PROLOGUE
The Gift of Life
The soldier struck down on the field of battle, if his wounds are more than superficial, may count his life expectancy in hours, or even minutes, unless he receives prompt medical aid. To give him that succor, and with it the gift of life, is the responsibility of the Army Medical Service, still called in World War II the Medical Department. Most of those whose wounds are not immediately mortal may be saved if the flow of blood is quickly stanched, the onset of infection halted, the effects of shock minimized, and, above all, if the casualty is speedily but gently moved to a place of safety where needful surgery can be performed. These "ifs" are many, but all of them fall within the medical mission. Each has its place in one of the most smoothly functioning organizations ever devised. So well did the Medical Department do its work in the Mediterranean theater that the chances of surviving battle wounds were 27 to 1: of 112,000 wounded, only 4,000 died.1
The cry "Medic!" uttered by a wounded man, or by a fellow soldier who has paused long enough to mark the spot, sets the machinery in motion and begins the chain of evacuation, officially defined as "the entire group of successive installations engaged in the collection, transportation, and hospitalization of the sick and wounded." If the casualty is conscious and has some mobility, he may help himself with antiseptics from his own first aid packet, or perhaps a tourniquet fashioned of a handkerchief or of a strip torn from his clothing. If he cannot help himself, and the tide of battle leaves no one else nearby, he waits. It will not be for long. A company aid man will soon be there, guided by voice, by some conspicuous marker such as a rifle stuck upright in the ground or a helmet hung from a low branch, or by instinct sharpened through months of combat. To illustrate the process, let us assume a casein which the wound is abdominal and severe, and let us say that the wounded man has applied sulfanilamide crystals and a dressing before consciousness begins to fade.
The wounded soldier will probably be found in ten to thirty minutes, depending on the movement of the battle, the number of wounded, the nature of
1 These figures do not include 35,000 killed in action, 20,000 taken prisoner, nor some 9,000 missing. All of these, by definition, were "battle casualties," but did not come within the purview of the Medical Department.
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the terrain, and similar factors. The aidman (there were normally two such men attached to each infantry company in World War II) is trained as a surgical technician. He has earned by repeated demonstrations of selflessness and endurance the respect he receives from his fellow soldiers. His mere presence in the company is a morale builder, because the men know that as long as "Doc" is there, they will not be left to die on the battlefield.
In this hypothetical case, a quick check is enough to tell the aidman the casualty is in shock. He calls at once for one of the four-man litter squads already moving out from the battalion aid station some 500-800 yards to the rear, where water and a measure of natural protection are available. Although he carries morphine, he will not use it because the casualty is unconscious. If it is toward the latter part of the Italian campaign, however, he will have plasma with him, which he begins to administer without delay. When the needle is taped in place and the flask suspended, perhaps from the same rifle butt that guided him to the spot, the aidman will check the wound, replacing the dressing if it seems necessary, and perhaps adding tape to make transportation easier. He then fills out an Emergency Medical Tag(EMT), copying the mans name and serial number from his dog tag, and indicating the nature of the wound, the approximate time it was inflicted, and the treatment so far given. The EMT is conspicuously attached to the patient and will go with him along the whole chain of evacuation.
By this time the litter bearers have reached the scene. The litter bearers, along with the aidmen, are the unsung heroes of the war. They have no weapons save strength, courage, and dedication beyond the call of duty; they have no protection save a steel helmet painted front and back with the red cross, and a red cross brassard on the sleeve; yet they move among fighting men and whining shells on the battlefield, concerned only for the safety and comfort of the man they lift so carefully onto a litter and carry so gently, avoiding any unnecessary jar or change of angle, back to a place of relative security--for the casualty but not for them. They will return at once to the battlefield.
At the battalion aid station, the wounded man will be examined for the first time by a medical officer, generally the battalion surgeon. Perhaps an hour has now passed since the wound was inflicted. The man is still alive, thanks to the plasma given him on the field, but he will not be for long without extensive surgery. If the battle is strongly contested--and what battle was not, in that "forgotten theater"?--there will be many casualties at the aid station, brought in from the various companies of the battalion by the four litter-bearer squads available or walking if their injuries permit that luxury. Let us assume that the case we are following is the most serious, and so receives the immediate attention of the battalion surgeon. In this late stage of the war, the other officer at the aid station will be nonmedical, generally Medical Administrative Corps, whose duties will include first aid, but will be primarily to keep the wounded moving--to hospitals farther to the rear if hospitalization is indicated, or back to the front with a bandage if the wound is slight. Manpower is never so plentiful that it can be dissipated by
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evacuating men still able-bodied. In addition to the litter bearers, there will be a group of enlisted technicians, who will change dressings, administer drugs, keep records, and perform such other duties as may be required.
There is nothing rigid about the field medical service. Improvisation and adaptation were the rule in World War II as they are today. There is a job to be done, and quickly, with whatever means are at hand. The job, in the case we are considering, is to get a man to surgery with the least possible delay consistent with keeping him alive. The battalion surgeon will probably not change the dressings the company aidman has applied, but will administer more plasma and perhaps morphine if the man shows signs of returning consciousness. The wound will be immobilized so far as its location permits to minimize the shock of further transportation, additional entries will be made on the EMT, and the patient will be speeded on the next stage of his journey. His destination now will be the clearing station of his division, located five to ten miles behind the front, and the field hospital set up adjacent to it specifically for forward surgery. When he leaves the battalion aid station he will pass from first to second echelon medical service--from regimental to divisional control.
Before we move on to the division clearing station with our hypothetical casualty, some further explanation may be in order. In the Mediterranean, as in other overseas theaters in World War II, each division was served by two different bodies of medical troops. Up to this point we have been dealing with personnel of the medical detachment, headed by the division surgeon. In the medical detachment of an infantry division toward the end of 1944 there were 32officers, including dental and administrative as well as medical, and 383enlisted men. Each regiment and each battalion had its medical section under a medical officer, with enlisted technicians attached as aidmen at the company level. In addition to the medical detachment, each division had an organic medical battalion, organized into a headquarters, three collecting companies, and a clearing company. The collecting companies, generally attached one to each regiment of the division, were basically ambulance and litter-bearer units. The clearing company, on the other hand, was equipped to function as a small--and sometimes not so small--hospital; or rather, two hospitals, for its two platoons were always prepared to set up independently. The usual procedure was to have one platoon in operation, the other packed and ready to "leapfrog" forward as the line of battle advanced. Between the clearing station and the battalion aid stations there might or might not be a collecting station, set up by the appropriate collecting company. In Italy, where the roads were relatively good and rugged country offered protection for clearing stations close to the front, the intermediate step was often bypassed. Ambulances, or jeeps fitted with litter racks, picked up casualties at the battalion aid stations, or if these were not accessible to vehicles, at ambulance loading posts within reasonable litter carry of the aid stations. If a collecting station were established, it would be located to serve two aid stations, or three if all the battalions of the regiment were engaged.
At the clearing station patients were again sorted--the French term triage is
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still used in the medical service to refer to this process--so that those whose wounds were critical might be cared for first; so that specialized needs would be referred to specialized skills; and as at the aid station, so that no man would be sent farther to the rear than his bodily condition required. Here there would be medical cases as well as battle wounds and injuries, for the clearing station was in effect the most forward hospital serving the division and therefore the most accessible from the front lines, where disease might claim as many victims as bullets. The system that developed in the Mediterranean about the middle of 1943 was to set up as close as possible to each division clearing station a platoon of a field hospital to receive those casualties in need of immediate surgery. The field hospital itself was a versatile new unit, capable of operating as a single 400-bed hospital, or as three separate 300-bed hospitals. When split three ways the surgical staff was wholly inadequate, but the deficiencies were made up by attaching teams from an auxiliary surgical group, some general, some specialized, but each a fully functioning unit with its own equipment as well as its own personnel.
Now let us get back to the casualty whose progress we are following along the chain of evacuation. He is picked up at the battalion aid station by a squad of litter bearers from the collecting company, sent forward from an ambulance loading post that might be only 300 or 400 yards away as the crow flies, but half to three-quarters of a mile by the narrow, winding trail that must be used. The tedious and difficult hand carry once completed, he will be delivered at the clearing station along with other wounded men of his regiment in a matter of minutes. It is now two hours or more since he received his wound, but he is still alive and his chances are now good, for he is only moments away from the finest in surgical skill and facilities. The field hospital to which he is immediately carried is a tent with packed earth floor, heated if necessary by oil stoves and lighted by generator-driven electric lamps. In physical appearance it is not at all like the fine modern hospitals at home, but in its equipment and in the skill and motivation of the two surgeons, anesthetist, and surgical nurse who with two enlisted technicians make up a surgical team, it is as good or better.
From the field hospital rearward progress is relatively standardized. The patient will be retained until he is strong enough to be moved without damage--possibly as much as a week. If the front advances significantly in that time, another field hospital platoon will set up adjacent to the new site of the division clearing station, leaving the old hospital or a detachment from it to operate where it is until all its patients are transportable. Our casualty, along with other holdovers, will next be moved to an evacuation hospital, still in the combat zone, in all probability still under canvas, but considerably farther to the rear. These units in World War II Tables of Organization were of two types: a 400-bed hospital that could be moved quickly in two installments with its own organic transportation, and a 750-bed hospital in which mobility was sacrificed for somewhat more complete facilities. Ideally one 400-bed "evac" backed up each division, some eight to twelve miles behind the clearing station, with one of
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the larger units supporting two divisions. Both types of evacuation hospital were prepared to give definitive treatment to all casualties. They were staffed and equipped, that is, to do whatever might be necessary for the recovery of the patient. The primary difference between these hospitals and the so-called "fixed" hospitals of the communications zone was their proximity to the front lines. For that very reason, however, they could not hold patients for any great length of time. As a rule only those who could be returned to duty within a week or two or, alternatively, passed on to a convalescent hospital, were retained. The convalescent hospital was another combat zone unit, where the man no longer in need of constant medical or surgical care but not yet strong enough to fight could regain his vigor. It conserved both professional and combat manpower by operating with a low ratio of medical officers to beds, and by retaining in the army area men whose services might otherwise have been lost indefinitely in the complex machinery of the replacement center. Those whose treatment would require a longer period of time were transferred to the communications zone. The particular casualty whose treatment and evacuation we are discussing will be one of these.
Had he been less severely wounded his injuries would have been dressed and rebandaged at the clearing station and he would have been moved to an evacuation hospital for surgery. As it is, he will be a transient at the evac, on his way to the communications zone. When he moves from the field hospital unit to the evacuation hospital he will pass from division to army control, at the same time entering the third echelon in the chain of evacuation. He will be brought to the evac by an ambulance of a collecting company, but this time it will be a company of a medical battalion (separate) --not organic to any formation, but in this case assigned to army and under control of the army surgeon. The next stage of his journey, which will bring him into the fourth echelon of the chain, will be in all probability too long for an ambulance run.
After a day or two at the evacuation hospital, with a fresh dressing on his wound and a new entry on his Emergency Medical Tag, our casualty will be moved by ambulance to a nearby railhead, port, or airstrip to continue rearward by whichever mode of transport is most convenient to the location. In Italy, except for Anzio where all transportation was by water, it would have been by hospital train, or by C-47 cargo plane rigged with litter racks to hold 18 or 20 non ambulatory patients and staffed by personnel of a medical air evacuation transport squadron. Either way, responsibility and control would have rested with the communications zone, most likely in the Mediterranean with a base section. This particular casualty will require further, probably extensive, surgery before his damaged organs are restored to relatively normal use, so that a general hospital is indicated.
The numbered general hospital overseas (as distinct from the named general hospital in the zone of interior), singly or in a grouping or center, enjoys the relative safety of the communications zone. It had in World War II 1,000 to 2,000 beds, with many specialties represented on its staff and equipment adequate for almost any situation it might
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be called upon to meet. A less difficult case than the one we are following might go to a station hospital, which would perform most of the functions of a general hospital--indeed might be acting as a general hospital--but would be smaller, with fewer specialists and less complete equipment. The World War II station hospital had anywhere from 25 to 900 beds; in the Mediterranean most were 500 beds. The station hospital normally serves a post or garrison, referring its more serious cases to a general hospital, but in a theater of operations requirements dictate use. In the Mediterranean the station hospital in practice was often indistinguishable from the general hospital, although a larger proportion of its patients were apt to be service or other rear echelon troops. In both types medical cases usually outnumbered surgical.
In the general hospital our casualty might have another, more leisurely, operation, but this will depend on the probable length of his stay, which will be determined by the theater evacuation policy and by the judgment of the medical officers on his case. An evacuation policy establishes the number of days of hospitalization the theater medical authorities feel they can give to any one case. The policy in the Mediterranean Theater varied from 30 to 120 days, but for most of the time it was 90. This meant that if a patient admitted to a communications zone hospital would in the opinion of his doctors be fit for duty in 90 days or less he would be retained and treated, being returned to his unit or sent to a replacement center when he was recovered. If, on the other hand, the chances of his recovery within that time were remote or nonexistent, he would be sent to the zone of interior as soon as he could safely be moved so great a distance. It is clearly to the advantage of a theater to have as long an evacuation policy as possible, because the longer the policy the more sick and wounded will be kept in the theater for future combat operations. It is the availability of beds and of trained personnel in relation to the incidence of battle wounds, injuries, and disease that determines the policy.
Full recovery, in the case we are following, will take months or possibly years of prolonged and specialized treatment. The patient will therefore not stay long at the general hospital, but will be sent home to the United States as quickly as possible. When he boards hospital ship or plane, according to the availability of transportation and the urgency of his case, he will enter the fifth and final echelon of the chain of evacuation. Thus it may well be that two weeks after being severely wounded in the mountains of northern Italy, this particular soldier will be admitted to Walter Reed Army Hospital in Washington, or to one of the other named general hospitals that may be closer to his home. There he will remain until cured, or until everything that can be done for him has been done. If his doctors believe he is still in need of medical attention, he will be transferred to a Veterans Administration hospital. He is perhaps not quite. as whole as he was, but he is alive and capable of useful citizenship. That gift of life he owes to the dedication and skill of the men and women who make up the medical service of the U.S. Army.
