1947-03-05, #4: Doctors' Trial (late afternoon)

THE MARSHAL: The Tribunal is again in session.

KARL GEBHARDT — Resumed DIRECT EXAMINATION (Continued)

BY DR. SEIDL:

Q: Witness, before the recess you were speaking of the instructions for the first series of experiments of this 36 persons have you anything to add?

A: The second group of 36 women, consisting of 3 times 12, they were always ordered 5 times 2, as I believe I have discussed in the last session, and were the experiments from which expected success. Unfortunately, only local abscesses were caused of a limited nature. By abscess I understand pus surrounded by membrane. There was no outward excess of any sulphamilamide drug. We had one important result wherever germs and drugs were found together in the fluid one can speak of complete sulphamilamide success, a result which never existed at the front and during War, especially in the case of abscess, because abscess is surrounded by membrane. We had sent in a temporary report, because we were under pressure of events and absolutely had to have some result. The result was so unsatisfactory that on the one hand, I had to say that the experiments were not quite adequate, that I had a result from sulphamilamide therapy, but not for the front. On the other hand that I could not reject all the drugs, because the rivalry was not clearly settled in view of the limited nature of the experiment. I was attempting this below the line of abscess to not endanger any lives. This report was sent to Grawitz and Stumpfegger, who was with Himmler, and so forth.

Q: To make this clear, the first group were the 15 men?

A: Yes, the 15 men in July.

Q: The second group was the 36 women, 3 times 12 women?

A: Yes. Infection, plus contact materials.

Q: Is it true that the Reich physician SS, Dr. Grawitz, on the 3d of September 1942, in inspecting Ravensbruck demanded that the conditions had to be made more severe in order to make conditions similar to War time conditions?

A: At the beginning of September, on the basis of my report, I was called on for an opinion to Grawitz, and to report on the results which might be expected.

Grawitz, and as I shall explain later, Stumpfegger, in the beginning of September, came to me. Since Grawitz was coming to Ravensbruck and for that reason I turned up on the same day, so that Fischer could demonstrate the patients under my protection. That is the impression which the testimony of witnesses gives repeatedly where they have to wait for a time, and I say these are the patients whom I operated on. I assume that was all on the same occasion. Grawitz was able to prove to me that the infection were limited and not of a war nature.

And he was able to prove to me that I got not any clear medical information, only assumption, and what clinical conditions resulted might perhaps be expected. For another reason the argument became rather violent. Grawitz turned to Fischer, who presented the cases to him. He gave the discussion place —

Q: Please speak more slowly, witness.

A: — and then he said unfortunately that war like wounds had to be used, that a shooting infection by earth and material cloth. Of course, I did not accept these conditions and I looked for a way out to get the experiment into my hands in such a way that either all safeguards a higher degree of infection might be obtained, and cases might still remain under my control, I did not want to give up and say I did not reach any conclusion, so that the wounds similar to war wounds be created somewhere else. And so we came to the prevention of the third group, and that is a matter of least resistance in the matter of international experimentation technic.

Q: You did not carry out the order then?

A: No.

Q: Then how were the experiments continued?

A: In war like wounds — And we started, our own technic, the infection at the outer side of the calf far from the joint, where it is not under pressure, where the cast does not hurt it. In other words, we chose the most suitable place, after all medical considerations.

We injected in a place where the bleeding had been reduced and where the circulation of the blood had been reduced. Since this blocking off of the muscles has been called such a horrible thing. I shall further describe briefly the purpose and the effect of this blocking off. The incision in the muscle is about the length of a finger. From these muscle fibers, which have the thickness of a finger, perhaps the thickness of a pencil or a little less in the middle fiber, at the top, a loop of catgut is applied and at the bottom. The whole sides of this center part are in the circulation and the so-called collateral circulation. If one says a piece of muscle is eliminated completely by tying off the center from the top and the bottom, that is false. One wants to prove that the sulfonamide could not leave the center at all, because there is this loop of catgut at the top and the bottom. One forgets that the blood comes from both sides. The increased quantity is the focus of infection in the center area and do nothing but delay the access of the blood and limit it, It does not stop the blood completely and this is not permanent because the catgut dissolves and is affected by the infection.

In every text book for experimentation one finds this listed as the most favorable way of interconnecting the blood circulation, a part which regulates itself. The consequence is that in this center strip the center strip is not nourished as well as if the blood came from all four sides. Consequently, I can determine almost mathematically where the most serious damage in the whole wound will be. I ordered and directed the infection for it is immediately accessible to operation. If an experiment is thought through to the end at all, then it was in this aspect the safety measures were introduced. Just as I had taken the first group without contact materials then in these cases I left the contact materials out completely so that there might not be any accumulation of effect on something which I had not done previously. On all the experiments I had operated the bacteria, the banal infection of streptococci and staphylococci. I had put in first in a group 3-A without gangrene. I have already explained it was that when the joints a are all together that often appears, that they eat up the oxygen and therefore gangrene is especially prevalent.

I spread out my method of infection and introduced the greatest measures of security possible. I am convinced that there was no better way to come to this limit or level of infection with gangrene symptoms, with less danger than with this series of experiments since from the very beginning abnormal special conditions had prevailed, which never happened in any normal wound.

From the very moment of infection when the wound is inflicted, the experimental subject is in a plastic case, completely quiet and he does no have to go to a doctor downstairs and wait under normal conditions.

Q: Witness, how many persons were in this third group?

A: This was two times twelve beginning in September were the harmless infections and in November or sometime late in October or probably November was the period for the group with gangrene. Twelve for the tying off of muscles and twelve for gangrene. It is not so that everyone gets gangrene who is in contact with germs and I did not have to get serious cases of gangrene, there are transition cases that are locally limited which have a certain tendency to develop, which can be dealt with if one is able to operate and sacrifice the muscle. Unfortunately the element of fate stands above all medical action and sometimes in contrast to all calculations; three people died.

A: One witness has said that Osteomyelitis was caused artificially; is that true?

A: Osteomyelitis is a disease of the marrow of the bone and to cause that artificially is one of the most difficult problems an experimenter can undertake. The first assignment I had was to create an artificial infection in the bone marrow and none of us succeeded in doing that. The bone marrow is such a defense system, the infection decreases. Unfortunately, however, osteomyelitis occurs from outside, one can see that on the picture of serum very well, that an abscess presses on a muscle for a long time and injures the muscle, attacks the periosteum and then goes through the small channels into partly deep down. These things become dangerous only if they effect the joint and destroy the joint.

If I would discuss the individual cases of the patients who have been brought here, I can show that not a single joint was damaged. Out of seventy five people minus twelve had to do with gangrene.

Q: Were you of the opinion in the new series of experiments, these twenty four subjects, that the experiments could be conducted without fatalities?

A: Yes, of course. Whatever I said at every Congress was proven and the infections were under my supervision from the very beginning. The only real objection to the way they were carried out is the fact that in surgery there is no absolute system of nature, and suddenly an infection is carried somewhere else in spite of all precautionary measures.

Q: Then you are of the opinion that everything was done that could be done according to experiences of medicine to control the wound infection?

A: I am absolutely convinced and in reviewing the experiments, I shall take the liberty of pointing out this single point, which I consider important that up to now no scientist has proven to me that in my doings I was neglige in even the slightest respect and that in my own conviction as a doctor, I am convinced that I controlled the cases and that is if gangrene occurs and I interfere with the methods of surgery, I am not afraid to sacrifice muscles, to give blood transfusion, and add serums so that I can stop this infection. As far as there is anything certain in surgery, in all the preparations which we made, and I shall come to this point when I describe the points when I come to the lists and curves, it says when they were given sulfonamide when the incision is made, when a second operation has to be performed, when the cast is removed, there is drainage and the counter measures were stated as modern serum was given and blood transfusions.

No German soldier and no private patient was treated differently in case of gangrene at Hohenlychen and fate has given me these three deaths on my conscience.

MR. McHANEY: If the Tribunal please, I would ask that the witness be instructed to speak in a lower tone of voice. The listeners are apt to be influenced more by what he says than the volume in which he delivers it, and we have some difficulty keeping our attention on the English translation when there is such a large volume of German coming from the witness himself.

THE PRESIDENT: The suggestion of Counsel for the Prosecution is, I think, somewhat well taken. If the witness would speak in a lower tone of voice and considerably slower, the translation would be much more satisfactory.

BY DR. SEIDL:

Q: Witness, please keep your answers in such a way that they can be translated in respect to volume as well as speed.

Now if I understand you correctly, you were convinced that the infection could be controlled because the camp Ravensbrueck was only a few kilometers from your clinic at Hohenlychen, and that either you yourself or Dr. Fischer or some other surgeon from your clinic could get there in time if necessary to operate and combat the infection.

A: I had current reports on the patients, and I saw the patients myself at the decisive moments. Fischer had rent experience in this field which I have emphasized. We had the curves, the charts, the case histories, and we had the necessary facilities, and we had brought them from Hohenlychen to Ravensbrueck, and the patients were supplied with them. Further operations in sulfonamide experiments were therapeutic measures. In order to combat the diseased places in the muscles where the infection had taken to, it was important that we could be reached quickly so that the delay would not permit the gangrene to spread — it can spread in twenty-four hours — and endanger the patient.

Q: What do you know about the deaths, and why was there no amputation in these cases?

A: I believe that I can remember the three deaths very well. But I only remember three, I have always said that. With the things that have happened in the meantime, all the patients I have taken care of, it was not that Fischer or I overlooked an amputation, and it is certainly not true that an amputation can in all cases save the life of the patient, as in the case of gangrene. As I remember the case histories, the most serious patient had a large abscess on the hip.

Probably the corresponding glands had been affected. The infection on the calf and the abscess on the hip — what can I amputate? One can amputate when the infection is limited on the calf. We did not have such cases because we forced the infection to the place where we wanted it, but we were not able to prevent that the infection spread to a different area and that it should run up the blood vessel as does happen occasionally. There are infections of the veins, and then the patient dies suddenly, and it is a definite risk to perform any operation because the power of resistance is only on the border-line, hanging by a hair. If we perform such major operations to save the patient's life, then you may believe that we would have undertaken an amputation, or would you not believe that a surgeon of my experience does not know when he has to amputate; and unfortunately that is the first experience that an operator like Fischer learns in wartime; to amputate in time.

As far as I remember the deaths, were an abscess of the glands, an infection of the veins of the blood vessels, and one died in spite of all transfusions from general sickness. This happens in cases of infection when there is no possibility to stop infection by local surgery. But one cannot conclude that any medical measures which should have been taken were overlooked and because just by seeing case history from a distance one cannot decide that at that moment that patient should have been operated on. I am convinced that in those three cases which Fischer resorted to me exactly which I saw and in which the therapy was discussed that we certainly did not overlook anything as far as one can humanely say that one did what one considered necessary.

I wanted to publish this result or report it to the public from the beginning. If you did not assume that I had any humane or surgical motives, you may assume that I did everything so that I would be able to publish the results.

Q: In the individual series of experiments, what was the immediate harm, and what, in your opinion, was the later and the final harm?

A: I have already described it to you briefly, and in the individual groups there was no permanent damage in the case of the men. In the second group of thirty-six, you have seen one patient here.

After all 60 had been gathered together, you probably picked out the worst cases. They have scars without any secondary damage. But they are not endangered from the infection. It is very difficult to say how is the damage judged here. One can leave the impression up to the layman. One can have the patient describe it himself, or if it is to be useful scientifically for later generations, one can keep documents for evidence to future generations.

German judicial procedure requires the person expressing an opinion to be very clear here. It distinguishes between a limitation of the working capacity of the human being in percentage, and, on the other hand, the court not the person expressing, the opinion nor the patient — but the court considers what suffering he has undergone. It is not so that the cosmetic concept is recognized, but I can understand that in such an exceptional case where non-volunteers were forced to submit to this, — I did not force them, but the German State did — today as patriots they are asked for their opinion. I may express myself as expert in my own case only to this extent, that it seems to me to be going a little too far to say to me the patients would rather have died because as women they would have a bid scar.

For twenty-five years I worked with disabled persons. If there is any concept, it is that a person with the most horrible scars, the most horribly disfigured who is a burden on his surroundings absolutely wants to stay alive if he is any position to reach a decision, and then there is an important concept which may not be omitted, whether the damage can be repaired in the long run.

In modern surgery we have advanced so far that any muscle damage which is cosmetic damage can be compensated for at least to the extent that the scar deformity can be compensated for by moving the muscle down from above. That must be mentioned because the cosmetic conditions can definitely be improved.

If you will permit me I should say that the first group suffered no damage at all; that the second group had their abscesses and scars without any important loss, no interference with their performance or their appearance, but do have a scar. On most serious examination the damage is under fifteen per cent, and perhaps I might tell the Tribunal under the German concept 33-1/3 per-cent is a total loss of the knee joint, the most important joint of the human being, and 50 to 60 per-cent for the loss of a limb. In the third group as I shall show in individual cases, this is the characteristic of the course of the case according to fate.

The most serious case was Kusmirzuk. She was from group 3-A without the gangrene; and, as I have demonstrated, and Broel-Plater, who was from the most serious group in which the ones died. If Kusmirzuk has twenty-five per-cent, then Plater is not fifteen% and what was the damage? They sacrificed the diseased muscle, and you can see from the two cases scar present in detail that the incision near the joint, that is the one at the top part of the knee joint, and the one at the ankle was the only real danger for the patient, that the abscess might go deep into the joint and destroy the joint, so that the patient would be unable to walk, and that the whole body might be poisoned, which did not occur there. That this did not happen in any of the cases was a reference to the nerve question. Professor Alexander discussed it with me and at the last we came to the same decision, but I may repeat it because it can easily be misunderstood for a layman. The nerve is a cable which runs into the muscle and now a nerve can be destroyed in two ways, either the nerve is injured at the top of the cable, and then that is serious and cannot be repaired or the muscle, the organ to which the cable is attached, as in this case, is in part removed, or a scar is caused, and has grown first to the foundation, and the circulation is interfered with, and then the nerve has only a limited value, and for years and decades it will recover through massage, and these ankle parts which you have seen are certain to have impaired the function of the foot, but that is no nerve damage.

That can be very easily proved, because a good surgeon would not have performed an operation using the muscle supplying in part the same nerve, and in the second place Dr. Alexander from the very beginning was of this opinion because he omitted the electrical nerve damage, which is the only decisive method. It can clearly be seen that the muscle no longer moves and that the poor woman did suffer damage. The important thing in experiments, not because they are my experiments, is that the experts say they are influenced by the cosmetic aspect. On the other hand one can say that the important thing of a disease is the concealing aspect which is not easily recognized or a total loss. On the other hand large parts of muscles have to be sacrificed in these cases, but the lives of these patients were saved by so doing, and it was even so that the joint was not affected. There is not a single case where any joint was in the least affected. Of course, every person has a large group of muscles and if only ten per-cent is destroyed, he can stand on this log, if the joint is destroyed, if part of the joint is missing or if the limb is amputated, then he is much more seriously restricted.

Giving a full critical view of the situation which I shall describe in detail and with the strictest point of view towards myself and the consciousness that this opinion will be later read by other doctors, I am of the opinion first, in view of mortality, if I take only twelve of the cases where the muscle was tied off and the cases of gangrene, then three of them died to my certain experience. That is twenty-five per-cent, a result unknown in gangrene therapy, but I have taken the liberty of proving that all thirty-six other women should be included because they were not infected with gangrene among other things and with contact materials, and some of them could have died too, in spite of all of our efforts. I believe one can put the twenty-five per-cent in parenthesis with the thirty-six others, which gives you a percentage of death of five to six per-cent. I believe that there was no other case as serious as Kuxmirzuk.

I do not recall any such case. I gave them all to the same place and they will probably be present here. The highest damage was thirty per-cent and the lowest fifteen or less. There are serious muscle defects which for therapeutic reasons were carried out to save the joints; there were no amputations. To this decisive point with the understanding of the Tribunal I shall give a very clear explanation: I assert that my orders for the experiments were so complete and thought out so thoroughly from a scientific point of view that aside from matters of fate they could not have been better. I further assert that all therapeutic care humanly possible for these people, all measures for protecting their lives, were first considered, if I doubted whether I should emphasize the scientific assignment or the protection of the people, if I put the groups next to each other and ask you to consider the preliminary experiments to get a quite clear clinical condition, the 36 women with contact material and resting of wounds, so that the abscesses could achieve only a certain extent, and if at last I take the cases where muscles were tied off, and determine exactly where the infection had to occur at a known place to a known extent, immediately accessible to operation, I believe that those are the three most important things to prove, that I contend I acted decently from a scientific or human point of view. On the other hand I know that I will have to prove these three statements and I can change the conditions of the experiments. In transition from the second to the third group, after a long consideration, I kept resting the wounds, as the most normal and secure. I did not permit any motion which would drive the germs further in, and cause the gangrene to break out at a place unknown to me. I used the method of tying off the muscle. I ask the Court since I am interested only in the events of this decisive point, to give me a chance in a simple way in an experiment on myself, that if I make an incision at the same place, but introduce the same infection at the same place as was done to these women, and then move it, that is, not rest it, gangrene will break out on my leg, but not at the intended place as in all of this group, but somewhere else on my leg, and I ask you in this desperate situation without any assistance from outside to permit this experiment because I believe I will thus be able to show the most essential point of our whole work. Up to now gangrene has been combated only by surgical measures.

That is, an abscess which arises somewhere with its surrounding membrane could never be influenced by chemical means from the outside, but by passing on the sulfonamide by electrical means into the abscess, as Fischer worked it out, I am convinced with any luck the abscess will stop abruptly. I do not need to add that, in my opinion, I ask for this purely as proof for my reputation and my work without any calculation or advantage or other benefit.

DR. SEIDL: Mr. President, in view of the last statement of the defendant Gebhardt I shall submit an application in writing to the Tribunal.

Q: Witness, the first witness here before the Court was a Polish citizen, Karoleska. I shall have you show photographs which the prosecution submitted as Exhibit No. 11. This is Document NO 1081 and 1081b. To which group did this witness belong?

A: Karoleska was operated on 14 August 1942. Then she would belong to this so-called second group with thirty-six women where incisions were made and contact materials introduced. She was operated on again on the 6th of September by secondary incision and now she has this healed scar. No damage to the nerves. No interruption to the joint. That is, injuries of 15 to 20 percent, if one speaks in favor of the patient. When the Court considers what the patient had to suffer and how much her total life is influenced, I am convinced that she is the worst of this group and most are better than this case.

Q: The prosecution submitted as Exhibit 225 an affidavit of Jadwifa Kaminska, Document NO-876, page 46 of the English Document Book 10.

A: She was operated on 15 August 1942. It describes the course of the treatment as she was not given anything to eat, morphine, plaster cast, dressing changed by me, the necessary secondary operations. It says expressly that her leg is healed with the exception of scars. I believe, therefore, that one can say that Kaminska belonged perhaps to the better one and the one presented here was worse. I should think that the second group is more or less between these two.

Q: The next document I will have you shown is NO-877, Exhibit 228 of the prosecution, page 61 of the English Document Book 10. This is an affidavit of Yanina Iwanska. To which group did this person belong?

A: The same group. She was operated on at the same time. The case is the sane. Dressing changed by Fischer under my control. She speaks of drainage; she says metal pieces were put in and out. Maybe there was an abscess. She says in her report that she is healed and that later she had drainage from the leg. These three cases more or less describe the second group totally healed. Traces of infection and definite scars as shown were without any important loss.

Q: Another witness who was examined before this Tribunal was Maria Kusnerchak. I shall have you shown pictures of this witness of Prosecution Exhibit 219, Document 1080. To which group did this witness belong?

A: According to this she clearly belonged to Group 3a. That is, in October here there was no gangrene. Her muscle was tied off. The whole clinical course of the experiment is described very well and she says I examined her in November. She had several operations. The scars are seen here clearly. Once the upper, and once the lower joints were endangered and saved by sacrificing the muscle. She is certainly one damaged most severely. She has no loss of nerves but loss of function secondary. Joints are free. The leg was saved. There is no sign that infection endangered the person as a whole because blood circulation is all right. It is something that can be improved by further operation and treatment afterwards. It can be reduced by at least ten percent. She has no bone focus. Kusnerchak seems affected more then Dsido although Dsido is more seriously ill. I should like to say that Kusnerchak has about 33 1/3% loss, which is equal to the loss of a knee joint and that is a high estimate considering all she suffered and the cosmetic appearance.

Q: Another witness, Maria Broel-Plater.

A: Maria Broel-Plater —

Q: Just a minute, witness. The prosecution submitted the pictures of this witness as Exhibit 209, Document 1079. To which group did this witness belong?

A: Broel-Plater and Dsido both belong to the gangrene group. That is the group showing most serious infection and you will see that the one who was operated on last in that is Broel-Plater, who had the much more harmless condition than Kusnerchak who was from a much more harmless experiment.

She describes the case. Says that everything was done that was necessary. In case of Broel-Plater there were no complaints of loss of nerve, no big muscle connection, only the two scars, no interference of the bone and a very slight infection of the periosteum. That is a very good result although from the most serious group. That could almost be from the beginning group. Then there is someone who suffered more, that is Dsido.

Q: The last witness examined before this Tribunal is the witness, Jadwiga Dsido. The picture which Prosecution has submitted is number NO-1082, exhibit 214. To what group did this witness belong?

A: She was in the gangrene group at the end. One can see from her the infection from the calf muscles going up and endangering the knee joint. From the cross incision at the outside of the knee joint this harm is prevented. And then it goes down and in toward the bone and again by an incision, so that not only this focus of infection is healed but the joint is saved. Dsido is a classical example of therapy which combats infection with the knife and prevents effecting the joint. In the case of Dsido it is very important that subsequent treatment was already introduced when subsequent operation reduced the loss of function. This, of course, does not reduce our responsibility, but is a fortunate change of improvement.

THE PRESIDENT: When counsel for a defendant refers to any exhibit which has been offered in evidence by Prosecution and received in evidence, defendant's counsel will call attention to three things — the number of the document, the document number as an exhibit, and the page in the English document book upon which that exhibit may be found so that the Tribunal may readily refer to that document if it desires to do so.

The Secretary General will return these Document Books to the office but will bring them back for the Tribunal tomorrow morning and put them on the desk.

(The Tribunal adjourned until 0930, 6 March 1947.)