Contents

CHAPTER VIII

Casualty Survey, Cassino, Italy

Allan Palmer, M.D.¹

Casualty surveys of civilians killed or injured in air raids in England had yielded detailed information about the wounding power of bombs and about the relative value of different measures of protection. The advantage of such surveys was that the investigator could conveniently study not only the casualties themselves but also the circumstances under which they were injured.

Useful information had also been obtained in the past from surveys of battle casualties undergoing treatment in base hospitals. However, this information was limited since the casualties seen represented only a small and usually a selected proportion of the total.

It had long been felt that more useful information could be obtained by studying the casualties incurred by selected units engaged in a specific operation for which full details were available and, particularly, if such a survey could be made further forward than the base hospitals. While the survey had to be limited² because of shortage of time and personnel, it has shown that studies of a similar kind could be successfully carried out, and it has also provided useful guides for further procedures.

The scene of the battle was about 75 miles southeast of Rome along 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 a railroad and a main road to Rome (Highway No. 6, fig. 266). Figures 267 and 268 show the terrain in the vicinity of Monte Lungo with the highly advantageous enemy defensive positions.

Operations to bridge and advance across the Rapido River were begun during the night of 19 January 1944 and were successfully completed on 12 May.

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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FIGURE 264.-Rapido River valley area, Italy, 6 February 1944. German's Gustav Line. Monte Cassino with Benedictine monastery on the summit of the hill (left) and Cassino at the base.

The main U.S. troops engaged in the operation were the 141st and 143d Infantry Regiments, 36th Infantry Division, and the 34th Infantry Division, Fifth U.S. Army.

Fighting was of the static kind and was confined for many days to an isolated area of mountainous country, as shown in figures 269 and 270. Allied and enemy forces were not visible to each other, and there was little small arms fire. Most wounds were inflicted by artillery and mortar shells and by landmines. The bulk of the fighting with the casualties sustained, occurred during the hours of darkness, especially when river crossings were attempted. 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 fire was laid down, inflicting a very large number of casualties as wave after wave of troops advanced in the region of the river.

The U.S. Army units engaged in this action had obtained previous experience of this type of warfare in operations which had resulted in the capture of three mountain strongholds, Trocchio, Porchia, and Lungo. These hills lay to the rear of the Rapido front and between U.S. troops and Highway No. 6. The mountainous terrain necessitated the use of mules for the transport of supplies and ammunition.

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FIGURE 265.-Town of Cassino, Italy, 6 February 1944. The Cassino castle is on the small hill in the foreground and the Benedictine monastery is on the summit.

The stubborn resistance by the enemy in his attempts to maintain control of Highway No. 6, and the considerable advantage of the terrain and entrenched enemy positions, made the fighting the bitterest experienced by U.S. troops in the whole Italian campaign. During the later stages of the campaign, 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 installations which served the Fifth U.S. Army front in the Cassino area. They included six evacuation and three field hospitals and two clearing companies, in the following order:

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FIGURE 266.-Map of the area in which the casualty survey was conducted. The route of evacuation and location of U.S. medical installations are indicated.

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FIGURE 267.-View from center of Monte Lungo, Italy, 18 February 1944. (Center) Monte Sammucro. (Right) San Pietro. Highway No. 6 is along the bottom and the San Pietro road up center to San Pietro. This tremendously advantageous defensive position held by the enemy for some weeks accounted for many casualties sustained by the Fifth U.S. Army. Note shell craters in the foreground.

Casualties were carried out of the actual battle zone by litter squads and jeeps. The ALP (ambulance loading points) (fig. 266) were located immediately outside the battle zone. The routes followed by the ambulances to Highway No. 6 are also shown in figure 266. One of them consisted of a railway track from which the rails had been removed.

Casualties were sorted in the vicinity of the ALP. Those whose main injuries were either cranial, thoracic, or abdominal were sent daily to the 15th and 38th Evacuation Hospitals. The majority of other casualties were evacuated alternately to the 11th and 94th Evacuation Hospitals on even-numbered days and to the 8th and 16th Evacuation Hospitals on odd-numbered days. On occasions when full loads could not be made up with cranial, thoracic, or abdominal casualties, all types of casualties were taken to the 15th and 38th Evacuation Hospitals.

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FIGURE 268.-German emplacements south of Monte Lungo, Italy, 26 December 1943. Tank trap and approaches where Germans removed everything but stumps, then mined the field.

The dead, including some German dead, were removed from the casualty areas by the Graves Registration Service and taken to one of the two burial grounds (CEM, fig. 266) which were located in advance of the evacuation hospitals.

Within a few minutes after they were wounded, men who could not help themselves were given first aid either by a medical aidman or by one of their fellow soldiers. Walking casualties were then directed to the nearest aid station or left where they had fallen to be transported later by litter.

The following information on the time taken to evacuate casualties 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 100 casualties received at his hospital on 21 January, the second day of the Rapido River operation. The average time taken for a casualty to reach the nearest aid station after wounding proved to be 5 hours and 55 minutes. Some men had to be brought from the far side of the river which they had already crossed, and a few such casualties did not reach aid stations for a period of 24 hours or even longer. The average time from aid station to clearing station was 2 hours and 48 minutes and from clearing station to evacuation hospital, 58 minutes. The average total time required from the time of injury to entry into a hospital for definitive treatment was 9 hours and 41 minutes.

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FIGURE 269.-Aerial view of Monte Lungo (Cassino-Mignano-Esperia area), Italy, 1944, showing the rugged terrain.

ANALYSIS OF CASUALTIES

An initial survey of the problem indicated clearly that, with only three medical officers available to carry out the work, it would be impossible to do more than survey a sample of those casualties who reached the 8th and 38th Evacuation Hospitals. While it was realized that this procedure would impose a bias on the information collected, it was hoped that the missing factors 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 the relevant period.

2. Total number of killed and wounded for the two units concerned (the 141st and 143d Infantry Regiments).

3. Data about the causes of death and regional distribution of wounds in the dead. These data were being collected by the Graves Registration Service on special forms for transmission to Washington, D.C. However, the EMT (emergency medical tags), filled out by the medical aidman on the battlefield and then attached to the body of the dead soldier, was the only recorded information about wounds and cause of death. The bodies were buried fully clothed without preliminary examination by a medical officer.

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FIGURE 270.-Cassino area, Italy, 6 March 1944. The terrain traveled by the mortar squads is tough, rocky, and hard to get over.

FIGURE 271.-Approach to Monte Cassino, showing the German's excellent line of fire, 30 May 1944. The trees were parched by shellfire and bombings. White tapes indicate the limit to which the terrain has been cleared of landmines. Ruins of Benedictine monastery in background.

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FIGURE 272.-Town of Cassino being destroyed, 15 March 1944. In one of the war's most concentrated air bombings, the town of Cassino was completely destroyed. German-held Cassino had long blocked the Allied advance toward Rome.

FIGURE 273.-Cassino area, Italy, 18 May 1944. Ruins of Cassino castle, "Hangman's Hill," towers above the city.

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4. Details about those casualties from the two units concerned who were selected by the clearing companies for treatment in the 15th and 38th Evacuation Hospitals, which dealt predominantly with injuries of the head, thorax, and abdomen. A daily report of casualties, which includes a statement about the regional distribution of wounds, was made by all hospitals to the Surgeon, Fifth U.S. Army. A study of these reports, together with an analysis of the records of the cranial and trunk casualties, and of the dead, of the two units concerned would complete the casualty picture for these two infantry regiments during the first week they were engaged in the crossing of the Rapido River (20-27 January).

A few casualties from other units which were engaged in the same 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 Evacuation Hospital and 27 at the 38th Evacuation Hospital. This group of casualties consisted of 6 officers and 94 enlisted personnel. The majority of the casualties were able to give their approximate geographical position in relation to 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 majority were engaged as infantry troops armed with either rifles or machineguns, and a smaller number were wounded while carrying a footbridge or a boat or when they were in a boat. Of the remaining 10 men, 5 were on guard duty and the other 5 were 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 the enemy, 40 received their wounds when standing erect, and the remaining 50 men were hit either when lying or kneeling or after they had taken cover in a ditch or a foxhole. The following tabulation lists the incidence of single and multiple wounds in relation to the position of the casualty:

The tabulation indicates very clearly that men lying down, or otherwise taking cover, are less likely to receive multiple wounds than men standing erect.

The difference in the incidence of multiple wounds in soldiers taking simple cover and those not taking cover is highly significant statistically 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 knew what type of weapon had caused their wounds. Table 170 shows the number of casualties caused by different weapons and the incidence of fractures.

The preponderance of wounds due to artillery and mortar shells and mines is what would be expected in operations of the kind studied.

TABLE 170.- Incidence of fractures in 100 casualties, by causative agent

The sizes of the fragments responsible for wounds were estimated from X-rays in 28 cases. The weights of the fragments were estimated in grams from their linear dimensions. A large series of X-rays of fragments of known weight were available as a standard.

All but 1 of the 28 casualties in question had been wounded by either artillery- or mortar-shell fire. The exceptional case had been wounded by a landmine. Table 171 summarizes the information obtained on this point and also gives the distances from the burst at which the casualties stated they were injured. Of the 28 casualties, 10 sustained injuries only from fragments weighing 1 gm. or more, while another 5 were hit by smaller fragments in addition to hits by fragments of the larger size. The remaining 13 casualties were injured by fragments weighing less than 1 gm. and in 4 of these only fragments 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 have been included in the table as injuries of the head.

Although none of the casualties seen had been wounded in more than three regions of the body, the number of wounds in any one casualty was often

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TABLE 171.-Distribution and weight of fragments in 28 casualties, by distance from shellburst

TABLE 172.-Distribution of 133 single and multiple wounds in 100 casualties, by anatomic location

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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 likely to be experienced close to the burst of large bombs at distances where severe or fatal injuries from fragments are almost certain to occur. Since artillery shells have a very much lower charge-weight ratio than bombs (a 155 mm. shell only contains 4.8 pounds of explosive), the chances of receiving blast injuries to the lungs without serious fragment injuries are even more unlikely from shellfire than from bombs.

There is no reliable evidence that so-called blast concussion is a direct consequence 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 flying debris or from sudden body displacement. Rupture of the eardrums, however, occurs at very much lower blast pressures than does lung damage, and it is the most sensitive indicator of injury due to blast. In the group of casualties surveyed, there were no instances of damage to the lungs. In 15 casualties, one or both eardrums had been ruptured. Of these men, 11 had also received other injuries from fragments and only 4 had ruptured eardrums as their sole injury.

Of these 15 casualties, 13 were standing erect or had their head and shoulders exposed when they were injured. The other two, although apparently lying protected in slit trenches, were also close enough to the shellburst to experience earth movement, displacement, and partial burial by loose earth nearby. The stated distances (in feet) at which the casualties sustained a blast injury from bursting projectiles is as follows:

It is a remarkable fact that 11 of the 15 casualties were within 10 feet of bursting projectiles and sustained injury due to blast but escaped fatal fragmentation wounds.

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Casualty Rates

When a small group of casualties is surveyed, the probability of an incident being reported is proportional to the number of casualties it involves or, if wounded men only are reported, to the number of wounded. Having recognized that in this survey an individual incident may be reported more than once, it is necessary to make use of Haldane's method for correcting for this factor. By making use of his formula

(formula)

where N equals the number of incidents reported, C the number of casualties (killed and injured grouped together) and T the total number of men exposed to injury, it is found that the estimated casualty rates from artillery 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 estimated for the same two weapons in previous casualty surveys.

Excluding the American casualties at Cassino, it would thus seem that Allied artillery and mortar were both more efficient than those of the enemy. Such a conclusion would only be justified, however, if it could be assumed 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 as those inflicted by the enemy in other theaters and significantly fewer than enemy casualties from the same weapon. On the other hand, American casualties due to enemy artillery at Cassino are significantly greater than Allied casualties 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

NOTE.-Statistics were obtained by author while serving as scientific observer with Professor Zuckerman (see footnote 1, p. 531).

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As already emphasized, this casualty survey was initiated to discover whether useful and complete information could be obtained in the battle area. While this objective was not achieved in the present case, the investigation has definitely shown that it could be in a future survey, if special arrangements were made in advance to obtain from central records a complete picture of the tactical problem and of the casualties incurred and if the survey itself were adjusted in advance to the size of the staff available to carry out the work.

The advantages of surveying casualties in the forward evacuation hospitals and of examining the dead at their burial grounds are obvious. In these locations, complete casualty data for a specific tactical operation, pertaining to the uninjured, slightly and severely wounded, and the dead can be obtained before the various types of casualties are dispersed, before original X-rays are separated from the casualties, before memory of specific details of incidents is clouded by time or colored by self-interest, and before the dead are buried and lost to detailed examination.

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