CHAPTER VI
Salerno to the Gustav Line
By 10 July 1943, when the invasion of Sicily was launched, Lt. Gen. Mark W. Clark`s Fifth Army had been training in North Africa for six months without any specific objective. Alternative plans had been prepared for operations against Sardinia and for landings at various points in southern Italy, but a final choice was deferred until the end of the Sicily Campaign was in sight. The successful bombing of Rome on 19 July helped tip the scales in favor of the Italian mainland. The Combined Chiefs of Staff approved Operation AVALANCHE for the Naples area on 26 July, the day after the fall of Mussolini. 1Thesite was eventually narrowed to Salerno and the target date fixed as 9September.
The Italian campaign was never an end in itself. It was not intended to strike a decisive blow at Germany through the back door. Two of its purposes were to tie down enemy troops and acquire additional bases for air attacks on German centers of production and communications. After strategic air bases in southern Italy were secured, the campaign would become a giant holding operation, the success of which would be measured not in territory gained but by the size of the enemy force immobilized. It was recognized from the beginning that Italy would require appreciable quantities of food, clothing, fuel, and medical supplies to maintain her civilian population. The anticipated gains nevertheless appeared to outweigh this additional logistical burden.2
As in earlier Mediterranean campaigns, operations in Italy were to employ both American and British troops. The invading force was again to be the 15th Army Group, under command of General Alexander, although Fifth
1 General sources for the Salerno-Gustav Line campaigns are: (1) Fifth Army History, pt. I, From Activation to the Fall of Naples, pt. II, Across the Volturno to the Winter Line, pt. III, The Winter Line, pt. IV, Cassino and Anzio (Florence, Italy: L`Impronta Press, 1945; (2) Chester G. Starr, ed., From Salerno to the Alps: A History of the Fifth Army, 1943-1945 (Washington: Infantry Journal Press, 1948); (3) AMERICAN FORCES IN ACTION, Salerno: American Operations from the Beaches to the Volturno (Washington, 1944), From the Volturno to the Winter Line (Washington, 1944), and Fifth Army at the Winter Line (Washington, 1945); (4) Craven and Cate, eds., Europe-TORCH to POINTBLANK; (5) Morison, Sicily-Salerno-Anzio; (6) Field Marshal the Viscount Alexander of Tunis, "The Allied Armies in Italy from3rd September, 1943, to 12th December, 1944, Supplement to the London Gazette, 6 June 1950, pp. 2879-2918; (7) Mark W. Clark, Calculated Risk (New York: Harper and Brothers, 1950), pp. 183-282, 311-33; (8) Truscott, Command Missions ; (9) Eisenhower, Crusade in Europe;(10)Kesselring, A Soldier`s Record; (11) S. Sgt. Richard A. Huff, ed., The Fighting Thirty-sixth (San Angelo, Tex: Newsfoto Publishing Co., 1946), unpaged; (12) Taggart, ed., History of the Third Infantry Division in World War II; (13) Dawson, ed., Saga of the All American; (14) The Fighting Forty-fifth;(15)Howe, 1st Armored Division.
2 (1) Clark, Calculated Risk, p. 3. (2) Army Service Forces, Final Report, Logistics in World War II (Washington, 1947), p. 39. (3) Logistical History of NATOUSA-MTOUSA, pp. 331-40.
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Army would replace Seventh Army with some reshuffling of combat elements. Montgomery`s British Eighth Army was to cross the Strait of Messina and move over the instep of the Italian boot to seize the important Foggia air base on the Adriatic side of the peninsula. Clark`s Fifth Army was to expand northward from the Salerno beachhead to occupy the vital port of Naples. Operations in Italy thereafter would be determined by circumstances and by Allied strategy for the war as a whole.
Fifth Army was to consist initially of two corps, one British and one American. The British10 Corps, commanded by Lt. Gen. Sir Richard L. McCreery, included an armored and 2 infantry divisions, augmented by 2 Commando units and 3 American Ranger battalions. The U.S. VI Corps, under Maj. Gen. Ernest J. Dawley, included 1 airborne, 1 armored, and 4 infantry divisions. The assault troops were to be the British 46th and 56th Infantry Divisions, the Commandos, the Rangers, and the American 36th Infantry Division, the last without previous combat experience but fresh from intensive training in both amphibious and mountain warfare.
Two regimental combat teams of the 45th Division, which had been diverted to Fifth Army midway through the Sicily Campaign, were to constitute a floating reserve. The 34th, which had seen hard fighting in Tunisia, and the 3d, which had participated in the TORCH landings and fought throughout the campaign in Sicily, were to be brought in as rapidly as shipping became available. The British 7th Armoured and the U.S. 1st Armored Divisions were to beheld back for later use, when terrain and circumstances warranted.
Medical Plans for AVALANCHE
Fifth Army was activated on 5 January 1943, with headquarters at Oujda, French Morocco. It was the first American field army organized overseas during World War II. The medical section, drawn in part from personnel of the task forces and in part from the United States, was initially headed by General Blesse. Col. (later Maj. Gen.) Joseph I. Martin became Fifth Army surgeon in April when Blesse became Surgeon, NATOUSA.3
By way of preparation for its still unspecified mission, Fifth Army established various specialized training centers, including the Invasion Training Center at Arzew, Algeria, devoted to amphibious tactics. Medical personnel participated in all training exercises. The surgeon and members of his staff made frequent inspections of medical operations in the theater, including observations of combat on the Tunisian front. From time to time members of the medical section were placed on temporary duty with the British First and Eighth Armies in Tunisia in order to study the organization of the British medical service and its methods of hospitalization and evacuation.
Medical planning for the Salerno assault was directed by Colonel Martin, with Col. Jarrett M. Huddleston, the VI Corps surgeon, participating in matters affecting the corps. A British medical officer representing 10 Corps was detailed to the planning group, and close liaison
3 Except as otherwise noted, sources for this section are: (1) Annual Rpt, Med Sec. NATOUSA, 1943; (2) Annual Rpt, Surg, Fifth Army, 1943; (3) Glenn Clift. Field Opns, pp. 203-19; (4) Zelen, Hospitalization and Evacuation in MTOUSA; (5) Unit rpts of med units mentioned in the text.
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was maintained throughout with the medical section of Allied Force Headquarters. With certain important variations, the plans for medical service in Italy followed those carried out in Sicily.
Combat Medical Service
In addition to the medical detachments and medical battalions organic to the divisions committed, plans for the Italian campaign called for the use of one ambulance company and four medical battalions to be controlled by VI Corps. One of these--the 261st Amphibious Medical Battalion, specially trained for beach operations--could not be spared from Sicily and the 52d was substituted. The other separate medical battalions on the original troop list were the54th, the 161st, and 162d.
The two latter units were reorganized just before the Salerno operation from the 1st and2d Battalions, respectively, of the 16th Medical Regiment, which went out of existence at this time. Both battalions had seen combat service in Tunisia. Only the 162d was scheduled for the D-day convoy, so that it alone was organized into three collecting-clearing companies on the Sicilian model. It was the 162d Battalion that drew the beach assignment.
If this combat medical support seems inadequate in comparison to that employed in the Sicily Campaign, it must be remembered that the Salerno assault was to be made over only one relatively narrow beach and that only two American divisions were to be used, in contrast to the 4-division, multiple-beach assault in Sicily. A difference of emphasis in the plans for Italy would also bring evacuation hospitals into action at an earlier stage of the fighting. As was true in the Sicilian operation, all medical units to be employed in the Salerno landings were given rigorous training in amphibious warfare, along with the combat elements they were to serve.
The combat medical units were to be supported by elements of the 4th Medical Supply Depot on the D-day convoy. In addition to the regular maintenance allowances, medical personnel in the assault were to carry extra supplies of critical items such as plasma, litters, blankets, atabrine, plaster of paris, dressings, and biologicals. Medical supplies in specially designed containers were also to be carried ashore by the combat troops. Developed at the Fifth Army Invasion Training Center, these containers were made from empty mortar shell cases, were waterproof, and would float
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easily. Maximum weight was seventy pounds.
Hospitalization
Plans for hospitalization, both in the assault phase and in subsequent stages of the campaign, took full account of delays and deficiencies in bed strength experienced in previous Mediterranean operations. As in Sicily, each division (except airborne) was to be supported by one 400-bed evacuation hospital. The number of 750-bed evacuation hospitals assigned to Fifth Army, however, was double the previous allowance of one for each two divisions. General Blesse, who had been willing to abandon the 750-bed evacuation altogether after the campaign in southern Tunisia, had come to regard it as a most valuable unit when properly used.4 In addition, four field hospitals, and a fifth less one platoon, were scheduled for the use of U.S. ground forces in Italy.
The 400-bed evacuation hospitals on the Fifth Army troop list were the 15th, with combat experience in both Tunisia and Sicily; the 93d, with Sicilian experience; and the94th and 95th, both of which had served as fixed units in Africa. The 750-bedevacuation hospitals were the 38th, with Tunisian experience; and the 8th,16th, and 56th, all of which had operated as fixed hospitals in the theater. Field hospitals on the troop list were the 4th, less one platoon, with experience in the Middle East; the 10th and 11th from Sicily; and the 32dand 33d, direct from the United States. The 3,000-bed 3d Convalescent Hospital was also assigned to Fifth Army for duty in the combat zone.
These mobile units were to be followed into Italy within 45 days by six 500-bed station hospitals and four 1,000-bed generals. The troop list also called for the early arrival of a general dispensary, a food inspection detachment, a hospital train,2 medical laboratories, 2 medical supply depots, and 3 malaria controlunits.5
The troop list thus called for 9,500 mobile beds and 7,000 fixed beds, to be phased in as rapidly as the progress of the campaign and the availability of shipping permitted. Beyond this point the preinvasion planning did not extend. The further build-up of hospitals in Italy would be determined by events.
The pattern for the use of mobile hospitals laid down in plans for the beach interlude of the Italian campaign differed sharply from the plans followed in Sicily. In the earlier campaign, field hospital platoons with attached surgical teams had gone in with the D-day convoy, but no evacuation hospitals had been sent to Sicily before D plus 4. In the Italian plans, nine teams of the 2d Auxiliary Surgical Group were to be in the assault wave, attached to the divisional clearing platoons and to the beach battalion. Field hospitals were scheduled for later convoys, to be used only after the beachhead was secure; but two evacuation hospitals, the 95th (400 beds) and the 16th(750 beds), without their nurses, were to be on the D-day convoy. The nurses were to come on D plus 2.
In spite of the emphasis on the early provision of adequate hospitalization in Italy, it would still be necessary for
4 Col T.H. Wickert, Rpt of Visit to ETO and NATOUSA, 1 Sep to 24 Oct 43.
5 See pp.327 ff., below.
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hospitals in the Bizerte-Tunis area to carry the primary burden until sufficient fixed beds could be established on the peninsula. The Eastern Base Section was directed accordingly to make 450 beds a day available from D plus 4 through D plus 30. Corresponding arrangements were made to shift patients to the Constantine, Oran, and Casablanca areas to provide the needed beds.6
Evacuation
Plans for evacuation from the Salerno beachhead followed the Sicilian pattern. The Navy was again to be responsible for personnel on naval vessels between ports of embarkation and the high-water mark on the landing beaches. During the first three days of the operation, American casualties were to be evacuated to North Africa on troop transports, in care of naval medical personnel, but LST`s with Army medical attendants aboard would also be available ifneeded.7 Thereafter, hospital ships were to be used, under direct control of Allied Force Headquarters. Two British hospital ships were to begin evacuation from U. S. beaches at dawn on D plus 3, and a third British vessel was to follow twenty-four hours later. The casualties in each case were to go to Bizerte. On and after D plus 5, hospital ships were to be dispatched to Italy on request of Fifth Army, and routed back to such North African ports as AFHQ might designate.8
Air evacuation was also to follow the general pattern used in Sicily, with the 802d Medical Air Evacuation Transport Squadron again drawing the assignment. This time, however, litters and blankets were given top priority on air transports from North Africa and Sicily, rather than being left for slower and less certain transportation by water. Air evacuation was to start as soon as suitable landing fields were available, tentatively forecast for D plus7. 9
Medical Support in the Conquest of Southern Italy
Salerno Beachhead
The Salerno landing stook place as planned on the early morning of 9 September 1943. The surrender of Italy, announced over radio to the troops of Fifth Army and to the world by General Eisenhower a few hours earlier, in no way lessened the hazard of the operation. Veteran German troops, including armor and heavy guns, were already alerted in the area, with reinforcements close at hand. Minefields held the transports twelve miles offshore and forced loaded landing craft to stand by for hours at their assembly points while channels were being cleared. All of the assault waves were met by heavy fire.10
6 AFHQ Msg7235, Surg to CO EBS, CG MBS, CG Fifth Army, 28 Aug 43. See also pp. 196-197,above.
7 Each LST had one medical officer and two enlisted men from the Medical Department. The officers were detached from the 23d General Hospital, then staging at Casablanca, and the enlisted men were drawn from a replacement depot in the Eastern Base Section. Surg, NATOUSA, Journal, 24 Aug 43.
8 The Italian Campaign, Western Naval Task Force: Action Rpt of the Salerno Landings, Sep- Oct 43, pp. 213-16.
9 (1) Med Hist, 802d MAETS, 1942-44. (2) Med Hist, Twelfth Air Force.
10 (1)The Italian Campaign, Western Naval Task Force: Action Rpt of the Salerno Landings, Sep- Oct 43. (2) Opns Rpt, VI Corps, Sep 43. (3)Fifth Army History, pt. I, pp. 31-42. See also, additional sources cited at the beginning of this chapter.
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The first U.S. combat teams ashore, the 141st and the 142d, met stiff opposition. One battalion of the 141st was pinned down on the beach for more than twelve hours, but other elements of the 36th Division advanced inland up to three miles. Similar gains were made in the British sector, with Ranger spearheads on the extreme left flank penetrating as far as five miles. The first days fighting included German tank attacks against infantry positions. As in Sicily, the tanks were turned back by bazookas, grenades, and accurately directed fire from naval guns, as well as by artillery.
Medical Service in the Assault- Collecting companies of the 111th Medical Battalion, organic to the 36th Division, were split for the assault into three sections, each consisting of one medical officer and twenty-two litter bearers. One section accompanied each battalion landing team, working directly with personnel of the battalion aid station. For the first several hours of combat, medics could do little more than administer first aid. Casualties were left in ditches and foxholes, or behind dunes--wherever cover of any sort could be found--until darkness made it possible to move them. Two of the three collecting companies of the 111th were assembled by late afternoon and set up their stations on the fringes of the ancient walled town of Paestum. The clearing company landed toward evening, but could not establish station until its equipment was unloaded on D plus 1.
The only clearing stations in operation on D-day were two set up by the 162d Medical Battalion, which constituted part of the beach group attached to the 531st Engineer Shore Regiment. The beach group also included the medical section of the 4th Naval Shore Battalion and a supply dump established about noon by a detachment of the 4th Medical Supply Depot.
Casualties were gradually collected as stations were set up, and before dawn of D plus 1 substantial numbers had reached the beach installations. All units were shorthanded, with some men yet to come ashore and others wounded or separated from their outfits. In the circumstances, it was impossible to follow any rigid doctrine. Casualties were brought to the beach by whatever means were at hand, including ambulances, jeeps, trucks, and hand-carried litters. In some instances the naval shore battalion sent its own medical officers and corpsmen inland to work with the Army doctors and help bring out the wounded.
Casualties were evacuated to the transports by the naval shore battalion as opportunity offered and as small craft were available. The total from the American sector through D plus 1 was 678.11
The 179thRegimental Combat Team of the 45th Division was committed from the floating reserve early on 10 September, D plus 1, followed by the 157th RCT the next day. Again each battalion landing team was accompanied by its
The medical sources primarily relied upon for the assault phase are: (4) Annual Rpt, Med Sec, NATOUSA, 1943; (5) Annual Rpt, Surg, Fifth Army, 1943; (6) Annual Rpt, Surg, VI Corps, 1943; (7) Unit rpts of div surgs, med bns, hosps, and other med units mentioned in the text.
11 This figure, from the Report of the Fifth Army Surgeon for 1943, is considerably higher than the total of 430 for the same 2-day period listed in the records of the Peninsular Base Section later. The larger figure presumably includes Navy as well as Army casualties. See also, Table 19, p. 343, below.
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LITTER BEARERS WADING TO LANDING CRAFT OFF SALERNO, 9 SEPTEMBER
own aid station personnel and by a litter section of the organic medical battalion, in this case the 120th. Collecting companies were assembled within a few hours. The clearing company of the 120th, although it had been divided into three detachments for the landings, was reassembled on the afternoon of 10 September and opened station near Paestum on the 11th.
Evacuation from the front was following a normal pattern by D plus 2, although lengthening lines continued to be under intermittent fire. Even the beach installations were not secure as enemy planes were still in the air. One German plane was shot down and exploded a hundred yards from the clearing station of the 120th Medical Battalion. "Patients carried in but a few hours before," observed the battalion historian, "displayed unusual agility in jumping from operating tables into foxholes."12
Only 128 casualties were evacuated seaward on D plus 2 because of a shortage of small craft, which were being used to unload ammunition, and there was no evacuation at all on D plus 3, 12 September. The hospital ship Newfoundland stood offshore until dusk but was ordered to move fifty miles out to
12 Hist,120th Med Bn, Sep 43.
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PLANNERS OF THE INVASION OF ITALY. Generals Truscott, Eisenhower, Clark, and Lucas.
sea for the night, so that her lights would not guide enemy planes to the transport area. She was bombed and sunk before she could return the next morning. Evacuation by hospital ship actually began on 13 September, D plus 4; air evacuation started four days later.
Facilities forholding casualties ashore were still inadequate, despite careful planning to avoid just such a contingency.13 Personnel of the 95th and 16th Evacuation Hospitals had landed about noon on D-day, but their equipment was scattered and suitable sites were not yet available. The 95th had 250 of its 400 beds ready for occupancy by 0600 on 12 September. The larger 16th was not able to get into operation until midnight 14-15 September. Both units were in the vicinity of Paestum. The nurses of both hospitals had been aboard the Newfoundland when that vessel was bombed. Some suffered minor injuries, and all lost personal belongings. The nurses were carried back to Africa by rescuing ships and did not rejoin their units until 25 September.
13Surg, NATOUSA, Journal, 13 Sep 43.
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The beach clearing stations of the 162d Medical Battalion were no longer needed by 13 September and were closed on that date. For the remainder of the beach phase of the operation casualties were evacuated by collecting companies of the 162d Medical Battalion directly from the division clearing stations to the evacuation hospitals, and thence to ships or planes. No other corps or army medical battalions were available until after the breakout.
A massive German counterattack launched on 13 September drove a deep wedge between the British and American salients, penetrating to within three miles of the beach, but the ground troops finally stopped the attack with the aid of naval gunfire and Allied planes. The 504th Parachute Infantry Regiment of the 82d Airborne Division was dropped behind enemy lines at this time. With Eighth Army closing in from the south, the Germans had no time for another attempt. They withdrew slowly, fighting all the way, but by 20 September the beachhead was secure.
Coinciding with the German withdrawal there was a regrouping and reassignment of U.S. units. Maj. Gen. John P. Lucas took command of VI Corps from General Dawley on 20 September. The 3d Division replaced the battle-weary 36th in the line, and the 34th Division, which reached Salerno at about the same time, went into reserve. On the 10 Corps front, the British 7th Armoured Division entered combat.
The next phase of the campaign would carry the Allied forces to Naples and to the Volturno River beyond. The 7th Armoured and the 82d Airborne Divisions moved up the coast on the left flank, followed by the British 46th Division. The British 56th, a few miles inland, drove for Capua, while the 3d struck toward the Volturno by way of Avellino. The 45th, on the right flank, swung out in a wide arc toward Benevento, where the 34th, operating to the right of the 3d since 26 September, caught up. Attached to the 34th was the 100 thBattalion, made up of American-born Japanese, which would later be part of the 442d Regiment.
Hospitalization on the Beachhead- All army medical units reverted to army control on 21 September. By this date the build-up of medical facilities was substantial, with new units arriving steadily as the campaign moved northward. The 3d and 34th Divisions were accompanied by their organic medical battalions, the 3d and 109th, respectively. The 93d Evacuation Hospital reached the area on 15 September, opening at Paestum the following day. The 94th, which arrived about the same time, was established at Battipaglia a week later. The 8th and 38th Evacuation Hospitals, both 750-bed units, and the 52dMedical Battalion disembarked on 21 September, although all equipment belonging to the 8th was lost by enemy action. Still another 750-bed evacuation, the 56th, reached the beachhead on 27 September, followed next day by the 16lst Medical Battalion.
Despite the number of hospitals ashore, beds remained at a premium during the entire month of September. Many units were slow in getting into operation because equipment was lost or delayed. The rapid troop build-up made heavy demands on hospital facilities, and the disease rate--especially from malaria--was higher than had been antici-
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pated. Typical was the experience of the 95th Evacuation Hospital, first U.S. hospital to be established on the European continent in World War II. The hospitals commander, Lt. Col. (later Col.) Paul K. Sauer, reported:
At times we were overfilled to such an extent that all cots were in use, other patients remained on the litters on which they had been brought to us in lieu of cots, and others were given two blankets to enable them to sleep on the ground. When the tents were filled to capacity, patients were laid on the outside along the walls of the tents with their heads inside and their bodies outside. On one night even this method was insufficient to take care of all the patients and forty of them slept under the open sky between the tents. Fortunately the weather was balmy and dry.14
The weather did not long remain either balmy or dry. On the night of 28 September a violent storm leveled the tents of the 16th Evacuation Hospital, where 961 patients were being cared for, and did severe damage to the installations of the95th. By heroic effort, all patients were rescued without injury and moved to a tobacco warehouse about a mile away, made available for the emergency by Services of Supply. There they were temporarily cared for by personnel of the 8th Evacuation. The tobacco factory was later operated as an annex to the 16th, by personnel of the 8th. General Blesse, who arrived on the beach head on 25 September, had spent the preceding night at the16th Evacuation and witnessed the destruction.15
As soon as the storm was over, the 38th Evacuation Hospital, still in bivouac awaiting assembling of its equipment, began setting up a hospital, using equipment borrowed from the still inactive 56th. The 38th began admitting patient sat 0830, 29 September. (Map 21)
Across the Volturno
Combat Medical Service-During the drive to the Volturno, medical service in the field followed a normal pattern. Division clearing platoons leapfrogged one another, casualties being carried back to the beachhead by the corps medical battalions. Collecting companies of the 52d Medical Battalion took over evacuation of the 45thand 3d Divisions from the l62d on 29 and 30 September, respectively. The 34th Division, the 82d Airborne, and the Rangers were evacuated by collecting elements of the 162d Medical Battalion.16
The advancing troops were delayed by mountainous terrain and by the expert demolitions for which the retreating Germans were noted. The enemy chose to fight only rear-guard actions until he reached prepared positions beyond the Volturno. Avellino fell to the 3d Division on 30 September, and a reconnaissance troop of the 45th entered Benevento two days later. The British 7th Armoured Division had meanwhile
14AnnualRpt, 95th Evac, 1943.
15 In addition to unit reports of the hospitals mentioned, see Col Reeder, Diary of Inspection Trip With Gen Blesse, 25 Sep-2 Oct 43. See also Ltr, Col Bauchspies to Col Coates, 15 Apr 59, commenting on preliminary draft of this volume. Colonel Bauchspies was at that time commanding officer of the 16th Evacuation Hospital.
16 Military sources for this section are the same as those cited in previous notes, with the addition of Fifth Army History, pt. I. pp. 43-49; Pt. II, pp. 1-55; and Opns Rpts, VI Corps, Oct and Nov 1943. Medical sources include theater, army, corps, and division surgeons reports already cited, and unit rpts of medical units mentioned in the text.
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MAP 21--Fifth Army Hospitals and Medical Supply Dumps, 9 October 1943
occupied Naples without opposition on 1 October, leaving the city to be garrisoned by the 82d Airborne.
As VI Corps neared the Volturno, the distance between division clearing stations and evacuation hospitals lengthened, finally approaching the 100-mile ambulance runs of the Tunisia Campaign. To cut down the long haul over bomb-scarred and blasted roads, the 93d Evacuation moved from Paestum to Montella, along the 3dDivisions route to Avellino, on 2 October. In Naples, on the same date, the 307th Airborne Medical Company and a detachment from the 162d Medical Battalion opened a provisional evacuation hospital. The 307th had arrived from Sicily by boat only two or three days earlier.
By 6 October forward elements of both 10 and VI Corps had reached the Volturno River. Eighth Army, meanwhile, had captured the vital complex of airfields around Foggia on 1 October, and had moved on to extend the Volturno line to Termoli on the Adriatic.
At the Volturno, Fifth Army paused only long enough to bring up equipment necessary to replace bridges blasted by the retiring enemy, and to move artillery forward through hub-deep mud. In its upper reaches the Volturno River flows southeast, or roughly parallel to the long axis of the Italian peninsula. At the
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point where the Calore enters the Volturno from the east, the latter river turns west at an acute angle to reach the Tyrrhenian Sea some 20 miles north of the Bay of Naples. The south bank, from the coast to a point just east of Capua, a distance of perhaps 15 miles, was held by 10 Corps. The VI Corps front continued the river line another 15 miles to the junction with the Calore, and on eastward for a similar distance to the point of contact with Eighth Army. The 3d Division crossed the Volturno through the Triflisco Gap on the left of the VI Corps front, while the 34th crossed 8 or 10 miles farther east, near the mouth of the Calore. The 45th Division held the right flank, advancing into the mountains north of the Calore and east of the Volturno.
The 3d and 34th Divisions began crossing the river at 0200 on 13 October, after prolonged artillery preparation. Incessant rain during the first week of October had turned the normally shallow stream into a swift-flowing torrent, 200 or 300 feet wide and varying in depth from about 4 feet to the height of a tall mans shoulders. Rubber boats and rafts were used, and some swam the swollen river, but most of the men waded across, clinging to guide ropes with one hand and holding their rifles overhead with the other. All crossings were made under continuous fire from machine guns and small arms on the north bank and from artillery farther to the rear.
Battalion aidmen, reinforced by litter bearers from the collecting companies of the organic medical battalions, forded the river with the assault troops. Ambulance loading posts were set up on the near shore, close to the sites previously chosen for bridging, and casualties were ferried back until dawn on rafts pulled by ropes. When daylight made further evacuation across the river impossible, casualties were held in pools on the far bank, wherever terrain afforded adequate protection.
On the 3d Division front, light bridges were thrown across the river during the first day of the attack. The engineers, working under direct observation and artillery fire of the enemy, had more difficulty in the 34th Division area, but despite the hazards managed to span the stream by the morning of 14 October. As soon as the bridges were available, collecting companies of the organic medical battalions crossed the Volturno to follow the troops. Clearing stations remained on the south bank until the bridgehead had been pushed several miles beyond the river. The 3d Medical Battalion had a station in operation north of the Volturno the morning of 16 October, and the l09th Medical Battalion clearing station, supporting the 34th Division, was functioning on the far bank by the 18th. Thereafter, until the Winter Line was reached about the middle of November, evacuation from both divisions followed the normal pattern, the clearing platoons bypassing one another as the troops advanced.
The 52d Medical Battalion took over evacuation of the 34th Division from the l62d on 17October, thus becoming responsible for all evacuation from VI Corps.
Simultaneously with the Volturno crossings of the 3d and 34th Divisions, the 45th moved up on the east side of the river to parallel the advance. Fighting was heaviest on the lower slopes of the Matese Mountains, where the task of bringing out the wounded was formi-
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MEDICS TREATING ITALIAN GIRL INJURED IN THE VOLTURNO AREA
dable, but the heights of Piedimonte d`Alife were gained by 17 October without undue casualties.
Enemy positions on the coastal plain, meanwhile, had proved stronger than anticipated. The British 46th Division on the 10 Corps left flank, and the 7th Armoured in the center, had forced crossings of the Volturno the night of 12-13 October, but the British 56th Division in the Capua area had been unable to cross without taking losses deemed too heavy by the Fifth Army command. Plans for further advance were therefore altered by shifting the corps boundary to the east. The 56th displaced to its right, crossing on the 3d Division bridge at Triflisco on 15 October. The 3d Division also shifted to the right, into the 34th Division sector, while the 34th crossed the upper Volturno on 19 October to a position in front of the 45th.
Both corps moved slowly forward against stubborn opposition for another two weeks. Then on the night of 3-4 November the 45th crossed the Volturno from east to west, south of Venafro, and the 34th recrossed north of that town, leaving the 504th Parachute Infantry, which had come into the line a few days
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earlier, to strike toward Isernia and hold the high ground on the right flank. The 3d Division struck toward Mignano Gap on the left of the corps area.
By 15 November Fifth Army had reached another German defensive position, the Winter Line. Since 6 October a strongly fortified river line had been breached and gains registered from seventeen miles along the coast to forty-five miles on the right flank of the Fifth Army front. The new line extended along the south bank of the Garigliano River to the junction with Eighth Army west of Isernia, and included the towns of Mignano and Venafro. The mountains, however, had become steadily more precipitous and the weather progressively worse. A halt was called for regrouping and reconsideration of strategy.
In the immediate combat zone, the problems of evacuation incident to a difficult river crossing were succeeded by those of mountain fighting in which the enemy was dug in on every slope in mutually supporting positions that commanded every access road and trail. Mines, booby traps, and snipers were everywhere. Each new advance was
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MAP 22--Fifth Army Hospitals and Medical Supply Dumps, 15 November 1943
made in the face of machine gun and artillery fire from dominating slopes. The storming of mountain peaks was commonplace. Men suffered increasingly from exposure, and the strain began to show in a sharply rising incidence of combat neurosis.
The tasks of the aidmen and the litter bearers were the most arduous. Medical officers often worked at night by flashlight, with both doctor and patient concealed under blankets. Aid stations were generally 300 to 500 yards behind the point of contact with the enemy, but were sometimes as much as a week ahead of their vehicles, restricting them to such drugs and equipment as could be hand-carried. The numerous caves found in the Italian mountains were often used for aid station sites because they could be blacked out, and because they offered a measure of protection from rain, snow, and enemy shells. Collecting stations were eliminated wherever possible, but
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when used were 1 to 4 miles behind the lines, with clearing stations 6 or 8 miles farther to the rear. The irregularities of the front, however, and the exigencies of mountain fighting not infrequently brought clearing stations within range of enemy guns. Six-man litter squads were usually necessary, with carries often taking eight to twelve hours. When the corps medical battalions were drained of personnel, additional litter bearers were supplied from the combat units. Casualties among medics, and particularly among litter bearers, were high.17
Hospitalization-To keep the ambulance runs relatively short, Fifth Army hospitals moved into the combat zone as rapidly as suitable sites became available, with the 400-bed evacuations leading the way. The 95th opened in Naples on 9 October. The 93d moved hastily from Montella to Avellino on 11 October, after bombed-out bridges and swollen streams threatened to isolate the unit; then advanced again on 24 October to Piana di Caiazzo, where it was the first American hospital north of the Volturno. The 94th shifted from Battipaglia in the Salerno area to take over an Italian military hospital in Maddaloni, where it opened on 11 October. November 5 saw the94th Evacuation in Riardo, a dozen miles north of Capua. Still farther forward, the l5th Evacuation, newly arrived from Sicily, opened at Alife east of the Volturno, on 2 November. (Map 22)
The 750-bed evacuation hospitals also moved up to new locations during the period of the Volturno campaign. The 56th opened at Avellino on 6 October, shifting to Dragoni across the river from the 15th on 2 November. The 8th and 38th Evacuation Hospitals opened in Caserta on 16 October, followed by the 16th Evacuation on the last day of the month. The 38th moved on to the Riardo area, just north of the site of the 94th, on 8 November.
The field hospitals, as already noted, were late in coming into the theater, and were used only in part for direct support of the army. The 32d Field opened in Caserta on 16 October, where it functioned for ten days as an evacuation hospital before being attached to the base section. The 10th Field moved into Caserta on 29 October, also functioning as an evacuation hospital. The 11th Field, though in the theater, was inactive until the next phase of the campaign. The two available platoons of the 4th were assigned to the base section as an air evacuation holding unit.
Only the 33d Field Hospital performed services similar to those of the field units in the Sicily Campaign. One platoon of the 33d joined the 120th Medical Battalion on 17 October, operating with the 45th Division clearing station as a holding hospital for nontransportables and for forward surgery. Another platoon of the 33d joined the 11th Medical Battalion, in Army reserve with the 36th Division, on 21 October; and the remaining platoon went into the combat area with the l09th Medical Battalion, in support of
17 (1) Capt Robert L. Sharoff, The Infantry Battalion Aid Station in Operation, Med Hist Data, 3d Med Bn, 23 Oct 43. (2) Ltr, Col W. W. Vaughn to Brig Gen R. W. Bliss, 18 Jan 44, sub: Observations From Overseas Casualties. (3) Annual Rpt, Surg, 54th Div, 1943. (4) Hist, 120th Med Bn, Nov43.
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the 34th Division, the following day. All three platoons were reinforced by teams of the 2d Auxiliary Surgical Group.
The 3d Convalescent Hospital was also assigned to Fifth Army from its arrival in the theater on 10 October, but functioned in Naples rather than in the forward area until near the end of the year.
The Winter Line
Fifth Army was substantially reorganized during the last two weeks of November, before launching a direct assault against the fortified positions of the German Winter Line. The headquarters of II Corps, now under General Keyes, arrived from Sicily in October. On 18 November the 3d and 36th Divisions were assigned to II Corps, which took over the center of the Fifth Army front. The British10 Corps remained on the left flank; the 34th and 45th Divisions, making up VI Corps, were on the right.18
The 36th Division, out of combat since 20 September, began to relieve the 3d on 17 November, the 3d going into bivouac for a rest. The strength of II Corps was maintained, however, by attachment of the 1st Italian Motorized Group on 22 November and of the 1st Special Service Force the following day. The 1st Special Service Force, a commando-type unit with six battalions organized into three "regiments," had a strength equivalent to one regimental combat team--about 5,000 men. It was composed of U.S. and Canadian troops, specially trained for mountain fighting and in raiding tactics.
Three Ranger battalions and elements of the 504th Parachute Infantry were also at the front, to be used as the army commander might direct. The 1st Armored Division began unloading at Naples on 15 November and went into Army reserve. Two French divisions, the 2d Moroccan and the 3d Algerian, were also on the way from North Africa as components of a French Expeditionary Corps (FEC) under General Juin.
In addition to medical units already in the Fifth Army area, the 54th Medical Battalion and the 11th Field Hospital were assigned to II Corps. The Italian and French units under Fifth Army command had their own medical organizations, including field and evacuation hospitals.
The Winter Line proved to be only a series of strongly held outposts a few miles in front of the heavily fortified Gustav Line, where the Germans planned to make their main stand. The key to the Gustav Line was Monte Cassino, dominating the entrance to the Liri Valley through which Highway 6 and a doubletrack railroad ran northwest to Rome, a distance of about eighty miles. The approach to the Liri Valley lay through the Mignano Gap, known to the troops as Purple Heart Valley, which was controlled on either side by German-held mountain masses and barred at its outlet by the Rapido River. The plan of
19Militarysources for this section include: (1) Opns Rpts, VI Corps, Nov 43- Jan44; (2) Opns Rpts, II Corps, Nov 43- Jan 44; (3) Fifth Army History, pt. III. Citations to additional military sources will he found at the beginning of this chapter. Medical sources for the Winter Line campaign include: (4) Annual Rpt, Med Sec, NATOUSA, 1943; (5) Annual Rpt, Med Sec, MTOUSA, 1944; (6) Annual Rpts, Surg, Fifth Army; (7) AnnualRpts, Surg, VI Corps, 1943, 1944; (8) Annual Rpts, Surg, II Corps,1943, 1944; (9) Unit rpts of div surgs and med units mentioned in the text.
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campaign called first for driving the enemy from his mountain stronghold, and then forcing a crossing of the Rapido south of Cassino, at the same time executing a wide flanking movement through the mountains northwest of the town.
The attack began on 1 December with an assault against the Camino hill mass south of the Mignano Gap. The main effort was directed at the left flank by the46th and 56th Divisions of 10 Corps, while the Special Service Force of II Corps attacked simultaneously from the right. The infantry advance was preceded by the heaviest concentration of artillery fire yet used in the Italian campaign, but the result was indecisive. It was still necessary for foot soldiers to scale the heights and storm the enemy positions one by one. The operation was rendered still more hazardous by three days of continuous rain. Both lines of advance and lines of supply were under enemy fire, while bad weather prevented any effective air support. The entire Camino complex was nevertheless secured by 9 December.
The 34th and 45thDivisions of VI Corps were meanwhile attacking northwest from Venafro with the ultimate objective of outflanking Cassino by taking Sant`Elia and Atina. The VI Corps attack, launched on 29 November, was slow and costly. By 4 December the 34th Division, on the left, had gained about a mile, at a cost of 777 casualties. The 45th continued to inch forward for another five days, taking several important hill positions but making little headway toward its goal.
In the second phase of the Winter Line campaign, II Corps was to seize Mt. Sammucro, which formed the northern rampart of the Mignano Gap, and Mt. Lungo, which cut the center of the valley. VI Corps, with the 2d Moroccan Division replacing the 34th, was to try again for Sant`Elia and Atina. The II Corps objectives were taken by 17 December, after bitter seesaw battles for every knob and crest, but VI Corps again failed to make substantial headway in its flanking attack. Lack of reserves for speedy exploitation of gains was an important factor.
Mt. Trocchio, the last mountain stronghold before Cassino, was II Corps major objective in the third phase of the Winter Line campaign. The position was taken, again after slow and bitter fighting, by noon of 15 January 1944, but the crossing of the Rapido was delayed for another week by the failure to outflank Cassino from the north, and by an over-all change of plans.
General Alexander, commanding the 15th Army Group, issued orders on 2 January for the seaborne flanking movement to Anzio, and VI Corps was assigned the operation. A reshuffling of Fifth Army forces gave the 45th and 3d Divisions to VI Corps at this time. The 34th Division went back into the line as a II Corps unit, replacing the 36th, while the 3d Algerian Division relieved the 45th. The VI Corps sector was taken over by the French Expeditionary Corps the first week in January. The 1st Armored, which had been attached to II Corps about 15 December in hopes of a breakthrough into the Liri Valley, remained temporarily in the line, but went ultimately to VI Corps for the Anzio landings.
The capture of Mt. Trocchio brought Fifth Army up to the main defenses of the Gustav Line. During two months of
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rugged mountain fighting in the foulest kind of weather, the Allied forces had advanced an average of five to seven miles. Casualties had been heavy, but battle fatigue and exposure had taken an even greater toll. The enemy too had suffered heavily, but he appeared to have gained his purpose of achieving a winter stalemate. Eighth Army had driven up the Adriatic coast as far as Ortona, but Montgomery`s forcesal so failed to force a passage through the rocky fastnesses of the central Apennines to Rome.
Battlefield Evacuation- As in the Volturno campaign, the primary medical problemof the Winter Line was evacuation of casualties from the battlefields. The difficulties inherent in carrying wounded men down steep, boulder-strewn slopes, often in total darkness, were aggravated by cold and almost incessant rain or snow. Main highways were frequently under enemy fire and were overburdened with a steady stream of combat equipment. Secondary roads and trails were so deep in mud that ambulances could rarely come within five miles of the lines.
All available litter bearers of the corps medical battalions were assigned to the divisions, and these were periodically supplemented by assignment of combat personnel. Toward the end of the year, AFHQ authorized the addition of 100 litter bearers to each organic medical battalion. Continuous replacements were necessary at all levels of the medical service. Litter bearers were exposed to the same hazards as the combat troops. Many of them camped along the evacuation routes, but without the protective clothing worn by the infantrymen. Casualties among medical officers were also high, but the only available replacements were men from fixed hospitals in the base sections who lacked both battle experience and conditioning. Collecting companies were used sparingly, and where used were reduced to one medical officer each. Medical officers of the corps medical battalions were often detached for duty with the divisional medical units.19
A variety of expedients were adopted to speed the process of evacuation. Casualties from the 34th Division were brought down from Mt. Pantano by litter bearers who lined both sides of the trail and passed litters from hand to hand over their heads. 20 Litter carries ran as long as 12 to 15 hours, with 6-man squads working in relays. The 109th Medical Battalion reported using 16 such squads to move casualties over a 5-mile stretch on 12 January 1944. On the longer routes, aid stations were set up along the way to supply first aid, plasma, and hot drinks, and to give walking wounded a chance to rest. The 120th Medical Battalion used pack mules to bring out trench-foot cases, and experimented with a mule-carried litter, apparently unaware of the similar experiments carried out by the 9th Medical Battalion in Tunisia and Sicily. Experiments were also made with a modified breeches buoy, improvised from an equipment line, for lowering casualties down precipitous slopes.21
Some indication of the magnitude of
19 (1) Pers Ltr, Gen Blesse, Surg, NATOUSA, to Gen Kirk, 26 Nov 43. (2) Surg, NATOUSA, Journal, 28 Dec 43. (3) Med Hist Data, 54th Med Bn, 26 Sep 44. See also, reports of div surgs and med bns mentioned elsewhere in the text.
20 Bull of the U.S. Army Medical Department (July 1944) , p. 26.
21 Clift, Field Opns, p. 250-a.
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WOUNDED MAN BEING DUG FROM DEBRIS NEAR CASSINO
the evacuation problem may be gathered from reports of the two corps medical battalions primarily responsible for moving casualties from clearing stations to the mobile hospitals in the combat zone. The 52d Medical Battalion evacuated 25,125 sick and wounded from division clearing stations between 30 September and the end of the year. Between 15 November and 15 January the 54th Medical Battalion evacuated 16,186 patients. Even these figures do not tell the whole story, since some evacuation before 15 November was handled by the 162d Medical Battalion, while the 52d continued to operate through January.
Hospitalization-The heavy casualties of the Winter Line campaign, coupled with transportation difficulties over muddy and congested roads, soon made it necessary to bring more hospital beds into the combat area. The 95th Evacuation Hospital moved up from Naples on 28 November to a site just beyond the Volturno northwest of Capua, where it was joined by the 10th Field from Caserta on 1 December. The 15th Evac-
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MAP 23--Fifth Army Hospitals and Medical Supply Dumps, 15 February 1944
uation moved from Alife, east of the Volturno, where it had twice been flooded, to Riardo, where the 38th and 94th were already operating, on 15 December. The 8th Evacuation opened at Teano, in the same general area, the following day, while the 16th Evacuation moved from Caserta to Vairano on 28 December. For all hospitals, siting was a problem for the engineers, with mud the ever-present obstacle to be surmounted. The 93d and 95th Evacuation Hospitals, designated for the Anzio operation, were closed early in January 1944, but their places were taken by the 3d Convalescent, which opened at Pignataro Maggiore on6 January, and the 11th Evacuation, which arrived from Sicily in time to open at Vairano on 14 January.(Map 23)
With the exception of the 56th Evacuation at Dragoni and the 93d at Piana
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di Caiazzo, all of these Fifth Army hospitals were strung out along Highway 6, within a 10- or 12-mile stretch. The medical installations in the army area, including clearing and collecting stations, all suffered more or less severe damage in a New Year`s Day storm, the l5th, 38th, and 94th Evacuation Hospitals being the hardest hit. All patients of the l5th and 38th had to be moved, as well as most of those of the 94th.
The Cassino Stalemate
By way of prelude to the Anzio landings, which were scheduled for 22 January 1944, Fifth Army sought to engage the maximum German strength by way of a direct assault against the Gustav Line. The French Expeditionary Corps on the right led off on 12 January with a 3-day drive that carried General Juin`s colonials to the mountains north of Cassino. General McCreery`s British 10 Corps, with the 5th Infantry Division substituted for the 7th Armoured, crossed the lower Garigliano near the coast on 17 January. By the 20th of the month, the 5th and 56th Divisions had secured a bridgehead extending to high ground north of Minturno, but the 46th Division had failed to get across the river farther upstream, near the II Corps sector.22
Carnage Along the Rapido- The main assault was launched by General Keyes II Corps in the center of the Fifth Army front on the night of 20 January, only a few hours before the Anzio armada sailed from Naples. The assignment was probably the most difficult of the entire Italian campaign. The U.S.36th Division, commanded by Maj. Gen. Fred L. Walker, was to cross the Rapido below Cassino in the vicinity of Sant`Angelo, seize that town, and advance as far as Pignataro Interamna. Combat Command B of the 1st Armored Division was to pass through the 36th and exploit up the Liri Valley, while the 34th Division was to create a diversion before Cassino and be prepared to attack from east or south, or to follow the armor through the 36th,as circumstances dictated. The 45th Division was in reserve, to be thrown into the Cassino battle or be shipped to Anzio as the tide of battle might require.
It was a very large order. Cassino and the mountains surrounding it were heavily fortified anchor points in the Gustav Line, from which enemy artillery could rake the whole line of the Rapido River and cover the Liri Valley with crossfire. The river, itself, at that point, was a swift-flowing stream 25 to 50 feet wide and 9 to 12 feet deep, with high, brush-covered banks on either side. The approaches had been skillfully and lavishly strewn with mines, and the low ground was waterlogged by deliberate flooding. On the German side the ground was higher, with the town of Sant`Angelo perched on a 40-foot bluff that gave perfect observation. Mines and wire entanglements were backed up by a belt of dugouts and concrete pill boxes, from which the entire river line could be
22 The chief military sources for this section include: (1) Fifth Army History, Pt. IV, pp. 27-57, 87-100, 175-85; (2) Opns Rpts, II Corps, Jan-Apr 44; (3) Huff, ed., The Fighting Thirty-sixth. See note at the beginning of this chapter for additional sources. The more important medical sources are: (4) Annual Rpt, Med Sec. MTOUSA, 1944; (5) Annual Rpt, Surg, Fifth Army, 1944; (6) Annual Rpt, Surg, II Corps, 1944; (7) Unit rpts of div surgs, med bns, and other med units mentioned in the text.
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blanketed by machine gun fire. The failure of the British 46th Division to cross the Garigliano earlier in the day, moreover, had left the southern flank unsecured.
After concentrated air and artillery preparation, the 141st Regimental Combat Team moved through the mine fields to its crossing points north of Sant`Angelo, while the 143d RCT took up positions along the Rapido south of the town. The Germans were neither surprised nor unprepared. Artillery, rocket projectors, and automatic weapons met the assault. Boats were destroyed before the launching or sunk in midstream. Bridges were knocked out before they were in place. Only a handful of men from the 141st reached the western bank, and thesome what larger number from the 143d who achieved the crossing were quickly immobilized. Before dawn those able to return were recalled.
A second attempt the following day was only slightly more successful. Fog and smoke screens covered the crossings, but the German guns were zeroed in. One battalion of the 143d RCT and elements of the 141st managed to advance a half mile or so beyond the river, but reinforcement and resupply were alike impossible. The men were driven back to the river, and those who could not withdraw were isolated. When ammunition gave out, the battle was over. The 36th Division had been badly beaten.
Although many of the wounded could not be reached, and others could be brought out only with great difficulty, 308 battle casualties were processed through the clearing station of the 111th Medical Battalion on 21 January and 291 the following day. With only five medical officers available to handle this record flow of wounded, it was impossible to retain them long in the clearing station. The nontransportables were transferred immediately to a platoon of the 11th Field Hospital, which was adjacent. Those who could stand the journey were sent back by ambulance and truck to the evacuation hospitals, which were still concentrated along Highway 6 from Vairano, twenty miles behind the front, to Capua on the Volturno. Transportation was supplied by the 54th Medical Battalion.
When the Sant`Angelo sector quieted, a truce was arranged for 25 January from 1400 to 1700, and litter bearers from two collecting companies of the 111th Medical Battalion crossed the Rapido to remove the dead and wounded. A German guide led them through the mine fields and up to the barbed-wire entanglement about 10yards from the stream. There German medics turned over 12 American wounded, stating that 18 more were in the German hospital. An opportunity to inspect these was offered, but time did not permit. The dead were so numerous that all could not be removed in the 3-hour period of the truce.
The 2-day "battle of guts" cost the 36th Division 2,019 officers and men in killed, wounded, and missing, of whom 934 were wounded. 23
Frustration at the Gustav Line- The failure of the 36th Division to establish a bridgehead in the Liri Valley forced a quick change in plans. The French Ex-
23 Annual Rpt, Surg, Fifth Army, 1944, p. 40. Fifth Army History, Pt. IV, p. 47, gives a total of 1,681, broken down into 143 killed, 663 wounded, and 875 missing but the surgeon`s figures, based on unit reports, appear the more reliable.
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peditionary Corps, which had renewed its drive on 21 January, was ordered to concentrate its strength on its own left flank, while the 34th Division attempted a crossing of the upper Rapido just below the village of Cairo, at the boundary of the II Corps and FEC sectors. The 34th jumped off the night of 24 January.
Enemy positions were much the same as those encountered by the 36th Division farther south, but this time the bridgehead held. First across the river, on the morning of 25 January, was the 100th Battalion. Other elements of the 133d Regimental Combat Team followed, and all held grimly to their gains through the night of 25-26 January. The 135th RCT forced another crossing just north of Cassino in the early hours of 26 January, and the 168th crossed the next day, with four tanks. The engineers got more tanks across early on the 29th, in time to help repel a determined counterattack. To exploit the gains, the 142d RCT of the 36th Division, which had not participated in the earlier action, was attached to the 34th Division, and with the French Expeditionary Corps gained commanding heights north of Cairo. The bridgehead was secure by 31 January.
For the next two weeks II Corps threw all its strength and battle toughness into an effort to break through the Cassino defenses and cut Highway 6 behind the main German positions. The fighting was hard, close, and continuous. On 2 February elements of the 34th Division broke into Cassino itself, and on the 5th a patrol reached the walls of the Benedictine monastery high above the town. The 36th Division, decimated though it was, went back into the line. About a third of the mountainous area northwest of Cassino was overrun, and a decisive triumph seemed almost at hand. The Germans, however, were furiously reinforcing their crumbling lines, and the Allied drive was stopped a bare mile short of Highway 6. On 12 February II Corps went over to the defensive. During the next ten days the 34th and 36th Divisions were relieved by Lt. Gen. Sir Bernard Freyberg`s New Zealand Corps, made up of the New Zealand 2d Division, the Indian 4th Division, and the British 78th Division, all from the Eighth Army front.
The pattern of evacuation during the period from 24 January to 14 February resembled that of the Winter Line campaign. Litter carries were long, difficult, and exhausting since vehicles were unable to penetrate far into the mountainous area where the fighting was in progress. Again more litter bearers were essential. The 54th Medical Battalion loaned all that could be spared, averaging about 150, to the collecting companies of the divisional medical battalions. Others were recruited from among Italian labor troops, and still others were combat replacements not yet committed to battle. But the bulk of them came from noncombat elements of fighting units and from among fighting men themselves. Over 800 additional litter bearers were used by II Corps on the Cassino front in January and February 1944.
Casualties were heavy during the battle for the bridgehead, but became even heavier as tired troops penetrated the main defenses of the Gustav Line. The clearing station of the l09th Medical Battalion, supporting the 34th Division, had its busiest day on 3 February, when 430 patients, 268 of them with battle wounds, were processed. For the en-
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RETURNING WOUNDED FROM THE RAPIDO, JANUARY 1944
tire period from 24 January to 19 February, when relief of the 34th Division was completed, 4,795 patients passed through the division clearing station, of whom 2,248 were battle casualties. For the 111th Medical Battalion clearing station, the total processed was 5,709, including 1,733 wounded in action, for the period from 18 January to 22 February during which elements of the 36th Division were in the line.
The 54th Medical Battalion was taxed to the utmost to provide transportation to the rear. In order to shorten the ambulance run as much as possible, two hospitals were displaced forward along Highway 6 during the Cassino assault. The 10th Field moved from Capuato a site four miles southeast of Mignano on 28 January. It was leapfrogged on 11 February by the 94th Evacuation from Riardo. Set up just south of Mignano, the 94th was the farthest forward of any Fifth Army hospital on the Cassino front. For a time all hospitals in the army area were so crowded that orderly scheduling of admissions was impossible.
After the relief of II Corps, medical units accompanied the badly battered 34th and 36th Divisions to rest areas be-
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AID STATION IN SANT`ELIA AREA, smoke from a German shell rising in the background.
hind the lines. Neither division returned to combat on the southern front. The New Zealand Corps renewed the attack on Cassino, 15-20 February, but, aside from destroying the monastery, achieved no more success than had the Americans. The Cassino front lapsed into inactivity until 15 March, when the New Zealand Corps launched a second drive, preceded by the heaviest air and artillery bombardment of the Italian campaign. But again the Gustav Line held, and the frontal attack was abandoned.
Hospitalization in the Army Area
Hospitalization Policy
All hospitalization in the army area throughout the Italian campaign was centrally controlled by the Fifth Army surgeon. As long as the line of evacuation lay along a single highway, as in the first days of the breakout from the Salerno beachhead, it was possible to funnel casualties through one ambulance control point, where they were routed to the available evacuation hospitals in groups of fifty at a time. Since there was no sorting of casualties at the control points, however, the actual burden on the hospitals proved very uneven and treatment of some patients was unnecessarily delayed.24
24 Except as otherwise noted, this section is based on the reports of the Fifth Army surgeon for 1943 and 1944. and on the reports of the individual hospitals and medical battalions functioning in the Fifth Army area.
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As the troops advanced toward the Volturno, one evacuation hospital was designated for the support of each division, but since some units encountered much stiffer opposition than others, this system, too, proved unsatisfactory. Under combat conditions, it was found that one evacuation hospital could not safely handle more than 100 surgical admissions in a 24-hour period. When the designated hospital was filled, casualties had to be rerouted to other installations, with consequent delay in treatment and longer immobilization of ambulances.
With the establishment of additional hospitals in the army area toward the end of the year, two evacuation hospitals were assigned to receive casualties from each division. One hospital took all admissions for twenty-four hours; then closed to catch up and rest its personnel while the other took over for a similar period. This system, like its predecessor, proved only partially successful, since the casualty load varied markedly from day to day with the progress of the fighting. It remained in effect only until late January 1944.
The plan next put into effect continued throughout the remainder of the war in Italy. Hospitals were arranged in depth along the axis of evacuation to the rear. Corps evacuation officers were informed early each morning by the Fifth Army evacuation officer, Maj. (later Lt. Col.) Ralph A. Camardella, how many surgical and how many medical cases they might send in the course of the day to each hospital in stated sequence. Under this system, no hospital would be overburdened unless the aggregate casualties for the day exceeded the combined quotas of all the hospitals in the area.
Specialization
A major factor in the orderly working of this system was the increasing use of specialized facilities to siphon particular types of cases. Toward the end of October1943, following the pattern established in Sicily, field hospital platoons were set up adjacent to the division clearing stations for forward surgery and retention of patients whose further transportation would be hazardous. Keeping these patients in the division area lightened the burden on the evacuation hospitals. After the 10th Field Hospital moved into the Capua area at the beginning of December, its facilities were used primarily for medical cases whose hospital expectancy did not exceed twenty-one days.
A further development late in 1943 was the more consistent use of clearing companies of the army medical battalions for hospitalization. Both the 161st and 162d Medical Battalions were reorganized in October to give each clearing platoon 250beds, instead of the 125 previously assigned. Additional personnel needed to operate the larger units was drawn from the collecting companies. These expanded platoons were then used to increase the bed strength of the forward hospitals. One clearing platoon of the 162d was attached to the 56th Evacuation Hospital at Dragoni from 6 November to 21 December, while the other clearing platoon of the same battalion served to augment the facilities of the l5th Evacuation Hospital during its stay at Alife. An expanded clearing platoon of the 161st Medical Battalion was attached to the 10th Field Hospital near Capua, where it served as a convalescent ward. At its Vairano site, the 16th Evacu-
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ation Hospital also used a clearing platoon as a convalescent ward during most of January 1944.
Late in December the use of clearing platoons as hospitals was carried another step forward. On the 21st of that month a platoon of the 162d opened as a venereal disease diagnostic and treatment center, and ten days later a platoon of the 161st,with psychiatrists and other additional personnel attached, became the Fifth Army Neuropsychiatric Center. Both of these special hospitals were in the vicinity of Capua until the end of March, when a general resiting of Fifth Army hospitals took place.25 The movement of the 3d Convalescent Hospital into the army area early in January completed the establishment of specialized facilities immediately behind the lines. In sum, these units went far toward freeing the evacuation hospitals for their primary mission, the treatment of battle wounds.
The use of specialized facilities in the army area was also designed to save for combat duty as large a proportion of those hospitalized as possible. Medical cases such as respiratory diseases, fevers of various types, jaundice, dysentery, venereal disease, and trench foot could usually be treated close to the front and, with convalescent beds available, could often be held long enough for a cure. Specialization also permitted adequate care by the minimum number of medical officers.
The extensive employment of specialist personnel was another feature of the Fifth Army system of hospitalization. In
addition to the medical specialties represented by the establishment of separate hospitals for venereal disease and neuropsychiatric cases, twenty-five teams of the 2d Auxiliary Surgical Group were employed in field hospital platoons and in evacuation hospitals. Wherever possible, Medical Corps officers were replaced by officers of the Medical Administrative Corps, despite the resistance of unit commanders in the field. Fifty MACs had been so assigned before the Winter Line was reached, and twenty-five more had been requested.26 These officers were used in supply, operations, personnel, records, and other administrative positions and increasingly, when the shortage of medical officers became acute, as assistant battalion surgeons and in the collecting companies where evacuation rather than medical care was the primary mission.
Statistical Summary
U.S. bed strength in the Fifth Army area as of 15 January 1944, including field hospital platoons with the division clearing companies, clearing platoons used as expansion units, the neuropsychiatric and venereal disease hospitals, and hospitals staging for Anzio, was approximately 10,000. The total remained the same at the end of April, though it was divided between the Cassino front and the Anzio beachhead. Hospital admissions from Fifth Army to U.S. installations from 9 September 1943 through 30 April 1944 are shown in Table 5. It should be borne in mind that the figures for January, February, March, and April include hospital admissions on the Anzio
25 See pages 255-56, 258-59, below, for more detailed discussion of the NP and VD hospitals. The resiting of hospitals before the Rome-Arno Campaign is treated on pages 290-91, below.
26 Pers Ltr. Gen Blesse to Gen Kirk. 17 Nov 43.
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TABLE5- HOSPITAL ADMISSIONS FROM FIFTH ARMY, 9 SEPTEMBER 1943-30 APRIL 1944a
beachhead, which are not separately available by months. It will be noted that the disease rate was highest in December, when weather conditions were at their worst, while battle casualties reached their peak in February, when both fronts were fullyengaged.27
Evacuation From Fifth Army
Patients who could not be returned to duty within a reasonable time--usually twenty-one days, although there was no general policy--were moved as rapidly as they became transportable to fixed hospitals in North Africa and in the developing communications zone around Naples. During the period of army control, all evacuation out of the combat zone was to Africa, by sea from the Salerno beachhead, and by air from Naples. Responsibility for evacuation out of Italy shifted to the newly activated Peninsular Base Section on 1 November, with Fifth Army thereafter responsible only for clearing its own hospitals.28
Evacuation in the army area, like hospitalization, was centrally controlled by the Fifth Army surgeon. Evacuation hospitals reported daily as to the number of patients ready for disposition, and each was given a quota twenty-four hours in advance of movement. Wherever possible, by arrangement with the base surgeon, specific hospitals were designated to receive the evacuees. Though this system was new in the theater, it worked smoothly in most instances. Among the practical difficulties encountered were occasional communication failures, and a tendency on the part of evacuation hospital commanders to move patients who should have been retained in order to use up the allotted quota of fixed beds.29
27 See pp.273-74, below.
28 Seep. 326, below.
29(1) Annual Rpt, Surg, Fifth Army, 1944. (2) Annual Rpt, 10th Field Hosp, 1943. (3)Annual Rpt, 15th Evac Hosp, 1943.
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Collecting companies of the army medical battalions were attached to the evacuation hospitals to handle the actual transportation. Until late November 1943, when adequate transportation became available to the base section, patients from front-line hospitals were taken by army ambulance directly to the point of treatment or of embarkation to Africa. Beginning on 22 November, most were carried only to the railhead, where they were transferred to the 41st Hospital Train and army responsibility ended. Until near the end of the year the train ran only between Naples and Caserta, a distance of about twenty-five miles. Beginning on 26 December the loading point was extended ten miles to Sparanise, in the immediate vicinity of the main concentration of evacuation hospitals behind the Winter Line.
U. S. Army ambulancesal so evacuated the field hospital of the 1st Italian Motorized Group to the Italian military hospital at Maddaloni. Evacuation hospitals of the French Expeditionary Corps were generally cleared by French ambulances to the Sparanise railhead, where FEC patients were allotted space on the hospital train.
Medical Supplies and Equipment
When planning for the Salerno landings got under way, the Sicily Campaign was at its midpoint and the defects of the Seventh Army supply system were already clear. Chief among these defects were the late arrival of medical depot personnel and the failure to submit supply requisitions to Services of Supply headquarters for editing. There were consequent delays in the establishment of issue points, with some unnecessary loss of material, and excessive quantities of a number of supply items were delivered to the island.30
With this Sicilian experience in mind, an effective liaison was established between the SOS Medical Section and the office of the Fifth Army surgeon. All supply requisitions were cleared through SOS but changes were made only by mutual agreement. To deal with the beach supply problem a detachment consisting of one officer and twelve enlisted men of the 4th Medical Supply Depot was scheduled for the D-day convoy.
All medical units going ashore in Italy carried their full Table of Basic Allowances supply load, augmented by special items such as plasma, atabrine, and extra splints and dressings. In addition, considerable quantities of medical supplies were carried ashore by the combat troops. These were packed in the sealed, waterproof containers designed for the purpose at the Fifth Army Invasion Training Center, and were dropped on the beach as the men carrying them went ashore.
The assault personnel of the 4th Medical Supply Depot made their way under fire to a previously designated site on the beach, where they dug in. The men then collected the scattered supply containers and medical equipment as it was unloaded, and set up a dump. Within five hours of its landing, the 4th Medical Supply Depot was issuing supplies to meet emergency needs. One hundred tons of
30(1) Rpt of Med Supply Activities, NATOUSA, Nov 42-Nov 43. Other sources primarily relied upon in this section are: (2) Annual Rpt, Surg, Fifth Army, 1943; (3) Annual Rpt, Surg, Fifth Army, 1944; (4) Annual Rpt, Med Sec. NATOUSA,1943; (5) Annual Rpt, Med Sec, MTOUSA, 1944; (6) Unit rpts of the4th and 12th Med Depot Cos, 1943 and 1944; (7) Davidson, Med Supply in MTOUSA, pp. 50-60.
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medical supplies were unloaded during the night of 9-10 September, together with some 200 tons of organizational equipment belonging to the 16th and 95th Evacuation Hospitals. Personnel of the two hospitals collected and sorted their own equipment, which was stored by the supply group until hospital sites became available.
The supply dump operated on the beach for four days. Then on 13 September the original detachment was relieved by a new and larger segment of its organization, consisting of two officers and fifty-two enlisted men, who brought with them four 21/2-ton trucks, a ¼-ton truck, and a weapons carrier. The enlarged detachment moved the dump to Paestum, near the newly laid out hospital area. The depot was gradually enlarged until it occupied thirteen wall tents.
During the first days at the beachhead there were some shortages of expendable items, due primarily to losses by enemy action, damage in handling, and accidental immersion. Replacements were ordered by cable from North Africa and were promptly received. By 21 September, when the advance out of the beachhead began, a 14-day level of medical supplies was available.
A supply depot was established at Avellino early in October, where the medical supply responsibility for Fifth Army was transferred from the 4th to the 12thMedical Supply Depot, along with fifty tons of supplies. The detachments of the 4th that had served the beachhead then joined the remainder of their unit in Naples, where a base section organization was being set up.31
Thereafter, the12th Medical Supply Depot--l2th Medical Depot Company after 3 December1943--followed the Fifth Army advance as closely as terrain and circumstances permitted. The Avellino dump was closed on 25 October, being supplanted by a depot at Caserta. A forward issue point was established at Riardo on 6 November, coincident with the launching of the attack on the Winter Line. On 17 December a larger depot was opened in a monastery at Calvi Risorta. Like the Riardo depot in the Fifth Army hospital area, the new dump was operated by the base section platoon. One hundred and twenty tons of medical supplies were moved forward to Calvi Risorta, using eighty trucks. By this date items of medical supply were generally plentiful.
The 1st Advance Platoon of the 12th Medical Depot Company was assigned on 8 January 1944 to VI Corps for the Anzio operation. On the 26th of that month, in support of the first unsuccessful assault on Cassino, the 2d Advance Platoon moved from Riardo to the village of San Pietro, just off Highway 6 about midway between Mignano and Cassino. Since most of the buildings in the area were destroyed, the supply dump functioned under canvas.
Professional Services in the Army Area
Medicine and Surgery
Forward Surgery-Fifth Army followed and further refined in Italy the techniques worked out during the late stages of the Tunisia Campaign for bringing the best in surgery as close as possible to the combat soldier. Detailed instructions as to the preferred management of various types of wounds were issued
31See p.326, below.
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shortly before the invasion, 32 but initial reliance was placed on the experienced teams of the 2d Auxiliary Surgical Group. In the landing phase, these teams were attached to the clearing stations, shifting to the evacuation hospitals as they were established. When the front was stabilized north of the Volturno late in October 1943, field hospital platoons, each with two to eight surgical teams, were setup adjacent to the division clearing stations, on the pattern developed in Sicily. Although these 100-bed units were somewhat larger than experience had shown to be necessary, no suitable substitute was available. 33
With the commitment of the field hospitals, a system of triage was instituted at the clearing stations. Patients who could stand the ambulance trip were sent back to an evacuation hospital. Those who could not safely be moved were carried by litter to the field hospital for immediate surgery. The nontransportable category generally included cases of severe shock, intra-abdominal wounds, thoracoabdominal wounds, sucking chest wounds, and traumatic amputations. Patients treated in the field hospital units were retained until they could be safely moved, up to a maximum of fourteen days. As in Sicily, personnel and equipment sufficient for postoperative care of remaining patients were left behind when the hospital moved.34
Important changes in management of surgical cases during the southern phase of the Italian campaign included the wider use of penicillin, which had been allocated for specific treatments in the closing months of 1943, but became relatively plentiful early in 1944; radical debridement and other prophylactic measures to prevent gas gangrene; and the extensive use of whole blood, made possible by the establishment of a blood bank in Naples in February 1944.35
Another significant administrative development in forward surgery was the employment of a surgical consultant by Fifth Army toward the end of 1943. The assignment went to Maj. Snyder, who had served in a similar capacity with II Corps in the Tunisia and Sicily Campaigns. The theater consultant in surgery, Colonel Churchill, continued to devote much of his time to the inspection and improvement of surgery in the army area. Fifth Army also benefited, as II Corps and Seventh Army had not, from the close proximity of fixed hospitals in the base section, permitting frequent conferences for exchange of experience and ideas among medical officers.
Neuropsychiatry-Experience in Sicily tended to confirm the conclusions reached by Major Hanson and his asso-
32FifthArmy Med Cir 1, an. 2, sub: Surg Procedures, 25 Aug 43.
33Afterthe Sicily Campaign, General Blesse and Colonel Churchill concluded that the ideal unit for forward surgery would be a 120-bed surgical hospital, capable of operating in two 60-bed sections. See (1) Col Wickert, Rpt of Visit to ETO and NATOUSA, 1 Sep to 24 Oct 43. Except as otherwise noted, sources for this section are: (2) Annual Rpts, Surg, Fifth Army, 1943,1944; (3) Annual Rpt, Med Sec, NATOUSA, 1943; (4) Annual Rpt, Med Sec, MTOUSA, 1944 ; (5) Annual Rpt, 11th Fld Hosp, 1944; (6)Annual Rpts, 33d Field Hosp, 1943, 1944; (7) Annual Rpts, 2d Aux Surg Gp,1943, 1944.
34 For a nonprofessional, but vivid and moving account of life in one of those field hospital units, see Margaret Bourke-White, They Called It The Purple Heart Valley (New York: Simon and Schuster, 1944) , pp. 123-32.
35 (1)Surg, NATOUSA, Journal, 3 Nov 43. (2) Fifth Army Med Cir No. 4, 20 Oct43, sub: Gas Gangrene. For discussion of the organization and operation of the blood bank, see pp. 352-53, below.
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ciates during the Tunisia Campaign that the majority of psychiatric cases arising as a result of combat could be returned to duty in a relatively short time if treated close to the source of disturbance. It was largely on the basis of Hanson`s findings that the War Department in October 1943 authorized the addition of a psychiatrist to the staff of each division surgeon, a practice followed in World War I but later abandoned. A group of psychiatrists was recruited for the purpose, and Hanson himself, at the request of the Surgeon General, returned to the zone of interior to assist in their indoctrination.36
36 (1) Hanson, comp. and ed., "Combat Psychiatry," Bulletin, U.S. Army Medical Department, Suppl (November 1949) pp. 33, 45. (2) Pers Ltr, Gen Blesse to TSG, 13 Dec43. General Blesse was understandably reluctant to let Hanson go, but felt that the mission was of such importance as to justify recalling his neuropsychiatric consultant from Italy to undertake it. "I hope," he wrote to General Kirk in the letter cited above, "you will not find it necessary to keep him there very long for I need him, and if you have no objection I would like to have him return here just as soon as possible." Principal sources for this section include: (3) Hanson, comp. and ed., "Combat Psychiatry," Bullet in, U.S. Army Medical Department, Suppl (November 1949); (4,) Annual Rpts, Surg, Fifth Army, 1943, 1944; (5) Annual Rpt, Med Sec, NATOUSA, 1943; (6) Annual Rpt, Med Sec, MTOUSA, 1944; (7) Surgs` rpts for 1943 and 1944 of the divs and corps mentioned in the combat sacs of this chapter.
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From the outset of the Italian campaign, battalion and regimental aid stations were directed to retain cases of mild neurosis such as anxiety states and exhaustion. These were to be fed, offered opportunity to bathe, and given a sedative sufficient to ensure sleep. Cases requiring more than thirty-six hours treatment were sent to the division clearing stations, where heavier sedation was given. Those who still did not respond after seventy-two hours were sent on to the evacuation hospitals, where they were given more specialized treatment and returned to duty or evacuated to the communications zone, according to their hospital expectancy. Of the 2,749 cases disposed of between 9 September and 31 December 1943, 6 percent were returned to duty from divisional installations, and 20 percent from Fifth Army hospitals, the remainder being evacuated out of the army area.
Several factors combined to produce this relatively small percentage of returns to duty. The urgent need for beds in the evacuation hospitals during months of almost continuous combat sent to base hospitals many psychiatric casualties that might have been reclaimed in the combat zone. Evacuation hospital staffs had little time to devote to such cases, and treatment varied with each installation. Even where adequate treatment was available, the very atmosphere of an evacuation hospital tended to convince the patient that his illness was organic and to fix rather than to allay his anxieties.
The solution adopted by Colonel Martin was the creation of a specialized neuropsychiatric hospital to operate as close as possible to the actual battle lines. Known as the Fifth Army Neuropsychiatric Center, the hospital was formed from the 2d Platoon of the 601st Clearing Company, 161st Medical Battalion, with beds for 250 patients. Four psychiatrists were added to the staff, others being attached at intervals when the case load required it. The enlisted personnel was approximately double that of a normal clearing platoon, the wardmen being specially trained for the job. The center opened on 21 December 1943 in the Teano-Riardo area, where the bulk of Fifth Army medical installations were then concentrated. It continued to function at various locations throughout the war, never out of earshot of artillery fire.
Every effort was made to avoid a hospital atmosphere. There were no nurses. Pajamas, sheets, and pillows were not issued. Patients slept on regulation cots, made their own beds, policed the area. So far as possible, routine military discipline was maintained, and the idea of a prompt return to duty was always kept before the men.
After 21 December1943, all psychiatric cases that could not be handled at the division level were sent directly to the Neuropsychiatric Center. There they were kept under sedation for two days, but were still expected to go to meals, wash, and shave every day. After the effects of sedation had worn off, the men were interviewed--usually on the third or fourth day of their stay. The interview was designed to elicit a full story of what had happened to the men in combat, with probing into their premilitary histories confined to the bare essentials. Each individual case was evaluated in
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TABLE 6- DISPOSITION OF NEUROPSYCHIATRIC CASES IN FIFTH ARMY SEPTEMBER 1943-APRIL 1944
this interview and the decision made as to eventual disposition. A man might be returned to duty promptly, retained for further treatment, or evacuated to the rear, according to the severity of his symptoms and the nature of his responses under questioning.
By March 1944 each U.S. division of Fifth Army had its own psychiatrist, who screened the cases as they came to the clearing stations. The system was functioning smoothly as a single process by the time the drive to Rome was launched in May, but was still to be significantly improved at the division level later in the year.37
The disposition of neuropsychiatric cases in Fifth Army for the period from September 1943 through April 1944 is shown in Table 6. The sharp decline in returns to duty from division clearing stations in November 1943 reflects the impact of continuous and increasingly severe fighting under steadily deteriorating conditions of weather and terrain. The ameliorating effect of the Fifth Army Neuropsychiatric Center first appeared in January 1944. February was the month of heaviest fighting at both Anzio and Cassino. The improved figures for April represent virtual freedom from combat, improved weather conditions, and the first results of the assignment of psychiatrists at the division level.
Diseases of Special Interest: Infectious Hepatitis- The period between the Salerno landings and the launching of the May 1944 offensive toward Rome showed no unusual incidence of disease among Fifth Army troops. In the early weeks of the drive, malaria, sandfly
37See pp.314-16, below.
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fever, and dysentery predominated.38 Respiratory diseases appeared with the advent of the rainy season, but not in unusual volume. The only disease worthy of special notice as a problem for the medical service during the period, other than those discussed under separate headings in this chapter, was infectious hepatitis. The disease was first noted in July 1943 in North Africa, but was confined mainly to units of the 34th Division. In Italy it became general shortly after the Salerno landings, and reached a peak rate of 121.0 cases per 1,000 per annum for the second week in October. The rate for the entire month of October was 93, dropping sharply and steadily thereafter to 11 in April 1944. Hepatitis consumed manpower out of all proportion to its incidence, since the average time lost was sixty days for each patient.39
Infectious hepatitis was intensively studied by Fifth Army medical officers during and afterthe outbreak, but without arriving at definite conclusions as to its mode of transmission, or the factors influencing its virulence. The disease was seasonal in character, being most widespread in the fall months. It appeared to be more common among seasoned troops than among men newly arrived in the theater. There was some evidence of a relationship between hepatitis and a previous history of diarrhea. The studies made in the winter of 1943-44, however, did not produce enough information to prevent another and still
more virulent outbreak in the late fall of 1944.40
Preventive Medicine
Venereal Disease-The control of venereal disease in Italy proved to be even more difficult than it had been in Africa. After more than twenty years of fascism and three years of war, the Italian economy was a patchwork of makeshifts in which sheer hunger often overrode moral considerations. Food was to be had on the black market for a price, and the price could be obtained by prostitution. To women whose men were dead or broken, prisoners of war, or doing forced labor for a conqueror, there seemed no other way. In cities such as Naples the opportunities for clandestine contacts were so numerous that neither inspection of licensed brothels nor putting the houses off-limits offered any solution. The psychology of the soldier, moreover, was that the longer he remained in combat, the more remote were his chances of getting home. As time went on, his memories dimmed and he came increasingly to live for the moment.41
Italian doctors stated, and laboratory tests tended to confirm the estimates, that by 1944half the available women in Italy had some form of venereal disease, and that in the populous areas 95 to 100 percent of all prostitutes showed clinical evidence of one or more venereal diseases. Add to this high rate of infection the aggressiveness of the women, and the nature of the problem becomes
38Surg,NATOUSA, Journal, 11 Oct 4 43.
39 (1) Annual Rpts, Surg, Fifth Army, 1943, 1944. (2) Annual Rpts, Surgs, 3d,34th, 36th, 45th, 1st Armd Divs, 1943, 1944. (3) Annual Rpts, Surgs, II and VI Corps, 1943, 1944.
40 See detailed discussion in Annual Rpt, Surg, Fifth Army, 1944, and p. 451, below.
41 This section is based primarily on the annual reports of the Fifth Army surgeon for 1943 and 1944 and on the reports of corps and division surgeons in the Fifth Army area.
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clear. For example, when the 3d Infantry Division was training near Naples early in January 1944 for the Anzio operation, the division surgeon reported that "prostitutes from Naples descended upon our encampment by the hundreds, outflanking guards and barbed wire. They set up `business` in almost inaccessible caves in the surrounding bluffs. Many of them gained entrance into camp by posing as laundresses. .. . Each day several large truck loads of screaming, screeching prostitutes were collected in the Division area and delivered into the custody of the Italian police." 42
Fifth Army dispensed with its venereal disease control officer in September 1943 when the Army went into combat. In that month the venereal disease rate was low, but it began to rise sharply with the capture of Naples in October. In December the position of control officer was reestablished, and Maj. (later Lt. Col.) Sydney Selesnick was assigned to it.
It was not practicable to attempt any direct control of houses of prostitution. Italian laws governing the traffic were respected, and their enforcement was abetted by Allied Military Government officials in all occupied territory. The most that could be done in the army area was to maintain a continuous educational drive, to see that preventive devices were issued and that prophylactic stations were readily available, and to bring in known prostitutes for examination, and treatment if they were infectious. Line officers were held responsible if their units showed any disproportionate incidence of venereal disease.(Table 7)
Along with these preventive measures, every effort was made to reduce the time lost from duty on account of venereal disease. An important step in this direction was the establishment on 31 December 1943 of the Fifth Army Venereal Disease Diagnostic and Treatment Center to function in the army area. The 2d Platoon of the 602d Medical Clearing Company, 162d Medical Battalion, formed the nucleus of the new organization, which was augmented by personnel drawn from the collecting companies of the battalion. When fully staffed, the VD center had 4 Medical Corps officers, a Medical Administrative Corps officer, and 92 enlisted men. It had 250 beds. A mobile unit of the 2dMedical Laboratory was attached, adding an officer and 5 enlisted men.
Throughout the Gustav Line and Rome-Arno Campaigns 90 percent of all Fifth Army venereal cases--except those on the Anzio beachhead--were treated in the center, which could move to a new location in six hours, carrying its patients with it. Uniformity and continuity of treatment cut down materially the time lost from duty per case. The recovery time was further reduced after penicillin became generally available for venereal cases in mid-February 1944.43
Disposition of patients by the Fifth Army Venereal Disease Diagnostic and Treatment Center in the first four months of 1944 is shown in Table 8. Although the center did not formally open until the end of December, a considerable number of cases were already in the hospital on 1 January, accounting for the
42 Annual Rpt, Surg, 3d Div, 1944.
43 Penicillin had been used in the theater in the treatment of gonorrhea as early as November 1943, but only on special allocation, arranged by the theater venereal disease control officer. Surg, NATOUSA, Journal, 16 Nov 43.
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TABLE 7- VENEREAL DISEASE RATE PER THOUSAND PER ANNUM, BY DIVISIONS, SEPTEMBER 1943-APRIL 1944
large number of dispositions in that month.
Malaria Control-The Fifth Army malaria control program was part of a theater-wide effort. The necessary organization was set up well in advance of the malaria season, primary responsibility being vested in the Fifth Army medical inspector, Colonel Gilmore. Colonel Gilmore`s assistant, Maj. (later Lt. Col.) Raiford A. Roberts, was named operational director of the control program, and Capt. Joseph J. Bowen served as malariologist from February 1944, on detail from the 2655th Malaria Control Detachment. The operating groups were the11th Malaria Survey Unit and the
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28th and 42d Malaria Control Units, with the effective co-operation of the Fifth Army engineers.44
Malaria control measures were carried out at all echelons, each echelon being responsible for its own area. Each corps, division, regiment, battalion, and company had its own nonmedical malaria control officer. Each formation down to and including the battalion had its own malaria control committee. At corps and division levels, these committees consisted of the medical inspector, the engineer, and the malaria control officer. For regiments and battalions the committees were composed of the surgeon and the malaria control officer. Each company, battery, and similar unit had an antimalaria detail of at least two enlisted men, including a noncommissioned officer. In the higher echelons the antimalaria function was largely planning and supervisory. At the company level the antimalaria details were responsible for carrying out control measures in the unit area and for a radius of one mile around it. Italian doctors and sanitary engineers familiar with the local conditions were fitted into the control organization, and through the Allied Military Government (AMG) the civilian population was also included.
The engineers conducted most of the large-scale control activities, such as draining flooded areas, clearing obstructions from waterways, and filling in craters, as well as applying larvicides to water surfaces. Italian troops and civilian laborers were freely employed in this work.
In order to give intelligent direction to the whole malaria control program, two special schools were organized by Captain Bowen. One of these, on the Anzio beachhead, will be discussed in the following chapter. The other served personnel of II Corps in the highly malarious coastal region south of the Garigliano River. The school was conducted under the auspices of the 54th Medical Battalion between 1 and 27 March 1944, during which period 101 officers and 976 enlisted men, including 466 noncommissioned officers, were trained in the techniques of malaria control. Posters were prominently displayed throughout the corps area, and a training film on the cause and control of the disease was shown continuously during the malaria season.
The control problem was rendered much more difficult by the thoroughness with which the Germans had destroyed pumping plants, dikes, culverts, and drainage systems, flooding large sections of reclaimed land. It was nevertheless a successful program in terms of its ultimate results. The malaria case rate per 1,000 per annum among Fifth Army troops rose sharply from 83 in September 1943 to 193 for the following month, dropped to a low of 45 in December, and was only 85 for April 1944. Even in the most malarious months of June, July, and August, the case rates were only 94, 82, and 70 respectively. These rates compare favorably with those for the theater
44 Main sources for this section are: (1) Annual Rpt, Surg, Fifth Army, 1944; (2) Annual Rpt, Surg, II Corps, 1944; (3) Annual Rpt, Med Sec, MTOUSA,1944; (4) Ltr, Capt Bowen, Asst Malariologist, 2655th Malaria Control Detach (Overhead), to Surg, NATOUSA, 29 Dec 44, sub: Stat Analysis of Malariain MTOUSA, 1944; (5) Ltr, Col Andrews, Acting Malariologist, American Sec, AFHQ, to Surg, NATOUSA, 10 May 44, sub: Antimalaria Inspection Tour of VI Corps, Fifth Army, II Corps and Adriatic Areas of U.S. Military Occupation 25 March-3 May 44; (6) Andrews, "North Africa, Italy, and the Islands of the Mediterranean," Communicable Diseases, Malaria.
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as a whole, which were 95 for October1943, 31 for December 1943, and 80 for April 1944. The rates for the theater as a whole in the summer months of 1944 were 70 for June, 81 for July, and 92 for August.45
When II Corps moved out of the Minturno sector in the May offensive, responsibility for continuing malaria control work passed to the Peninsular Base Section.
Trench Foot-Trench foot appeared among Fifth Army troops early in the Winter Line campaign and continued to plague commanders until the spring of 1944. The condition was first reported in mid-November 1943. Within a week more than 200 cases had been hospitalized. The total for the month was 305, with 1,323 cases reported in December. The January and February figures were still higher, with a sharp decline in March. For the first three months of 1944, upwards of 4,000 trench foot cases were treated, divided fairly evenly be-
45 (1) Annual Rpt, Surg, Fifth Army,1944. (2) Final Rpt, Preventive Medicine Officer MTOUSA, 1945.
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tween the Cassino front and the Anziobeachhead.46
Fifth Army troops were not equipped for the physical conditions that confronted them in the winter of 1943-44. There had been no adequate indoctrination as to the danger of trench foot, and no preparations to prevent it. Troops had only the standard army shoe or combat boot, with light wool socks, which did not give protection against either cold or dampness. Heavy wool socks became available later in the winter, but could not be worn until it was possible to issue larger shoe sizes. Neither were there enough socks on hand to permit the daily change recommended by the surgeon.
In the bitter mountain fighting before Cassino, where cold and rain or snow were almost incessant, front-line troops could not hope to keep their feet dry, and, continuously in range as they were of enemy small arms fire, they could not risk giving away their positions by movement merely to exercise their limbs. Manpower was too short to permit rotation, so many men went for a week or more without opportunity to dry or warm their feet and little chance even to walk on them. Trench foot was an almost inevitable consequence.
While the condition was intensively studied by medical officers of Fifth Army and proper prophylactic measures were determined, little headway could be made until more suitable footgear became available.47
Typhus-An epidemic of typhus that broke out in Naples in October 1943 posed a serious threat to Fifth Army. The account of measures taken to combat the epidemic and to prevent its spread to Fifth Army troops properly belongs in another chapter.48 It will be sufficient here to say that vigorous action to prevent louse infestation was taken, and was effective. For several months Naples was off-limits to Fifth Army troops except on necessary business, and all military personnel entering or leaving the city were treated with insecticides.
Dental Service
Facilities for dental prosthetic work remained scarce during the summer of 1943 when Fifth Army was staging for the invasion of Italy, but with that exception the troops were dentally in good condition when the campaign began. In the assault phase, only emergency dental work was done, while most of the dental officers and enlisted personnel performed other duties. By 1 October, however, the Fifth Army dental service was solidly established. Three divisional dental laboratories were in operation and others were functioning in connection with the
46 Figures reported differ considerably. For the months of November 1943 through March1944, Annual Report, Medical Section, MTOUSA, gives 5,058 but concedes that the 1943 figures are too low. Annual Report, Surgeon, Fifth Army,1944, gives 5,710 cases for the same period, while the total is reduced to 5,274 in Annual Report, Surgeon, Fifth Army, 1945. The text follows Annual Report, Surgeon, Fifth Army, 1944, and Fifth Army Medical Circular No. 6, 24 November 1943. For discussion of trench foot at Anzio, see pages 285-86, below. For more technical treatment, see Col. Tom F. Whayne, USA(Ret.) and Michael E. DeBakey, M.D. Cold Injury, Ground Type "Medical Department, United States Army, in World War II" (Washington, 1958), pp.101-25. Whayne and DeBakey also accept the figures reported by the Fifth Army Surgeon for 1944.
47 Compare the 1943-44 record with that of the winter of 1944-45 in the north Apennines, page 452, below.
48 See pp. 462-65, below.
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evacuation hospitals. By 1 December there were twenty laboratories in the army area, including two mobile units built on 2½-ton truck bodies by the 34th and the 1st Armored Divisions.49
In mid-December 1943 the II Corps surgeon, Colonel Ginn and the corps dental surgeon, Lt. Col. Gerald A. McCracken, organized a II Corps Prosthetic Dental Clinic and Laboratory. The clinic was housed in a hospital ward tent supplied by the 54th Medical Battalion, which also furnished lighting fixtures, a generator, and the necessary laboratory tables, benches, and operating platforms. One dental officer was detached from the 54th Medical Battalion, and one from the 11th Field Hospital. The same two organizations also furnished between them one laboratory technician, two chair assistants, and one clerk. The remainder of the personnel consisted of two prosthetic dental teams of one officer and four technicians each, from the 2d Auxiliary Surgical Group. One of these teams was withdrawn late in February 1944.
Early in January a similar clinic was organized at the army level by the Fifth Army dental surgeon, Colonel Cowan. The Fifth Army Dental Clinic was housed with the 2d Platoon of the 602d Medical Clearing Company, 162d Medical Battalion, which was also the nucleus of the venereal disease center. Like the II Corps clinic, its personnel and equipment were drawn from other medical units. The Army clinic had four dental officers, with an appropriate complement of enlisted men.
Both II Corps and Fifth Army dental clinics were originally designed primarily for prosthetic work, but both quickly enlarged their facilities to handle all aspects of dentistry except X-ray work.
Another clinic, similarly equipped and staffed, was set up as an organic part of the Fifth Army rest center in Naples, moving with the center to Caserta when the typhus epidemic put the former city off-limits.
As in earlier campaigns, the more extensive dental facilities of the divisions were usually located in the service area, with routine dental work being done during slack periods in the clearing stations. During actual combat only emergency work was performed.
While dental officers in Fifth Army increased from 154 in September 1943 to 233 in April 1944, their numbers did not keep pace with the rise in troop strength. The ratio of dental officers to mean troop strength in September was 1:740. In April it was 1:1010 Through better organization and more efficient distribution, however, the amount of dental work done showed a steady increase over the 8-month period. (Table 9)
Veterinary Service
In the hard mountain fighting before Cassino, pack animals were extensively used, bringing the Veterinary Corps into action in something more than its food inspection capacity. Early in the Winter Line campaign, veterinary officers of the34th and 45th Divisions procured such animals as they could and organized divisional pack trains. Other than the division veterinarian and his sergeant, no
49 Chief sources for this section are: (1) Annual Rpts, Surg Fifth Army, 1943, 1944; (2) Annual Rpt, Surg, II Corps, 1944; (3) Annual Rpt, Med Sec. MTOUSA,1944; (4) 1943 and 1944 rpts of the combat and med units in Fifth Army, Sep 43- Apr 44.
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TABLE 9- DENTAL SERVICE IN FIFTH ARMY, SEPTEMBER 1943-APRIL 1944a
trained personnel were available. Food for the animals was scarce and of poor quality, and the animals themselves were old, chronically lame, undersized, and generally in poor condition. Despite these handicaps, however, it was soon apparent that pack trains would be a virtual necessity if troops were to be supplied in the mountains.50
With the recognition of this necessity, Col. Clifford E. Pickering, Fifth Army veterinarian, was directed to help in the procurement, care, and rehabilitation of animals. The task was no easy one. First the Italian Army, and later the Germans, had systematically looted the farms; and the Germans had killed such animals as they could not use themselves, in order to make still more difficult the economic and military problem of the Allies.
Colonel Pickering learned from Italian sources that a considerable number of animals bred for military use had been distributed among farmers for concealment from the Germans. With the assistance of former Italian cavalry officers and local carabinieri, these were located and assembled. Enough feed for their immediate needs was found in a partially destroyed factory at Maddaloni. Nails and horseshoes were made from scrap iron in improvised blacksmith shops. An Italian breeding depot was re-established as the Fifth Army Remount Depot, which was turned over to the base section at the end of the year.
Another substantial group of animals was located in Sardinia, where the prompt revolt of the Italian garrison had saved 5,000 mules, 1,500 horses, 3,000 saddles, and quantities of shoes from the vengeful Germans. Pack trains were organized on the island with Italian per-
50 This section is drawn primarily from the annual reports of the Fifth Army surgeon for 1943 and 1944, and the reports of the division surgeons whose units participated in the Winter Line and Cassino campaigns. See also, Miller, United States Army Veterinary Service in World War II.
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sonnel, each train having 4 line officers, a medical officer, a veterinary officer, 400 enlisted men, and approximately 325 animals. Two of these trains reached the mainland of Italy before the end of 1943. On their arrival, a Fifth Army Provisional Veterinary Hospital was organized, using 4 officers and 53 enlisted men drawn from the pack train complements. The hospital opened at Visciarro on 8 December. December also saw the arrival of a French veterinary hospital, with 5 officers and 74 enlisted men from North Africa with elements of the French Expeditionary Corps. The French also brought their own animals in substantial numbers.
More pack trains arrived from Sardinia in January 1944, together with two more Italian-staffed veterinary hospitals, the 110th and the l30th. Each of these had four veterinary officers, one administrative officer, and 100 enlisted men. These units were set up in the forward area, while the provisional hospital, renamed the 210th Veterinary Hospital (Italian), was turned over to the Peninsular Base Section.
In February an Italian cavalry officer, Col. Berni Canani, was named liaison officer between Colonel Pickering`s office and all Italian units, a position in which his services proved invaluable.
A U.S. veterinary evacuation hospital and some separate veterinary companies were requested for Fifth Army by General Blesse in November 1943, in anticipation of a wider use of animals in the mountain fighting approaching the Gustav Line. It was March 1944, however, before the only American veterinary evacuation hospital to serve in the Mediterranean, the 17th, reached Italy, and no veterinary company was available to Fifth Army before the final days of the war.51 The 17th Veterinary Evacuation Hospital was set up near Teano.
The outstanding veterinary problems of the Winter Line and Gustav Line campaigns were the care and rehabilitation of poor quality, poorly conditioned animals whose very physical debility increased their proneness to battle wounds, and the provision of feed adequate both in quantity and quality. Equipment for ridding the animals of lice was very deficient during this period. While feed increased in quantity, there was little improvement in quality until crops were harvested in the rehabilitated areas of Italy and shipping became available.
Animal strength in Fifth Army rose from 986 horses and 4,136 mules in January 1944 to 2,226 horses and 10,433 mules, or 12,659 animals in all, in April. Of this peak total, 2,023 horses and 7,266 mules were with the French Expeditionary Corps, which had its own treatment facilities. During the 4-month period, January-April 1944, 608 U.S. and Italian animals were admitted to the hospital of which 368 were returned to duty, 197 were evacuated to base, and 47 died or were destroyed.
51 (1) Surg, NATOUSA, Journal, 15 Nov 43. (2) Annual Rpt, 17th Vet Evac Hosp,1944. The 45th Veterinary Company (Separate) arrived in the Mediterranean in the summer of 1944, but was immediately assigned to Seventh Army, then training for the invasion of southern France.
