CHAPTER I
General Considerations of Battle Trauma
The inevitable consequence of war is physical injury to large numbers of men. The injury may be caused directly by the weapons and engines of combat (battle injuries) or may arise from the environment in which soldiers must operate (nonbattle injuries, disease). Thermal injuries, because they are the result of environmental heat or cold, are classified as nonbattle injuries, though they are usually incurred in the line and in some respects might more reasonably be classified as combat injuries. The sum total of all these injuries, no matter what form they may assume, is designated as war trauma.
Military strategy and tactics have been greatly influenced by injury and disease in many recorded campaigns. Medicomilitary history is the continuing record of the effect of trauma and of the planning and research instituted to improve methods of (1) treatment and repair of the injuries which result from it, and (2) rehabilitation of battle casualties.
Disease formerly exacted a much heavier toll in war than did combat injuries.1 It is only in quite modern times, in fact, that battle deaths have exceeded deaths from disease. This reversal was first observed in the Danish War of 1864 in the German forces. A similar excess of battle deaths over disease deaths prevailed for German troops in the Franco-Prussian War of 1870-71, in the campaign in South-West Africa in 1904-7, and in World War I. Records for the Russo-Japanese War show a ratio of deaths from disease to battle deaths of less than 1 for both Russian and Japanese troops.
Improvement in this respect was considerably longer in coming in the United States Army (table 1). The ratio of deaths from disease to battle deaths (killed in action or died of wounds) in the Union Army in the Civil War (1861-65) was 1.81:1. In the Spanish-American War, the ratio for the year 1898 was 12.65:1 if deaths from typhoid in the United States are included. The ratio for the whole United States Army for a period coinciding almost exactly with the duration of the war (1 May 1898 to 31 August 1898) was 5.25:1. For the calendar year 1898, the ratio in the overseas area was 2.82:1.
In World War I, the tide finally turned; the ratio of deaths from disease to battle deaths (killed in action plus died of wounds) became 0.34:1 in the American Expeditionary Forces in Europe and 1.02:1 for the whole Army. In World War II, the ratio for United States forces in the European Theater of Operations was 0.01:1; for the total United States Army, if killed in action are included, the ratio is 0.07:1.
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1 Gordon, J. E.: The Strategic and Tactical Influence of Disease in World War II. Am. J. M. Sc. 215: 311-326, March 1948.
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TABLE 1.- Morbidity and mortality data for the United States Army in four major wars,1861-1945 1
The Army-wide death rate for disease in World War II was reduced to less than one-twentieth of its World War I level. Case fatality rates for disease were reduced to about one-fifteenth of this level. Morbidity rates for disease were generally reduced by about a third, although the experience in special theaters, particularly the tropical theaters at the beginning of the war, was not uniformly favorable. The average daily rate for noneffectiveness per 1,000 average strength from all causes in the total Army was 58 in World War I (April 1917-December 1919) and 44 for World War II (1942-45) . Comparable rates for noneffectiveness for all disease in the whole Army were 42 for World War I and 30 for World War II per 1,000 average strength.
The case fatality rate for battle casualties in World War II was approximately half of the rate for World War I (exclusive of gas casualties), the decrease reflecting the better medical care provided in World War II. The case fatality rate for nonbattle injuries, on the other hand, increased by about one-half in World War II as compared to World War I. In terms of total Army strength, the death rate from battle causes decreased by about one-half between World War I and World War II, but the non-battle-injury death rate in World War II was almost double the rate for World War I.
As these data demonstrate, disease has become progressively less costly in war, while battle trauma and nonbattle injuries have become relatively more costly.
THE EPIDEMIOLOGY OF TRAUMA
In the past, a great deal of effort has been expended in collecting the records of battle casualties and in classifying, analyzing, and interpreting them. Serious endeavors have been made to assess the influence on casualty
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rates of such factors as equipment, training, nutrition, fatigue, seasoning, leadership, psychologic preparation for war, and motivation in general. The emphasis, however, has been almost entirely on battle casualties and the important communicable diseases. Up to the present time, the role of total mass injury has received little attention. Almost no attempt has been made to study noncombat injuries and to assess their importance in terms of the mass problem or to determine whether military trauma can be approached epidemiologically. On the contrary, it has been the general practice to look upon nonbattle injuries and accidents as losses that are inevitable and that must be accepted when many men operate many machines under stress. Even less attention has been paid to the trauma that comes about directly as the result of environment. Thermal injuries, as already rioted, are included in Inc carter category.
The advances which have been made in medical science have provided a better understanding of the causation of communicable disease, and a better knowledge of the behavior of disease has therefore also become predictable, at least to some degree. It was this predictability, together with the development of the tools, procedures, and methods for the control of disease, that brought about the reversal, already commented upon, in the relative positions of disease and injury in the two World Wars. Historically, however, the change from the conviction that loss from disease is an inevitable part of military operations to the concept of concerted programs of prevention for its control or eradication has been slow to evolve. Military history provides dramatic episodes in this evolution. Against the conquest of typhoid fever in World War I, for instance, must be set the disastrous effect of the dysenteries on the British forces on the Gallipoli Peninsula in 1915-16. Furthermore, the evolution of the new concept has been incomplete as well as slow, as is demonstrated by the casualties suffered from malaria by the Allied forces in the Pacific in World War II.
As disease has become increasingly less costly in war, both battle casualties and nonbattle casualties have become relatively more costly, and the question has naturally arisen: What can be done to make trauma less of a liability? There seems no real reason why mass injury should be less amenable to epidemiologic evaluation and interpretation than mass disease. Much progress has been made in the experimental and clinical study of trauma. Treatment by surgical measures has made great strides, and knowledge of the clinical management of the individual traumatized soldier is now far advanced. The study and understanding of injuries likely to be sustained in given types of operations have become scientific enough to make preliminary estimates accurate within reasonable limits.
If, however, trauma is to be viewed as an entity, these advances are not enough. Trauma must be studied through the whole range of cause and effect and in terms of time, place, and person. It must be analyzed from the standpoint of the primary role of agent, host, and environment. All of the factors, in short, which arise from, or which influence, these various circumstances and
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which produce the final effect of trauma, or which prevent its occurrence, must, be evaluated and considered.
Such an epidemiotogic concept of trauma is not entirely new. Pirogov,2 toward the close of the last century, declared that war is the epidemiology of trauma. This is an extremely perceptive observation, though somewhat oversimplified, since military trauma, as already pointed out, is not a single entity. An investigation of the epidemiology of trauma as a group composed of special types of injuries would be as nonproductive as a study of the epidemiology of the exanthematous diseases as a group. In the same manner that the epidemiology of measles, scarlet fever, and smallpox, for instance, must be studied disease by disease, so must the general field of military trauma be broken down into its component parts. Thus, the epidemiology of accidents might be subdivided into industrial, vehicular, and other special types. The epidemiology of thermal injuries would be subdivided into those caused by heat and those caused by cold. Only by such an approach to single components that are relatively clear-cut entities and are amenable to study can the broad principles applicable to trauma as a whole be ascertained.
Although this approach has never yet, been properly or fully utilized, one component of nonbattle trauma-cold injuries of the ground type-assumed such tactical and strategic importance during World War II that it was necessarily studied on a mass basis. This was not a necessity which had been anticipated. The history of most past wars, including World War I, shows that during cold weather military activities were always either considerably lessened or came, to a practically complete halt. It seems reasonable to assume, furthermore, that environmental factors will exert, the same influence during the winter on each of the two opposing military forces. In World War II, however, the decision, in the autumn of 1944, to go forward with an intensive winter campaign in the European theater, in an effort to hasten the end of the war, reversed the usual circumstances, and the reversal introduced an unusual opportunity to study the mass effects of injuries caused by cold during large-scale military operations.
Before World War I, trauma caused by cold had never been subjected to thorough scrutiny as a military problem. That conflict, with its static trench warfare, saw trenchfoot develop into a significant medical and surgical problem among British and French troops, as well as among German troops. The studies on cold injury which were undertaken then, as soon as the problem became apparent, were directed toward defining the clinical nature of this type of trauma, establishing the pathologic process, and determining effective forms of therapy. Prevention was emphasized in practice, but chiefly as it could be applied to the individual soldier, to rotation of units, and to supplies. It is true that all of these considerations are fundamental, but their applicability under
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2 Pirogov, N. I. Das Kriegs-Sanitäts-Wesen and die Privat-Hűlfe auf dem Kriegsschauplatze in Bulgarien and im Rűcken der Operirenden Armee 1877-1878. Aus dem Russischen von Dr. Wilhelm Roth and Dr. Anton Schmidt. Leipzig: Verlag von F. C. W. Vogel,1882, P. 299.
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the static trench warfare of World War I could not have been expected to meet. the exigencies of the active mobile warfare characteristic of World War II.
The over-all problem of mass injury caused by cold was not approached epidemiologically in World War I. In fact, trenchfoot was not even conceived of as subject to epidemiologic principles and laws. At that time, epidemiology was chiefly construed to mean the detailed study of outbreaks of infectious diseases. Its scope did not include chronic disease or injury nor did it encompass the study of disease or injury as a whole. Its application to chronic noninfectious disease, however, was not long in coming after the war ended. Emerson's 3 discussion of heart disease as a public health problem was first published in 1921. His similar discussion of mental health was published in 1922. Since that time, the development of the broad concept of epidemiology in the field of noncommunicable diseases, injuries, and accidents has been chiefly the work of Gordon.4
This same observer, with his associates in ETOUSA (European Theater of Operations, United States Army), showed in World War II that mass injury is quite as susceptible to epidemiologic analysis as is mass communicable disease.
A similar epidemiologic analysis of cold injury, ground type, was not made for the Army as a whole in World War II. Its feasibility, however, is clearly evident in the field surveys and investigations carried out in the European theater (p.176) and by analyses of the data collected in the Office of the Chief Surgeon of that theater and in the Office of the Surgeon, MATOUSA (Mediterranean Theater of Operations, United States Army). These records, supplemented by records of individual units and divisions, all proved, as will be shown in detail in the course of this presentation, that, as a crippling malady, cold trauma behaves in accordance with the same biologic laws and principles that govern diseases of large populations.
The most significant and most distressing fact about cold injuries in World War II is that the experiences in one theater were not transmitted to the other theaters. The experiences in the Aleutians in 1943 were lost on the Mediterranean theater. The European theater did not profit from the lessons learned in the Mediterranean theater, though the experience in Italy clearly demonstrated that trenchfoot is a condition which is almost entirely preventable if an epidemiologic analysis of its causation is made and if there is aggressive command support. The cold injury experience in that theater occurred in the winter of 1943-44. The prevention and control program established the following winter was extremely effective. The losses from cold injury were materially less than those sustained the previous winter. Yet it was not until the late months of 1944, after an even more devastating cold injury experience, that a similarly effective program was instituted in the European theater.
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3 Emerson, Haven: Selected Papers. Battle Creek: W. K. Kellogg Foundation, 1949.
4 (1) Gordon, J. E., and Augustine, D. L.: Tropical Environment and Communicable Disease. Am. J. M. Sc. 216: 343-357, September 1948. (2) Gordon, J. E.: The Epidemiology of Accidents. Am. J. Pub. Health 39: 504-515, April 1949. (3) Gordon, J. E.: Epidemiology--Old and New. J. Michigan M. Soc. 49: 194-199, February 1950. (4) Robert, H. L., and Gordon, J. E.: Home Accidents in Massachusetts. A Study in the Epidemiology of Trauma. New England J. Med. 241: 435-441, 22 Sept. 1949.
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In the planning of the assault on Japan, the exorbitant military cost of losses from cold injury in Italy and in western Europe was fully recognized by the War Department and the Commander in Chief, AFPAC (United States Army Forces in the Pacific). The result was a well-coordinated wet-cold indoctrination program which made use of the principles and practices tested in those theaters and which, if its implementation had proved necessary, would undoubtedly have reduced to negligible proportions losses from this cause in the Pacific.
