CHAPTER VIII
Casualty Survey, Cassino, Italy
Allan Palmer, M.D.1
Casualty surveys of civilians killed or injured in air raidsin England had yielded detailed information about the wounding power of bombsand about the relative value of different measures of protection. The advantageof such surveys was that the investigator could conveniently study not only thecasualties themselves but also the circumstances under which they were injured.
Useful information had also been obtained in the past fromsurveys of battle casualties undergoing treatment in base hospitals. However,this information was limited since the casualties seen represented only a smalland usually a selected proportion of the total.
It had long been felt that more useful information could beobtained by studying the casualties incurred by selected units engaged in aspecific operation for which full details were available and, particularly, ifsuch a survey could be made further forward than the base hospitals. While thesurvey had to be limited2 because ofshortage of time and personnel, it has shown that studies of a similar kindcould be successfully carried out, and it has also provided useful guides forfurther procedures.
The scene of the battle was about 75 miles southeast of Romealong a 6-mile sector, the front of which lay along the Rapido River (fig. 264)immediately south of the town of Cassino (fig. 265). This front flanked arailroad and a main road to Rome (Highway No. 6, fig. 266). Figures 267 and 268show the terrain in the vicinity of Monte Lungo with the highly advantageousenemy defensive positions.
Operations to bridge and advance across the Rapido River werebegun during the night of 19 January 1944 and were successfully completed on 12May.
1In November 1943, Maj. Allan Palmer, MC, was relieved of his assignment as chief of the laboratory service, 30th General Hospital, European theater, for the purpose of joining Prof. Solly Zuckerman, C.B., F.R.S., in the Mediterranean theater for indoctrination in field casualty survey methods. Professor Zuckerman, as scientific advisor to the Allied Air Forces leaders, held an honorary commission as Group Captain and later was the commanding officer of a component of the Royal Air Force known in the Mediterranean theater first as the Special Air Mission and later as the Bombing Survey unit. When the Secretary of War established the U.S. Strategical Bombing Survey in 1944, Zuckerman's organization finally became known as the British Bombing Survey Unit. Major Palmer was one of the two American scientific observers attached to this unit. With the help of a Royal Air Force medical officer, Squadron Leader C. Spicer, from Professor Zuckerman's unit, and an American medical officer, Maj. (later Lt. Col.) Roberto F. Escamilla, of the 59th Evacuation Hospital, who was detailed by the Seventh U.S. Army surgeon, and in liaison with General Martin, Fifth U.S. Army surgeon, Major Palmer conducted the specimen survey of 100 battle casualties sustained by the Fifth U.S. Army during the Rapido River conflict south of Cassino from 20 to 27 January 1944.-J. C. B.
2While it is true that this survey covers only relatively few casualties, incurred during a short interval of the total campaign, it is an excellent demonstration of the organization and conduct of a casualty survey and the scope of information available.-J. C. B.
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The main U.S. troops engaged in the operation were the 141stand 143d Infantry Regiments, 36th Infantry Division, and the 34th InfantryDivision, Fifth U.S. Army.
Fighting was of the static kind and was confined for manydays to an isolated area of mountainous country, as shown in figures 269 and270. Allied and enemy forces were not visible to each other, and there waslittle small arms fire. Most wounds were inflicted by artillery and mortarshells and by landmines. The bulk of the fighting with the casualties sustained,occurred during the hours of darkness, especially when river crossings wereattempted. In general, the enemy's guns and mortars were zeroed in (fig. 271)to cover the area traversed by U.S. troops, and periodically a harassing firewas laid down, inflicting a very large number of casualties as wave after waveof troops advanced in the region of the river.
The U.S. Army units engaged in this action had obtainedprevious experience of this type of warfare in operations which had resulted inthe capture of three mountain strongholds, Trocchio, Porchia, and Lungo. Thesehills lay to the rear of the Rapido front and between U.S. troops and HighwayNo. 6. The mountainous terrain necessitated the use of mules for the transportof supplies and ammunition.
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The stubborn resistance by the enemy in his attempts tomaintain control of Highway No. 6, and the considerable advantage of the terrainand entrenched enemy positions, made the fighting the bitterest experienced byU.S. troops in the whole Italian campaign. During the later stages of thecampaign, concentrated aerial bombardment assisted in the capture of Cassino(figs. 272 and 273).
MEDICAL FACILITIES AND EVACUATION OF CASUALTIES
Figure 266 shows the layout of the medical installationswhich served the Fifth U.S. Army front in the Cassino area. They included sixevacuation and three field hospitals and two clearing companies, in thefollowing order:
11th Field Hospital (Near Venafro) | 94th Evacuation Hospital (Semimobile) |
422d Field Hospital (French) | 15th Evacuation Hospital (Semimobile) |
16th Evacuation Hospital | 8th Evacuation Hospital |
11th Evacuation Hospital (Semimobile) | 601st Medical Clearing Company (Separate) |
602d Medical Clearing Company (Separate) | 10th Field Hospital |
38th Evacuation Hospital |
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Casualties were carried out of the actual battle zone bylitter squads and jeeps. The ALP (ambulance loading points) (fig. 266) werelocated immediately outside the battle zone. The routes followed by theambulances to Highway No. 6 are also shown in figure 266. One of them consistedof a railway track from which the rails had been removed.
Casualties were sorted in the vicinity of the ALP. Thosewhose main injuries were either cranial, thoracic, or abdominal weresent daily to the 15th and 38th Evacuation Hospitals. The majority of othercasualties were evacuated alternately to the 11th and 94th Evacuation Hospitalson even-numbered days and to the 8th and 16th Evacuation Hospitals onodd-numbered days. On occasions when full loads could not be made up withcranial, thoracic, or abdominal casualties, all types of casualties were takento the 15th and 38th Evacuation Hospitals.
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The dead, including some German dead, were removed from thecasualty areas by the Graves Registration Service and taken to one of the twoburial grounds (CEM, fig. 266) which were located in advance of the evacuationhospitals.
Within a few minutes after they were wounded, men who couldnot help themselves were given first aid either by a medical aidman or by one oftheir fellow soldiers. Walking casualties were then directed to the nearest aidstation or left where they had fallen to be transported later by litter.
The following information on the time taken to evacuatecasualties from the battle zone was provided by Col. John W. McKoan, Jr., MC,Commanding Officer, 8th Evacuation Hospital, who had made a special study of 100casualties received at his hospital on 21 January, the second day of the RapidoRiver operation. The average time taken for a casualty to reach the nearest aidstation after wounding proved to be 5 hours and 55 minutes. Some men had to bebrought from the far side of the river which they had already crossed, and a fewsuch casualties did not reach aid stations for a period of 24 hours or evenlonger. The average time from aid station to clearing station was 2 hours and 48minutes and from clearing station to evacuation hospital, 58 minutes. Theaverage total time required from the time of injury to entry into a hospital fordefinitive treatment was 9 hours and 41 minutes.
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ANALYSIS OF CASUALTIES
An initial survey of the problem indicated clearly that, withonly three medical officers available to carry out the work, it would beimpossible to do more than survey a sample of those casualties who reached the8th and 38th Evacuation Hospitals. While it was realized that this procedurewould impose a bias on the information collected, it was hoped that the missingfactors in the analysis could be obtained later by a study of central records.The whole complex of data which would have to be collected was as follows:
1. Strength of forces engaged in the operation during therelevant period.
2. Total number of killed and wounded for the two unitsconcerned (the 141st and 143d Infantry Regiments).
3. Data about the causes of death and regional distributionof wounds in the dead. These data were being collected by the GravesRegistration Service on special forms for transmission to Washington, D.C.However, the EMT (emergency medical tags), filled out by the medical aidman onthe battlefield and then attached to the body of the dead soldier, was the onlyrecorded information about wounds and cause of death. The bodies were buriedfully clothed without preliminary examination by a medical officer.
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FIGURE 273.-Cassino area, Italy, 18 May 1944. Ruins ofCassino castle, "Hangman's Hill," towers above the city.
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4. Details about those casualties from the two unitsconcerned who were selected by the clearing companies for treatment in the 15thand 38th Evacuation Hospitals, which dealt predominantly with injuries of thehead, thorax, and abdomen. A daily report of casualties, which includes astatement about the regional distribution of wounds, was made by all hospitalsto the Surgeon, Fifth U.S. Army. A study of these reports, together with ananalysis of the records of the cranial and trunk casualties, and of the dead, ofthe two units concerned would complete the casualty picture for these twoinfantry regiments during the first week they were engaged in the crossing ofthe Rapido River (20-27 January).
A few casualties from other units which were engaged in thesame operation as the 141st and 143d Infantry Regiments were also studied.
During the survey period (20-27 January 1944), 100 WIA(wounded in action) casualties were interviewed-73 at the 8th EvacuationHospital and 27 at the 38th Evacuation Hospital. This group of casualtiesconsisted of 6 officers and 94 enlisted personnel. The majority of thecasualties were able to give their approximate geographical position in relationto the Rapido River, state their assigned duty at the time they were wounded,and describe and identify the type of enemy weapon responsible for their wounds.Of the casualties, 90 were hit while advancing toward the enemy. The majoritywere engaged as infantry troops armed with either rifles or machineguns, and asmaller number were wounded while carrying a footbridge or a boat or when theywere in a boat. Of the remaining 10 men, 5 were on guard duty and the other 5were wounded while engaged in carrying the dead from the firing zone.
Effect of Posture on Wounds
Of the 90 casualties who were hit while advancing toward theenemy, 40 received their wounds when standing erect, and the remaining 50 menwere hit either when lying or kneeling or after they had taken cover in a ditchor a foxhole. The following tabulation lists the incidence of single andmultiple wounds in relation to the position of the casualty:
Standing: | Number |
| Single wounds | 18 |
| Multiple wounds | 25 |
Kneeling or lying: | |
| Single wounds | 38 |
| Multiple wounds | 15 |
The tabulation indicates very clearly that men lying down, orotherwise taking cover, are less likely to receive multiple wounds than menstanding erect.
The difference in the incidence of multiple wounds insoldiers taking simple cover and those not taking cover is highly significantstatistically according to the chi-square test which gives x2=7.84(n-1, P<0.01).
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Weapons Responsible for Wounds
Almost all of the casualties who were interviewed felt certain that they knewwhat type of weapon had caused their wounds. Table 170 shows the number ofcasualties caused by different weapons and the incidence of fractures.
The preponderance of wounds due to artillery and mortar shells and mines iswhat would be expected in operations of the kind studied.
TABLE 170.- Incidence of fractures in 100 casualties, by causative agent
Causative agent | Number of casualties | Number of fractures |
Shell: | ||
| Artillery | 42 | 9 |
| Mortar | 31 | 10 |
| Artillery or mortar | 3 | 2 |
Landmine | 13 | 3 |
Hand grenade | 9 | 2 |
Bullet: | ||
| Machinegun | 1 | 1 |
| Rifle | 1 | --- |
| Total | 100 | 27 |
The sizes of the fragments responsible for wounds were estimated from X-raysin 28 cases. The weights of the fragments were estimated in grams from theirlinear dimensions. A large series of X-rays of fragments of known weight wereavailable as a standard.
All but 1 of the 28 casualties in question had been wounded by eitherartillery- or mortar-shell fire. The exceptional case had been wounded by alandmine. Table 171 summarizes the information obtained on this point and alsogives the distances from the burst at which the casualties stated they wereinjured. Of the 28 casualties, 10 sustained injuries only from fragmentsweighing 1 gm. or more, while another 5 were hit by smaller fragments inaddition to hits by fragments of the larger size. The remaining 13 casualtieswere injured by fragments weighing less than 1 gm. and in 4 of these onlyfragments of less than 50 mg. were found.
Regional Distribution of Wounds
Table 172 shows the regional incidence of wounds in the total sample studied.Since four of the casualties had no obvious external injury, their wounds havebeen included in the table as injuries of the head.
Although none of the casualties seen had been wounded in more than threeregions of the body, the number of wounds in any one casualty was often
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TABLE 171.-Distribution and weight offragments in 28 casualties, by distance from shellburst
Distance from shellburst (in feet) | Weight of fragments | Total fragments | Casualties | |||
1-50 | 50-250 | 250-1,000 | 1-5 | |||
Mg. | Mg. | Mg. | Gm. | Number | Number | |
Artillery shells: | ||||||
| 0-10 | 17 | --- | 8 | 7 | 32 | 5 |
| 10-20 | 3 | 7 | 7 | --- | 17 | 2 |
| 20-30 | --- | --- | --- | 1 | 1 | 1 |
| 30-40 | --- | --- | --- | --- | --- | --- |
| 40-50 | --- | --- | --- | --- | --- | --- |
| Over 50 | --- | --- | 4 | 2 | 6 | 3 |
| Total | 20 | 7 | 19 | 10 | 56 | 11 |
Mortar shells: | ||||||
| 0-10 | 48 | 21 | 12 | 2 | 83 | 8 |
| 10-20 | 1 | 1 | 2 | --- | 4 | 3 |
| 20-30 | --- | --- | --- | 1 | 1 | 1 |
| 30-40 | --- | --- | --- | --- | --- | --- |
| 40-50 | 6 | --- | --- | --- | 6 | 1 |
| Over 50 | 2 | --- | --- | 5 | 7 | 3 |
| Total | 57 | 22 | 14 | 8 | 101 | 16 |
Landmine, 0-10 | 2 | --- | --- | --- | 2 | 1 |
| Total | 2 | --- | --- | --- | 2 | 1 |
| Grand total | 79 | 29 | 33 | 18 | 159 | 28 |
TABLE 172.-Distribution of 133 single and multiple woundsin 100 casualties, by anatomic location
Anatomic location | Single wound | Multiple wounds | Total wounds | ||
2 regions involved | 3 regions involved | Number | Percent | ||
Head | 20 | 5 | 1 | 26 | 19.5 |
Thorax | 5 | 8 | 1 | 14 | 10.5 |
Abdomen and scrotum | --- | 8 | 1 | 9 | 7.0 |
Extremities: | |||||
| Upper | 17 | 11 | 2 | 30 | 22.5 |
| Lower | 28 | 23 | 3 | 54 | 40.5 |
| Total | 70 | 55 | 8 | 133 | 100.0 |
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as many as six or eight. Table 172 also includes several cases in which men were wounded either in both upper or in both lower extremities.
Only 4 of the 100 casualties required amputations. In two, toes had to be removed because of compound fractures due to shell fragment wounds of the foot. The other two casualties were men who had to have a lower limb removed because they had stepped on a landmine. One of the two was a squad leader who was advancing with a mine detector which did not respond to the mine which caused his injury. This casualty thought the mine probably had a plastic case.
Blast Injuries
The blast pressures necessary to cause injury to the lungs are only likelyto be experienced close to the burst of large bombs at distances where severeor fatal injuries from fragments are almost certain to occur. Since artilleryshells have a very much lower charge-weight ratio than bombs (a 155 mm. shellonly contains 4.8 pounds of explosive), the chances of receiving blast injuriesto the lungs without serious fragment injuries are even more unlikely fromshellfire than from bombs.
There is no reliable evidence that so-called blast concussion is a directconsequence of the impact of a blast wave on the head. Cranial symptoms,amnesia, and mental confusion are probably due to blows on the head from flyingdebris or from sudden body displacement. Rupture of the eardrums,however, occurs at very much lower blast pressures than does lung damage, and itis the most sensitive indicator of injury due to blast. In the group ofcasualties surveyed, there were no instances of damage to the lungs. In 15casualties, one or both eardrums had been ruptured. Of these men, 11 had alsoreceived other injuries from fragments and only 4 had ruptured eardrums as theirsole injury.
Of these 15 casualties, 13 were standing erect or had their head andshoulders exposed when they were injured. The other two, although apparentlylying protected in slit trenches, were also close enough to the shellburst toexperience earth movement, displacement, and partial burial by loose earthnearby. The stated distances (in feet) at which the casualties sustained a blastinjury from bursting projectiles is as follows:
Number of casualties | |
Distance from burst (feet): | |
| 0-5 | 9 |
| 5-10 | 2 |
| 10-15 | 1 |
| 15-20 | 1 |
| 20-25 | 1 |
| Unknown | 1 |
| Total | 15 |
It is a remarkable fact that 11 of the 15 casualties were within 10 feet ofbursting projectiles and sustained injury due to blast but escaped fatalfragmentation wounds.
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Casualty Rates
When a small group of casualties is surveyed, the probabilityof an incident being reported is proportional to the number of casualties itinvolves or, if wounded men only are reported, to the number of wounded. Havingrecognized that in this survey an individual incident may be reported more thanonce, it is necessary to make use of Haldane's method for correcting for thisfactor. By making use of his formula
where N equals the number of incidents reported, C thenumber of casualties (killed and injured grouped together) and T the totalnumber of men exposed to injury, it is found that the estimated casualty rates fromartillery shells is 26.5?2.85 percent. The estimated casualty rate from mortar shells is 28.5?2.25 percent. These rates do not differ significantly from each other.
Table 173 summarizes these and the casualty rates estimatedfor the same two weapons in previous casualty surveys.
Excluding the American casualties at Cassino, it would thusseem that Allied artillery and mortar were both more efficient than those of theenemy. Such a conclusion would only be justified, however, if it could beassumed that the tactical use of both weapons was the same on both sides.American casualties from enemy mortar shells at Cassino are of the same order asthose inflicted by the enemy in other theaters and significantly fewer thanenemy casualties from the same weapon. On the other hand, American casualtiesdue to enemy artillery at Cassino are significantly greater than Alliedcasualties have been in other theaters and are of the same order as U.S.soldiers have inflicted upon the enemy by that weapon.
TABLE 173.- Estimated casualty rates from Allied and enemy artillery and mortar shells
Men at risk | Area | Probability of becoming a casualty from- | |
Artillery shells | Mortar shells | ||
Percent | Percent | ||
New Zealanders | Tunisia | 16.87?1.88 | 26.30?1.83 |
English | ...do... | 18.18?5.81 | 39.74?5.54 |
Enemy | ...do... | 25.51?3.11 | 60.00?9.80 |
Americans | Cassino | 26.5?2.85 | 28.5?2.25 |
NOTE.-Statistics were obtained by author whileserving as scientific observer with Professor Zuckerman (see footnote 1, p.531).
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As already emphasized, this casualty survey was initiated todiscover whether useful and complete information could be obtained in the battlearea. While this objective was not achieved in the present case, theinvestigation has definitely shown that it could be in a future survey, ifspecial arrangements were made in advance to obtain from central records acomplete picture of the tactical problem and of the casualties incurred and ifthe survey itself were adjusted in advance to the size of the staff available tocarry out the work.
The advantages of surveying casualties in the forwardevacuation hospitals and of examining the dead at their burial grounds areobvious. In these locations, complete casualty data for a specific tacticaloperation, pertaining to the uninjured, slightly and severely wounded, and thedead can be obtained before the various types of casualties are dispersed,before original X-rays are separated from the casualties, before memory ofspecific details of incidents is clouded by time or colored by self-interest,and before the dead are buried and lost to detailed examination.
