20.2.1. Deaths occurring aboard submarines on war patrol 299
  20.2.2. Conditions of health limiting durations of submarine operations 299
  20.3.1. Communicable diseases 300
  20.3.2. Injuries 300
  20.3.3. Diseases of the digestive system 300
  20.3.4. Diseases of the skin 300
  20.3.5. Diseases of the infectious type 301
  20.3.6. Diseases of the genitourinary tract 301
  20.3.7. Diseases of the ear, eye, nose, and throat 301
  20.3.8. Miscellaneous 301
  20.3.9. Dental 301
  20.3.10. Diseases of the mind and nervous system 301
  20.3.11. Diseases of the motor system 301
  20.3.12. Diseases of the lung 302
  20.3.13. Diseases of the blood and circulatory system 302
20.4. DISCUSSION 302
  20.5.1. General considerations 307
  20.5.2. Case histories 308
  20.6.1. General Considerations 310

408832 O-57-20




Since the primary wartime mission of submarines was to sink enemy ships, any cause or combination of causes which worked to impair the major function of the submarine was of military importance. In some instances the ship's crew was unable to perform efficiently and purposefully because of illness. Thus, the importance of the health of the crew and overall habitability are readily apparent.

In order to appreciate the medical problems in submarines it is necessary to be acquainted with the difficult environments and state of existence aboard the typical submarine in which submarine personnel lived and fought on combat patrol. It was a life characterized by extremely crowded living and sleeping conditions, limited water supply, frequent high temperatures emanating from the enginerooms and humidity resulting from the shutting down of ventilation during periods of contact with the enemy. Life aboard was monotonous for long periods. Many missions were marked by days of fruitless patrolling and of almost intolerable monotony and boredom, the routine occasionally broken by contact with the enemy, when excitement and tension were at a high pitch. In contrast, some patrols were of short duration and with a great deal of action, the men remaining at battle stations for hours on end.

After the approach and attack the submarine had to submerge and wait out the inevitable depth charging. The lights went out and the men sat in the dark, the submarine being unable to defend herself or to shoot back. The harrowing experience of a severe depth charging brought out the best in a submarine crew.

Life aboard a submarine is unnatural and unhealthy compared with life on a surface craft. There is no regular variation between day and night, for the lights have to burn all the time within the boat. There are no Sundays and no

  weekdays. Therefore, life was monotonous and without rhythm. There was no regular time for sleeping since a large part of the fighting was done at night. These factors, plus the stench on board, the constant racket, and the motion of the ship would seem to add up to a bad state of morale. Excessive smoking and drinking of strong coffee are also factors which must not be ignored, for both affect the men's stomachs and nerves, especially if they indulge in them at night on an empty stomach.

Submarines are built compactly and living arrangements are dictated by and are secondary to military requirements. Sleeping accommodations were so limited that with an average sized crew of about 75 men it was always necessary for some of the men to share bunks by sleeping in shifts, so-called "hot bunking." Stowage space for personal gear was markedly limited. Reading, card playing and listening to records were the only recreations. Once the submarine was underway only the authorized watch were allowed topside. A patrol in enemy waters necessitated dawn to dusk submergence so that the men did not see the sun for days on end.

The incidence of disease in submarine personnel reflects the disease incidence in a population of healthy young adult males, as influenced by the environment in which they reside. Prolonged residence in specialized craft such as submarines, where there is no sunlight, and ventilation with weather air is reduced to only part of the day, where there is close association in the sleeping and working spaces-when enhanced by the presence of heat and humidity-presents ideal conditions for the spread of disease.

The diseases peculiar to submarines have been ascribed to consist of colds, constipation, skin diseases and various physical complaints of neurogenic or psychogenic origin. While it is true that


these diseases are encountered in the majority, they must not be considered as the only conditions existent.

The following tabulations are the products of laborious research and studies made from approximately 1,500 of recorded official patrol reports and delineates the vital medical problems encountered during World War II experience. From these tables it can be seen that there are

  some five or six medical conditions and complaints which occurred on war-time patrols. Some speak of the three C's-colds, "catarrhal fever," and constipation-as being common to life aboard submarines; but to these should be added headaches, skin rashes, minor bruises, and lacerations. These conditions are far more common than the tables indicate because the majority of them are not associated with admissions to the sick list.
Diagnostic title and classification Number cases
Number sick
days reported
Communicable diseases 2,363 1,078
Injuries 1,212 1,069
Diseases of the digestive system 1,758 1,094
Diseases of the skin 1,340 167
Diseases of the infectious type 374 621
Diseases of the genitourinary tract 338 307
Diseases of the ear, eye, nose, and throat 273 148
Miscellaneous 712 12
Dental diseases 155 73
Diseases of the mind and nervous system 62 32
Diseases of the motor system 27 83
Diseases of the lung 9 4
Diseases of the blood and circulatory system 7 22
Total 8,630 4,710
  20.2.1. Deaths occurring aboard submarines on war patrol.

Cause Number of
Number of
Asphyxiation 26 1
Drowning (lost over the side) 17 13
Battle injuries 12 10
Accidents 3 3
Suicide 1 1
Pneumonia 1 1
Malignant lesion 1 1
Unknown 1 1
Total 62 31
20.2.2. Conditions of health limiting durations of submarine operations.
Cause Number of
Excessive personnel fatigue 9
Illness of commanding officer 6
Battle casualties 5
Acute appendicitis 2
Multiple asphyxiations 1
Serious injury 1
Pneumonia 1
Mumps 1
Mental disease 1
Copper sulfate poisoning 1
Unknown (fever) 1
Total 29


20.3.1. Communicable diseases.

Disease Number cases
Number sick
days reported
Colds 1,419 94
Catarrhal fever, acute 404 416
Angina, Vincent's 176 7
Sore Throats 155 38
Tonsillitis, acute 92 146
Influenza 23 74
Mumps 21 35
Measles, German 18 22
Fever, D.U 19 83
Malaria, D.U 15 54
Pneumonia, D.U 11 56
Dengue fever 5 33
Chicken pox 2 20
Meningitis, D.U 2 - - -
Scarlet fever 1 - - -
Total 2, 363 1,078
  20.3.3. Diseases of the digestive system.

Disease Number cases
Number sick
days reported
Gastroenteritis, acute 854 317
Constipation 691 12
Appendicitis* 127 578
Abdominal pains, D. U 30 36
Diagnosis undetermined 27 108
Hemorrhoids 15 3
Ulcer (mouth) 7 20
Ulcers (gastric), D. U 3 0
Obstruction, intestinal 2 7
D. U. (gall bladder) 1 6
D. U. (thyroiditis) 1 7
Total 1,758 149

* Diagnosis appendicitis includes: Cases
Appendicitis, acute 68
D. U. (appendicitis) 48
Chronic appendicitis 11
Total 127

20.3.2. Injuries.

Disease Number cases
Number sick
days reported
Wounds, lacerated 446 331
Contusions, sprains, and abrasions 295 215
Burns, unclassified 101 70
Wounds, shrapnel, gun shot 73 100
Fractures, unclassified 71 195
Heat exhaustion 74 15
Sunburn 32 2
Asphyxiation 29 0
Rupture, traumatic
  Hernia, inguinal 22 67
  Ear drum 10 7
Amputation, traumatic 16 13
Dislocations 13 20
Intracranial injury 12 14
Submersion, nonfatal 8 10
Foreign body, traumatic (eye) 7 10
Electric shock 3 _ _ _
Total 1,212 1,069
  20.3.4. Diseases of the skin.

Disease Number cases
Number sick
days reported
Fungus infections 645 60
Heat rash 322 8
Pediculosis, pubis 126 0
Scabies 104 13
Dermatitis (D.U.) 83 26
Cyst, sebaceous 26 29
Ulcer, skin 13 21
Urticaria 9 0
Ingrowing nail 6 0
Herpes 5 10
Total 1,339 167


20.3.5. Diseases of the infectious type.

Disease Number cases
Number sick
days reported
Cellulitis 193 386
Furuncles 131 62
Jaundice, acute infectious 21 68
Lymph adenitis 11 39
Abscess 10 17
Rheumatic fever 6 30
Carbuncles 2 19
Total 374 621

20.3.6. Diseases of the genitourinary tract.

Disease Number cases
Number sick
days reported
Gonorrhea urethra, acute 109 45
Urethritis, acute, nonvenereal 67 26
Gonorrhea urethra (D.U.) 56 31
Prostatitis, unclassified 24 6
Penile lesions (D.U.) 20 28
Syphilis 16 52
Renal disease (D.U.) 15 22
Calculus, urinary system 13 35
Epididymitis, acute and orchitis, acute 11 25
Cystitis, acute 5 29
Balanoposthitis 1 0
Varicocele 1 8
Total 338 307

20.3.7. Diseases of the ear, eye, nose, and throat.

Disease Number cases
Number sick
days reported
Otitis, externa (otomycosis) 84 14
Conjunctivitis, unclassified 67 55
Earache (D. U.) 32 3
Eye complaints (strain) 28 0
Sinusitis, acute 17 28
Otitis media, acute 13 7
Ear infections, D.U 11 29
Tonsilitis, chronic 6 0
Stye 6 0
Mastoiditis, acute, D.U 5 12
Ear wax, accumulated 4 0
Total 273 148
  20.3.8. Miscellaneous.

Disease Number cases
Number sick
days reported
Headache 624 0
Seasickness (motion sickness) 87 11
Anti inoculation 1 1
Total 712 12

20.3.9. Dental.

Disease Number cases
Number sick
days reported
Toothache 85 68
Gingivitis, unclassified 52 2
Extractions 18 3
Total 155 73

20.3.10. Diseases of the mind and nervous system.

Disease Number cases
Number sick
days reported
Psychoneurosis, anxiety 25 4
Psychoneurosis, hysteria 9 2
Psychoneurosis, unclassified 6 0
Psychosis, unclassified 5 11
Neuritis, unclassified 6 10
Paralysis, unclassified 2 1
Paralysis, facial nerves 2 0
Epilepsy 2 _ _
Migraine 2 2
Diagnosis undetermined (syncope) 2 2
Diagnosis undetermined (vertigo) 1 0
Total 62 32

20.3.11. Diseases of the motor system.

Disease Number cases
Number sick
days reported
Arthritis, unclassified 11 41
Bursitis, acute 7 34
Myositis, acute 3 8
Rheumatism, muscular 5 0
Osteomyelitis, acute, D.U 1 0
Total 27 83


20.3.12. Diseases of the lung.

Disease Number cases
Number sick
days reported
Tuberculosis, pulmonary 4 0
Pleurisy, D.U 4 4
Asthma 1 0
Total 9 4
  20.3.13. Diseases of the blood and circulatory system.

Disease Number cases
Number sick
days reported
Heart disease (D.U.) 5 16
Hemophilia 1 6
Epistaxis 1 0
Total 7 22
The causes of death appearing in table 20.2.1 are figures exclusive of those men lost on 52 overdue submarines. As far as can be determined, some 62 men lost their lives on 31 patrols. One of the more tragic episodes occurred on the U. S. S. B____ when 26 crew members were trapped in the after battery compartment consequent to a fire and were asphyxiated.

Seventeen men on thirteen patrols lost their lives by drowning. These men were swept over the side from the bridge in severe weather (hurricanes or typhoons) or while working topside inspecting battle damage, "shifting the vents," battle surface, etc. It is remarkable that not more men were lost in this manner.

Deaths from battle injuries were in connection with gun engagements between submarines and enemy surface craft. The gun crews were in an especially vulnerable position, exposed to weather, sea, and enemy fire. Of approximately 50 men injured in battle surface, 10 were either killed instantly or died aboard the submarines of their wounds. In addition, two men were killed when submarines were strafed by enemy planes.

Accidental deaths accounted for the lives of three men aboard operating submarines. The gunnery officer on one boat was killed instantly while checking the twin .50 caliber machine guns topside and two bullets passed through the lower part of his chest. On one occasion a torpedo skid slipped athwartships and crushed the head of a torpedoman, who died later of his intracranial injuries. A lookout, thrown against the platform railing by a large wave, died later from internal injuries.

Four additional deaths were from different causes. One man committed suicide on a patrol. One man died while on patrol of DU (pneumonia).

  Another died: "Apparently of internal hemorrhage. Investigation by the squadron medical officer indicated that the cause of death may have been a malignancy." A fourth man died of unknown cause, no details were given other than "A chief petty officer died aboard."

The success of the mission of a submarine was occasionally compromised by defects in the health of the personnel or by deficiencies in the habitability of the ship. On 29 patrols, health was a major or contributing factor that limited the duration of operations. Excessive personnel fatigue of magnitude enough to terminate the patrols of 8 fleet type submarines occurred only in the first 2 years of the war. Five other patrols were concluded with personnel endurance exhausted and it would have terminated the patrol had not operational orders done so. Illness of the commanding Officer terminated six patrols, however there was nothing unusual about these illnesses. Serious battle casualties as a result of surface engagements were responsible for termination of five patrols. The remaining patrols were terminated due to unavoidable conditions. Mass illness among the crew was reason for impairment or interruption of approximately 4 percent of all patrols.

Communicable diseases were reported on 400 patrol reports, as outlined in table 20.3.1. They accounted for a great number of sick days and lost man days (1,068 days on 211 patrols). common colds, "catarrhal fever," "sore throats," and acute tonsillitis were very common and few patrols were made without a varying incidence of these infections. These illnesses were enough of a problem to be cause for special notice in approximately 140 patrol reports. The pathogens causing these infections were obviously introduced


aboard the submarine by men returning from shore leave. The infections could be traced to contact with shore-based personnel, to lowered individual resistance while ashore, foul weather during training period, etc. A high incidence of common colds was commonly seen within the first 3 weeks of the cruise, frequently before the submarine reached the operational area. As a rule, the common colds were short-lived, reaching their peak during the first and second weeks and subsiding thereafter. Patrols made in the northern areas of operation, especially in the winter were likely to be handicapped by colds. The combination of foul weather, the cold damp interior of the submarine, overcrowding and inadequate protective clothing enhanced the development of colds. Colds were commonly experienced with the rapid transit from warm climate to cooler operational areas. In general, once the colds ran their course, little difficulty was experienced thereafter. The best prophylaxis against colds consisted of supervised rest and recuperation between patrols and an attempt to maintain optimal atmospheric and living conditions while on patrol.

Ten patrol reports mention the occurrence of 11 cases of DU (pneumonia). Three of these cases diagnosed as pneumonia were later proved to be tuberculosis. Other communicable diseases occurred but were no great problem.

According to patrol reports injuries were the second most common type of medical condition encountered. The nature and frequency of these injuries has been presented in table 20.3.2. The majority of the injuries fall into the category of lacerations, contusions, sprains and abrasions and they accounted for better than half of the total number of accumulated sick or lost man days.

Topside injuries consisted of those sustained by personnel clearing the bridge, those incurred during foul weather, and those men injured by being swept over the side. Numerous injuries were sustained in the lightning-like maneuvers necessary to clear the bridge of 8 or 10 men, in the relatively few seconds that elapse between the time the diving signal is given and the submarine is 30 to 60 feet below the surface. Smashed fingers, broken ribs, dislocations, bruised shoulders and lacerations of various degrees are commonly encountered in the mass exodus of men from the bridge through a 24-inch hatch and down the slippery and precipitous ladder into the conning

  tower. The bridge of a submarine offers scant protection against heavy weather. Not infrequently it may be inundated to the extent that men stand waist deep in water. Personnel are frequently thrown about the bridge and against the periscope housing by rough seas, sustaining painful and serious injuries. In view of the scant protection the bridge offers against heavy weather, it should not be difficult to understand how men could have sometimes been washed overboard.

Below decks, all hands to a lesser degree were subject to injuries as a result of rough weather. Men were often thrown from their bunks and sustained more or less severe injuries by collision with projecting machinery. An impressive number of men were burned subsequent to spilling of hot coffee or hot foods in sudden rolls of the ship. Electrical burns were common while men were handling the various electrical circuits. Occasionally chemical burns were sustained in association with the batteries. Battle surface attacks on enemy shipping and in engagements with the enemy exacted their price in terms of painful shrapnel and bullet wounds. The gun crews were often injured by being thrown about by heavy seas and in accidents associated with the guns themselves.

Among diseases of the digestive system, enumerated in table 20.3.3, the four most common medical conditions encountered, in order of their frequency, were acute gastroenteritis, chronic constipation, acute appendicitis, and abdominal pain of undetermined origin. Most cases of gastroenteritis and practically all cases of constipation were not admitted to the sick list. In only nine reports was food definitely incriminated in episodes of mass food poisoning. It is fortunate that it was an infrequent occurrence, for mass food poisoning aboard a submarine on patrol may not only be incapacitating but could cripple the striking force of the boat. Constipation is generally taken for granted among submarine personnel as it is almost an occupational disease. It is associated with the problem of diet, the small amount of roughage available, insufficiency of fresh fruit, excess of carbohydrates, improper eating habits, irregularity of meals and sleep, lack of exercise, motion of the ship, and toilet facilities which are sometimes difficult to operate. Constipation is not an insurmountable problem when intelligently managed by the hospital corpsmen. If it is


uncontrolled, it may result in minor complaints or in conditions that cause diagnostic error. On more than one patrol, constipation was treated as appendicitis, yet these factors were relatively unimportant when contrasted with the resultant disaster that might have occurred if the hospital corpsman had made the reverse diagnostic error and instituted vigorous treatment.

Probably no single disease has been the cause of more anxiety to submarine personnel than appendicitis. In view of the fact that medical officers could not be carried on submarines and the frequent occurrence of appendicitis, it became necessary in the early phases of the war to formulate a policy governing the treatment of all cases of appendicitis, and to promulgate it widely. All submarine officers and, of course, the hospital corpsmen entering the submarine service were carefully indoctrinated with the policy regarding appendicitis. They were taught that it is difficult to diagnose appendicitis and that diagnostic errors are frequent. Moreover, even with certain diagnosis, statistics pointed out that with conservative treatment more cases would recover than will go on to rupture. Consequently, the developed policy was one of conservative treatment. The heroic instances of removal of the appendix by the hospital corpsmen with the assistance of the commanding officer early in World War II are a matter of record. Although some of these instances may have been life-saving, they were not the best advisable procedures at the time. The conservative treatment recommended in suspected cases of appendicitis was NO food by mouth; NEVER give a cathartic; absolute bed rest; minimal amounts of water by mouth and combating dehydration with intravenous fluids; low gentle enemas if necessary; sedation to produce quiet rest; and sulfonamides and penicillin when it became available. Additional information was furnished to the effect that even though the patient belonged to the small percentage who rupture, there was considerable chance that the infection would be walled off and an abscess would be developed which could be drained more easily later on. Realizing this and taking into consideration the almost impossible conditions under which an operation would have to be performed, the final obvious order was "NEVER resort to surgery." Submarine medical officers should appreciate the fear of acute appendicitis,

  in the absence of a doctor or hospital facilities, that is shared by many submarine sailors, including the hospital corpsmen. The submarine medical officer should make a careful evaluation of submarine personnel during physical examinations given before and after a patrol. At these times, individuals with family or personal history of suspicious attacks or the presence of indicative symptoms should be made the subject of a prophylactic interval appendectomy, if conditions permit.

Diseases of the skin, table 20.3.4, are frequent among submarine personnel. The conditions most commonly encountered on physical examinations following patrols were: Heat rashes, fungus infections, acne vulgaris, furunculosis, scabies, and pediculosis. The nature and frequency of these conditions are often expressive of the ship's general state of cleanliness, its adequacy of air conditioning and the availability of fresh water for bathing and washing clothes. It is possible, to a lesser extent, that the incidence of skin rashes is related to the lack of sunlight.

One cannot help but be impressed by the relationship between "heat rashes" and efficiency of the air conditioning. There are a number of facts which support the contention of correlation between heat rash incidence and the efficiency of the air-conditioning systems:

1. In prewar submarines, where there was no air conditioning and temperatures of 95° to 100° F. were the rule, with accompanying relative humidity approaching 100 percent, heat rash affecting entire crews, with blondes most affected, was the rule rather than the exception.

2. In submarines existent during the early part of World War II, where air conditioning was limited to certain compartments and temperatures similar to those indicated above were existent, increased incidences occurred in personnel occupying compartments that were not air conditioned.

3. In the older types of submarines, increased incidences of heat rashes occurred in men whose bunks were not adjacent to the air stream from blowers or fans.

4. In submarine types where air conditioning existed, increased incidence of heat rash and other skin maladies occurred on patrols in which the air-conditioning machinery was nonoperative because of engineering casualties.

5. Quiet running, with shutting down of air


conditioning and ventilation, increased the incidence of heat rash.

Fungus infections, furuncles, cellulitis, and other skin conditions noted during wartime patrols occurred more frequently in personnel such as engineers, perhaps because of their contact with grease and oil. The necessary custom of "hot bunking" which is common in all submarines is no doubt contributory to the spread of skin diseases. Mattresses becoming soaked with perspiration probably also lead to increased occurrence of heat rashes. The submarine atmosphere and the nature of residence therein is particularly conducive to the spread of pediculosis and scabies.

The majority of diseases of the genitourinary tract (table 20.3.6) aboard submarines were gonorrheal in origin. During war patrols, because of the incubation period of venereal diseases causing initial symptoms to appear at a time remote from the initial contact, reports are frequent of venereal disease appearing after departure on war patrols, thus necessitating keeping infected individuals aboard. Such sporadic occurrences have been productive of two interesting observations:

1. That venereal diseases during submarine war patrols appear singularly free of complications.

2. Apparently, aboard submarines the hazards of contracting a venereal disease by casual contact are at a minimum, despite the necessity of sharing bunks and the markedly limited lavatory facilities.

It appears most important that post-patrol and pre-patrol physical examinations be conducted with special emphasis toward eradicating infected individuals previously successful in concealment.

Among other genitourinary diseases observed during wartime submarine patrols, calculi of the urinary system seems to have been observed rather frequently. So far as is known, all cases occurring aboard submarines on war patrol were treated without incidence. Probably the most important significance of urinary calculi or ureteral colic is its difficulty in differential diagnosis among patients complaining of acute abdominal pain, which may be a recurring problem with which the submarine hospital corpsman has to deal, and submarine medical officers should devote some effort to aid the hospital corpsman in the differential diagnosis. Centrifuging urine specimens to detect the presence of hematuria is possible aboard submarines

  through the utilization of the centrifuge in the engineroom.

The prevalence of diseases of the eye, ear, nose, and throat is indicated in table 20.3.7. The incidence of otomycosis among submarine personnel is presumed to likely account for the relative frequency of "earache" and "ear infections." The high noise level in enginerooms is believed to result in increasing deafness to those constantly exposed. Post-patrol examinations from time to time have revealed individuals with dullness of auditory acuity which could be traced to the noise of engines. Eventually, all submarines carried a supply of ear wardens but it is felt that they were not universally worn and were not popular with engineroom personnel.

A number of cases of ruptured ear drums have been reported from the concussion of the deck guns. Gun crews commonly used cotton to protect their ears which, with the blast, was apt to fall out and in the stress of the situation could not be replaced readily. Complaints of aerotitis are frequent and are consistent with the changing ambient pressure. This latter condition, while of no great moment in the type of submarines existent during World War II, is becoming increasingly a subject of concern in the newer vessels equipped with the snorkel. A valve, commonly called the head valve, located on top of the snorkel air intake tube exposed above the water's surface, closes when submerged due to temporary loss of depth control, heavy seas, emergency deep dives, etc. During the period when the head valve is closed, air supply for the diesel engines is drawn from the approximately 35,000 cubic foot volume within the boat. This air is consumed at a rate varying from 5,600 to 12,000 cubic feet per minute depending upon engine speed and whether one or two engines are running.

Utilization of air from within the ship results in considerable reduction in pressure within the boat, and is analogous to ascents by aircraft to relatively high altitudes. Appropriately enough, these reductions in pressure within the boat are recorded by an altimeter, while the submarine is cruising along with keel depth of 59 feet below the surface. Ear effects are not manifest during the period of closure of the snorkel head valve while the atmospheric pressure is being lowered. However, on return to proper snorkel depth and opening of the head valve, those who cannot equalize pressure


because of closure of the eustachian tube will experience considerable pain and ear damage. Before our submarines accumulated much experience in snorkeling it was feared that there would be widespread ear damage. Experience has shown that it is a relatively minor problem.

Eye strain was a common complaint of submarine personnel in World War II. Headache, sunburned eyes, and conjunctivitis, subsequent to prolonged exposure to sunlight, were frequently seen in crews returning from wartime patrols. A special lookout training program was important to reduce the incidence of eye strain in those personnel. Eye irritation has been the subject of considerable comment during wartime submarine patrols. Possible etiological factors have been listed:

1. Tobacco smoke, in that eye irritation appeared after periods of smoking.

2. Acrolein from the fat in cooking has been indicated, because of the frequency of complaints near meal time.

3. Aldehydes from diesel engine exhaust leaks.

4. Sulfuric acid vapor from storage batteries.

5. Fumes from fuel and lubricating oils.

6. Ozone emanating from precipitron installations within the generators.

Individuals unaccustomed to the environment of a submarine and coming aboard, particularly under operating conditions, may have experienced this smarting of the eyes and observed the hydrocarbon-like odor in the air, presumably associated with the diesel fuel and lubricating oils. All medical officers who have examined crews returning from war patrols will recall the peculiar oily odor which emanates from the clothing and skin of submarine crews and lingers in the sick bay long after they have departed.

Chronic and acute seasickness among submarine personnel (table 20.3.8) especially in men new to the ship, is a problem encountered by the medical departments of bases and tenders, and especially in the winter months. The solution, sometimes difficult, must be arrived at through consideration, by the personnel and medical officers, of the several factors involved. Health records, especially of incoming men, must be scrutinized for relation to this condition. Medical officers should make certain that the proper entry is placed in the health record of a man removed from a submarine because of chronic seasickness. It would

  seem fair to assume that such personnel are physically not qualified for submarine duty.

Headaches (table 20.3.8) among submarine personnel are common, especially during prolonged submerged operations, because of the slight increase of pressure within the boat, and because of the vitiation and depletion of oxygen and the increase of carbon dioxide content of the air. Headaches are also related to the close confinement, noise of the engines, battery gases, increasing nervous tension, fatigue, and perhaps inadequate lighting.

The status of dental diseases (table 20.3.9) aboard submarines is probably best described in the words of a dental officer who actually made a wartime patrol with the view in mind of studying the dental situation under combat conditions: "It is imperative that the oral tissues of submariners be placed in good condition prior to extensive patrol periods in war areas. Toothache or tissue infections render a man impotent as a fighting man when his time and efficiency are vital factors in the success of a submarine attack. Submarine crews present an alarming susceptibility to dental diseases. Dental caries are rampant and can be laid to diet very high in carbohydrates and to very poor oral hygiene. Most all submariners are heavy coffee drinkers and they drink it black and sweet. Long patrols with necessary abstinence from alcoholic beverages seem to create a desire for sweets. A continued carbohydrate diet of this type increases susceptibility to dental caries.

On the actual patrols, conditions are unfavorable for good dental hygiene. Water is insufficient for frequent bathing, and the shower room is secured most of the time unless a water reserve has been built up. Dental hygiene is closely allied with bathing habits and, upon questioning, many of the men admit their toothbrushes remain unused day after day. The submariner just doesn't seem tooth-conscious. Lack of good oral hygiene leads to loss of tissue tone. Resistance to oral infection is low and gingival recession is prevalent. One submarine captain, through his welfare fund, purchased all available dental floss and constructed an adequate dispensary to be placed in the control room for all hands. A page from a dental journal illustrating correct use of dental floss was secured to the bulkhead alongside. This captain had become alarmed at the large


number of cavities developing in the teeth of his men "and wanted to do something about it."

It is highly desirable that all submarine personnel receive careful medical and dental examinations and indicated treatment prior to departure from the continental limits. The reasons are threefold. First, the nature of submarine duty demands the constant maintenance of high standards of physical fitness and mental alertness. Second, it seems not unlikely that the incidence of certain dental infections-gingivitis, Vincent's infection-is more common among submarine personnel returning from war patrols than is generally appreciated. Third, medical and dental facilities aboard submarine tenders

  and ashore at advanced bases are at the disposal of the crews of submarines "stopping off" or undergoing normal refit prior to entering the war zone.

These facilities are adequate for the correction of emergency medical and dental conditions developing in a crew previously checked in the United States, but lack of time and trained personnel makes difficult the furnishing of extensive and detailed treatment sometimes necessary in neglected crews. At the present time dental kits for emergency treatment are aboard most submarines and the hospital corpsmen have been instructed in the proper methods of dental hygiene and emergency treatment for dental conditions.

20.5.1. General considerations.

There can be no doubt that the traumas sometimes experienced by the personnel in the submarine service were as great, if not in excess, of that experienced by any other group in the war. Allied submarines enroute to and from their area of operations could not claim immunity from attack by friendly planes. While patrolling enemy-held waters they were "lone wolves", subject to vicious attack when sighted by enemy air and surface antisubmarine units. In the late war, the depth charge was the main Japanese antisubmarine weapon. With every attack, submarine officers and men could not help but wonder when the next aerial bomb or depth charge would make a direct hit. It was common knowledge that submarines were being lost to enemy counterattacks. While being hounded, unable to fight back, the submerged submarine ran silent. All men except those necessary to control the ship were in their bunks. Those up and about removed their shoes. Talking and unnecessary noises were kept at a minimum. With all ventilation, air conditioning and refrigeration units secured, the interior of the boats became excessively hot and humid. The enforced inactivity and the helplessness of their situation and the actual trauma caused by the exploding depth charges was enough at times to terrify the bravest of men. Other encountered hazards, such as the continual harassment of enemy radar-equipped night planes, floating or moored mines, fear of shallow water and air/sea

  rescue operation tenseness, could not help but impose severe emotional stress. If to these is added the strain of reconnaissance operations, minelaying, and the fruitless days of patrolling without enemy contacts, the stamina required of individual men and the very high caliber of leadership demanded of the commanding officers becomes apparent.

As a result of the conditions peculiar to submarine warfare just described, numbers of psychiatric casualties were encountered. The general manifestation evidenced by men under the stress of psychiatric trauma and the physical strain of repairing material casualties in excessive heat, humidity, and pressure can be described as excessive physical weariness, with headaches and lethargy and sometimes heat exhaustion. It was not uncommon in the 24-hour period succeeding depthcharge attacks to see a number of cases of mild gastric disturbance with slight nausea, abdominal cramps, slight diarrhea, acidosis, and headaches, with rapid recovery without treatment. Occasionally, following depth-charge attacks, the entire crews exhibited generalized impairment of appetite. Among other symptoms occurring after depth-charge attacks have been attacks of nausea with vomiting, to include hematemesis, insomnia, nervousness, dizziness, and spots before the eyes. These conditions were not only prone to occur in relatively inexperienced personnel but also in those with previous wartime patrol service. The following case histories are examples of actually encountered psychiatric casualties.


20.5.2. Case histories.

One man stated that he had been perfectly content with his duty aboard the U. S. S. _____ on her first patrol until the initial depth charges. In describing these he said: "My nerves seemed to give out. I shook all over. I couldn't keep my hands still and I stammered. I couldn't seem to breathe, and sweated all over. When I would lie down black spots came in front of my eyes and it seemed like I was going to faint. I wanted to scream, and wrapped my head in a pillow so I wouldn't. After that I lost my appetite and couldn't sleep. When I did get to sleep, I'd dream of terrible things and would awaken with a great start as though someone was calling me. The second attack we had was the same way. Now whenever the diving alarm sounds I start to shake all over. I wouldn't like to go out again unless I have to. I'm afraid that I couldn't take it the next time."

A second man had reported aboard the U. S. S. _____ as an emergency replacement. At the conclusion of this patrol, his first, of some 63 days' length, he was put ashore for administrative reasons. Two weeks later he appeared, requesting: "I want to be disqualified from submarine duty because my nerves can't take it." On this particular patrol the ship had received severe and prolonged depth charges. "The first depth charges weren't so bad. I was scared, sure. Everybody was scared, but I thought they had gone. Then when they came back for the second time I was stunned beyond the point of being scared. I couldn't move, sleep, or think. I felt anxious, weak, and jittery. I don't want to make no more runs. I don't think that I can take it."

A third man had returned from a long and arduous patrol, the first part of which had passed without incident following which he described the gradual onset of fatigue and nervousness. On one occasion, while standing lookout in a severe storm, "the ship took a 50-degree roll, staying in that position for at least a minute. I was wedged in on the bridge; the seas were mountainous and passing over me. I was looking down straight into the ocean, the waves breaking over my head. The hatch was open but I couldn't possibly get down. I 'Ad given up all hopes for us but finally the ship righted itself. I was very scared and couldn't get over it. Then I thought I had gotten over it, but it wasn't so and each time upon the

  bridge, in a storm, I was frightened. When we arrived here I felt that it would be all right. The recuperation period went well. On our first trial run, yesterday, I took several messages. I knew what was going on. I knew what they were as I took them but then I couldn't remember them. In emergencies I can't seem to think. I seem to be paralyzed. When we dive I'm afraid. I thought I could stick out the patrol but I can't go through with it. I feel afraid the minute I go below and I'm afraid that I'll do something that will endanger everyone."

On one occasion a hospital corpsman brought a patient from a submarine, en route to its area of operation, to the dispensary at an advanced base. The patient's chief complaint was abdominal pain. After examination, it was decided that his difficulties were likely due to chronic constipation. Note was made of the presence of many tattoos, there being scarcely a square inch of skin which was not covered with some design or other. He had been a tattoo artist in civilian life. No notice was made of constriction of the pupils which surely must have been present. Some 2 weeks after the submarine had departed he confessed being a morphine addict, upon apprehension at attempted theft of the submarine's supply of the drug. The subsequent withdrawal symptoms proved difficult to manage and were most intense at a time when his services were badly needed as a radar technician.

"During the close depth charge attack one man, a chief commissary steward, a veteran of patrols on other submarines, showed extreme nervousness and mental depression. Later he was caught in the act of apparently committing suicide by the hospital corpsman who took an open knife from his hand as he attempted to slash it across his throat. Three other men witnessed this scene. Early in the patrol he was given small amounts of sodium amytal and elixir of phenobarbital to quiet his nerves. He kept bothering the hospital corpsman for more after the depth charging. He reported aboard the day before we left for patrol. Found in his jacket was a recent request for his own disqualification for submarine duty. His presence aboard is a definite hazard to our morale and he will be temperamentally disqualified and transferred upon arrival for mental observation."

This man had been in the Navy for 7 years,


being first associated with submarines in 1942. Having made seven war patrols he returned in the spring of 1944 to the States for "new construction." At the Submarine School, New London, he was, for the second time, found physically qualified for submarine duty, being assigned to the U. S. S. ____ on which he remained until the time of his death.

Nothing is known concerning his early medical record. During his naval career he had not been ill. He had attended the 12th grade in school. At the Submarine School he graduated 52-2 in a class of 97-21. He had been married for about a year. According to friends the marriage was very successful. As far as is known, there were no financial difficulties. No evidence of disciplinary action of importance was available in his Naval Service Record. He was a moderate drinker, gambled as much as the average sailor whose superstitions he shared.

Three close and personal friends, serving with the patient throughout the seven war patrols aboard the U. S. S. ____ and aboard the new submarine and with him at the time of his death, volunteered the following. All agreed that he was one of the most popular men aboard the ship, being a big, hard-working and unusually conscientious person. "He was always doing something, helping someone, anything to keep himself busy." Early in 1944 the submarine on which he was serving inadvertently submerged with the upper conning tower hatch open which resulted in serious flooding of the ship. The resultant situation was harrowing and hazardous. Our patient was greatly impressed by this incident. On one occasion, following repair of the damage to the submarine, "We were making a night surface approach on a ship over a period of 3 to 4 hours. The smoking lamp was out and we just sat around waiting. He was more nervous than usual. A couple of us noticed that all of a sudden he jumped up and tried to hide behind a warhead to smoke a cigarette. When he lit the match we could see how shaky his hands were. After that he kept walking up and down."

Following this patrol the four men were transferred back to the States. At the time men began to assemble for the new submarine our patient was advised by one friend that "he had had enough and should stay in the States."

At one time arrangements were made for his

  transfer but he decided, at the last moment to remain with his friends. Once, after they had departed, he told a friend : "I'm kicking myself - because I didn't take that swap. I hate like hell to go out now because I know if I make one run I'll be a nervous wreck." All agreed that very soon during trial runs the old nervousness returned. "He began biting his fingernails. Once or twice we took a few off-angle dives. Every time we'd do this he'd be upset, biting his nails and lips. He was a very light sleeper. Sometimes he'd jump up in the middle of the night, look all around, take his flashlight, and check all of the valves in the compartment." "He used to worry about making a wet dive (flooding). One time he said : 'If this boat ever makes a wet dive, I'll never go to sea in subs again.'"

Prior to the departure of the new submarine from Pearl Harbor a new type of weapon was taken aboard. Although the patient was specially trained in these "* * * taking them aboard made a big difference in him. He wanted off and said that he didn't want to have charge of them. The first night they were aboard he wouldn't sleep in the compartment. He'd just go near them and sweat and tremble all over. When he came back to the compartment to sleep I noticed that sometimes the slightest noise would wake him. He'd jump out of his sack and run over to them with his flashlight and examine everything. I don't think that from the time we took them on until he killed himself that he had more than 3 hours of sleep."

From this time on increasing nervousness was observed by his intimate friends in his behavior. A last minute request for transfer at Pearl Harbor, lacking adequate reason, was refused. When under way, he requested sleeping tablets from the hospital's corpsman on a few occasions. A few days later he locked himself in the lavatory and shot himself through the head. Shortly before his death he wrote two letters in one of which the statement was made: "I have hated submarines since one day a year ago when the U. S. S. ____ flooded her conning tower but came back up."

Medical observers have pointed out that the diagnosis, psychoneurosis anxiety, is all too frequent in the submarine service and that a trained and emotionally neutral observer during any depth-charge attack would almost certainly detect


true symptoms in many of the crew. However, perhaps some slight disturbance was considered to be a reasonable and normal reaction to the situation. At any rate, it is apparent that only those reactions interfering with the performance of duty have been recorded.

During the past war there were recorded 114,000 enlisted man patrols and 12,160 officer patrols. Fifty-six possible psychiatric casualties during the 126,160 man patrols give a percentage of 0.00044 casualty cases of a psychiatric nature occurring per man patrol. Though these figures may be somewhat incomplete and underestimated, nevertheless it must be obvious that the submarine service had a very enviable record so far as

  emotional or psychiatric breaks are concerned. The reasons for this record are important, particularly in the light of planning for future national emergencies. They perhaps may be summarized under the following general headings: (1) selection of the candidates for the submarine service; (2) training of submarine personnel; (3) morale or esprit de corps of the submarine service; (4) pre- and post-patrol physical examinations to determine fitness for continued duty aboard submarines; (5) generous use of rest camps between patrols and the rotation of personnel to home areas, as makeup personnel for new construction submarines; (6) confidence in the submarines, their officers, and their shipmates.
20.6.1. General considerations.

One of the most gratifying developments in the general practice of medicine during the past decade has been the dramatic drop in the tuberculosis mortality rate. In less than 10 years, the number of deaths from this once dreaded disease has been reduced from a high of 45.9 to 12.5 per 100,000 population. However there has not been a corresponding diminution in the incidence rate. unfortunately this factor remains relatively constant. The 1953 census indicated 1,200,000 of active and arrested cases of tuberculosis in the continental limits of the United States. Obviously these figures imply that tuberculosis continues to be a significant hazard in naval submarine medicine practice, and demands continued surveillance and other prophylactic procedures. A most effective preventive measure is to eliminate active and potentially active cases by rigid screening procedures. In this connection it must be noted that physical examinations frequently fail to reveal any positive findings in minimal tuberculosis. Such cases often are without symptoms or abnormal physical, X-ray and laboratory findings. An elevated erythrocytic sedimentation rate should, however, be viewed with suspicion and warrants continued observation of the donor.

The importance of tuberculosis transmission among submarine personnel was considered in the early phases of World War II by the Bureau of Medicine and Surgery. It was soon recognized that the overcrowded submarine environment under wartime operations presented optimum

  conditions for the spread of quiescent or minimal tuberculosis lesions, often not readily discernible on routine physical examinations. Consequently every possible measure was taken to detect and control suspicious cases among submarine crews and those in training for submarine duty. This was accomplished by the inauguration of a rigid program of compulsory periodic chest X-ray examinations and a policy of transferring all individuals found suffering from any type of tuberculosis lesions or suspicions thereof from all submarines. In addition, all personnel attached to tenders, rescue vessels, bases and other units of the submarine force who were suspected of harboring tuberculosis lesions, except those of the primary type, were also transferred to lessen the hazard of contaminating submarine relief crews.

Notwithstanding these extraordinary preventive standards, however, the World War II incidence rate of the submarine force was 0.43 percent as compared to an entire fleet incidence of 0.32 percent. It is interesting to note that despite the fact that tuberculosis transmission is enhanced by exposure to active cases and that crowded living conditions aboard a submarine on war patrol may contribute to lowered resistance to infection, in only one vessel which had reported an open case was there evidence of other infections traceable to this source. This occurrence created considerable concern in the beginning of the tuberculosis program but vigilant alertness and careful examination of other submarine crews failed to disclose any further similar instances.


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