Late September, 1944—Nijmegen
Medical personnel shuffled litters in and out. Outside the doors, the courtyard teemed with humanity. Clusters of aid-men loitered in anticipation of the jeeps, which were operated by their casualty collecting detachments. Like foraging ants they traversed the division area, to and from the regimental aid stations, and they would return direct to the imposing walls of the seminary. The seminary looked like an institution of classical learning, if nothing else for the blanket of vines which clung in patches to the dull brick construction. It was the most suitable location they could find for a division hospital. Mostly because of its size.
Had one of the early developers of the American airborne been able to peer into the future and see this sight, it would have surpassed all comprehension. The scale, the efficiency were beyond anything they envisioned, which wasn’t much. If casualty care in Nijmegen could be considered near seamless, it was not a product of the vision of early airborne developers in the US Army.
It was a gradual acceleration to the display of efficiency on the grounds of the Nijmegen seminary. But the only question that mattered is did it work?
In the early days, any semblance of airborne medical care was apathetic, born out of being told to by General Headquarters. The design of the airborne medical company that deployed overseas with the 82nd Airborne Division, the “All-Americans,” was not built with purpose in mind. It lacked all the celerity required for mobile, airborne warfare (although this was not unique to the medical departments).
Its composition was little more than a plagiarism of the casualty collection company in a standard division. It brought it outside its context, leaving it without its complementary parts. Its miniaturization was the only adaptation to airborne needs. Of course, had the airborne division been worked as originally envisioned, it may well have sufficed. But the assumptions were proven false in Sicily, and to get to the point of near seamlessness in Nijmegen, reforms were needed.
They did something that had not been done before, where the division was the unit of action for airborne warfare. Like today, they lived in a time of change, technological and otherwise. It serves as a discussion guide for questions of division operations. What’s the right balance of vehicles? What does the formation look like? How are corps, division and brigade troops connected?
Motorization
Major Ivan Roggen, Regimental Surgeon of the 504th Parachute Infantry, felt their early designs and trainings were still based on a static, World War I model. The All-Americans’ experience in Sicily laid bare the need for increased motorization. Motorization would allow them to fill the gaps in the organization as it pertained to evacuation, for which there were precious few vehicles. In the immediate term, the summer of 1943, trucks were a zero-sum game in the division. They were platforms with myriad uses. Like a C-17 today, being multi-mission has always been a two-edge sword. As demand increased, they were forced to choose between reallocating vehicles to one at the expense of another. In September 1943, they opted to give the priority to motorizing artillery.
But a year later, the number of vehicles used by the airborne medical company will have doubled. This allowed them to give close-in support through collection detachments.
Another weakness in the airborne medical company was teased out in Sicily. The decision to commit the All-Americans piecemeal to the fight meant the first two regiments would not have division medical support. At the time, the table of organization was for an all-gliderborne company. Meaning, there were no division medical personnel who could jump with the assault regiments. To remedy this in time for the Sicily invasion, members of the 307th Airborne Medical Company were sent to a truncated jump school in Africa to become qualified parachutists. The bureaucratic remedy caught up in 1944.
Authority for each unit of an airborne division to contain parachutists regardless of specifications of Tables of Organization was granted by the War Department. This authorization…was a distinct advantage to the medical service in two major ways; it made each medical detachment more versatile in that it could be airborne either by parachute or glider, and the parachutists in glider medical units were later of great value as replacements for the regular parachute medical units. — LTC Edward Sigerfoos, MC Division Surgeon, 17th ABN DIV
Organized for Purpose
Their newfound motorization gave way for an organization built for purpose. Although a full division airborne assault had yet to be realized in early 1944, shattered were the meager assumptions of early days. And resources that were impossible earlier, were now available. The All-American’s chief surgeon, Lt. Col. Wolcott Etienne, and Major William Houston wielded their motorization to transform a vision into reality.
That purpose was a clear delineation of an evacuation process, and who was responsible for what steps, making it a seamless journey. Their organization remained airmobile, but optimized for maneuver and fully invested in the resources (aircraft and gliders) commiserate to the task. It was not an apathetic effort. Throwing people at the problem was not always the solution. At the battalion level, cutting them was. Most fundamentally, it was in-step with how the division was planning to fight, linked to the mission it was expected to accomplish.
In Normandy, the organization proved itself.
Task Organization
One of the things that made the early days of parachute medicine apathetic was the belief that the scope of their accomplishment in the fields of care and evacuation behind enemy lines would be so limited as to prevent their investment. The ambitious plan for September 1944 required this to be addressed, for in that month the All-Americans would be thrust well into the enemy’s rear, well beyond the umbilical cord that maintained ground units.
The number of road miles commonly cited to portray the All-American’s isolation is somewhat deceptive. Those miles are typically measured from the front of XXX Corps on 16 September, the day before Operation MARKET. But when calculating casualty evacuation, the casualties are not going to the front, but the rear of the front. Calculated in real terms, the distance was 73 miles. (An ambulances’ round-trip: 146 miles.) Even if the (lone) road was opened within a few days, the throttle of traffic would be at a premium limiting the evacuation numbers. Thus, even with an “open” road, evacuation could be days away. Competing demands for the multi-use C-47 airplane in theater would throttle air-lands. The situation presented would have left the division with a large casualty collection point, but without the staff to man the ward. So isolated, a full surgical compliment to provide advanced, life-saving procedures was necessary.
In the expeditionary manner the US Army will be forced to operate in during future conflict, the problem has changed little. To borrow a phrase, it still faces the “tyranny of distance.” The All-Americans in Operation MARKET GARDEN can serve as a starting point from which to explore the task organization which will be required in large scale combat operations with medical units integrating with tactical units to support echelons above brigade. In 1944, the All-Americans were augmented by a field hospital detachment to provide this care. Whisked from their station and given glider training, and shucked of bulky equipment, they sailed into battle. It would carry the medical service of the All-Americans to its apex.
Supply
Another throttle effecting casualty care, in a practical sense, was the aerial delivery of supplies. Due to the clogged road, supplies failed to be delivered via ground means. This brought about the importance of fieldcraft, such as condoms used as flutter valves for collapsed lungs. It also required officers to make serious decisions about the survivability of patients and a return on investment in using up vital commodities. In Operation MARKET, the use of whole blood was throttled.
In conclusion, it must be stated that [the] most important point in care of wounded is early arrival to an installation such as this where practically all medical and surgical therapy is available. — Capt. Chester Lulonski, MC 307th Airborne Medical Company
So, Did it Work?
This self-contained medical apparatus led to the images outside the Nijmegen seminary in late September 1944 upon which this essay opened. The question did it work? is an interesting study.
Owing to its success, the field hospital detachment returned to battle under the All-Americans in the Ardennes. It operated until mid-January, when a directive from First United States Army forbade any major surgery in division areas. The relief of the field hospital detachment likely led to a longer period to return after wounding. In Holland, General Gavin noted they “speedily returned many [casualties] to their front line posts.” It did lead to a perceptible increase in the number of fatalities post-aid station. From Battle Surgeons:
“For the 504th, Anzio, Holland and the Belgian Bulge were the hottest campaigns, and comparable in casualty figures. A review of 81 paratroopers classified as “died of wounds” shows there were 27 each in Anzio and Belgium, and 16 in Holland. As a percentage of total wounded men, there was a 4% difference in fatalities post-aid station, illustrating the effect this life-saving capacity had on the tactical unit. Outside of Cheneux, the fierceness and wound patterns of which being an aberration, an unscientific review of the regiments fatalities during the Belgian Bulge shows most occurred in January after the relief of the field hospital. [i.e. in a much compressed timeframe]”
Army Technical Publication (ATP) 4-02.55 bases its casualty assumptions on the rates of past wars. The Army today must reconcile questions similar to those of their predecessors; those of scale, maneuverability, and task-organization. It’s a well-worn cliché that the nature of war never changes, but the character does. The ATP’s figures are broken down per 1,000 strength. As the Army revamps for battle at scale with divisions in the field, it would do well to game how it organizes for care and evacuation at scale. Celerity and scale frustrated the All-Americans in the Mediterranean. Building a medical system to service an entire airborne division required a metamorphosis, one never done before. The blossoming of ideas carried them to fullness, and the study of their example can carry another renaissance in care.
Tyler Fox is an independent historian. He writes the Substack publication, Ridgway’s Notebook, and is the 33rd Honorary Member of the 504th Parachute Infantry, where he regularly works on historical projects. His book Battle Surgeons: Care Under Fire in the 504th Parachute Infantry will be released in December 2023.
Find Tyler’s new book, Battle Surgeons: Care Under Fire in the 504th Parachute Infantry HERE
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