marriage to a nurse sensitized him to issues related to pressure injuries. Dr Neil left us with a fascinating historical footnote from a world cataclysm that adds to our knowledge of Nazi medicine while providing a unique perspective on today’s practices in preventing and treating pressure injuries.
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