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Chapter VII

Contents

CHAPTER VII

Accidental Trauma

Major Edgar L. Cook, MC, USA
and
John E. Gordon, M. D.*

NONBATTLE INJURY

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

*Professor of Preventive Medicine and Epidemiology, Harvard University School of Public Health, Boston, Massachusetts. Formerly Colonel, MC, AUS.


234

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.


235

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 ARMY, 1900-45

Year

Disease

Nonbattle injury

Year

Disease

Nonbattle injury

1900

15.79

6.95

1923

2.01

1.90

1901

9.58

4.36

1924

1.94

1.89

1902

12.78

2.71

1925

1.77

1.99

1903

7.02

2.28

1926

2.27

1.67

1904

4.05

3.73

1927

2.35

1.65

1905

3.73

2.86

1928

2.30

1.80

1906

3.77

2.76

1929

2.29

2.05

1907

3.57

2.14

1930

2.08

1.81

1908

3.63

2.59

1931

2.47

2.13

1909

3.28

1.81

1932

2.11

2.15

1910

2.50

1.86

1933

2.11

2.10

1911

2.70

2.05

1934

2.04

1.99

1912

2.47

2.30

1935

2.09

1.75

1913

2.60

2.55

1936

2.00

2.03

1914

2.35

2.05

1937

1.87

1.61

1915

2.53

1.92

1938

1.54

1.71

1916

2.71

2.48

1939

1.55

1.50

1917

4.91

1.22

1940

1.04

1.76

1918

18.81

1.39

1941

.60

1.58

1919

7.61

1.34

1942

.68

2.08

1920

4.67

2.24

1943

.58

2.26

1921

2.24

2.02

1944

.55

2.45

1922

2.28

2.28

1945

.62

2.47


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.Considering

1Mortality Statistics 1910. Washington, Government Printing Office, 1913.
2Vital Statistics. Special Reports 26, No. 1, USPHS, FSA, 4 Apr 47.


236

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. These facts are important, because the majority of the Army population is male and of these age groups.

Classification of Army Casualties

ARMY REGULATIONS

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:

A battle casualty is a traumatism (wound or injury) which is incurred as a direct result of enemy action during combat or otherwise, or is sustained while immediately engaged in, going to, or returning from a combat mission. It does not include traumatisms occurring on purely training flights or missions. Psychiatric cases occurring in combat will not be reported as battle casualties.

The term "injury" will include traumatisms other than those defined as "battle casualty." (The term "traumatism" refers to morbid conditions due to external causes. It includes acute poisoning except food poisoning, the results of exposure to heat, cold, and light as well as various types of wounds.)

All cases other than those due to injury or battle casualty will be classed as ''disease." Included among the disease cases will be patients suffering from reactions to medication other than acute poisoning, patients admitted for the sequela of an injury incurred prior to entering service, and patients readmitted for the results of a traumatism (battle or nonbattle) incurred during service.

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-

3Fatal accidents and the venturesome male. Statist. Bull. Metrop. Life Insur. Co. 30: 6-7, Mar 1949.


237

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.

Chart 2. Schematic arrangement of classification of nonbattle injury.

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


238

surgeon, gives a stimulating account of medical problems in his Military Journal during the American Revolutionary War from 1775 to 1783. 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:

It is apparent . . . that external or violent causes were by far the most important cause of death in the Army in 1931. Thus they caused 46 percent of all fatalities. . . During the early period [1852-1861], deaths from external causes were only 11 percent of the total ones as compared with 50 percent during the last 10 years [1922-1931]. . . .Fatalities from automobiles, airplanes, etc., are largely responsible for the greater relative increase in deaths from violent causes.

4Thacher, James: A Military Journal during the American Revolutionary War from 1775 to 1783. Boston, 1823.


239

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.

TABLE 11. ACCIDENTAL INJURY* IN THE TOTAL UNITED STATES ARMY, BY CAUSATIVE AGENT, 1939

Causative agent

Admissions

Deaths

Disability discharge

Days lost

Average days per admission

Number

Percent of total

Number

Percent of total

Number

Percent of total

Number

Percent of total

Total

20,215

100.0

214

100.0

124

100.0

389,084

100.0

19

Motor vehicles

1,845

9.1

97

45.3

48

38.7

67,028

17.2

36

Aircraft

138

.7

36

16.8

1

.8

3,252

.8

24

Athletics

4,621

22.9

5

2.3

14

11.3

82,250

21.1

18

Falls

2,596

12.8

8

3.7

14

11.3

60,560

15.6

23

Fighting

1,091

5.4

---

0

3

2.4

20,368

5.2

19

Firearms

240

1.2

6

2.8

7

5.6

7,512

1.9

31

Drowning

22

.1

22

10.3

---

0

---

0

0

All others

9,662

47.8

40

18.8

37

29.9

148,114

38.2

15


*Excludes cases of homicide and suicide.
Source: Annual Report of The Surgeon General, U.S. Army, 1940.

The 1940 Annual Report of The Surgeon General, at the end of the analysis of data on accidental trauma made the following statement:

These tables give rather detailed information as to the causative agent, show wherein the fault lay in many cases, and serve as sources of data to indicate the most fruitful fields of accident prevention. However, it should be remembered that there is no evidence here as to the particular combination of circumstances which brought about the causation of the injuries. It is emphasized that this information can be obtained only by a detailed study of each case, and that such studies by unit commanders and medical officers can do much in the prevention of injuries.


240

Col. Samuel Adams Cohen, MC, made the following statement in an article in The Military Surgeon, November 1940: "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:

It cannot be overemphasized, however, that the problem of accidents and accident prevention should be the direct concern of the medical officer. Since he is the guardian of the health of the personnel, he should be the predominant influence in the prophylaxis of accidents.

The medical officer should explore all factors that may lead to accidents and make appropriate recommendations for eliminating them or decreasing their frequency. The gratifying experiences of the medical officer's successful efforts to stamp out many diseases and reduce the incidence of other diseases should be an added incentive for him to do likewise with accidents.

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

1.  Unit commanders and all officers having charge of troops should familiarize themselves with the most common causes of accidents and make definite plans for their prevention.

2.  Soldiers should be given careful instruction in getting on and off trucks. Greater caution should also be exercised to keep men from falling out of moving vehicles.

3.  More careful and more thorough training of drivers should be attempted. Also, more frequent changing of drivers who are exhausted or who are on the point of falling asleep should be effected.

4.  Soldiers should be instructed to walk on the proper side of the road, and to rest and sleep in places where a vehicle is not likely to strike them.

5.  Drivers should not suddenly start vehicles which have been standing for a long time without first looking around and underneath the vehicle.

6.  Irregularities of the terrain in the camp site and objects over which they might stumble in the dark should be pointed out to the soldiers.

7.  An attempt should be made to guard against branches striking the eyes.

8.  Soldiers should be instructed in the proper method of lighting and caring for gasoline stoves and in the proper method of handling gasoline.

9.  Soldiers should be cautioned against letting ammunition, even supposedly blank ammunition, get close to the fire.

5Cohen, S. A.: Accidents in the Army and their prevention. Mil. Surgeon 87: 434-443, Nov 1940.
6Fineberg, M. H.: A survey of the accidents resulting from Army maneuvers with recommendations for their prevention. Mil. Surgeon 91: 75-81, Jul 1942.


241

10.  Players participating in sports should be more adequately protected and more carefully supervised.

11.  More care should be taken to prevent objects from falling on soldiers.

12.  Fights and brawls might be lessened by better discipline with specific reference to drinking and gambling.

13.  Soldiers should be instructed in the proper method of lifting heavy objects.

14.  Inexperienced soldiers should be given pointers on how to use an axe.

15.  Rings should not be worn by soldiers on maneuvers.

ACCIDENT PREVENTION DURING WORLD WAR II

General Policy

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. The policies and pro-

7SOS Cir 55, 31 Aug 42.


242

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. 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. 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.

8Memo, Chief of Staff, US Army, for PMG, 5 Dec 42, sub: War Department Safety Council. HD: 322.
9WD Cir 438, 14 Nov 44.


243

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

10WD Memo W850-44, 8 Feb 44.
11ASF Cir 360, 25 Sep 45.
12WD Cir 305, 5 Oct 45.


244

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.

Activities Overseas

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.


245

Chart 3. United States nonbattle injury death rates, per 1,000 per annum, continental United States and overseas, 1940-45. These are preliminary data based on statistical health reports.

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.

13Gordon, J. E.: A history of preventive medicine in the European Theater of Operations, U. S. Army, 1941-1945. HD: 314.7-1.


246

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:

Because of the importance of nonbattle injury as a source of noneffectiveness, there has long been evident a need for an adequate and effective control program, both in the Continental U. S. and overseas. During 1943 nonbattle injuries overseas caused a loss of almost four million man-days and battle injuries a loss of perhaps half this amount. The loss of time from nonbattle injuries is in large part preventable by means of a suitable control program.

14ETMD, SWPA, Jun 1944. HD: 350.
15Final Rpt, Prev Med Off, Off of Surg NATOUSA, 2 Nov 45. HD.


247

DEATHS

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

Killed in action

930

Nonbattle casualty

574

Disease

152

Died of wounds

94


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

16ETMD, SOPAC Base Comd, 16 Nov 44. HD: 350.05.
17See footnote 14, p. 246.
18See footnote 13, p. 245.

TABLE 12.  DEATHS DUE TO NONBATTLE INJURIES IN THE UNITED STATES ARMY, BY THEATER OF ADMISSION AND YEAR OF DEATH, 1942-45

Theater

Total 
1942-45

1942

1943

1944

1945

Number

Total Army

60,054

6,751

15,561

19,053

18,689

United States

27,140

4,850

9,764

8,211

4,315

Overseas1

32,914

1,901

5,797

10,842

14,374

North America2

1,493

359

622

297

215

Latin America

1,587

385

509

487

206

Europe

12,484

199

779

4,058

7,448

Medicterranean3

5,644

149

1,915

2,277

1,303

Middle East

538

22

174

256

86

China, Burma, India

2,525

73

285

1,021

1,146

Pacific Ocean Areas4

}8,557

}348
}340

866

}2431

3943

Southwest Pacific4

629


See footnotes at end of table.


248

TABLE 12.  DEATHS DUE TO NONBATTLE INJURIES IN THE UNITED STATES ARMY,  BY THEATER OF ADMISSION AND YEAR OF DEATH, l942-45-Continued

Theater

Total 
1942-45

1942

1943

1944

1945

Annual rate per 100,000 mean strength5

Total Army

235.70

208.19

226.49

244.55

246.72

United States

184.09

182.54

188.40

206.73

147.19

Overseas1

306.57

324.53

343.44

283.88

309.56

North America2

303.21

356.80

319.83

229.81

315.85

Latin America

416.10

377.74

421.24

567.61

282.81

Europe

283.78

239.74

291.97

241.96

313.96

Mediterranean3

380.57

649.92

419.30

350.54

368.24

Middle East

368.00

363.88

328.03

553.91

210.32

China, Burma, India

575.85

834.67

719.37

605.19

517.60

Pacific Ocean Areas4

}276.62

}230.53
}477.37

297.02

}248.58

279.28

Southwest Pacific4

331.21


1Includes admissions on transports.
2Includes Alaska and Iceland.
3Includes North Africa.
4Not available separately in 1944 and 1945.
5The strengths on which these rates were based are mean strengths and will vary therefore from the official strength reports of The Adjutant General.

ADMISSIONS

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

NONEFFECTIVENESS

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-

19ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jul 44.
20ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jan 45.


249

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

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

TABLE 13.  SURGICAL DISPOSITIONS, SOUTH PACIFIC BASE COMMAND, UNITED STATES ARMY, 
MARCH-JUNE 1944

Type of cases

To duty

To Zone of Interior

Deaths

Total

Patients

Average hospital days

Patients

Average hospital days

Patients

Average hospital days

Patients

Average hospital days

Surgical disease

8,639

21

564

57

9

8

9,212

23

Injury

3,604

25

243

72

30

4

3,877

28

Battle casualty

873

29

286

55

23

9

1,182

35

No disease

466

12

1

62

0

0

467

12

Total

13,582

22

1,094

60

62

6

14,738

25


Source: ASF Monthly Progress Rpt., Sec. 7, Health, 31 Jan 45.

21See footnote 20, p. 248
22See footnote 13, p. 245
23See footnote 14, p. 246.


250

TABLE 14. CAUSES OF NONBATTLE INJURY, UNITED STATES ARMY, SOUTH PACIFIC BASE COMMAND, MARCH-JUNE 1944

Cause of injury

Number of patients

Hospital days

Percent returned to duty

Total 

Average

Falls and jumps

706

21,420

30

96.9

Moving objects

474

11,149

24

95.4

Organized athletics

385

8,550

22

96.6

Moving vehicles

368

10,775

29

88.9

Burns

354

9,377

26

95.5

Accidental discharge of guns and ammunition

235

10,018

43

78.7

Sharp objects

171

3,659

22

96.5

Lifting

135

2,393

18

99.3

Assault

135

3,090

23

95.6

Unspecified

467

12,438

27

93.4

Total*

3,430

92,869

27

93.9


*These represent cases among the 3,877 shown in Table 13 which were considered to be acute.
Source: ASF Monthly Progress Rpt., Sec. 7, Health, 31 Jan 45.

TABLE 15. CLASSIFICATION OF INJURY DISPOSITIONS BY SURGICAL SPECIAL FIELDS, UNITED STATES ARMY, SOUTH PACIFIC BASE COMMAND, MARCH-JUNE 1944

Special field

Percent of patients

Percent of hospital days

Average stay in days

Percent returned to duty

Orthopedic

47.5

56.3

33

92.9

General

44.9

37.1

23

94.9

Neurosurgery

3.4

4.1

33

71.5

Eye

2.5

1.6

17

85.7

Ear, nose, throat

1.2

.6

14

95.8

Urology

.5

.4

21

95.0

Total

100.0

100.0

28

93.0


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

24See footnote 20, p. 248.


251

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

25ASF Monthly Progress Rpt, Sec. 7, Health, 31 Jul 44.


252

TABLE 16. DEATHS DUE TO NONBATTLE INJURIES IN THE UNITED STATES ARMY, BY AREA OF ADMISSION AND CAUSATIVE AGENT, 1942.

Preliminary Data Based on Tabulations of Individual Medical Records

Causative agent

Total Army

Continental United States

Overseas

 

Number

Total

6,751

4,850

1,901

Aircraft accidents

2,986

2,122

864

Vehicle accidents

1,489

1,222

267

Firearms and ammunition

963

555

408

Falls, jumps

106

77

29

Athletics and sports

124

88

36

Ill-fitting clothing

---

---

---

Fire or heat

60

49

11

Tools, instruments

64

57

7

Chemicals

128

98

30

Excessive heat

29

26

3

Excessive cold

3

1

2

Other agents

799

555

244

 

Annual rate per 100,000 mean strength

Total

208.19

182.54

324.53

Aircraft accidents

92.09

79.86

147.50

Vehicle accidents

45.92

45.99

45.58

Firearms and ammunition

29.70

20.89

69.65

Falls, jumps

3.27

2.90

4.95

Athletics and sports

3.82

3.31

6.15

Ill-fitting clothing

0

0

0

Fire or heat

1.85

1.84

1.88

Tools, instruments

1.97

2.15

1.20

Chemicals

3.95

3.69

5.12

Excessive heat

.89

.98

.51

Excessive cold

.09

.04

.34

Other agents

24.64

20.89

41.65


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

26ETMD, SPA, 2 Dec 43. HD: 350.05.


253

TABLE 17. PRINCIPAL CAUSES OF ACCIDENTAL DEATH, SELECTED THEATERS OF OPERATION, WORLD WAR II, UNITED STATES ARMY, BY PERCENT OF ALL ACCIDENTAL DEATHS

Theater and year

Aircraft

Motor vehicle

Drowning

Firearms, explosives

European: 19431

54.5

13.0

2.5

8.5

Southwest Pacific: 19432

54.5

11.3

8.7

10.7

North African: January-May 19443

30.3

21.8

5.1

18.5

South Pacific: September 1942-August 19444

30.6

12.0

21.7

20.2


1Gordon, J. E.: History of preventive medicine in European Theater of Operations, 1941-1945. HD: 314.7-2.
2ETMD, SWPA, Jun 1944. HD: 350.05
3ASF Monthly Progress Rpt, Health, 30 Sep 44.
4ETMD, SOPAC Base Comd, Nov 1944. HD: 350.05.

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

27Annual Report of The Surgeon General, U. S. Army, 1940. Washington, Government Printing Office, 1941.
28See footnote 25, p. 251.


254

. . . .Sixty percent of the days lost were attributable to traffic accidents, in 6 percent of which alcohol was a contributing factor. Twenty-seven percent of the days lost were allocated to burns, and 13 percent to personal assaults and injuries. In 49 percent of the latter group alcohol was a contributing factor.

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:

I would suggest that those persons in charge of selective service or industrial activity be on the lookout for persons of the types here delineated and that such persons be given special attention in placement and treatment. It has been suggested, for example, that a person who is accident prone would probably do better in a commando or a paratroop unit or in some other more or less individualized and adventurous assignment, just as persons who are potential sufferers from cardiovascular disease, if they follow the coronary or anginal pattern, will do better and maintain health longer if given recognition and authority.

Whether better suggestions than these could be made will remain for those in charge of Army personnel to discover. The aim in this article was merely to call attention to the possibility of excluding from service persons with a well confirmed accident habit who may prove to be a liability to themselves and others or of placing them in such a way that their liabilities may prove if not an asset at least a minimal danger.

29Dunbar, F.: Medical aspects of accidents and mistakes in the industrial army and in the Armed Forces. War Med. 4: 161-175, Aug 1943.


255

In considering whether such persons should be rejected, carefully placed or treated, the material given here may be useful. Because of the limited time and personnel available for medical and psychiatric examination, it seems obvious that the greatest possible use should be made of social workers and public welfare agencies in supplying the specific details of past history here indicated as having a bearing on the problem.

The fact cannot be too much emphasized that persons whose histories suggest accident proneness are of most vital interest. Such persons can make the kind of mistake that sinks a ship, loses a battle or explodes a munitions plant. And apart from its consequences, the mistake will appear to be just the kind of unfortunate mistake that any one might make. But, nevertheless, there is evidence that only certain types of people make such mistakes.

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.

Environment

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,

30Menninger, William C.: Psychiatry in a Troubled World. New York, Macmillan, 1948, see p. 150.
31Ltr, Brig Gen R. W. Bliss, Asst SG, to ACof S G-4, thru CG ASF, 23 Aug 45, sub: Zone of Interior hospitalization. SG: 322 Hospitals.


256

is seen in the 1945 annual report of the 8th Evacuation Hospital in the Mediterranean Theater of Operations. The report states:32

The surrender of the German Army created the problem of handling thousands of German troops. . . . The overturning of one 10-ton trailer killed several and put the remainder of the 50 Germans in the hospital. During May, the roads were filled with a great variety of German vehicles, many of them in rather bad repair, manned by German drivers and transporting Germans to P.  O. W. stockades at Modena, Florence and points south. . . .

With the end of the war, a great deal of confusion arose. Added to the stream of German Prisoners of War were thousands of Italian civilians who suddenly decided to go somewhere other than where they were located. Roads were crowded with civilians, men, women, children and infants in arms, on foot, bicycles, carts, wagons, old cars and dilapidated trucks. Displaced persons and repatriated individuals trying to get home added to the confusion.

Military personnel seemed also affected by the rush and confusion and continued to operate vehicles at high speed and in a reckless fashion. Accidents were frequent and tragic. A truck load of Russians, formerly German prisoners and labor troops, returning to Russia, overturned, killing one woman and sending 15 other individuals to the hospital. Italian civilians scrambling into an abandoned German ammunition dump for wooden boxes, precipitated an explosion that killed many and put 18 civilians in the hospital.

A regiment of Czechoslovakian troops sent numerous patients to the hospital. German Prisoners of War continued to be admitted for illness and injury until the Prisoner of War hospital at Mantova began to function. During May, 592 patients out of a total of 2,183 admissions were due to accidents of various kinds, including accidental gunshot injuries. With the break-up and surrender of the German Army, unfamiliar weapons fell into the hands of the Allies as captured material and souvenirs. During the month of May, 42 soldiers shot themselves, and 31 more were shot by their buddies, while handling enemy guns, usually pistols.

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

32Annual Rpt, 8th Evac Hosp MTO, 1945. HD.
33See footnote 14, p. 246.
34Monthly Progress Rpt, Sec. 7, Health, Sep 1944.


257

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

35See footnote 34, p. 256.
36Tobin, W. J.; Ciccone, R.; Vandover, J. T., and Wohl, C. S.: Parachute injuries. Army M. Bull. 66: 202-221, Apr 1943.
37ETMD, Persian Gulf Comd, Oct 1944. HD: 350.05.


258-259

TABLE 18. SOUTHWEST PACIFIC AREA, UNITED STATES ARMY NONBATTLE INJURIES, APRIL 1944, BY TYPE AND ARM OR BRANCH OF SERVICE (2,676 COMPLETED CASES)

Arm or branch of service

Total nonbattle injuries

Lacerations

Abrasions and contusions

Other wounds

Strains and sprains

Fractures

Burns

Old injuries

Dislocations

Eye injuries

All others

Gasoline

Chemical

Others

Total Southwest Pacific Area

2,676

441

385

129

777

421

176

19

102

89

33

29

75

Officers

---

22

20

4

34

18

2

1

5

6

5

1

---

Enlisted men

---

419

365

125

743

403

174

18

97

83

28

28

75

Engineers

442

81

73

25

108

79

23

1

16

15

3

4

14

Officers

10

---

3

1

3

2

---

---

1

---

---

---

---

Enlisted men

432

81

70

24

105

77

23

1

15

15

3

4

14

Air Corps

423

58

51

26

142

60

32

1

20

13

2

9

9

Officers

46

12

4

2

12

6

2

---

3

3

1

1

---

Enlisted men

377

46

47

24

130

54

30

1

17

10

1

8

9

Infantry

335

55

48

9

110

53

20

1

8

17

3

1

10

Officers

6

---

1

---

2

1

---

1

---

1

---

---

---

Enlisted men

329

55

47

9

108

52

20

---

8

16

3

1

10

Quartermaster

253

45

40

4

84

38

15

---

10

6

4

---

7

Officers

5

1

1

---

2

1

---

---

---

---

---

---

---

Enlisted men

248

44

39

4

82

37

15

---

10

6

4

---

7

Medical Corps

179

31

27

5

48

30

11

2

8

6

2

2

7

Officers

8

---

2

---

4

1

---

---

---

---

1

---

---

Enlisted men

171

31

25

5

44

29

11

2

8

6

1

2

7

Ordnance

168

29

25

9

43

20

18

1

10

4

---

4

5

Officers

5

3

---

---

1

1

---

---

---

---

---

---

---

Enlisted men

163

26

25

9

42

19

18

1

10

4

---

4

5

Field Artillery

119

24

14

8

31

18

5

5

4

5

1

2

2

Officers

3

---

1

1

1

---

---

---

---

---

---

---

---

Enlisted men

116

24

13

7

30

18

5

5

4

5

1

2

2

Coast Artillery

115

18

7

9

28

23

10

---

5

2

6

1

6

Officers

1

---

---

---

---

---

---

---

---

---

1

---

---

Enlisted men

114

18

7

9

28

23

10

---

5

2

5

1

6

Signal Corps

112

17

7

3

30

19

13

1

8

6

1

2

5

Officers

2

1

---

---

---

1

---

---

---

---

---

---

---

Enlisted men

110

16

7

3

30

18

13

1

8

6

1

2

5

Cavalry

70

18

5

6

19

7

10

---

1

1

1

1

1

Officers

---

---

---

---

---

---

---

---

---

---

---

---

---

Enlisted men

70

18

5

6

19

7

10

---

1

1

1

1

1

Nurses

15

2

4

---

5

2

---

---

---

1

1

---

---

Others

445

63

84

25

129

72

19

7

12

13

9

3

9

Officers

17

3

4

---

4

3

---

---

1

1

1

---

---

Enlisted men

428

60

80

25

125

69

19

7

11

12

8

3

9


Source: ETMD, SWPA, Jun 1944. HD: 350.05.


260

TABLE 19. BATTLE AND NONBATTLE CASUALTIES BY MILITARY OCCUPATION SPECIALTY, FOUR INFANTRY DIVISIONS, FIFTH UNITED STATES ARMY, OCTOBER 1943 THROUGH MARCH 1944

Military occupational specialty 

Percent of division casualties

Casualties per 1,000 table of organization strength per division combat day

Number

Title

Battle 

Nonbattle

Total

Battle 

Nonbattle

Total

745

Rifleman

38.1

25.5

30.4

12.2

10.7

22.9

603

Gunner

8.0

5.5

6.4

6.2

5.5

11.7

653

Squad leader

8.1

7.5

7.8

5.2

5.9

11.1

761

Scout

1.1

1.0

1.0

4.9

5.5

10.4

657

Litter bearer

1.2

1.7

1.5

3.4

5.8

9.2

746

Automatic rifleman

3.9

2.9

3.4

4.8

4.3

9.1

652

Section leader

1.4

1.7

1.6

3.7

5.4

9.1

651

Platoon sergeant

1.8

1.8

1.9

3.9

4.7

8.6

504

Ammunition handler

8.3

9.0

8.7

3.6

4.8

8.4

238

Lineman telegraph and telephone

1.4

2.0

1.8

2.7

4.7

7.4

675

Messenger

2.6

2.5

2.6

2.8

3.3

6.1

610

Antitank gunner

1.0

1.0

1.0

2.4

3.3

5.8

060

Cook

.7

1.9

1.4

1.2

4.5

5.7

531

Cannoneer

1.2

2.7

2.1

1.4

4.2

5.6

245, 345

Truck driver

2.6

7.0

5.3

1.0

3.5

4.5

014

Auto mechanic

.4

1.0

.7

1.0

3.3

4.4

539

Section chief

.2

.5

.4

1.0

3.3

4.3

225

Surgical technician

.5

.7

.6

1.6

2.5

4.0

177

Radio operator

.5

.9

.7

1.1

2.4

3.6

521

Basic

4.0

4.1

4.0

1.4

1.9

3.3

821

Supply NCO

.2

.5

.3

.8

2.6

3.3

695

Orderly

.2

.4

.3

.9

2.1

3.0

405

Clerk typist

.2

.6

.4

.5

2.0

2.5

 

Other enlisted men

7.0

13.1

10.9

1.8

3.7

5.5

Total enlisted men

94.6

95.5

95.2

3.7

4.7

8.4

  Officers

5.4

4.5

4.8

4.0

4.2

8.2 

Total division

100.0

100.0

100.0

3.7

4.7

8.4


Source: ASF Monthly Progress Rpt, Sec. 7, Health, 30 Sep 44.


261

condition, some having as many as 6 admissions. Distribution according to branch is shown in the following tabulation:

Branch

Cases

Quartermaster

104

Engineer

91

Port personnel

73

Ordnance

71

Railway

51

Medical personnel

26

Military police

12

Others

38

Total

466


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:

Battle casualties

135 (49.4 percent)

Eye disease

101 (37.0 percent)

Accidental injury

37 (13.6 percent)

38ETMD, NATO, Sep 1944. HD: 350.05.


262

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.

TABLE 20. EVENTUAL DISPOSITION OF 212 PATIENTS WITH EYE INJURIES, NORTH AFRICAN THEATER OF OPERATIONS, UNITED STATES ARMY, 1944

Type of casualty

Number

Evacuated to Zone of Interior

Returned to duty class B permanent

Returned to duty A-1

Type of disposition unknown

Number

Percent

Number

Percent

Number

Percent

Number

Percent

Total

212

68

32.0

26

12.2

110

51.8

8

4.0

Battle casualties

88

53

60.3

8

9.1

25

28.4

2

2.2

Accidental injury

37

6

16.2

8

21.6

22

59.4

1

2.8

Disease

87

9

10.3

10

11.4

63

72.4

5

5.9


Source: ETMD, NATO, Sep 1944. HD: 350.05.

Burns

In the North African Theater of Operations it was stated that:39

The great majority of burns in the theater occur in the Lines of Communications, from accidents and unauthorized use of gasoline. During the month of August, the 73rd Station Hospital, sited in Constantine, records 222 admissions to the surgical service, 94.3% of which were non-battle casualties; 10.35% of admissions were for burns. It is stated that 65% of the burns were caused by accidents with the fire units of field ranges.

The 54th Station Hospital in Tunis reports 53 burns, many severe, among 998 surgical admissions, 108 of which were battle casualties.

Gasoline burns often involve large areas of body surfaces, but tend to be negligible in depth. Only rarely is skin grafting required. This impression is gained from examination of large numbers of these burns and from reports of the surgeons in the Mateur-Bizerte area during the summer months. It is contrary to the impressions received at the 12th General Hospital, where large numbers of burns are treated in Mediterranean Base Section. This, however, was during the cold and damp spring months. It is suggested that, in the hot (95o-110o ) dry summer climate of Tunisia, gasoline tends to vaporize more readily and produces a true flash explosion of short duration. Full thickness burn areas are produced by contact with the flaming liquid as it is thrown into the air by the explosion, or spilled from the burning container. It is quite possible, therefore, that during the approaching cool rainy season, the gasoline burns may be more severe. Such variables, always modifying the pattern of trauma, constantly must be kept in mind in judging the relative merits of therapeutic procedures.

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

39ETMD, NATO, Sep 1943. HD: 350.05.


263

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.

Poison Liquor

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

40ETMD, NATO, Feb 1944. HD: 350.05.
41See footnote 13, p. 245.


264

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.

Control Measures

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-

42See footnote 5, p. 240.
43See footnote 6, p. 240.
44See footnote 15, p. 246.
45ETMD, SWPA, Dec 1944. HD: 350.05.

 


265

TABLE 21. SELECTED PREVENTABLE CAUSES OF NONBATTLE INJURIES, EUROPEAN THEATER OF OPERATIONS, UNITED STATES ARMY, FEBRUARY 1942 TO MARCH 1944

Cause of accident

Percentage which specified types of accidents constituted of all nonbattle injuries where the patient was-

Returned to duty

Evacuated to the Zone of Interior

Died

1942

1943

1944 January-March

1942

1943

1944 January-March

1942

1943

1944 January-March

Motor vehicle accidents

9.4

7.9

6.2

17.2

21.8

19.0

18.2

12.9

17.7

Tank and tractor accidents

.5

.3

.4

2.9

0

0

0

.4

.9

Bicycle accidents

2.9

5.1

2.9

2.3

7.6

6.0

1.6

1.2

.5

Other road accidents

1.0

.8

.3

2.9

2.2

0

0

2.2

2.6

Air transport accidents

2.3

3.5

2.2

.6

5.5

1.0

39.6

54.2

44.0

Firearms

2.9

2.2

1.3

17.8

15.3

13.0

13.0

8.5

21.7

Machinery

1.0

1.6

.9

1.1

5.5

1.0

.5

.6

0

Burns

.6

0

.9

0

0

0

0

0

0

Total

20.6

21.4

15.1

44.8

57.9

40.0

72.9

80.0

87.4


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,

46See footnote 13, p. 245.


266

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

To prevent such unnecessary injuries, it would seem possible that the various types of stoves used for cooking or heating should be made more "foolproof," since explosions resulting from the use of improper type of fuel or failure to clean the jets are too common. The proper method of making, lighting, filling and cleaning the various types of G-I or improvised stoves, should be better demonstrated and unless their use is absolutely necessary the use of such stoves should be discontinued.

The average soldier is not acquainted with the potential dangers of improper use of gasoline. This is demonstrated by the statements overheard on a "burn" ward where other patients see these seriously injured men and are amazed that such injuries can and do result from gasoline.

Gasoline is too vital an item of war to be used for cleaning clothing or burning garbage and some conservation could be accomplished by disciplinary measures.

To summarize, it would seem possible to reduce the incidence of accidental burns by:

1.  Proper instruction in the danger of the indiscriminate use of gasoline.
2.  Proper instruction in the use of the various stoves that require gasoline for fuel.
3.  Disciplinary measures where infractions have occurred after the men have been instructed.

It would seem possible to attain all of these aims by the use of a well prepared color movie that could demonstrate to the troops what might be a real cause of disability to themselves and the loss of important equipment by the careless use of gasoline.

In the Persian Gulf Command certain measures for the reduction of low back injuries were suggested:48

1.  General Measures for Reducing Back Injuries

a.  Don't lift loads too heavy to lift or support normally.
b.  Always face swinging loads and cables.
c.  Don't push heavy loads with body "off balance,"
d.  Learn to lift objects correctly (lift with legs and back, not back alone).
e.  Don't stand under heavy loads.
f.  Never be in such a hurry as to be careless.

2.  Special Measures for Reducing Truck Driver Low Back Injuries

a.  Have better cushioned seats for drivers (even if it is a supplemental cushion and back rest.)
b.  Have sufficient belts provided so that all deserving cases can wear one.
c.  Provide adequate rest periods for drivers between long hauls.
d.  Provide, preferably, a hard surface bed, one that will not sag.
e.  Advocate massage and heat to backs after a long trip (This should be done preferably by trained personnel, as it relieves fatigue symptoms early).
f.  Avoid sudden jerking motions while shifting or making a curve.
g.  Avoid accidents.

47See footnote 40, p. 263.
48See footnote 37, p. 257.


267

Conclusion:  Low back injuries appear to be one of the outstanding forms of injury among troops, requiring long hospitalization or loss of time from normal duties. As brought out in this report, this is particularly true among truck driver personnel in all branches of the service. If some, or all, of the suggested measures can be taken to afford relief, or prevention of injuries, the noneffective rate among troops can be greatly lowered. Troop commanders have a great responsibility in preventing injuries of this nature. If they will conduct lectures and safety campaigns for instruction of troops and better understand these injuries and their treatment themselves, perhaps, more than anything else, this would prove to be one of the best forms of prophylaxis.

Evaluation

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:

Hospital and quarters cases of non-battle injuries averaged 18.9 days per patient for 1943, 16.3 days for 1944. This represents a reduction of 13.7% in average hospitalization time per patient admitted to hospitals and quarters for non-battle injuries.

The average non-effective rate for non-battle injuries was 8.5 per 1,000 per annum for 1943, 7.0 per 1,000 per annum for 1944. The reduced rate with a strength of 750,000 has resulted in saving of 1.125 man days per day in the SWPA. Because of this reduction in rate, approximately 1,000 more hospital beds are released every day and approximately 125 more men are available for duty every day who would be confined to quarters as a result of non-battle injuries.

Twenty-two more men would have been evacuated to the U. S. and 8 more would have died from non-battle injuries if the same rate for 1943 had prevailed for the first 6 months of 1944.

Admission rates of non-battle injuries to hospitals and quarters for the 6 month period previous to the initiation of the Accident Prevention Program was 174 cases per 1,000 per annum; the 5 months following the initiation of the program shows 146 cases per 1,000 per annum, a reduction of 16%. With a strength of 750,000, this reduction in rate will result in a decrease of 5,700 admissions to sick reports for non-battle injuries per year.

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

49See footnote 15, p. 246.
50See footnote 45, p. 264.


268

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.

Chart 5.  Nonbattle injury rates. A comparison of hospital admission rates for 8 months preceding accident prevention program and for 5 months after institution of program.

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


269

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. 

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