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The Mediterranean in Retrospect
The Mediterranean was never regarded by American strategists as a decisive theater. Its major objectives were few and soon achieved. The commitment of U.S. forces in North Africa indirectly eased the pressure on the Stalingrad front, where the Russians were preparing to launch a winter offensive, and in America it gave a needed boost to public morale. The Tunisia Campaign ended the threat of Axis penetration into the Middle East, with its oil and its vital lines of communication. The conquest of Sicily knocked Italy out of the war and opened the Mediterranean to Allied shipping. But Italy, aside from the air bases it supplied for bombing the German homeland, was a liability, without enough strategic value to balance the concomitant responsibility for a large and predominantly destitute civilian population. The justification for the Italian campaign, after the Foggia airfields were secured, was that it could be so managed as to engage. more German than Allied troops and thus contribute indirectly to the ultimate winning of the war. It was, in short, a diversion in force, in which the "force" was never quite enough for total victory but was always too great to invest in stalemate.
For such a campaign the theater was kept lean. Stripped again and again of its best troops and facilities to strengthen the build-up for Normandy and later to mount the invasion of southern France, replacements were inexperienced and slow in coming. The Medical Department through the whole period of active fighting was plagued by shortages--of personnel, of beds, of medical units, and of various supplies. Yet by virtue of ingenuity, skill, organization, improvisation, and endless hours of hard work, the medical mission was carried out with speed and precision at every level. The Mediterranean experience embraced in one theater almost every condition that would be met on any front in a war that enveloped the globe. The innovations, the modifications, the practical expedients that emerged from it became standing operating procedures as one crisis followed another. Passed along to army surgeons in Europe and the Pacific, they also became part of the collective wartime experience of the Medical Department and gave to the medical service in the Mediterranean an importance that the combat forces it supported never achieved.
Although United States Marines had stormed ashore on Guadalcanal and Tulagi in the Solomon Islands some three months before the Allied landings in North Africa, that invasion was in reinforced division strength only, with all medical support furnished by the Navy. TORCH was the first World War II amphibious operation of any size for U.S. Army troops, and the first in which Army field medical installations were tested in
an assault. It succeeded only because determined opposition failed to develop. Had the French resisted strongly, the landing forces, spotted as they were along a thousand miles of African coast, would have been individually overwhelmed. Had the casualties been even moderately high, the medical troops in the landings would have been unable to handle them with the small number of beds and meager supplies at their disposal. Even the equipment available was sometimes useless under the conditions of the invasion. The standard army ambulance of the time, for example, proved to have inadequate traction on the loose sand of the African beaches, and its silhouette was dangerously high. Medical supplies were strewn across the landing beaches with no one detailed to collect, sort, and issue them. Plans for medical support of the operation had been drawn up, some in England and some in the United States, without co-ordination or sufficient knowledge of local conditions that might affect the accomplishment of the medical mission.
In subsequent landings on Sicily, at Salerno and Anzio, and finally over the white sands of the French Riviera, modifications and improvements were introduced to overcome the shortcomings of each earlier amphibious effort. For the invasion of Sicily, a clearing element was attached to each collecting company to enable the companies to furnish hospitalization until the regular hospitals arrived. Medical supply items were hand-carried ashore by medical troops, but litters and blankets were late in coming. This lag was corrected at Salerno, where medical depot personnel were on the D-day troop list. Additional medical supplies, in waterproof containers light enough to float, were carried onto the beaches by combat troops. At Anzio, field and evacuation hospitals, combat loaded, were added to the assault convoy. Four and a half months later, medical troops trained on the basis of Mediterranean experience (and not a few who were themselves veterans of one or more Mediterranean assaults) put their skills to the test in the invasion of Normandy. Medical support of the army that landed in southern France in mid-August 1944 was as near flawless as such a thing can be. The cumulative experience of Europe and the Mediterranean again helped to save American lives halfway around the world, on Leyte, Luzon, and Okinawa.
In addition to five major amphibious operations in the theater, Medical Department personnel supported combat and service activities in the Tunisian desert; in the steep, wooded mountains of Sicily and the sharper ridges of the Apennines in Italy; slogged through rain and mud, and shared with the infantry the perils of snow and ice; crossed flooded rivers and miasmic marshlands, and penetrated valleys still raked by enemy fire. Only the jungle was missing and even that was to be found in associated minor theaters.
These widely varying conditions of climate and terrain required many different means of bringing out the wounded. The versatile jeep was early fitted with litter racks and used to move casualties from places inaccessible either to wheeled or half-track ambulances. In one operation in Africa half-ton trucks with tires removed were run over rails, each truck carrying six litter patients. Both in Tunisia and in Sicily mules brought out the wounded in country too rough for vehicles of any kind. In the high moun-
tains of northern Italy cable tramways made it possible to move casualties in minutes between points that would have taken hours on foot.
For the longer hauls, hospital ships and trains were employed. The Mediterranean theater pioneered in the use of transport planes to move casualties not only in rear areas but from hospitals far forward in the combat zone. Experiments with small Piper Cubs as ambulance planes were not successful enough to justify general use, but the helicopters later used for front-line evacuation in Korea were developed out of the same need and purpose. Necessity also taught the medical authorities in the Mediterranean that troop transports with hospital ship platoons attached to supply necessary medical service could safely move all but a limited few types of patients. It should be noted that neither the patient-carrying planes nor the transport vessels were marked with the Geneva Cross, but none were lost through enemy action. On the other hand, four properly identified and lighted hospital ships were deliberately bombed, two of them sinking.
The backbone and single indispensable element in the evacuation system was the litter bearer. It took strength, stamina, gentleness, and a high order of courage to collect the wounded on the field while the fighting, often enough, was still in progress, and by relays of four-man teams to carry the casualties sometimes as much as ten or twelve miles over mountain trails impassable to any vehicle, too steep even for mules. In the Italian campaign there were never enough litter bearers. In emergencies-- which were frequent--cooks and bands-men and company clerks were pressed into service, and there were many partisan volunteers whose aid was invaluable.
The stringencies of the theater forced the Medical Department at every echelon to stretch equipment and personnel to the utmost. Personnel assigned to hospitals temporarily not in operation, including those newly arrived and not yet assigned, were always attached to other units where their services could be utilized until required by their own installations. The cellular type of organization proved most effective because of its versatility and mobility. Surgical teams were an excellent example but only one of many in a genre that included malaria control units, veterinary food inspection detachments, and hospital ship platoons that were seen more often ashore than at sea. As the war progressed and replacements became more and more difficult to procure, medical officers were replaced in every permissible assignment by Medical Administrative Corps personnel. Such substitutions extended to medical supply, evacuation, and numerous purely administrative activities. Another successful expedient was the substitution of Women's Army Corps personnel for enlisted men in a variety of hospital tasks. Large numbers of Italian prisoners of war, available after the Axis collapse in Tunisia, were organized into service companies, and many of them assigned to the Medical Department where they proved themselves competent in almost all nonprofessional functions. Local civilians were also employed extensively in all Mediterranean areas to perform tasks that would otherwise have fallen to enlisted men.
One of the more successful expedients
devised was the use of clearing platoons to augment bed strength of field and evacuation hospitals. With additional attached personnel, these platoons were also employed as separate forward hospitals for specialized functions, including neuropsychiatric, venereal, and gastrointestinal cases. Such devices made it possible to hold in the army area men who would otherwise have been evacuated to the communications zone, and thereby to shorten materially the time lapse before return to duty. Mediterranean experience tended to emphasize mobility and versatility. The more mobile a hospital was, the closer to the front lines it could be used. The best example is that of the field hospital platoon, deriving its strength from attached surgical teams. These platoons were first used in the Sicily Campaign as 100-bed forward surgical hospitals, reduced to 50 beds by the date of the southern France invasion. This experience contributed much to the development of the MASH (Mobile Army Surgical Hospital) units employed so effectively in Korea. Other devices successfully used to conserve Medical Department personnel were shortening lines of evacuation, and grouping fixed hospitals in concentrations to permit maximum use of skills by specialization, at the same time reducing the overhead by providing as many services as possible in common.
At the army and theater levels the Mediterranean experience underlined certain organizational principles. In a theater that was always a combined operation, the Americans were generally outranked by their British counterparts, which produced unnecessary friction. At the same time, it was the conviction of many officers in position to know that the United States medical service maintained higher standards than the British, and certainly medical skills, drugs, instruments, and equipment were more plentiful in American hospitals. U.S. soldiers hospitalized in British installations were quick to note the difference, which often led to a lowering of morale. At the army level Mediterranean experience demonstrated, as did the experience of every theater, the importance of giving the army surgeon a place on the staff of the commanding general. Similarly, the mission of the theater surgeon called urgently for a staff relationship with the theater commander. It was the absence of such a relationship that produced the awkward dichotomy between the theater medical organization and that of the Services of Supply. In the European theater and elsewhere the jurisdictional problem was resolved by giving both surgeons jobs to the same man. In the Mediterranean, however, only personal cordiality between the individuals concerned, and a strong mutual desire to get on with the war, kept the medical service operating smoothly in both areas.
Emphasis in the Mediterranean was always on the role of Army medicine in conserving manpower--a mission often not fully appreciated by line commanders. In addition to treatment of the wounded and the sick, the Medical Department was responsible for preventing illness insofar as possible. In every war the United States has ever fought, the man-days lost through illness far exceeded those lost by enemy action. In World War II the ratio was approximately four days lost by disease and one by nonbattle injury for every day lost by combat wounds. Most of the illnesses
were preventable. In the Mediterranean the major time wasters were malaria, common respiratory diseases, diarrhea and dysentery, and venereal diseases, all of them largely, and some of them completely, preventable. In the Sicily Campaign, to take only one example, malaria cases alone outnumbered battle wounds. Not that the prevention of malaria was beyond the knowledge of the theater and army medical sections at that time; atabrine was ordered and was supplied. The failure was on the part of the line commanders, who did not compel their men to take the rather unpleasant preventive drug. Similarly, the prevention of venereal disease was--and is--a command function. The treatment, thanks to penicillin, was progressively shortened so that man-days lost declined, but treatment was the lesser aspect of the problem.
Among familiar preventive measures in the Mediterranean were the standard innoculations for those diseases for which an immunity could be built up; destruction of insect vectors, such as mosquitoes, flies, and lice; educational measures; and continuous inspection of meat and dairy products. Outstanding achievements of preventive medicine in the theater were the speedy and effective elimination of the threat of typhus in Naples at the end of 1943; the steady reduction of malaria rates after the campaign in Sicily; and the practical control of other local scourges such as cholera and bubonic plague.
A major contribution of the Mediterranean theater medical service to the management of wounds was the provision of whole blood in the forward areas. From the blood bank established in Naples early in 1944 whole blood was trucked to the Cassino front and shipped to Anzio by LST. Beginning late in May, during the Rome-Arno campaign, a daily blood plane carried the precious cargo to the Fifth Army front for distribution to the field and other hospital units where surgery was being performed. The Naples blood bank also supported the invasion of southern France in August, by plane to Corsica and PT boat to the landing beaches.
Another area in which the theater medical section pioneered was that of combat psychiatry. Begun on an experimental basis in Tunisia and Sicily, a technique of front-line psychiatric treatment was fully evolved early in the Italian campaign. The key figure was the division psychiatrist, formally assigned in the spring of 1944. If a man could not be restored to fighting trim by rest, sedatives, and minimal therapy at the clearing station, he was sent back to a special neuropsychiatric hospital, in the army area but still in the combat zone, for more specialized treatment. Only as a last resort, and in the full knowledge that his combat days were probably over, was a psychiatric case evacuated to the communications zone.
The Mediterranean, then, was a theater in which the lessons of ground combat were learned by the Medical Department as much as by the line troops. For Army medicine the lessons were of general applicability: treat battle casualties, including psychiatric ones, as promptly as possible, which is to say in the division area; keep hospitals and clearing stations mobile; be prepared to augment table of organization personnel by attaching specialized teams or other cellular units; shorten evacuation lines by keeping hospitals as far forward as possible, and shorten the patient turn-
around by treating as many as possible in the army area; never waste specialized skills by detailing men who possess them to work that others can do as well; treat disease as you treat battle wounds and anxiety states, as close to the front as you can, but use every means in your power to prevent disease.
No one will ever express more succinctly the creed of an army surgeon than did General Martin, Fifth Army Surgeon, throughout the Italian campaign. "The useless expenditure of life and suffering," General Martin wrote, "is as criminal as murder."