|OFFICE OF MEDICAL HISTORY AMEDD REGIMENT AMEDD MUSEUM|
HISTORY OF THE OFFICE OF MEDICAL HISTORY
Major Edgar L. Cook, MC,
The Wartime Problem
During World War II every 5th notification of the death of a member of the United States Army sent to American families was caused by nonbattle trauma, and every 20th was due to disease. In the past the problem of disease was more important than that of nonbattle trauma, but due to modern advances in prevention and treatment of infections there has been a relative change in position especially when mortality is used as the index. The effect of epidemics of infectious disease which rendered whole armies ineffective has been well documented in history. The relative importance of mortality from disease and nonbattle trauma in wars in which the United States has participated, and for which data are available, is presented in Chart 1.
In the Mexican War, 1846 to 1848, there were 28 deaths due to disease for each death due to nonbattle trauma. In the Civil War (Union Troops), the ratio was 9 to 1; Spanish-American War, 16 to 1; World War I, 12 to 1. In World War II the ratio was reversed for the first time with nonbattle injury deaths exceeding disease deaths. During this war there were 4 deaths from nonbattle injury to every death from disease. There were 61,640 deaths due to nonbattle injury, a rate of 2.40 per thousand per annum for the period December 1941 through 1945. For the same period, there were 15,779 deaths due to disease, a rate of 0.61 per thousand per annum. Thus, with death as the measure, one of the important mass health problems of a modern army is nonbattle injury.
The Peacetime Situation
Nonbattle injury, as well as disease, is present during periods of peace as well as war, and therefore is not a problem peculiar to war, although many times modified by operations in the field. Battle trauma, on the other hand, is
Chart 1. United
States Army death rates in various wars. (Death rate per 1,000 per annum.)
Considerable uncertainty surrounds the exact number of deaths from broadcause
groups during some of the early wars. This chart does not purport to be official
as to the precise values, but does represent the general level of relative
magnitudes of these values.
like a point or common source epidemic, being limited by definition to the period of conflict. A comparison of death rates for the years 1900 through 1945 is presented in Table 10. For many years, deaths from disease exceeded those for injury: after World War I the differences were never great. In 1922 the rates were even, and in 1925, 1932, 1936, and 1938 the nonbattle injury rates were higher. Beginning in 1940, the trends changed sharply, with nonbattle injury regularly exceeding deaths from disease, and by a considerable margin.
TABLE 10. DEATH
RATES PER 1,000 PER ANNUM, DISEASE AND NONBATTLE INJURY, TOTAL UNITED STATES
Source: Annual reports of The Surgeon General and "Army Battle Casualties and Nonbattle Deaths in World War II," Final Report, 7 December 41-31 December 46, AGO.
Civilian Accidental Trauma
The problem of accidental trauma has also shown increasing magnitude in the civilian population of the United States. In 1910, accidents ranked sixth as a cause of death,1 and in 1945, this cause of death was fourth.2 Considering
age and sex distributions of the two populations, accidental trauma has even more significance under civilian conditions than for the Army. In 1945, the leading cause of civilian deaths for the age group 1 to 24 years was accidents, and accidents ranked second for ages 25 to 45 years. The Metropolitan Life Insurance data for insured populations reveal a greater incidence of accidents in the male population.3 These facts are important, because the majority of the Army population is male and of these age groups.
Classification of Army Casualties
An understanding of the classification of military casualties is essential to evaluation of accidental trauma. The definitions of terms that follow are from Army Regulations (AR) 40-1080, 28 August 1945:
The classification in most instances is obvious but in others is arbitrary. Trenchfoot, although sustained in battle, is classified as a nonbattle injury. Also, when an individual is admitted with both a disease and an injury, the classification is according to the more serious condition at time of initial admission. When an individual with battle wound and disease or injury is admitted, he is classed as a battle casualty. The three major groups are well defined by regulations, but the subdivisions of nonbattle injury are not well distinguished.
A CLASSIFICATION OF NONBATTLE INJURY
Since Army regulations make no provision for the separation of the various kinds of trauma included under nonbattle injury, and since this study is primarily concerned with accidental trauma, an arbitrary division has been made, recognizing three broad subgroups. Chart 2 shows this in schematic arrange-
ment. Nonbattle injuries are divided into: accidental trauma, intentional trauma, and climatic trauma. Climatic trauma includes cold injury of all gradations from chilblains to frostbite, trenchfoot, and immersion foot. The class also includes trauma due to heat, a result evidenced in heat exhaustion or heat stroke. Intentional trauma includes homicide, suicide, and self-inflicted wounds. This leaves the group of accidental traumatic conditions resulting from automobile and aircraft accidents, burns, drowning, and other sources. The purpose of this arrangement is to make possible a specific and separate analysis of accidental trauma. In some instances, a particular case is found difficult to classify according to this scheme.
HISTORY OF ACCIDENTS AND ACCIDENT PREVENTION IN MILITARY PRACTICE
American Revolutionary War
Accidents have been a factor in military
operations of the United States Army since earliest days. The first Army
regulations drafted by Major General von Steuben in 1780 stated that surgeons
would remain with their regiments on the march as well as in camp so that in
case of sudden accidents they would be at hand to apply the proper remedy. There
are no officially recorded statistics on nonbattle injury during the
Revolutionary War, but James Thacher, a
surgeon, gives a stimulating account of medical problems in his Military Journal during the American Revolutionary War from 1775 to 1783.4 An entry under date of September 1776 states that "a soldier had the imprudence to seize a rattlesnake by its tail; the reptile threw its head back and struck its fangs into the man's hand." On 10 March 1782 he added, "A singular incident occurred in the Sixth Regiment to-day. Two soldiers were eating soup together, and one forbid the other eating any more; as he did not desist, his comrade gave him a blow with his fist on the side of his head, on which he fell to the ground and instantly expired. On close examination, I could discover no bruise or injury which could enable me to account satisfactorily for his death." This author also intermingles pertinent medical observations among his many vivid accounts of duels, brawls, and scalpings.
Nineteenth Century and the Twentieth Century to 1930
During the 19th century, accidental trauma continued to take its toll. It was commonly interpreted as being caused by events beyond control, that happened despite all foresight and expectation. Since accidents were considered inevitable, little attention was given to the question of prevention. The strongest efforts were made in attempting to solve the mysteries of unknown fevers and consumptive disease. The perfection of the microscope and Pasteur's work at the end of the century brought the infectious diseases into clearer focus.
During the first part of the 20th century, until World War I, there was scarcely mention of accidental trauma in the annual reports of The Surgeon General, although during that time a gradual narrowing of the gap between the death rates for disease and nonbattle injury was under way, as seen in Table 10. There is nothing to indicate that the problem of accidents was given much attention in World War I; again in all probability because of the relatively greater importance of disease control.
During the years of the 1920's the recognition of the importance of non-battle injury became evident. In the Report of The Surgeon General, U. S. Army, 1932, there is a paragraph on the increase in relative importance of injuries as a cause of death, stating:
Accident Activities of the Medical Department, 1930 to World War II
In the late 1930's a need for more detailed evaluation of the problems was generally appreciated. A reporting system was developed which was designed to evaluate death, defect, and disability from accidental injury. It included information on disability discharges, days lost, an analysis of the place of the accident, and whether it occurred on duty or leave. It also had an analysis of fault and of influence of alcohol. The collection of information was started in 1938. Data for 1939 were tabulated in the next annual report and it was stated that the 1938 figures were similar. Death, defect, and disability attributed to leading causes of accidental trauma were as presented in Table 11. With the onset of mobilization in 1940, the strength of the Army increased materially. The special reporting system for accidents was no longer considered feasible. The 1941 Annual Report of The Surgeon General did not present the detailed figures for the year of 1940.
ACCIDENTAL INJURY* IN THE TOTAL UNITED STATES ARMY, BY CAUSATIVE AGENT, 1939
*Excludes cases of homicide and suicide.
The 1940 Annual Report of The Surgeon General, at the end of the analysis of data on accidental trauma made the following statement:
Col. Samuel Adams Cohen, MC, made the following statement in an article in The Military Surgeon, November 1940:5 "In view of the numerical increase of its personnel and the broadening of the Army's mechanization, the problem of accidents therefore promises to assume increasing magnitude." He advocated a safety officer at every large post who would know the existing conditions at the particular post and be responsible for reducing the incidence of accidents. He outlined the role of the medical officer in the accident prevention program as follows:
Another contribution was made just before the beginning of hostilities, by Maj. M. H. Fineberg, MC, who made a survey of the serious accidents resulting from the maneuvers by the First United States Army in October and November 1941 with the object of suggesting methods for their prevention. On the basis of 1,820 cases studied, Major Fineberg made the following recommendations to lessen the number of accidents occurring during maneuvers:6
ACCIDENT PREVENTION DURING WORLD WAR II
Prior to the mobilization for war, safety activities were carried on with varying emphasis by several of the supply services as a part of plant protection. The Ordnance Department had a special safety section for problems related to explosives, and cooperation was maintained with the Corps of Engineers in building new powder and loading plants. This was an important move in the direction of prevention. The major emphasis in plant protection was devoted to fire, espionage, and sabotage. However, after 7 December 1941 accident prevention was stressed more strongly and considerable attention was given to the conservation of manpower. At that time the problem of concentration of effort was considered. Procurement of war material was considered of prime importance and safety efforts were turned in that direction rather than on troop activities.
In March 1942, the Plant Protection Division, Office of Under Secretary of War, was transferred to the Provost Marshal General's Office, and combined with the Emergency Operations Division to form the Internal Security Division. This placed the policy making responsibilities in the hands of The Provost Marshal General.
Reorganization of the Army (War Department General Orders 35, 1942), resulted in changing corps areas to service commands and transferred administrative functions from the procurement services to the service commands. Internal security and accident prevention were included in this transfer, and technical services were given certain responsibilities. The Chemical Warfare Service and Ordnance Department were given the responsibilities for continuing protection of field installations and facilities and manufacturing, storing, and processing explosives and allied substances. Since the Chief Signal Officer, Quartermaster General, and Surgeon General procured only inert items, they were assigned no responsibility for continuing protection.
Army Service Forces Safety Program
The Services of Supply Safety Program (later the Army Service Forces Safety Program) was established on 31 August 1942.7 The policies and pro-
cedures which had governed accident prevention in the Internal Security Program were greatly expanded. The loss of valuable manpower, and the resulting costly delays in war production, were cogent reasons for a comprehensive and aggressive accident prevention program in all plants and facilities vital to the war effort. Coordination between numerous governmental and private agencies engaged in various phases of accident prevention was stressed. Primary responsibility was given to the commanding officer of a Government-operated plant or facility and to the owner and operator of a privately operated plant or facility. The Provost Marshal General was charged with the preparation of general policies; supervision over accident prevention activities within the Services of Supply; and coordination in Washington with the Department of Labor, Bureau of Mines, War Production Board, Office of Civilian Defense, War Manpower Commission, the Navy Department, and numerous voluntary organizations including the National Safety Council, National Conservation Bureau, and National Bureau for Industrial Protection. The responsibilities of the Chief of Ordnance, Chief of Chemical Warfare Service, Chief of Transportation, and Chief of Engineers were outlined, but no mention of The Surgeon General was made.
In December 1942, the War Department Safety Council was organized.8 It consisted of representatives of the technical services and staff divisions of the Army Service Forces, the Army Air Forces, and the Navy. The officer in charge of occupational medicine matters in the Preventive Medicine Service, Office of The Surgeon General, United States Army, was designated to represent the Medical Department on that council. This council met once a month for discussion of War Department safety problems. In addition, annual meetings were held and were attended by representatives of civilian safety organizations.
Because of high admission rates for nonbattle injury in the United States, the scope of the safety program turned from production workers to military personnel. The first accident frequency reports had been tabulated in January 1943 and covered private plants. Reporting injuries of military personnel was established late in 1944 by adapting the morbidity reports program of The Surgeon General. 9 The accident rate of soldiers on furlough, leave, or pass was considered high, and in June 1944 War Department Pamphlet 21-10 "Private Droop has Missed the War" was published for distribution. In the fall of 1944 a War Department general safety manual, TM 2-350, was published. There is no mention that the Medical Department had any part in the preparation of this manual. Also in the fall of 1944, a bimonthly publication, "Safety Information," was started. Five issues were published before it was discontinued.
In February 1944, an advisory board on fire and accident prevention was established in the Office of the Under Secretary of War.10 Membership included the Assistant Provost Marshal General as chairman; the Director, Control Division, Army Service Forces; and the Air Provost Marshal. There were 2 additional members to serve in matters concerning fire prevention and 2 additional members on matters concerning safety measures. The Director of the Occupational Health Division, Preventive Medicine Service, Office of The Surgeon General, was 1 of the members representing safety. One of the functions of the board was to report quarterly to the Under Secretary of War providing factual data as to important trends of fire and accidents, both in actual number and as related to exposure, making necessary recommendations where other agencies of the War Department had previously refused or neglected to take action.
In September 1945, a revision of the accident reporting system and a restatement of policy was published.11 The Provost Marshal General was given the responsibility for the collection and analysis of accident statistics for Army Service and Ground Forces, the coordinated safety activities with appropriate governmental and private agencies, and with The Surgeon General, Director of Military Training, and Director of Personnel. The Surgeon General was given the responsibility of: (1) assisting The Provost Marshal General and Director of Military Training in determination of doctrine and in preparation of texts, manuals, and other aids for safety training of military personnel, and (2) coordinating with the Army Safety Program, his program for control and reduction of occupational diseases.
The new reporting system went into effect 1 November 1945 so that direct responsibility for collecting information on accidents now rested with The Provost Marshal General. One new "Report of Injury" form for use in recording accidental injuries to all types of personnel, and three new forms for summarizing accident frequency, causal data at posts and service commands, and technical services were provided. All accident data were to be routed through safety personnel of each echelon to The Provost Marshal General. In October 1945, the War Department Safety Council was abolished, as was the Fire and Accident Advisory Board.12 The Army Safety Program participated in National Safety Congresses of 1942, 1943, and 1944. Among the speakers at these conferences was The Surgeon General of the Army.
Occupational Health Division, Preventive Medicine Service
The Occupational Health Division of the Preventive Medicine Service of the Surgeon General's Office developed the occupational health program which
was carried throughout the war. In January 1944, the director of the Occupational Health Division recommended that a program of accident prevention be established for military personnel because of the high admission rate in Army hospitals for nonbattle injuries. He cited the value of such a program in industry and suggested to the Chief, Preventive Medicine Service, that an accident prevention division be established. This was not approved by The Surgeon General because accident prevention was not considered as a primary function of the Surgeon General's Office although its importance was recognized, and cooperation with other agencies continued. The Occupational Health Division assisted in the preparation of War Department Circular 252, 20 June 1944, sponsored by the Office of The Surgeon General. This circular gave directions by which medical officers in the field would prepare reports in all cases of accidental injury to military personnel, to be used by accident prevention officers.
The activities of the Occupational Health Division, Preventive Medicine Service, Office of The Surgeon General, endeavored to promote high standards of industrial medicine. The replacement examinations contributed to the accident prevention program by listing the number of individuals being placed on jobs beyond their physical capacities. A worker with defective vision, if placed on a job requiring perfect vision, would be likely to have accidents. The control of environmental factors such as toxic dusts, noise, and illumination may also be contributing factors in accidents. A worker may be partially overcome by some toxic fumes and perform his activities in such an abnormal manner as to receive an accidental injury. Such contributions are difficult to evaluate from statistics because of the many variables involved, but should be considered as an essential part of the overall program of accident prevention.
IMPORTANCE OF THE PROBLEM
A comparison of
nonbattle injury death rates and admission rates for troops stationed overseas
and in continental United States reveals that both the admission rates and the
death rates were much higher overseas (Charts 3 and 4). In many theaters active
accident prevention campaigns were developed and in most instances the surgeon
provided an analysis of the situation from medical records, as reporting of
accidents overseas through the Army Safety Program was not instituted until
after the war. There were also many special studies on automobile accidents,
poisoning, and burns. Additional studies were made on cold and heat trauma,
suicides, and self-inflicted wounds, but under the scheme of Chart 2 these
conditions have been separated from accidental trauma and will be covered in
other portions of the history.
In the European theater the theater surgeon had the responsibility of collecting statistical information on nonbattle injuries and presenting it to the provost marshal of the theater.13 The Preventive Medicine Division, Office of The Chief Surgeon, European Theater of Operations, prepared extensive analyses of nonbattle injuries for 1942, 1943, and the first half of 1944, the period immediately preceding continental operations. Because the major problems of trenchfoot and typhus control required the maximum utilization of the staff on the Continent, detailed analyses for the continental period were not made; but general features of accidents and injuries were abstracted and detailed studies made of specific problems. In 1943 a special study of automobile accidents was made.
Chart 4. United States Army nonbattle injury admissions to hospital and quarters, per 1,000 per annum, by month, continental United States and overseas. These are preliminary data based on sample tabulations of individual medical records.
Because of the importance of nonbattle injuries as a source of noneffectiveness in the Southwest Pacific in 1944, an investigation was made under the direction of a specially trained Sanitary Corps officer.14 The Surgeon, Headquarters, Mediterranean Theater of Operations, brought to the attention of the theater staff in 1944 the extent of the manpower loss resulting from injuries, and a safety committee was formed which developed a safety program.15 The Army Service Forces Monthly Progress Report, Section 7, "Health," dated 31 July 1944 stated:
Nonbattle injuries were responsible for 32,914 deaths overseas, a rate of 3.06 per thousand per annum, compared with 27,140 deaths in the United States, a rate of 1.84 per 1,000 per annum for the period 1942-45 (Table 12).
An analysis of deaths in the South Pacific area 1 September 1942 to 31 August 1944 revealed deaths from battle causes as 2,588, nonbattle casualties 765, disease 166, suicides 51, and cause undetermined 12.16 The survey in the Southwest Pacific revealed during the year of 1943:17
During the period October 1944 to June 1945, inclusive, there were more deaths in the European theater due to a single agent, alcohol poisoning (178), than to acute communicable disease (162).18
12. DEATHS DUE TO NONBATTLE INJURIES IN THE UNITED STATES ARMY, BY THEATER
OF ADMISSION AND YEAR OF DEATH, 1942-45
See footnotes at end of table.
12. DEATHS DUE TO NONBATTLE INJURIES IN THE UNITED STATES ARMY, BY
THEATER OF ADMISSION AND YEAR OF DEATH, l942-45-Continued
1Includes admissions on transports.
The admission rates to hospital and quarters for nonbattle trauma in overseas theaters were variable. In some areas, mainly the European theater, Mediterranean theater, and Alaska, the cold injury which is a component of nonbattle trauma was a large factor during the seasons of cold weather. In the Southwest Pacific area, a survey of 16,486 completed cases tabulated from the April 1944 admissions showed that 2,676 or 16 percent were admitted for nonbattle injury.19
Much of the military significance of the admission rate derives from the length of time the patients remain noneffective. A study was made of the average days lost per admission for troops overseas to hospital or quarters for the year ending 30 June 1944.20 The average number of days lost per admission was 48 for wounded, 13 for disease, and 19 for nonbattle injury. This excludes time lost subsequent to evacuation to the United States. There is a presumption, therefore, that these data are somewhat understated in terms of the true noneffective time. The report of this study further states, "The fact that the aver-
age patient suffering from an accidental injury loses 40 percent more time than the average disease patient helps to explain the tremendous drain on manpower which accidents cause overseas as well as at home."
A study of surgical dispositions was made for March through June 1944 in the South Pacific.21 Of 14,738 dispositions there were 3,877 injury patients with an average stay of 28 days; 3,604 were returned to duty; 243 were evacuated to the Zone of Interior; and 30 died. A detailed distribution of events is given in Table 13. The type of injury and days lost were tabulated. Accidental discharge of guns and ammunition caused 11 percent of the days lost, had the highest average of days lost, and the lowest percentage of return to duty (Table 14). The dispositions were also divided into specialty fields, with 47.5 percent orthopedic and 44.9 percent general (Table 15). During the 4 months, accidental injuries cost 92,869 man-days lost, or an equivalent of an entire division for a week.
Disability in an overseas theater cannot be measured by discharges from service, but can be by evacuations to the Zone of Interior, as these represent a loss to the theater. This varied in different theaters depending on the individual evacuation policy. An analysis was made of the cause of evacuation of nonbattle injuries to the Zone of Interior from the European theater of command for 1943. Of the 24,919 men admitted to hospital for nonbattle injury, 1.1 percent were evacuated to the Zone of Interior (3.2 percent died).22 In the Southwest Pacific during 1943 there were 751 nonbattle injuries evacuated to the United States, compared with 551 battle casualties.23 The South Pacific Base Command
13. SURGICAL DISPOSITIONS, SOUTH PACIFIC BASE COMMAND, UNITED STATES ARMY,
Source: ASF Monthly Progress Rpt., Sec. 7, Health, 31 Jan 45.
14. CAUSES OF NONBATTLE INJURY, UNITED STATES ARMY, SOUTH PACIFIC BASE COMMAND,
*These represent cases among the 3,877 shown in
Table 13 which were considered to be acute.
15. CLASSIFICATION OF INJURY DISPOSITIONS BY SURGICAL SPECIAL FIELDS, UNITED
STATES ARMY, SOUTH PACIFIC BASE COMMAND, MARCH-JUNE 1944
Source: ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jan 45.
evacuated 243 out of 3,877 injury dispositions, or 6.3 percent during the 4-month period from March through June 1944.24
OVERSEAS ACCIDENTS AS AN ECOLOGIC PROBLEM
In the study of mass disease the causes of origin and course are multiple. They reside in influences sometimes associated with an agent of disease, a
particular inciting cause; sometimes in innate or acquired characteristics of the host or population that suffers the disease or injury; and almost invariably in the many features of the environment in which both agent and host find themselves. An ecologic approach to causality is helpful in formulating a control program, for intelligent action depends upon a direct attempt to eliminate or modify identified causes. In any specific situation, causative factors are expected from all three general sources. Commonly one may exert dominant action, but rarely to the exclusion of all others. The complex of causation is an association of multiple factors.
Agents Acting in Accidents
In current considerations of accidental trauma, much variability exists in the use of the several terms of agent, agency, mechanism, and action. Many reports follow a common classification. Others employ an entirely different arrangement, sometimes unique and sometimes a mixture of many different classifications. This makes comparison difficult, and in some instances impossible.
One feature becomes strongly evident, namely an appreciable difference in death and admission rates for accidents, when these are arranged according to the various agents involved. This is clearly visible in the 1939 figures in Table 11. Aircraft injuries have a high mortality, but a low admission rate. During the first year of World War II, 1942, for which preliminary tabulations of individual medical records have been made, deaths due to aircraft accidents account for 44 percent of the total deaths from nonbattle injury in the Army, but only 1.8 percent of admissions for this class. The numbers of aircraft used in various areas influenced the death rates from accidental injury in that area. In Table 16 a comparison of death rates from nonbattle injury in continental United States and overseas for the year 1942 reveals a much higher death rate overseas for aircraft, firearms and ammunition, and for athletics and sports, while death rates from injury due to motor vehicles, fire, and heat were about equal. In three specific studies overseas, aircraft, automotive, drowning, and firearms-explosive accidents accounted for 72.5 to 85.2 percent of the total deaths from nonbattle injury in those areas (Table 17).
In the Southwest Pacific area in 1943, 54.5 percent of accidental deaths were associated with air transportation. Since that group was judged to constitute a special problem of control, accidental deaths related to aircraft, along with suicides and homicides, were excluded from nonbattle injury deaths by cause. Under that modification, automobiles were then responsible for 24.8 percent of all accidental deaths, firearms for 23.5 percent, and drowning 19 percent.25
TABLE 16. DEATHS DUE TO NONBATTLE INJURIES IN THE UNITED STATES ARMY, BY AREA OF ADMISSION AND CAUSATIVE AGENT, 1942.
Based on Tabulations of Individual Medical Records
Other variations in agent pattern included snakes and other reptiles as a biologic contribution to the more common physical agents of disease. In no theater did they play a prominent role in accidental trauma.
Among chemical agents in accidental injury, methyl alcohol was a considerable factor during the continental phase of operations in the European theater. An interesting variable of agents active overseas was the cited instance during 1 month in a Pacific island area when 50 percent of the nonbattle injury deaths were due to falling trees, weakened by preinvasion naval gunfire.26
17. PRINCIPAL CAUSES OF ACCIDENTAL DEATH, SELECTED THEATERS OF OPERATION, WORLD
WAR II, UNITED STATES ARMY, BY PERCENT OF ALL ACCIDENTAL DEATHS
1Gordon, J. E.: History of preventive medicine in
European Theater of Operations, 1941-1945. HD: 314.7-2.
Host or Population Factors in Causation
Many factors, such as anatomic structure, physiologic state, psychical constitution, and intrinsic characters contribute to accidents just as to disease.
The initial physical examination upon entrance into the service eliminates many physically handicapped individuals. However, there are special assignments in various branches of the services which make greater demands on physical qualification than are called for by entrance requirements to service. Complicated mechanized army equipment should be designed with consideration of the physical limitations of individuals operating the equipment. Considerable research initiated by the Preventive Medicine Service, Office of The Surgeon General, was conducted at the Armored Medical Research Laboratory at Fort Knox, Kentucky, on anthropometric measurements especially in relation to the design of tanks. Studies were also made on the physiologic and psychologic requirements of tank crews. This material was turned over to the Ordnance Department for use in the design of tanks.
Fatigue. Fatigue is another important factor. A fatigued individual often reacts sluggishly to stimuli at a time when precision and accuracy are essential and thus the liability to accidents is increased. In an overseas theater this factor is of no small consequence, because of the many circumstances calling for extreme effort.
Alcohol. Increased blood alcohol levels are capable of altering the reaction of individuals and may be a factor in the production of accidents. In the 1939 Army survey,27 in 636 out of 19,707 injuries, or 3.2 percent, alcohol was considered a contributing factor. In one Australian mainland base, surveyed over a 3-month period in 1943, in patients with nonbattle injuries entering general hospitals of the base, the influence of alcohol was assessed as follows: 28
In overseas areas during active operations, the availability of alcohol varies greatly. When beer and whiskey are not available, substitutes in the form of methyl alcohol, canned heat, and antifreeze have been used, all with serious toxic hazards.
Accident Proneness. Another inherent factor on causalty of accidents is the concept of accident proneness. The characteristic is otherwise referred to as that of accident repeaters or the accident habit. Such a concept raises the question of possible differences among individuals in liability to accidents, and if such differences exist, how they can be detected. A considerable amount of literature on accident proneness had been published before the onset of World War II but these studies had brought no definite tests for identification of such individuals. Flanders Dunbar29 reported the results of psychosomatic studies among industrial workers and members of the Armed Forces. In a psychosomatic study of cardiovascular and diabetic patients a control group had been selected, composed of patients with fractures admitted to the same hospital. On the basis of observations on these patients with fractures the author felt that the accident-prone person belonged to a personality type which could be described with fair accuracy. Such individuals give a history of a large number of previous accidents, and a lack of colds, indigestion, or other "vegetative disturbances." They did not finish educational courses which they undertook, whether grammar school, high school, or college. They had an unstable work record and changed jobs frequently. There was a tendency to focus on immediate values rather than on long-range goals, to appear casual about feelings and personal problems, and to avoid responsibility-to live from day to day. Dunbar concluded by stating:
Personality Changes. Menninger,30 after the war, brought attention to the personality factor in accidents by stating, "A small minority of combat soldiers were unable immediately to rechannel their aggressive behavior into socially approved activity. Following VE and VJ days in the various theaters, although no figures are available, it was apparent that automotive and traffic accidents increased."
Brigadier General Bliss31 in a letter to the Army Assistant Chief of Staff G-4, 23 August 1945, stated: "Early termination of hostilities in the Pacific will result in an immediate increase in anticipated evacuations from that area rather than the reverse. However, most of these evacuees will represent disease and non-battle injury patients rather than battle casualties."
The intrinsic characteristics of age, sex, and race were not analyzed in respect to accidents during the war experience of 1941-45. Alterations in age composition for the Army as a whole were recognized, primarily as a reflection of changes in the draft policy bringing a lower age at induction. A correlation with frequency of accidents is not known.
Physical aspects of the environment of man, such as weather, climate, season, soil, and terrain, were factors exerting a measurable influence on the incidence of accidents in different areas. In the United States a definite seasonal variation in incidence of admissions was observed for nonbattle injury. (See Chart 4.) Speculation could be offered as to the precise influence arising from these physical factors of environment as such, but data are insufficient for true evaluation.
The consideration of population pressures, crowding, density, and extent of movement are given considerable attention in evaluating causal factors in mass disease. An excellent illustration that these social factors of the environment contribute to accidents, along with others relating to host and to agents,
is seen in the 1945 annual report of the 8th Evacuation Hospital in the Mediterranean Theater of Operations. The report states:32
In the European theater following V-E Day, the Commanding General, Third United States Army, undertook special measures, such as intensifying the activities of Military Police patrols on main highways, in order to curb motor accidents involving military personnel and resulting from speeding and reckless driving. It is an ironical fact that several months thereafter he himself died as the result of a motor accident.
A separation of accidents by rank and service was made in the Southwest Pacific theater in April 1944 (Table 18) representing in all some 2,676 cases. Although personnel of the Corps of Engineers suffered 17 percent of the injuries, no statement of strengths was provided by which to determine rates.33
The Fifth United States Army conducted a study of battle casualties and nonbattle casualties from the standpoint of military occupational specifications (Table 19).34 The observations were based on the experience of the 3d, 34th, 36th and 45th Infantry Divisions while in combat between 9 September 1943
and 4 April 1944. The experience was thus heavily weighted by winter operations. During this period the rates were 3.7 for battle casualties and 4.7 for nonbattle casualties. For the Fifth United States Army during the period December through March the average rates were 1.2 for battle casualties and 3.3 for nonbattle casualties. For the Mediterranean theater as a whole, from 1 October 1943 to 1 April 1944, the rates were 0.4 for battle casualties and 3.0 for nonbattle casualties. By a wide margin the occupation of rifleman was the most dangerous. Both battle and nonbattle casualty rates were about twice as high as those for artillerymen (gunners), the next highest group. Before reasonable conclusions can be made about accidents, the material must be considered in terms of Chart 2. In the analysis under consideration, nonbattle casualty included both disease and cold injury. Cold injury has a high incidence among riflemen. The analysis states:35 "Combat may be said to increase exposure to a wide variety of diseases and injuries, to hinder the precautionary measures usual under non-combat conditions and to impair physical and psychological reserves to a degree which renders the individual more susceptible to disease and injury."
A study of parachute injuries was made for the first and second years of parachute training at Fort Benning, Georgia.36 From a total of 89,551 training jumps 1,386 injuries were noted, of which 272 were fractures and 2 died. During the first year of operations the total injury rate was 2.69 percent and the fracture rate 0.55 percent. During the second year the total rate was 1.48 percent and the fracture rate 0.29 percent. The injury rate was considered low in view of recognized hazards of parachute jumping. The possibility of effecting further reduction in accident losses through preventive measures was an outgrowth of this study.
SPECIAL STUDIES OVERSEAS
The following special studies are included because they represent important contributions to the prevention of accidental trauma overseas. They also represent examples of what can be done with a specific problem.
Low Back Injury
A survey of low back injury in the Persian Gulf Command37 was made for the 20 months between 1 March 1943 and 31 October 1944. The command was composed of supply troops of all branches. A review of case records revealed that 466 individuals were hospitalized for one or another type of low back
18. SOUTHWEST PACIFIC AREA, UNITED STATES ARMY NONBATTLE INJURIES, APRIL 1944,
BY TYPE AND ARM OR BRANCH OF SERVICE (2,676 COMPLETED CASES)
Source: ETMD, SWPA, Jun 1944. HD: 350.05.
19. BATTLE AND NONBATTLE CASUALTIES BY MILITARY OCCUPATION SPECIALTY, FOUR
INFANTRY DIVISIONS, FIFTH UNITED STATES ARMY, OCTOBER 1943 THROUGH MARCH 1944
Source: ASF Monthly Progress Rpt, Sec. 7, Health, 30 Sep 44.
condition, some having as many as 6
admissions. Distribution according to branch is shown in the following
Of the 466 patients, 138 were truck drivers who were either actually injured while driving or complained of aggravated symptoms while so engaged. Of the 138 patients, 94 were Quartermaster Corps truck drivers, accounting for all but 10 of the total low back injuries sustained by Quartermaster personnel. Many reasons in explanation of the undue incidence were considered such as (1) rough roads, particularly in the early months of the command when 8 to 12 hours were required to negotiate an average run of 150 miles; (2) hard, uncomfortable seats, particularly in the Studebaker 6 by 4 and 6 by 6 trucks, causing every bump to vibrate through the driver's body; (3) lack of drivers' belts as supports (not included in the tables of equipment); (4) long hours of driving with insufficient rest periods during peak tonnage months; (5) continued use of army cots which develop "sags" and do not afford relaxation to tired back muscles; and (6) failure of the drivers to seek proper massage and heat for tired back muscles after a run, and failure to report the conditions until the symptoms were severe. Accidents were more frequent during the early months in the theater and, therefore, more of these injuries were incurred. One hundred patients, approximately 21 percent, were transferred from a station or field hospital to the general hospital serving the command; and 20 were evacuated to the Zone of Interior for further observation and treatment. Specific preventive recommendations were made and are considered in greater detail under Control Measures.
Accidental Eye Injuries
A survey of eye
injuries was made at the 21st General Hospital, Eye Center, North African
Theater of Operations, for the period 10 May 1944 to 1 August 1944.38 The types of cases were distributed as follows:
The dispositions made of 212 of these cases are shown in Table 20. Twelve accidents happened near the frontlines, while 25 occurred in rear areas. The causes were extremely varied. Seven mechanics, struck by flying particles while at work, constituted the largest group from a single cause.
20. EVENTUAL DISPOSITION OF 212 PATIENTS WITH EYE INJURIES, NORTH AFRICAN
THEATER OF OPERATIONS, UNITED STATES ARMY, 1944
Source: ETMD, NATO, Sep 1944. HD: 350.05.
In the North African Theater of Operations it was stated that:39
Later from this theater the 12th General Hospital made a survey of burns during the first 8 months of its operation, from 26 January to 26 September
1943.40 The causes of burns were related to battle casualties in 49 instances (32.5 percent), and to accidental injuries in 102 (67.5 percent), a total of 151. The specific circumstances associated with accidental burns were gasoline fire in 77 cases, and burning plane, car, or motorcycle in 9 cases, to account for 84.3 percent of the total. Seven other cases were related to electricity; 5 to boiling water or steam; 1 each to mustard gas and shell explosion; and 2 were due to acid burns. A startling fact is that 85 percent of the accidental burns were the result of the use of gasoline in the bivouac area. When analyzed further, it was noted that the cause was the abuse of the use of gasoline. Americans in civilian life seldom use gasoline for heating and cooking but overseas it was common practice, with the result that unnecessary accidents were bound to occur unless instructions were given on the precautions to take. Some accidents were the result of explosion while lighting or filling various types of stoves; others were the result of pouring gasoline on an open flame; and still others were from cleaning clothes or equipment in the presence of an open fire. Some few were the result of using gasoline for burning garbage or insects. The final disposition of 102 cases of accidental burns was that 51 (50.0 percent) were sent to the Zone of Interior; 6 (5.9 percent) were classified limited service and 43 (42.1 percent) returned to combat duty. There were 2 (2.0 percent) deaths.
The most important group were the 86 cases of preventable burn resulting from the use or abuse of gasoline. Of this group more than half (44) had to be returned to the Zone of Interior. Many of these gasoline burns were serious, since 53 required skin grafting and the 2 deaths of the total burn cases were included. Deeply burned areas were frequent, because of clothing catching on fire.
Accidental poisoning by alcohol or substances thought to be alcoholic is to be expected in areas where the supply of ordinary alcoholic beverages is short. In the European theater 178 deaths were attributed to alcohol poisoning or a rate of 0.12 per 1,000 strength per annum for the period October 1944 to June 1945.41 During the same period acute communicable disease accounted for 162 deaths, a rate of 0.11.
Prior to the invasion of the Continent, in the United Kingdom, there were few difficulties. Beer was available, and although hard liquor was scarce, it could be obtained in recognized bars.
On the Continent the situation was very different. Beer was limited and wine did not have the potency of whiskey, so that frequent attempts were made to fortify wine with alcohol of undetermined quality. Samples of this liquor
were examined by the central laboratory of the theater in Paris. Methyl alcohol was the cause of most deaths, but other substances such as antifreeze and buzz bomb fluid were used accidentally or in the belief that they were potable. The majority of deaths due to methyl alcohol and other toxic agents were among ground combat troops. The Air Corps and troops of the communications zone were less involved, chiefly because their source of liquor supply was better and substitutes were not necessary.
In making a general evaluation of the accident problem in the years before the war, reports of The Surgeon General had stated that effective control measures would come through analysis of the individual local post or area. Colonel Cohen suggested that the medical officer contribute through an epidemiologic analysis of the situation, and that unit safety officers be appointed.42 Major Fineberg, who made a detailed analysis of accidents during maneuvers, made specific recommendations for control of accidents under such circumstances.43 In overseas theaters, European, Mediterranean, and Southwest Pacific, reports based on medical records were submitted to commanders for formulation of programs and evaluation of the problem. Special problems such as low back pain, burns, and poison liquor were studied. In the European theater an estimate of the amount of preventable accidents was made and given with other data to the provost marshal, Table 21. Eight principal causes were shown to be responsible for the accidents of about 20 percent of those able to return to duty, 50 percent of those evacuated to Zone of Interior, and 80 percent of the deaths. The approach to prevention was demonstrated. In the Mediterranean theater the extent of the manpower loss was brought to the attention of the Mediterranean theater staff by the theater surgeon and a safety committee was formed and drafted.44 Theater G-1 (personnel) was given the staff supervision responsibility and the theater provost marshal the operational responsibility.
In the Southwest Pacific the accident prevention program was delegated to the Office of the Assistant Chief of Staff, G-3 (Training) by the commanding general and a suitably trained Sanitary Corps officer was assigned as accident officer.45 Commanders of all bases and units under their command were instructed to appoint an officer to act as accident prevention officer. Pertinent data relative to the causes of nonbattle injuries, together with corrective measures for their reduction, were prepared by theater headquarters, and sent through channels to all base and unit accident prevention officers. Accidents occurring within each unit were recorded and analyzed by base and unit acci-
TABLE 21. SELECTED
PREVENTABLE CAUSES OF NONBATTLE INJURIES, EUROPEAN THEATER OF OPERATIONS, UNITED
STATES ARMY, FEBRUARY 1942 TO MARCH 1944
Source: Gordon, J. E.: History of preventive medicine in the European Theater of Operations, 1941-1945. HD: 314.7-2.
dent prevention officers and immediate corrective and/or disciplinary action was taken. The program was publicized by radio broadcasts, lectures, news bulletins, signs, posters, slogan contests, moving pictures, and film strips. Particular emphasis was also placed on measures to be taken for reducing the destruction and loss of vital equipment and supplies through carelessness and accidents. It was also suggested that an instructional and training program, devoted to swimming, be instituted through each Base S-3. The aid of the special service officer and Red Cross representative was utilized to develop such a program for reducing accidents and casualties resulting from swimming and diving, and to prevent drowning. It was estimated that 65 percent to 70 percent of the soldiers were unable to swim and that only 5 percent were proficient swimmers.
In the European theater where the problem of poison liquor was becoming evident, efforts were made to provide sources of safe and relatively mild drinks.46 A team consisting of a sanitary engineer, a toxicologist, and a beverage expert from Special Services Division, Headquarters, made special surveys of facilities for providing beer and soft drinks for the troops. Most of the breweries, many of which had closed during the war, were found acceptable when operated under American sanitary control. Breweries were reopened, processes were modified, facilities were occasionally provided to local operators,
and an adequate supply of beer was assured. No instance ever came to the attention of Army authorities of an outbreak of intestinal infection traced to beer.
Suggestions for the reduction of burns were made from the North African theater in March 1944. That headquarters recommended:47
In the Persian Gulf Command certain measures for the reduction of low back injuries were suggested:48
The Medical Department had been pointing out the increasing importance of nonbattle trauma before World War II, and during the war, especially in overseas theaters where admission and death rates were high. The Medical Department tabulated the data which enabled commanders to see the tremendous loss of manpower and thus establish programs of control. In the Mediterranean theater there was a marked drop in the nonbattle injury admission rate in 1945 and the theater surgeon felt this was due to the Accident Prevention Program.49 In the Southwest Pacific, a comparison was made of accident rates during the 8 months prior to the initiation of the program and the 5 months after it.50 This analysis revealed the following:
Such an evaluation (see Chart 5) certainly brings out the importance of prevention of nonbattle trauma in the saving of life as well as of medical facilities.
The contributions of the Industrial Hygiene Section, Preventive Medicine Division, Office of The Surgeon General, are more difficult to evaluate. Their
effort to promote industrial medicine contributed toward a good working environment and aided effort to place the individual in a job within his physical capabilities. These factors are important in accident prevention. The work on anthropometric, physiologic, and psychologic measurements at the Armored Force Medical Research Laboratory provided data for the design of vehicles and equipment which could be used more effectively and safely by the soldier. The activities of this laboratory are discussed further in the chapter on Occupational Health in another volume in this series.
Source: ETMD, USAFFE, Dec 1944. HD: 350.05.
In future operations the problem of alcoholic beverages and nontoxic beer needs serious consideration. The American soldier will find a substitute which may be poisonous, if a supply is not available.
In addition, the lack of knowledge of the use of gasoline was evident throughout World War II, and instruction in its use should be given serious emphasis early in the training of the soldier.
As the war progressed,
need was demonstrated for better classification and reporting of injuries,
especially those occurring overseas in theaters of operations. The Army Safety
Program system had been developed for analysis of the agency, act, and action of
accidental injury. This should be fused with medical records of type of injury,
duration of hospitalization, disability, and
discharges in order to define the problem as to time, place, and person, and as to the resulting death, or extent of defect and disability.
There is need for continued study on basic research on anthropometric, physiologic, and psychologic factors which would guide engineers in designing new equipment. The concept of accident proneness requires further testing to establish its validity and to determine whether objective or subjective physiologic or psychologic tests can be developed to detect such persons.
As the war closed, the
outstanding demonstration was the need for many professions to combine and work
on the problem of accidental trauma, which had become recognized finally as one
of the major mass health problems of armies; indeed, a problem that develops
even greater significance as armies become increasingly mechanized.