Neurosurgery during the Greco-Italian War (World War II): the management of war-related head injuries at the Italian field hospital of Sinanaj in Albania

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  • 1 Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano; and
  • | 2 Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
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During the Greco-Italian War (World War II [WWII], 1940–1941), an Italian field hospital was set up in Sinanaj, Albania. The hospital’s military surgeons carefully collected information about the characteristics and management of patients with war-related injuries. In 1942, they published a detailed report, with a section dedicated to the management of war-related head injuries. The aim of this report is to analyze that section, to describe the characteristics and neurosurgical management of war-related head injuries, and to depict the status of war neurosurgery in the Royal Italian Army during WWII. The analysis revealed that, during the Greco-Italian War (November 1940–April 1941), 149 patients with war-related head injuries were admitted to the Sinanaj hospital, and 48 patients underwent surgery. Head injuries were caused by bomb fragments in 126 patients, bullets in 5 patients, and other causes (falls from height, vehicle accidents, or rock fragments) in 18 patients. Six patients (12.5%) died after surgery. Before surgery, patients underwent resuscitation with blood transfusions and fluid. Preoperatively, a plain head radiograph was usually acquired to locate metallic and bone fragments. The surgical technique consisted of craniotomy or craniectomy, aggressive debridement of metallic and bone fragments, and watertight dural closure. Surgical drainage, overall aseptic technique, serial spinal taps, and perioperative antibiotics were used to prevent infections. The surgical aims and technique used by the Italian surgeons for the management of head injuries were similar to those of the Allied surgeons during WWII. Operative mortality was also comparable. Although the surgical technique for war-related head injuries has evolved since WWII, many aspects of the technique used by the Italian and Allied surgeons during WWII are still in the standard of care today.

ABBREVIATIONS

WWI = World War I; WWII = World War II.

During the Greco-Italian War (World War II [WWII], 1940–1941), an Italian field hospital was set up in Sinanaj, Albania. The hospital’s military surgeons carefully collected information about the characteristics and management of patients with war-related injuries. In 1942, they published a detailed report, with a section dedicated to the management of war-related head injuries. The aim of this report is to analyze that section, to describe the characteristics and neurosurgical management of war-related head injuries, and to depict the status of war neurosurgery in the Royal Italian Army during WWII. The analysis revealed that, during the Greco-Italian War (November 1940–April 1941), 149 patients with war-related head injuries were admitted to the Sinanaj hospital, and 48 patients underwent surgery. Head injuries were caused by bomb fragments in 126 patients, bullets in 5 patients, and other causes (falls from height, vehicle accidents, or rock fragments) in 18 patients. Six patients (12.5%) died after surgery. Before surgery, patients underwent resuscitation with blood transfusions and fluid. Preoperatively, a plain head radiograph was usually acquired to locate metallic and bone fragments. The surgical technique consisted of craniotomy or craniectomy, aggressive debridement of metallic and bone fragments, and watertight dural closure. Surgical drainage, overall aseptic technique, serial spinal taps, and perioperative antibiotics were used to prevent infections. The surgical aims and technique used by the Italian surgeons for the management of head injuries were similar to those of the Allied surgeons during WWII. Operative mortality was also comparable. Although the surgical technique for war-related head injuries has evolved since WWII, many aspects of the technique used by the Italian and Allied surgeons during WWII are still in the standard of care today.

The Greco-Italian war was fought between the kingdoms of Italy and Greece from October 1940 to April 1941 during World War II (WWII). This conflict began the war between the Axis powers and the Allies in the Balkans. Initially, the Greek army, supported by the British forces, resisted and counterattacked Italian soldiers who had invaded Greece from Albania, and the situation developed into trench warfare in the mountainous Epirus region for several months. Eventually, in April 1941, the German army intervened in favor of Italian forces, which rapidly forced the Greek army to surrender. As a result of the war, many Italian soldiers suffered war-related injuries, and health assistance for injured soldiers was established behind the lines. The organization of the Italian army for the management of injured soldiers consisted of first aid posts and sorting centers (where injured soldiers received immediate assistance, dressings, and resuscitative measures), second-level combat support field hospitals (where primary definitive surgical treatments were performed, commonly within 12–24 hours after the injury), and better-equipped specialized base hospitals in Albanian cities or back home in Italy for secondary treatments or nonurgent surgery.1 A field hospital was set up in Sinanaj (Fig. 1), an Albanian town located a few kilometers from the border with Greece and close to the frontline in the Epirus region. Several surgical teams worked in that hospital, including a group of surgeons of the 34th Italian Surgical Nucleus and of the 427th Field Hospital (Fig. 2) who had worked in the surgical departments of Milan and Bari before the war. During the war, these surgeons carefully collected information regarding the characteristics and management of patients with war-related injuries at the Sinanaj hospital, and in 1942, they published a detailed report (Fig. 3).1 Notably, a section of this report was dedicated to the management of war-related head injuries. This section contains descriptive and basic statistical data, together with some illustrative cases complete with clinical presentation, preoperative radiological images, a brief description of the surgical procedure, and postoperative outcomes. Finally, the surgeons discuss their surgical techniques and findings.

FIG. 1.
FIG. 1.

A and B: Photographs of the Italian military field hospital of Sinanaj in Albania. C: Map of the field hospital of Sinanaj: 1–4 and 6, barracks with operating rooms, radiology rooms, sterilization rooms, dressing and plaster rooms, wards for immediate postoperative observation of surgical patients, and generators; 7, emergency room and admission; 5 and 8–10, patient wards; 11, kitchen for officers; 12, kitchen for soldiers; 13, antiaircraft shelter; 14, dentistry ward. Photographs were taken during the Greco-Italian War (October 1940–April 1941) and were originally published in the report on the surgical activity of the Sinanaj hospital in Albania, written by the military surgeons of the 34th Surgical Nucleus and 427th Field Hospital.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

FIG. 2.
FIG. 2.

Photographs of the military surgeons, nurses, and soldiers of the 34th Surgical Nucleus (left) and 427th Field Hospital (right), who operated in the field hospital of Sinanaj during the Greco-Italian War. Photographs were taken during the Greco-Italian War (October 1940–April 1941) and were originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

FIG. 3.
FIG. 3.

Report on the surgical activity of the Sinanaj hospital in Albania, written by the military surgeons of the 34th Surgical Nucleus and 427th Field Hospital.1

The aim of the present study is to analyze and describe the characteristics and neurosurgical management of war-related head injuries at the Sinanaj field hospital, and to depict the status of war neurosurgery in the Royal Italian Army during WWII. The management of head injuries as described in the report is then compared to the management of head injuries in Allied armies during WWII and in contemporary war neurosurgery.

Patients Treated at the Hospital in Sinanaj

During the Greco-Italian War, 15,255 soldiers were admitted to the 312-bed Sinanaj hospital, of whom 9462 had war-related injuries, 4825 had frostbite, and 968 had medical disease. Among these, 91 soldiers were treated for war-related spine injuries and 149 soldiers were treated for war-related head injuries (1.6% of all soldiers treated for war-related injuries). Forty-eight soldiers (32.2%) underwent surgery for a penetrating head injury and 26 (17.4%) for a penetrating spine injury (14 underwent decompressive laminectomy, and the rest were treated for deep infections). The authors of the report note that the number of patients with head injuries who went through Sinanaj’s hospital and underwent a neurosurgical operation was probably larger; however, soldiers with head injuries who did not require emergency surgery were evacuated to more specialized base hospitals. The causes of the head injuries were metal fragments from artillery shells, bombs dropped by air bombers, or hand grenade blasts in 126 soldiers (84.6%); bullets in 5 soldiers (3.4%); and other agents in 18 soldiers (12.1%; vehicle accidents, rock fragments, or falls from height). Spine injuries were mostly caused by bomb metal fragments (67 patients [73.6%], including the 26 patients with spine injuries who underwent surgery), whereas bullets were the cause of spine injury in only 3 patients. Falls and vehicle accidents caused closed spine injuries in 21 patients.

Types of Injuries

Penetrating war-related head injuries were classified according to skull, dura, or brain penetration. One hundred thirteen patients (76%) had skull fractures with dura and brain penetration and in-driven bone and metal fragments. Exit wounds from fragments and bullets were evident in 5 injured soldiers. Intracranial and superficial wound infections often complicated injuries because of poor hygiene conditions and overcrowding at the first aid posts in the frontline, which prevented immediate and adequate management of wounds with accurate debridement and sterile draping. Also, the practice of not leaving a drain in place after suturing wounds with silk stitches at the first aid posts is addressed as a likely causative factor for infections.

Preoperative Assessment

The authors of the report claimed that physical and neurological examinations and cerebrospinal fluid qualitative analysis often did not suffice in providing complete preoperative information. Blast injuries usually caused depressed compound skull fractures or the penetration of bone fragments or foreign materials (metallic fragments, gravel, or dirt) into the cerebrum, which is associated with cerebral contusions and cerebral edema.2 In these settings, skull radiological imaging was of great value to obtain information about the extension of cranial fractures, the bony defect, and the number and location of in-driven bone and metallic fragments. At the Sinanaj field hospital, a portable device that allowed for the acquisition of plain radiographs was the only device for imaging the skull, whereas a dedicated radiotransparent bed and stereoscopic imaging were not available. Radiographs were printed in a makeshift chamber (Fig. 4). Despite such a shortage of means, the radiologist of the field hospital, Dr. Franco Fossati, successfully acquired and printed 121 plain radiographs of the head.

FIG. 4.
FIG. 4.

The makeshift obscure chamber where Dr. Fossati, the radiologist of the 34th Surgical Nucleus, printed 569 radiographs showing various body parts of injured soldiers. The photograph was taken during the Greco-Italian War (October 1940–April 1941) and was originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

Surgical Technique for War-Related Head Injuries

Before surgery, resuscitation with intravenous blood transfusions (200–300 ml each) and fluids was undertaken. The aims of surgery for penetrating injuries of the head were to repair and clean skin wounds, to drain brain abscesses, and to remove all retained intracranial metal and bone fragments. The authors of the report outlined the necessity of early surgery, as a delay inevitably increased the risk of infection, which was already evident in about 70% of the patients at presentation and usually developed between 24 and 36 hours after the injury. Patients with complex brain injuries (e.g., multiple retained fragments), which could not be definitively managed at the field hospital, were immediately evacuated to specialized and better-equipped hospitals. After surgery, patients were observed at the field hospital for a minimum of 10 days before being transferred to a base hospital.

The surgical instruments that were available for brain surgery consisted of a hand drill, Gigli saw, and bone rongeurs. After sterile draping (Fig. 5), a generous curvilinear skin flap with the wound defect in the center was generated. This was preferred to linear incisions for better surgical wound healing. The lacerated skin edge was widely excised with an ellipsoid incision. After skin incision, the bone entry hole of the metal fragment or bullet was enlarged with bone rongeurs, a Gigli saw, and a drill. The use of a chisel was discouraged. Abundant irrigation with warm 3% boric acid solution through a flexible rubber tube connected to a 20-ml syringe was used for aggressive debridement of devitalized brain tissue along the track made by metal or bone fragments and bullets. Fragments were then removed with blunt-tipped forceps, with no or minimal retraction or damage to the brain. Finger and probe exploration of the brain to remove fragments was discouraged. Surgery was aimed at removing all accessible bone and metallic fragments, provided that removal did not cause gross neurological injury. Watertight dural closure, primarily or using fascial grafts, and multilayered skin closure were performed. Leaving a drain in the surgical site was recommended, especially when large cavities existed, such as after abscess drainage. Surgical drainage was done using catgut wires, iodoform gauze, or silk layers. Subcutaneous, local, or intravenous pre- and postoperative sulfonamides were used to prevent and treat infections. Intrathecal administration of sulfonamides was avoided, as it caused spine injury and paraplegia in some patients. Postoperatively, serial spinal taps were performed, and the bedpost was elevated to reduce intracranial pressure and prevent cerebrospinal fluid fistula (Fig. 6).

FIG. 5.
FIG. 5.

A neurosurgical operation in one of the operating rooms of the Sinanaj field hospital. Military surgeons have draped the patient’s head, placed hemostatic clamps, and are performing a surgical operation for a war-related head injury. The photograph was taken during the Greco-Italian War (October 1940–April 1941) and was originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

FIG. 6.
FIG. 6.

Surgical ward at the Sinanaj field hospital. The photograph was taken during the Greco-Italian War (October 1940–April 1941) and was originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

Illustrative Cases

Case 1

On March 3, 1941, an infantryman was admitted to the Sinanaj field hospital for a penetrating head injury caused by the fragments of a hand grenade. On physical examination, a lacerated wound was evident in the right occipital region, with leakage of brain and cerebrospinal fluid. On neurological examination, the patient had complete vision loss. A preoperative plain radiograph showed that a large bony fragment penetrated approximately 3 cm into the brain at the site of the injury (Fig. 7). Local anesthesia was administered with Novocain injections. During surgery, the lacerated skin edge was excised, bone rongeurs were used to enlarge the bony opening made by metallic fragments, the dura opening was enlarged with scissors, and irrigation with warm 3% boric acid solution through a 10-cm flexible rubber tube connected to a 20-ml syringe was used for debriding devitalized brain tissue and debris along the path made by the bone fragment. Once exposed, the bone fragment and two grenade fragments were removed with blunt-tipped forceps. The dura and skin were closed, and a drain made with catgut wires was left in the surgical cavity. The drain was removed 24 hours postoperatively. The patient was transferred to the military hospital in Valona 12 days postoperatively. He had partially recovered vision at that time.

FIG. 7.
FIG. 7.

Left: Lateral radiograph showing a vault fracture close to the lambdoid suture with a bone fragment driven into the brain (black arrows). Right: Anteroposterior radiograph showing the skull defect and in-driven bone fragment (black arrow). These radiographs were acquired by Dr. Franco Fossati at the Italian military hospital of Sinanaj during the Greco-Italian War and were reproduced in the report of the hospital’s surgical activity.1

Case 2

On March 5, 1941, an infantryman was admitted to the Sinanaj hospital 42 hours after receiving a left parietal head injury caused by a mortar bomb fragment. On neurological examination, he was unconscious and bradycardic, and his breathing was stertorous. He was also febrile and had frequent seizures. A preoperative plain radiograph showed a large and depressed skull fracture with a bone fragment driven into the intracranial space (Fig. 8). During surgery, the bony fragment was elevated, and debridement was performed with boric acid irrigation. A drain was not placed, and the skin was closed with tape plaster. Six hours after surgery, the patient recovered consciousness, and 6 days postoperatively he wrote a letter to his mother in Italy. Eleven days after surgery, he was transferred to the military hospital in Valona.

FIG. 8.
FIG. 8.

Anteroposterior radiograph showing a depressed fracture in the left parietal region with a large in-driven bone fragment (black arrow). This radiograph was acquired by Dr. Franco Fossati at the Italian military hospital of Sinanaj during the Greco-Italian War and was reproduced in the report of the hospital’s surgical activity.1

Prognosis

Twenty-three soldiers with war-related head injuries died at the field hospital before undergoing necessary surgery. Six (12.5%) of the 48 injured soldiers who underwent surgery died after the operation. The authors of the report noted that in some cases surgery for war-related brain injury greatly improved the neurological status of the patient, even if they were comatose at presentation; thus, neurological status at admission should not be the only parameter driving the decision to perform surgery. However, many patients who survived surgery had permanent loss of neurological function, although the prevalence was not reported.

Discussion

In this article, we describe the characteristics of war-related head injuries and their neurosurgical management in the Royal Italian Army during the Greco-Italian War. Information was derived from the 1942 report of the Italian military surgeons who operated at the Sinanaj field hospital in Albania.1

The first observation made by the authors of the report is that the proportion of patients in the Italian army with war-related head injuries (1.6%) was remarkably lower than that observed during World War I (WWI) (18%–20%). The Italian surgeons attributed this discrepancy to several factors. First, in WWII, soldiers used protective metallic helmets more frequently than in WWI. Second, many soldiers with severe head injuries were preferentially treated at the field hospital of Turano, Albania, which was closer to the frontline than Sinanaj. Third, head injuries caused by the more powerful mortars and artillery pieces that were used in WWII were more likely to be lethal than the head injuries in WWI. Finally, patients were commonly transferred to Sinanaj’s hospital between 12 and 24 hours after sustaining a head injury, and therefore the report does not include all patients who were injured and died on the battlefield (killed in action) or died of wounds at first aid posts.1

Another relevant finding emerging from the analysis of the report is the relatively high number of head injuries caused by bomb fragments (84.6%), whereas only a minority of injuries were caused by gunshot bullets (3.4%). This finding is fully in line with the trend of war-related penetrating injuries of previous modern conflicts. In 1870, during the Franco-Prussian War, 88% of war-related injuries were caused by gunshot bullets, and only 5% of injuries by artillery. In 1905, during the Russo-Japanese War, 80% and 18% of war-related injuries were caused by bullets and artillery, respectively. Finally, in WWI (1914–1918), rifle and machine gun bullets and artillery shell fragments caused 23.5%–54.2% and 45.8%–75% of war-related injuries, respectively. Thus, the rate of war-related injuries caused by bomb fragments progressively increased during the modern industrial wars and especially during WWI, when it was remarkably higher than in previous wars. The likely reasons for this are that, during WWI, armies were entrenched and fought in a static position in many frontline areas, armies were more exposed to artillery, and more advanced technologies for bombardment, including artillery, air bombers, and mortars, were developed and vastly introduced into warfare.

The overall reported frequency of war-related injuries caused by bomb fragments during the Greco-Italian War ranged from 73.6% to 91%, whereas only a few injuries were caused by gunshot bullets. These data align with the Sinanaj hospital numbers for head injuries. The reasons, as noted by the surgeons at Sinanaj, are the rugged mountain terrain of the Greek frontline, which favored a static-position war and entrenchment; the high number of modern artillery pieces and mortars available to the Greek army, together with the air bombardment carried out by the advanced bombers of the British Air Force; and finally, the widespread use of protective metallic helmets, which limited the efficacy of gunshot bullets. Notably, even head injuries due to vehicle accidents and falls from height were more frequent than those caused by bullets, because of the extensive use of motorized vehicles on the rough mountain paths of Albania and the Epirus region.1

The general principles of penetrating head injury management described by the Italian surgeons at the Sinanaj hospital are similar in many aspects to those proposed by the military surgeons of the British and US armies during WWII.35 These include early resuscitative measures such as the administration of fluids and antibiotics, early definitive treatment or evacuation to base hospitals of injured soldiers who could not be managed definitively at the field hospital, and preoperative radiographs to localize all in-driven bone and metal fragments. Also, the surgical technique used by Italian military surgeons closely resembled that of Allied surgeons, which was a refinement of the technique initially introduced by Harvey Cushing during WWI.6,7 This technique consisted of exposure of the injury via craniotomy or craniectomy, and adequate and aggressive intracranial debridement and irrigation to remove all fragments, debris, and hematomas. Other surgical acts that were shared by Italian and Anglo-American surgeons were correct patient positioning to favor fragment removal, overall aseptic technique, debridement of scalp wounds, use of generous curvilinear flaps with the wound defect in the center to avoid a closure under tension, and watertight dural closure primarily or with a fascial graft if necessary.3

The need for infection prevention and treatment is also described in the report, and the precautions taken to achieve this aim have many similarities with those adopted by the Allied surgeons. These included lumbar drainage of cerebrospinal fluid to reduce postoperative fistula formation, prophylactic and postoperative antibiotics, adequate wound debridement with antimicrobials and antisepsis, abundant irrigation, leaving the surgical drain in place for the shortest period possible, and removal of all retained bone and metal fragments.3,79 The primary difference between the Italian and Anglo-American physicians was that penicillin was not available to the Italian army’s surgeons, who used only sulfonamides. Another major difference in the organization of neurosurgical care was that Italian war surgeons were not fully committed to neurosurgery and were performing abdominal, thoracic, orthopedic, and other surgeries together with brain and spine surgery.1 In contrast, Allied neurosurgeons were fully dedicated to neurosurgery and had attended specific neurosurgery courses before traveling to frontline hospitals, and mobile neurosurgery units could be deployed where the need for specialized neurosurgical care was greatest.3,10

Most of the Italian surgeons, like the Anglo-American ones, had been called up for duty from private and university practice, whereas only a minority of them were professional army surgeons.4,10 Because of the limited number of reports describing war neurosurgery in Italy during WWII, we do not know if those surgeons had received specific training in war-related neurosurgery before being deployed in war zone hospitals. However, their practice had likely been influenced by Italian and foreign military surgeons operating during WWI, such as Lorenzo Bonomo, an Italian army surgeon who wrote several papers and books about war neurosurgery, or Harvey Cushing, whose surgical techniques are cited sometimes in the report.11

Likely resulting from the adoption of similar surgical techniques and head injury management protocols, the death rate for head injuries of 12.5% that was reported by the Sinanaj surgeons compares with those reported by other American and British neurosurgeons operating during WWII. Ascroft reported a mortality rate of 15% in 292 patients treated for penetrating injuries of the head.12 Shearburn and Mulford, in their records of the 14-month Italian campaign, recorded an operative mortality rate of 12.3%.13 These operative mortality rates were considerably lower than those reported by surgeons during WWI, which were around 50% to 60%.3,14

As with many other series reported by surgeons during WWII, the main area of weakness of the report is the lack of long-term follow-up and functional/neurological outcomes.

Since WWII, the management of penetrating head injuries has evolved from the aggressive cranial debridement and watertight dural closure pursued by Italian and Allied surgeons. During the Israel-Lebanon War in 1982, the local minimal debridement and closure technique was introduced, following some studies that have indicated that aggressive cerebral debridement may result in worse outcomes.15 In current conflicts, with the application of modern medical technology and particularly computed tomography at combat support hospitals, large cranial decompression within 2–3 hours after injury, accompanied by intracranial pressure monitoring and ventricular drainage, and minimal debridement have become the standard.1618 Decompressive craniectomy allows for maximal intracranial pressure management prior to early transfer to tertiary military hospitals, which often occurs through long flights without neurosurgical assistance.17 In contrast, the only measure to lower intracranial pressure during WWII at the Sinanaj hospital was serial spinal taps, and patients remained at field hospitals for long periods. Finally, today, watertight dural closure is no longer commonly pursued by surgeons, and dural onlay substitutes are used to reduce operative time and facilitate subsequent cranioplasty.16,17

Nevertheless, several aspects of the management of head injuries during wartime described by Italian and Allied WWII surgeons have contributed to the development of the contemporary approach or are still in the standard of care.3

Conclusions

The status of Italian military neurosurgery during WWII, derived from the surgical management of war-related head injuries at the field hospital of Sinanaj, resembles that of US and British military surgeons at that time. The general principles of head injury management, surgical technique, and measure for infection treatment and prevention are similar to those described in the series of the Allied surgeons and share many aspects with the current standard of care.3

Acknowledgments

Most information presented in this article was taken from copy no. 486 of the report on the surgical activity of the Sinanaj hospital in Albania, which was written by Captain Nino Della Mano and colleagues in 1941. In May 1942, Captain Nino Della Mano gave copy no. 486 of the report to Lieutenant Colonel Amato Calcagni, who was a professional army surgeon working in Milan during WWII. Calcagni was the great-grandfather of one of the authors of the present article, Andrea Franzini, who recently found that copy.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Franzini, Rossini. Acquisition of data: Franzini. Analysis and interpretation of data: Franzini. Drafting the article: Franzini. Critically revising the article: all authors. Reviewed submitted version of manuscript: Franzini. Approved the final version of the manuscript on behalf of all authors: Franzini. Administrative/technical/material support: Franzini. Study supervision: Franzini.

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    Bell RS, Mossop CM, Dirks MS, et al. Early decompressive craniectomy for severe penetrating and closed head injury during wartime. Neurosurg Focus. 2010; 28(5):E1.

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Captain Benny Brandvold stands "at the ready" outside of Dhahran, Saudi Arabia, during the early phase of Operation Desert Shield, fall of 1990. © Benny Brandvold, published with permission. See the article by Martin et al. (E16).

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    A and B: Photographs of the Italian military field hospital of Sinanaj in Albania. C: Map of the field hospital of Sinanaj: 1–4 and 6, barracks with operating rooms, radiology rooms, sterilization rooms, dressing and plaster rooms, wards for immediate postoperative observation of surgical patients, and generators; 7, emergency room and admission; 5 and 8–10, patient wards; 11, kitchen for officers; 12, kitchen for soldiers; 13, antiaircraft shelter; 14, dentistry ward. Photographs were taken during the Greco-Italian War (October 1940–April 1941) and were originally published in the report on the surgical activity of the Sinanaj hospital in Albania, written by the military surgeons of the 34th Surgical Nucleus and 427th Field Hospital.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

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    Photographs of the military surgeons, nurses, and soldiers of the 34th Surgical Nucleus (left) and 427th Field Hospital (right), who operated in the field hospital of Sinanaj during the Greco-Italian War. Photographs were taken during the Greco-Italian War (October 1940–April 1941) and were originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

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    Report on the surgical activity of the Sinanaj hospital in Albania, written by the military surgeons of the 34th Surgical Nucleus and 427th Field Hospital.1

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    The makeshift obscure chamber where Dr. Fossati, the radiologist of the 34th Surgical Nucleus, printed 569 radiographs showing various body parts of injured soldiers. The photograph was taken during the Greco-Italian War (October 1940–April 1941) and was originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

  • View in gallery

    A neurosurgical operation in one of the operating rooms of the Sinanaj field hospital. Military surgeons have draped the patient’s head, placed hemostatic clamps, and are performing a surgical operation for a war-related head injury. The photograph was taken during the Greco-Italian War (October 1940–April 1941) and was originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

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    Surgical ward at the Sinanaj field hospital. The photograph was taken during the Greco-Italian War (October 1940–April 1941) and was originally published in the report on the surgical activity of the Sinanaj hospital in Albania.1 The photographer, who is unknown, was hired by the Royal Italian Army, which disbanded in 1943.

  • View in gallery

    Left: Lateral radiograph showing a vault fracture close to the lambdoid suture with a bone fragment driven into the brain (black arrows). Right: Anteroposterior radiograph showing the skull defect and in-driven bone fragment (black arrow). These radiographs were acquired by Dr. Franco Fossati at the Italian military hospital of Sinanaj during the Greco-Italian War and were reproduced in the report of the hospital’s surgical activity.1

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    Anteroposterior radiograph showing a depressed fracture in the left parietal region with a large in-driven bone fragment (black arrow). This radiograph was acquired by Dr. Franco Fossati at the Italian military hospital of Sinanaj during the Greco-Italian War and was reproduced in the report of the hospital’s surgical activity.1

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