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Medical interest in the battle casualty as to the type and anatomic location of his wounds, the correlated visceral damage, and the causative missiles has been in evidence since the earliest days of organized combat. The founding of the Army Medical Museum during the Civil War and the resultant collection of case histories, drawings, anatomic specimens, and recovered missiles was a major milestone in the accurate documentation of wartime medical history. Notwithstanding its seeming antiquity in the light of present-day standards, the collection is of unique and unparalleled value, and its complete exploitation has never been fully realized. Near the close of the 19th century, Col. Louis A. La Garde of the U.S. Army Medical Corps, in conjunction with the Ordnance Department, conducted numerous experiments in basic wound ballistics and later extended his observations to the casualties of the Spanish-American War.

During World War I, there were numerous small casualty surveys conducted by medical personnel of great vision and foresight, but there were no formal directives governing such activities. Col. Louis B. Wilson of the U.S. Army Medical Reserve Corps made a rather extensive study of the wounds in casualties of World War I, and this, coupled with his interest in the subject of ballistics, enabled him to reach a number of basic conclusions regarding the wounding effect of a bullet. In later years, Colonel Wilson was active in directing the ballistic research of Col. (later Brig. Gen.) George R. Callender, MC, and M. Sgt. (later Major, SnC) Ralph W. French. Much of this work was an attempt to carry out on a scientific basis experiments which would prove, disprove, or modify statements Colonel Wilson had made regarding the wounding potentials of small arms missiles.

Unfortunately, the excellent collection of pathologic specimens by the British Army Medical Service from World War I was partially destroyed during the bombing of London in World War II. This collection at the Royal College of Surgeons resulted from the activity of the British Medical History Committee which from its origin had a duty "to collect examples of the wounds and diseases suffered by soldiers in the present war [World War I]; to dissect and examine such specimens in order to fully understand their extent and nature so that the best means for their treatment might be adopted; and to preserve instructive examples so that they might be examined and studied not only by Army surgeons of today but also by medical men for many generations to come." According to Sir Alfred Keogh, Director-General of the Army Medical Service (20 Oct. 1917): "Such specimens are original documents, they constitute an original and reliable source of knowledge for all time, and supply the most valuable basis possible for present and future medical and

surgical treatment of the diseases and injuries of war." Such sentiments are still applicable in the elucidation of the value and function of a battle casualty survey unit. The collected information and specimens can be channeled into various fields for instruction, training, and developmental purposes, both within the medical service and within the other technical services, and for permanent display and historical storage.

In addition to determining the location and types of wounds in battle casualties, it is also essential that the members of a survey team be familiar with enemy ordnance materiel. One must learn to recognize the characteristics of the external wound and the permanent wound track and, in addition, attempt an identification of the causative missile, of its approximate mass, and of its striking velocity. In small arms missiles, it is desirable to be aware of the effective rate of fire and range of the weapon and the types and makeup of the ammunition. With fragment-producing weapons, it is essential to determine the types of shells and the mass distribution and initial velocity of the fragments. By means of such information, a more adequate and intelligent analysis can be made of wounds and their causative agents, and valuable data can be made available for dissemination to other technical services for weapons' evaluation and development of personnel armor. This leads to an excellent liaison and interchange of ideas, test results, interpretations, and guidance between the interested technical services.

Chapter I of this volume deals with the enemy ordnance materiel of World War II and Korea insofar as it had a bearing on casualty surveys. An attempt was made to make it as informative and readable as possible while still maintaining the security of information classified in the interest of national defense. Maj. James K. Arima, MSC, and Mrs. Doris Johnson (nee Walther) of The Historical Unit, U.S. Army Medical Service, were responsible for the collection and compilation of much of the information, and this was possible only after a review of a large number of publications, principally ordnance, and correlating the various weapon specifications which in many cases had a great variability. In addition, members of the various sections of the Ordnance Technical Intelligence Service, U.S. Army, were very helpful in reviewing the material for accuracy and security. The wholehearted cooperation of various members of the Ordnance Department in compiling the material and in its final review for publication has been most encouraging.

During the interim between World Wars I and II, active research on a probable mechanism of wound production by high-velocity missiles was conducted by General Callender. Most of this pioneer work was done in collaboration with Major French. In chapter II, they have utilized some of their original material to elaborate upon the correlation between a missile, its mass and velocity, and its wounding potential. Both authors are to be commended for the quality and originality of their research and for the particular correlation which has existed between their laboratory experiments and later fieldwork.

In September 1943, Mr. R. H. Kent, physicist at the Aberdeen Proving Ground, Md., contacted Dr. Lewis H. Weed, chairman of the Division of

Medical Sciences of the National Research Council, regarding the establishment of a research project designed to test the casualty-producing effectiveness of U.S. weapons. As a result of this request, a meeting of the newly created Conference on Wound Ballistics, later called the Conference on Missile Casualties, was held on 25 September 1943. General Callender presided and Dr. John F. Fulton was secretary of the meeting. After accepting the general tenets of Mr. Kent's proposal, the Conference granted contracts for research projects to several groups of investigators. One of these contracts led to the monumental work reported by E. Newton Harvey, Ph. D., and his associates (chapter III). Much of this material has been published in separate medical journal articles, but this volume would be grossly deficient if it were not present. Many of the original conclusions of this work have been the basis for continuing ballistic research after World War II. Floyd A. Odell, Ph. D., Technical Director of Research, U.S. Army Medical Research Laboratory, Fort Knox, Ky., and formerly of the Biophysics Division, Medical Laboratories, Army Chemical Center, Md., kindly furnished a copy of the original manuscript and a complete set of negatives for illustrations. The excellence of the illustrations in chapter III is due solely to the availability of these negatives.

The natural extension of basic wound ballistic laboratory research into field surveys and the increasing awareness of the need for data on battle wounds was recognized by the Conference on Missile Casualties, and in early October 1943, a general recommendation was made that special teams be appointed to conduct battle casualty surveys and that some attention be given to the training of personnel qualified to conduct these field activities. On 14 October 1943, the Conference prepared a formal proposal directed to The Surgeon General of the Army concerning the formation of a special survey unit which could receive its initial indoctrination in the United States and its subsequent training with Prof. Solly Zuckerman's group at Princes Risborough in England. It was felt that such a team should consist of approximately six to eight persons, including medical personnel qualified in pathology and surgery and other technical service personnel having training in physics, interior and exterior ballistics, and other ordnance specialties.

Subsequent to this proposal, General Callender informed the Conference on 5 November 1943 that The Surgeon General and Brig. Gen. Fred W. Rankin, Director, Surgical Consultants Division, were in agreement concerning the need for data on wounds in battle casualties but felt that the immediate shortage of trained men precluded the appointment of any special team. Instead, it was recommended that theater commanders be advised of the need for the information and that they then assign medical officers under their command to collect wound ballistic data for transmittal to the Conference on Missile Casualties. General Callender prepared an article in which he described the startling lack of available information and outlined the overall scope and organization of a casualty team and the type of data which was needed. This article was published in the March 1944 issue of the Bulletin of the U.S. Army Medical

Department. Before general publication, copies of the article were sent to all theaters of operations.

As a result of General Callender's article, a survey team was organized under Col. Ashley W. Oughterson, MC, to cover a phase of the Bougainville Island campaign from February to April 1944. Because of his tragic and untimely death near Cali, Colombia, in November 1956, Dr. Oughterson was never able to review the revision of his original report as it was prepared for chapter V of this volume. However, this manuscript was recovered through the gracious cooperation of his widow, the late Dr. Marion E. Howard, and was reviewed by another member of the original survey team, Dr. (then Colonel, MC) Harry C. Hull. The Bougainville survey team performed an outstanding and pioneer effort, and their organization and report served as the basis for the development and efforts of later casualty survey units. It is most regrettable that the death of Dr. Oughterson prevented him from seeing his report reach the final publication and public recognition which it so justly deserves.

Even before the dissemination of the directive prepared by General Callender, another young Army Medical Corps officer was actively engaged in the study of battle casualties. This officer was Capt. James E. T. Hopkins, MC, whose work in the New Georgia and Burma campaigns is reported in chapter IV. Because of his own innate interest and ambition, Captain Hopkins undertook a study of casualties in the New Georgia campaign for the period, July to August 1943. Following this, he was stationed in Burma and studied casualties there in the period, February through May 1944. Both of these surveys have produced unusual and valuable information regarding the type of casualty and causative agent in jungle warfare. Since case reports from this survey are unique in that they describe the battlefield duty and anatomic position of the soldier at the time he was wounded, they have been included in their entirety in appendixes A, B, and C. Some of the conclusions which were reached by the author regarding the training of infantrymen and their use and conduct in the field were highly pertinent and valuable at the time the original material was prepared and would undoubtedly prove of equal importance in the event of similar jungle-type warfare.

Simultaneous with the conduct of casualty surveys in the various areas in and about the Pacific, additional survey teams were being organized in Europe. Brig. Gen. (later Maj. Gen.) Joseph I. Martin, Surgeon, Fifth U.S. Army, Mediterranean theater, arranged for and obtained authority to study the killed in action, and Capt. (later Lt. Col.) William W. Tribby, MC, was assigned to this duty.

Captain Tribby worked in association with Quartermaster graves registration units at U.S. military cemeteries in Italy and studied a thousand Americans killed in action in the Fifth U.S. Army from April to November 1944. This survey probably represents the largest single study of killed-in-action casualties conducted during World War II, and its scope was not surpassed until the Korean War. The survey was concerned primarily with the accurate anatomic location of wounds, their probable causative agents, and the cause of

death. The original report contains an outline figure of the body for each case with exact location and extent of all wounds. Limitations of space precluded the inclusion of these anatomic drawings in chapter VI of this volume, but the original work is still available as an invaluable reference.

In addition to the survey of Fifth U.S. Army killed in action, another survey was conducted by Col. Howard E. Snyder, MC, and Capt. James W. Culbertson, MC, on battle casualty deaths in hospitals of the Fifth U.S. Army (chapter VII). A statistical analysis was made of case reports from field and evacuation hospitals on 1,450 fatally wounded American soldiers during the period from April through September 1945. Only a small fraction of the original material is contained in the present chapter. The authors concerned themselves not only with the anatomic location of wounds, the probable causative agent, and cause of death of the casualties but thoroughly investigated all the possible surgical avenues which might have had a bearing upon the fatal outcome of the soldier. Therefore, they investigated a wide variety of subjects ranging from time lapse between wounding and entrance into a medical facility and early surgery, possible effect of anesthesia, use of blood transfusions, and a wide variety of other topics all of which are immensely important to the military surgeon of any war.

Next, there are three chapters (VIII, IX, and X) and appendixes G and H all prepared and written by Maj. (later Lt. Col.) Allan Palmer, MC. Perhaps no other author in this volume has waited so long and so patiently for the publication of his works. Nevertheless, he was still able to maintain a wholesome interest in his original work and a genuine desire to cooperate in its final review. In April 1943, Major Palmer became associated with Professor Zuckerman for the purpose of studying field casualty survey methods. The first survey conducted by Major Palmer was with the Fifth U.S. Army during the Rapido River conflict south of Cassino in January 1944 (chapter VIII). Notwithstanding the small number of casualties in the survey, it still serves as a model for future field casualty survey studies. In addition, certain valuable information can be gathered concerning the type of casualties to be expected under certain specific forms of ground combat.

Major Palmer's major effort was concerned with a survey of all Eighth Air Force heavy bomber battle casualties returning to the United Kingdom during June, July, and August 1944. At this time, Major Palmer was chief of the Medical Operational Research Section, Office of the Chief Surgeon, European Theater of Operations, U.S. Army. The section had been organized under the direction of Maj. Gen. Paul R. Hawley, Chief Surgeon, and Col. (later Brig. Gen.) Elliott C. Cutler, MC. In addition to making a study of casualties (chapter IX), an exhaustive survey was made of the effects of flak striking aircraft and their correlation with the associated casualties among crew members (chapter X). Appendix G relates the accidental discharge of an aerial bomb at an airfield in England. Again, this survey can serve as a model for future studies of accidental discharges of weapons during wartime or during training procedures. Unfortunate as these accidents are, they can still serve as

a source of some valuable information concerning the potential and possible lethal effects of our own weapons.

After the work with the Eighth Air Force, the Medical Operational Research Section was reconstituted as a survey unit and moved into the Third U.S. Army area on the European Continent. The unit finally became fully operational just 2 days before V-E Day. Major Palmer prepared a very interesting and informative diary of the experience of this unit from the time it left England until the cessation of the war. It is of great interest for anyone who has been associated with a field casualty survey unit to read the diary and see the many pitfalls and complications which developed in the unit's attempt to become operational.

Owing to his field experience, Major Palmer was able to study the various casualty surveys from World War II and to correlate all the surveys in regard to anatomic location of wounds and to the possible causative agent (appendix H). Even though there is a mixture of casualty surveys conducted under different collecting criteria and composed of aircrew and ground force casualties, many interesting correlations can be obtained.

Despite the fact that this volume was originally intended to include only the work of World War II, the casualty surveys and subsequent development of personnel armor during the Korean War was such a natural outgrowth of the World War II experience that the Korean material could logically be included in this volume. Numerous investigators during World War II had advocated the development and use of some form of body armor for ground troops. Through the untiring efforts of Brig. Gen. Malcolm C. Grow of the U.S. Army Air Forces, personnel armor was provided for members of bomber crews and was of undenied success in reducing the number of overall wounds and the number of lethal wounds. Numerous prototypes had been developed for ground forces, and a test model was ready for field testing at the time of the conclusion of the war with Japan. Therefore, it would seem that body armor should have been a standard item of equipment at the onset of the Korean War. However, it was tragic to see the effect that peacetime had had on the thinking of those individuals who could have been responsible for the use of body armor at the immediate onset of the conflict. It was only due to the administrative ability and guidance of Col. (later Brig. Gen.) John R. Wood, MC, and several field surveys conducted under the leadership of Lt. Col. (later Col.) Robert H. Holmes, MC, that the responsible agencies would consent to the development of prototypes and the field testing of models. New statistics had to be compiled from field surveys, and old arguments had to be refought and won before any models were developed for field usage. Initially, Colonel Holmes laid the basic groundwork for the development and successful acceptance of personnel body armor for Army ground troops. Later, Lt. Col. (later Col.) William W. Cox, MC, and Maj. William F. Enos, MC, were instrumental in the final testing and standardization of the present all-nylon model. Numerous other medical officers as well as Quartermaster, Ordnance, and infantry officers

were also concerned with the gathering and interpretation of valuable field statistics.

It is perhaps a natural consequence of the American philosophy not to maintain a constant interest in certain military matters in peacetime. However, it is costly both from the usual sense of time and money lost and from the even more fundamental and irreplaceable point of view of human lives being lost when certain fundamental suggestions and conclusions reached in one war are completely lost in intervening times, and the points have to be regained in subsequent wars.

Chapter XI is concerned with the development of personnel armor for ground troops as seen in World War II. The major portion of this chapter must of necessity be concerned with various forms of helmet design and protection which were developed in response to varying needs of specific forms of combat duties. Most of the source material for this chapter was obtained from the historical files of the Ordnance Department. It was only due to the unlimited cooperation of historians in the office of the Chief of Ordnance, in offering all the available materials in their files to the authors, that this chapter is possible. Major Enos was one of the medical officers on the survey teams testing one of the prototypes of the Army personnel armor in Korea, and despite his resignation from the service he has still maintained an active interest in the field and has always been available to the Office of the Surgeon General for invaluable consultation and advice.

Development of personnel armor in the Korean War was so intimately associated with and a direct consequence of casualty surveys conducted in that conflict that both aspects have been combined in chapter XII. There is also a natural association of authors in this chapter for Carl M. Herget, Ph. D., is perhaps the foremost leader in laboratory investigations on basic wound ballistics and testing of personnel armor and Capt. George B. Coe, Ordnance Corps, was one of the foremost leaders in Korean casualty surveys. Dr. Herget and his able associates in the Biophysics Division, Medical Laboratory, Army Chemical Center, were instrumental in directing many of the Korean casualty survey units, since laboratory experiments had disclosed fields in which knowledge was vitally needed, and conversely much of the information that could be gained by field units was of utmost value to laboratory workers in directing their own research programs and in interpretation of some of their results. Captain Coe, then 1st Lieutenant, Medical Service Corps, made numerous trips to Korea as a member or as a leader of missions conducted for the field testing of body armor and the gathering of information concerning various types of battle casualties. In addition to this immense amount of fieldwork, he was also vitally concerned with and instrumental in the development of various prototypes of Army body armor, and before his transfer from the Army Chemical Center he was a mainstay in the development and the testing of newer models.

Many of the contributors to this volume have been most patient in awaiting publication of their World War II battle casualty surveys or results of research

in basic wound ballistics. Those whose work was done under the rigors and expediencies of combat conditions are to be commended for their devotion and zeal to the immediate treatment of the wounded soldier and, additionally, for their great desire to study the factors which were important in producing the casualty. Many of these contributors came into considerable conflict with their immediate superiors, who at the moment did not see the possible value or application of their investigations. Undismayed, they continued their vital studies while performing outstandingly their prescribed duties.

One of the most valuable lessons to be gathered from much of the reported work is the relative constancy of warfare up to the Korean War. Anatomic location of wounds, causative agents, ratio between the wounded and the killed in action have all remained relatively constant since the various studies originated during the Civil War. In addition, the importance of close liaison between the Army Medical Service and the other technical services is shown to be of utmost importance in the gathering and dissemination of fundamental information which can be utilized by all services in the greater fulfillment of their primary duty and in the development of future lines of endeavor. The editor is firmly convinced that there should be a small group of readily available and highly trained medical personnel who could be utilized for the conduct of battle casualty surveys or the investigation of peacetime training accidents on very short notice.

Because of the limited and technical nature of much of the original source material, the sole responsibility for the final preparation and interpretation of all the chapters is assumed by the editor.

A great many individuals other than the authors themselves were responsible for the final preparation and publication of this volume. Foremost among those who have patiently awaited its publication and have always been available for consultation and invaluable advice is General Callender. Col. Calvin H. Goddard, MC, was originally scheduled to be a coeditor, but his untimely death cut short an association which had always been most stimulating and enlightening to the present editor and had held great promise of future training and guidance for him. Colonel Goddard was one of those unique individuals who was most proficient and efficient in performing a number of varied tasks. Firstly, he was a medical officer, but he was also a noted historian and writer and a pioneer investigator and world-renowned authority on ballistics, small arms missiles, and weapon identification. His absence will be very evident in certain portions of this volume, but it was fortunate that the basic plan of the book had been formulated before his death. All the contributors have been most generous in consenting to review their material which, after a lapse of a number of years, must have seemed relatively foreign. Numerous members of various casualty surveys conducted during the Korean War have all been available for consultation and criticism of the manuscript.

A major vote of thanks must be tendered to Col. John Boyd Coates, Jr., MC, Director of The Historical Unit, USAMEDS, and to the members of the

various branches of that unit who were most cooperative and more than patient in waiting for the final delivery of the entire manuscript from the editor.

Special appreciation is tendered to Col. Charles A. Pendlyshok, MSC, former chief of the Special Projects Branch, for his never-failing interest in the progress of this volume; to Miss Elizabeth P. Mason, cartographic compilation aid in the Special Projects Branch, for her preparation of the maps; to Mrs. Josephine P. Kyle, former chief of the Research and Archives Branch, who, with her staff, provided much of the archival material and corroborated data obtained from other sources; and to members of the Medical Illustration Service, Armed Forces Institute of Pathology, who, under the direction of Mr. Herman Van Cott, chief of that service, prepared the excellent layouts for the illustrations and mounted them for printing.

Finally, the editor gratefully acknowledges the assistance of Miss Rebecca L. Duberstein, publications editor of the Editorial Branch, who performed the final publications editing and prepared the index for this volume.

Major, Medical Corps.