#opeeration anthropoid

[cursedreverie1945]

Modern Take on the Autopsy of Heydrich

As a result of his fierce repression of any opposition, with thousands of incarcerations and executions, within a relatively short time stability reigned in the Protectorate. The exiled Czech government made a decision to assassinate Heydrich.

On 27 May 1942, a poorly executed attack severely wounded but did not kill him. While traveling in his open car, Heydrich was injured on the left side of the chest by a grenade splinter. A passing lorry transported him to the nearest medical facility, Bulovka Hospital. Rebuilt in 1931, this hospital had become one of the most modern institutions in Europe. The head of its surgical department, Prof. Jan Levit, an experienced surgeon, was dismissed following the “Cancellation of Accreditations of Jewish Doctors” order of 17 March 1939. When Heydrich arrived at the hospital, Drs. Puhala, Slanina and the surgeon Snajder were on duty. Dr. Slanina conducted the first examination: “With a forceps and a few swabs, I tried to see the depth of the wound. I found pneumothorax, contusion of the lung and that the metal splinter, some 3 cm large, also transported pieces of upholstery through the diaphragm into his abdomen, damaging the spleen and the tail of the pancreas” [5]

The first step was to try to stop the hemorrhage by local pressure while Heydrich was lying on a table in the hospital director’s office. A photograph of the scene shows several figures standing around the table in a septic environment: some in street attire, some with no head or facial cover; their hands, whether gloved or not, are not visible.

The patient was then transferred to the operating room and surgery was performed by thoracic surgeon Walter Dick and abdominal surgeon J. Hohlbaum, both experienced German practitioners. Heydrich was anesthetized with a closed system, high pressure mask, and no indication of intubation. The chest was closed around a rubber draining Petzer tube connected to a suction device.

The Czech personnel were prohibited from entering the operating room or the floor where Heydrich was taken after his operation [6]. The abdominal surgeon sutured the diaphragm (a “four inch” tear), removed the splintered spleen, sutured the tail of the pancreas, and inserted a drain in the left corner of the abdomen. During the course of treatment, Heydrich received several blood transfusions as well as anti-gangrene and anti-tetanus injections.

Within two days the patient was recovering well; there is no record that postoperative X-rays were performed. From this point, SS chief Heinrich Himmler’s private physician, Dr. Karl Gebhardt, an orthopedic surgeon from Berlin, was in charge. Gebhardt bypassed all the other surgeons, preventing the use of sulphonamide (Prontosil ® 1 *) when Heydrich’s temperature rose, and forbidding the transfer of the patient for re-operation at any other hospital [6]. The omission of treatment with Prontosil was particularly noteworthy since “the SS and Hitler insisted on believing that *The first commercially available antibacterial drug, developed in the 1930s by Bayer Laboratories of the IG Farben conglomerate sulphonamides were a ‘miracle drug’ (Wundermittel) which could prevent all infections if only correctly administered” [1]. In the postoperative days, a gradual fever developed.  On the seventh day the patient was able to sit up in bed to eat, but he collapsed suddenly and remained in a coma until the early hours of 4 June when he died. An autopsy was performed within four hours of his death, which examined only those parts of his body that underwent surgery, excluding the head and legs. The full text of the autopsy report is analyzed below.  [7] Heydrich was a tall, athletic figure and active in sports; he was blond and had blue eyes and a long aquiline nose [Figure 2]. It is surprising, for a high ranking SS officer who should have been medically assessed on a regular basis, that an “enlargement of the left ventricle of his heart to 20 mm (2 cm) in width was measured on autopsy, in contrast to 4 mm of the right ventricle”, indicating a longstanding pathology. Also, several arteriosclerotic deposits were found, scattered in the branches of the coronary arteries, with a somewhat greater focus in the circumflex branch In the chest cavity several collections of pus-like fluid were found in the pleural angles and in the mediastinum. There was atelectasis of the left lower lung, a pericardial collection of about 100 ml, but more importantly, “on the pleural side of the diaphragm a fibrin encapsulated frill of hair was found”

Blood thrombi were found in the pulmonary artery, surrounded by conglomerates of fat droplets The source of this thrombosis was found in the pelvic venous plexus. “In the esophagus, a sour odor, apparently from vomited stomach contents.” The bronchi were “filled with foamy mucous” The tubes inserted into the patient’s chest and abdomen drained pus, which grew non-hemolytic Streptococcus, Staphylococcus and bacteria coli and proteus. • Histology of the liver and kidneys revealed inflammatory leukocytic infiltrations, which were also found in the myocardium together with fragmented myofibrils. Necrotic fibers were noted in the diaphragm and thoracic muscles. Although mentioned in subsequent reports in the literature, there was no proof in the autopsy findings of anaerobic gangrene or of botulism.

The medical reality in 1942, A retrospective review of the medical treatment that Heydrich received must be conducted within the context of 1942 knowledge and experience. What was the standard of German medical science in the early 1940s?

Indeed, most of the procedures in use today were available in 1942. Scientific work in Germany during the inter-war period was of the highest academic standard, and the Kaiser Wilhelm Gesellschaft in Berlin was one of the world’s leading scientific institutions. Many sections were headed by Nobel Laureates: Otto Warburg for medicine (who surprisingly was not arrested), Fritz Haber for chemistry (who escaped to England), and Albert Einstein for physics (who escaped to the United States).

Despite the decline in standards at this institution in the 1930s, it was largely responsible for the discovery of the first antimicrobial chemotherapeutic agent, sulphonamide, for which the German Gerhardt Domagk was awarded the Nobel Prize in 1939.

Although military technology had advanced during the Nazi period, pharmaceutical production was deficient. In contrast, the Allies had field hospital access to sulpha (later on even to penicillin) in 1942, but this was not the case in the Reich. Blood transfusions were routine practice, in accordance with the discoveries of the two blood groups (ABO and Rhesus) by the Austrian émigré Karl (Hess) Landsteiner (Nobel Prize laureate in 1930) and Alexander Solomon Wiener, both in the Jewish Hospital in Brooklyn.

Heparin, used for the prevention of venous thrombosis in immobile postoperative patients, was discovered in the 1920s by McLean and Howell in the U.S. Heparinization began to be used routinely in the USA in 1935 and in clinical practice in Stockholm in 1936 [8,9]. In 1942, in the Dachau concentration camp, experiments were conducted with a thrombotic agent, and it is assumed that heparin would have been available as an antidote. The pathophysiology of embolism was discovered in Berlin by Rudolph Virchow in 1858. Embolectomy was developed experimentally in 1918 by the surgeon Friedrich Trendelenburg and introduced in clinical practice in 1924 by his pupil Martin Kirchner in Konigsberg [10,11]. “Many German clinics quickly adopted the emergency bedside Trendelenburg operation for physiologically compromised patients in whom PE [pulmonary embolism] was strongly suspected” [12].

Splenectomy was a centuries-old procedure in clinical practice. The management of abdominal and chest wounds had been developed by German surgeons before World War I. A new approach to abdominal injuries was described in 1900 by Boeckel [13] and by another German surgeon, Borchardt, in 1904 [14]. Both communications dealt with “gunshot wounds to the pancreas.” The definitive treatment was finalized in a series of articles in the Annals of Surgery in 1905 [15-17]. The damaged pancreas required partial or total removal, with drainage to the exterior of fluid collecting in the retroperitoneal, lesser sac. There is no record of any drainage being inserted in that space in Heydrich’s case. The cause of death in the official autopsy report by pathologists Herwig Hamperl and Gunther Weyrich, both professors at Prague University, determined the cause of Heydrich’s death to be “septicaemia due to virulent Bacteria that led to parenchymatous intoxication of the liver, kidney and myocardium” [7].

The management of Heydrich’s care and the autopsy findings have been disputed. Among those who raised questions about the management was a French surgeon who asked: “could he have been saved?” [18]. Several reviews of this topic were published by historians [5,19 23], a neurosurgeon [6], a pathologist [24], and two anesthetists with obvious interest in intensive care [25].

These interpretations are interesting, but conflicting and inconsistent. To analyze each would not lead to a firmer conclusion. Instead, the present authors undertake a review of the original German autopsy report, translated by three linguists. Our interpretation of the autopsy report is presented here:

• The cardiovascular system: A preexistent, apparently unknown, hypertensive and atherosclerotic cardiovascular disease, with significant left ventricular hypertrophy, with a small amount of fluid in the pericardial sac. Although not sufficient for a cardiac tamponade, drainage of the pericardium would have improved the cardiac ejection. Inflammatory, myocardial damage was detected, possibly enhanced by the pre-existent arteriosclerosis. The presence of thrombosis in the pulmonary artery (augmented by fat accumulation) would no doubt be the main cause of sudden collapse, resulting in cerebral anoxia and terminal coma. The source of fat emboli in a patient with no bony fracture other than a broken rib cannot be satisfactorily explained. It might be that an existent hyperlipidemia in the system aggregated around the blood clots in the pulmonary artery. The thrombosis was not identified; neither embolectomy nor the use of anticoagulants was attempted.

• The respiratory system: The bilateral pulmonary edema, pleural and mediastinal purulent collections, atelectasis of the left lower lobe, would all lead to respiratory insufficiency.

• The digestive system: The acidic food regurgitation into the esophagus (in a patient eating just a few days after major abdominal surgery) led to aspiration and to a copious bronchial exudate reaction. No esophageal lavage or bronchial suction was performed. • Septicemia and multi-system failure: Multiple coccal and bacterial cultures were obtained from the thorax and sub phrenic space. Some of these would have been sensitive to sulpha. The histologically detected infiltrates in the liver, kidneys, and myocardium could be interpreted as signs of parenchymatous damage. The sources of the microbial invasion could have been hematogenic due to the initial septic intervention or the result of the retained foreign material. This material was a “frill of hair” from the car’s upholstery, made of animal (horse or swine) hair, and would have been detectable on postoperative X-rays. It is our conclusion that the cause of death was pulmonary embolism, originating in the pelvic plexus (or in the unexamined lower limbs), due to pulmonary insufficiency and to a multi-system septic failure.

Since the autopsy investigation did not examine the head, the possibility of anoxic brain damage cannot be excluded. In legal terms, the medical approach of the German doctors provided substandard medical care to one of their highest officers. Was this inadequate treatment a result of unintentional negligence or a criminal act?

The autopsy report surprisingly starts with a comment, forensic rather than medical, exculpating the surgeons involved from any wrong doing. Why was this necessary? So that they could charge only the attackers with responsibility and thus justify the severe reprisals to come? Or, as mentioned by some historians, to cover up an internal rivalry at the highest levels of the SS hierarchy? [3]. It is well known that Himmler, as SS chief and Heydrich’s immediate superior, had begun to feel that his own position was threatened by the ruthless ability and repeated successes of the younger man, such as the pacification of Bohemia/ Moravia.

Could Himmler have taken advantage of the unexpected wounding of Heydrich by sending his physician Gebhardt to hasten the Reichsprotektor’s death? The evidence from Heydrich’s medical treatment and autopsy suggests that Himmler may well have used Gebhardt as his instrument to dispose of a rival who Himmler feared would eventually supplant him. A complicating factor for both Himmler and Gebhardt, however, was Hitler’s genuine dismay when he learned of Heydrich’s death. Worse still, Gebhardt was accused of negligence by Dr. Theodor Morell, Hitler’s personal physician (Leibarzt).

Morell owned a factory that produced sulphonamides and argued that Gebhardt should have treated Heydrich with the drug. Gebhardt, on the other hand, insisted that sulphonamides were of little use and had not been required in Heydrich’s case. To maintain his standing in Hitler’s eyes, Himmler ordered Gebhardt to demonstrate the correctness of his position and so began Gebhardt’s barbaric medical experiments on concentration camp prisoners. Septic wounds were deliberately inflicted on male inmates at Sachsenhausen and then on female inmates, mostly Polish political prisoners, at Ravensbrück. Some of these victims were then treated with sulphonamides while others were not. Gebhardt’s procedures, like all the other unethical human experiments carried out by Nazi doctors, produced no results of scientific value but caused extreme suffering for the inmates who were subjected to them, with many dying and most of the survivors experiencing permanent mutilation. conclusions Reviewing the available clinical data and the autopsy findings, it seems probable that Heydrich became a victim of the same kind of medical malpractice at the hands of Gebhardt (possibly on the orders of Himmler) as was inflicted on the most powerless concentration camp prisoners. Such a turn of events would have been bitterly ironic for the architect of the “Final Solution,” had he been aware of it, but it was consistent with the medico-political ideology of Nazi Germany, as stated by Dr Brandt, which held that every individual was to be “completely used in the interest of society.” The surgical and pathological findings are highly suggestive of medical negligence. The question as to the extent of Himmler’s involvement remains unanswered, requiring further evidence.

Author and Journal information -

Focus IMAJ • VOL 16 • AprIL 2014 the attempt on the life of Reinhard Heydrich, Architect of the “Final solution”: a review of his treatment and autopsy George M. Weisz MD FRACS MA1,2 and William R. Albury BA PhD2 1 School of Humanities (Program in History of Medicine), University of New South Wales, Sydney, Australia 2School of Humanities, University of New England, Armidale, NSW, Australia

Slightly edited because I didn't want to post footnotes and repeated terminology,