HISTORY 0 F SUBMARINE MEDICINE 1 N WORLD WAR II By Captain C. W. Shilling, (MC) USN Medical Officer in Charge and Mrs. Jessie W. Kohl Scientific Staff Assistant 25 May 1947 U, S, Naval Medical Research Laboratory U. S. Naval Submarine Base, New London, Conn* TABLE OF CONTENTS CHAPTER PAGE I Introduction 1 II Medical Personnel: 3 A. The Submarine Medical Officer ... 3 B. The Hospital Corps Officer 12 C. The Submarine Pharmacist’s Mate • • 13 III Development of Use of Selection Procedures: 18 A. Physical Examination 18 B. Special Senses 20 C. Psychological Testing. ....... 21 D. Psychiatric Interview , 22 E. Pacific Reprocessing 24 F. Travelling Selection Boards .... 25 G. Escape Tank as a Criterion ..... 28 H. Indoctrination of BuPers Selection representatives 28 I. Report of Rejections ........ 29 J. Summary 29 IV Training Activities: A. School for Pharmacist’s Mates Enter- ing the Submarine Service, Submarine Base, New London, Conn 32 B. Refresher Training of PhM’s at Pearl Harbor ... ....... 35 C. Deep Sea Diving School, 7/ashington,D.C. 37 D. Submarine Training of Medical Officers at Medical Research Laboratory, N.L... 37 TABLE OF CONTENTS (contfd) CHAPTER PAGE E, Escape Training Tank, New London • 40 F, Second Class Diving School, Submarine Base, New London . • , . 44 G, Lookout Training School, New London 45 H, Interior Voice Communications, New London .••••• 52 V Special Care of Submarine Personnel • • • 63 VI Submarine Medical Facilities and Equipment 77 VII Analysis of Patrol Reports: 94 A. Surgical Care on a Wartime Operating Submarine 96 B. Medical Care on a Wartime Operating Submarine 115 C. Medical Aspects of Submarine Warfare- The Human Factor • • • 156 D. Psychiatric Casulaties in Wartime Submarine Service • 183 E. Submarine Escape Training Pays Off * 199 F. Submarine Food Problems 215 G* Upper Respiratory Infections and Con- tagious Diseases Aboard Submarines in Wartime • ••••«•••••••• 242 VIII Research Activities Within the Submarine Force 24$ IX Recommended Organization for Any Future Emergency • • . . . 300 X Bibliography 328 HISTORY OF SUBMARINE MEDICINE IN WORLD WAR II, I - INTRODUCTION Submarine medicine is a distinct medical specialty, requiring not only selection of specially qualified and competent Medical and Hospital Corps personnel, but also requiring additional specialized training* Tha primary duty of these Medical and Hospital Corps members is the same as for any other type of Navy duty, that is, the care of the sick and injured. They also share with the other units of the Fleet and shore stations the routine duties, - such as inspections, preparation of reports, etc. that pertain to their jobs. However, in addition to these more or less well defined duties, there are many special duties required of both the Medical and Hospital Corps personnel in the Submarine Service. They must become specialists in submarine construction and operation to the extent at least, that they will be able to understand the problems of maintaining a satisfactory environment for submarine personnel, and understand the pro- blems of submarine safety and salvage. This requires a knowledge of such things as the operation of rescue apparatus, such as the rescue "Bell”; the use of the submarine escape appliance, the Mlungn, and methods of escape from a disabled submarine; the treatment of casualties that may develop during 1 escape training; the normally required concentrations of oxygen and carbon dioxide, and methods for determining these percentages aboard a submarine; the special angles to the problems of food and nutrition, water supply and sewage disposal peculiar to submarines, In addition to this, the submarine medical officer must be proficient in the field of personnel selection, aid should be able to properly evaluate early signs of fatigue and war neurosis, so as to take men off the boats for proper rest and treatment before any breaks actually develop. The submarine pharmacists mate, the only medical repre- sentative normally aboard the submarine during war patrol, has additional duties as a member of the crew. He may be assigned such special duties as sonar operator or day or night lookout. He is usually the librarian, and is regularly assigned the cleaning detail for the after-battery compartment, A more detailed discussion of the training and duties of submarine Medical and Hospital Corps personnel follows in Chapter II, A complete bibliographyon all phases of submarine medicine is in process of preparation for the Bureau of Medicine and Surgery by Commander E, C, Hoff (MC) USNH and will be published in book form. 2 XI.- MEDICAL PERSONNEL A, The Submarine Medical Officer* Prior to the war there were no more than 8-10 medical officers actively interested in submarine problems. All such medical officers were primarily trained in deep-sea diving but were supposed to be qualified to handle either diving or submarine activities. The only exception to this type of training was that three young medical officers com- pleted part of the regular officer class at Submarine School at New London in the officer class graduating in May of 1933. With the advent of the war,- a greatly increased number of medical officers was immediately necessary and therefore training facilities were set up for instruction of additional medical officers at the Deep-Sea Diving School, Navy Yard, Washington, D.C,. For the first two years of the war, medical officers were trained solely as deep-sea divers, and as before were not given any additional training preparing them for submarine activity. The inadequacy of this partial training vras pointed out and the Officer-in-Charge of the Experimental Diving Unit, Navy Yard, Washington, D.C, by letter EDU/P11-1, dated 11 May 1943, requested the Commanding Officer of the U. S. Submarine Base, New London, Connecticut, to give s*me further training to the class of officers of the Medical Corps then under instruction at the Deep Sea Diving School. It was requested that the facilities of the Submarine Base, New London, be made available for additional training for this group for a period of two weeks, beginning 28 June 1943, "for lung tank instruction and escape, inspection and instruction trips on submarines, dark adaptation instruction and similar matter. Since many of these doctors will be assigned to sub- marine rescue vessels, it is considered that they should have more first hand knowledge of submarine practice than it is possible to give them in Washington, D.C,M The Commanding Officer of the New London Submarine Base approved this request and the first class of medical officers (five in number) arrived for further training in the Medical Research Department of the Base, on 28 June 1943. The staff of this department gave whole-hearted approval of the plan for giving future submarine medical officers a good indoctrination course in submarines at the Submarine Base, New London, and outlined a curriculum which included: submarine escape training; numerous submarine trips, both by day and night; inspection trips on an ASH, demonstration of its diving equipment, the rescue "Bell", etc.; lectures and demonstrations and actual participation in the submarine selection system; and the selection system for sound- listening personnel* They also visited various training activities. including the Submarine School and all of its departments; the Pharmacist's Mates School, the Interior Voice Communication School and the Lookout Training School* They also toured the Electric Boat Company, near the Submarine Base, New London, and observed submarines under construction* So successful was the outcome of this two weeks of training that each subsequent class at the Experimental Diving Unit was sent on to New London in its turn for this additional training, until in October of 1944, when the training period was extended to a full three weeks* This arrangement continued until the end of the war period* In order to give further emphasis to this distinct medical specialty, an insignia was devised in 1943 to be worn by qualified submarine medical officers; and the requirements for designation as a Qualified Submarine Medical Officer were set up* They were subsequently revised, as per the Circular Letter No. 44-44 quoted below: MANUAL CIRCULAR LETTER NO. 44-44 44-883 —Changes in Articles D-7020, H-9604(2), D-5112, and E-1314, BuPers Manual Pers-IOD-JK, A2-2/EN4, 27 July 1944 ACTION: ALL SHIPS AND STATIONS (Eno*: (A* Copy of subject changes) 1. The secretary of the Navy having approved the enclosed changes in Articles D-7020, H-9604, D-5112, and E-1314, Bureau of Naval Personnel Manual, on 13 July 1944, they are published for the information and guidance of all concerned.--BuPers• L. E. Denfield# Enclosure (a) changes in bureau of naval personnel manual Revise entire article E-1314 to read as follows: "E-1314. Qualification for Submarine Medical Officer# A candidate for classification as a submarine medical officer must qualify as follows: (1) Served in this capacity for a period of twelve months in a submarine squadron, or in a vessel whose mission is diving, or at a shore station where his primary duties have been with divers or the training of submarine personnel# (2) Be a graduate of the Deep Sea Diving School, Navy Yard, Washington, D.C,, or have served a three year tour of duty at the Experimental Diving Unit, Navy Yard, Washington, D.C.; or be a graduate of the course given for medical officers at the Submarine School, New London, Conn. (3) He shall be recommended by his squadron commander, or if shore based, by his commanding officer, —after having satisfactorily proven his practical ability in submarines and deep sea diving. He shall further be recommended by his squadron medical officer and senior medical officer, wherever such have cognizance over him. Following this, he will demonstrate his knowledge of submarine and diving medicine by an examination, which shall consist of: (a) A written examination, prepared by a Central Board of Medical Officers, located at the Experimental Diving Unit, Navy Yard, Washington, D.C., and consisting of three or more medical officers, at least two of whom shall be qualified in submarine medicine. This examination shall be complete in nature and shall cover the following listed subjects: physiology of respiration, treatment of caisson disease, selection of submarine personnel, submarine escape—utilizing the rescue chamber or the lung, emergency measures to be used in a disabled submarine on the bottom in deep water, (i.e, oxygen requirements; how much oxygen to be released per man per hour; what measures are to ■6 be taken against noxious gases, such as chlorine, physiology of bubble formation; gas laws; helium diving; oxygen poisoning; effects of pressure on the body* (b) An article or paper of sufficient scope for compre- hensive coverage of some phase of submarine medicine or medical aspects of deep sea diving* (This is not to be required if the individual has published at least one scientific article dealing with submarine or diving problems.) (4) The following is the detailed qualification procedure to be followed: (a) Letter requesting examination originated by candidate stating his qualifications, routed via cognizant medical officer and squadron commander to the Central Board of Medical Officers for Qualification of Submarine Medical Officers, Experimental Diving Unit, Navy Yard, Washington, D,C. (b) Forwarding by the Central Board of Medical Officers of questions for supervised examination. (c) Return of examination of papers to Central Board with article referred to in Paragraph 3-b, or copy of published paper, as an enclosure. (d) Recommendation by Board to the Chief of Naval Personnel, via the Chief of the Bureau of Medicine and Surgery. (e) Notification by letter to the candidate, by the Chief of Naval Personnel, (5) In cases where qualified Medical Officers who are former members of the Central Board are available in fleet units, a Board may be formed locally by precept from local commanders to facilitate and expedite qualification. Three or more medical officers will constitute this Board, to include the qualified Central Board Member. Proceedings, examination, and article as an enclosure, are to be forwarded to the Chief of Naval Personnel, via the Central Board and the Chief of the Bureau of Medicine and Surgery* Navy Dept. Bulletin 31 July 1944 Because of the resignation of many of the regular Navy medical officers, following the end of the war, as we11 as the separation from the service of all of the Reserve medical officers. the number of available submarine medical officers became entirely too small to even fill the most urgent needs of the Submarine Service# In order to meet this need in October of 1946, a plan was worked out by BuMed and BuPers, whereby officers of the Medical Corps, interested in becoming submarine medical officers, might attend a regular six-months course at the U# S# Naval Submarine School, New London, Connecticut# A curriculum was worked out whereby this group of doctors (12 in number) might attend the regular line officer classes for one half of their tine, and the other half of their time would be spent under the direction of the Medical Research Laboratory, acquiring the specific background required for submarine medicine# All details have been arranged and the first class is expected to arrive on 7 July 1947, to become a part of the 85th officer class of the Submarine School# In addition to this, in order to attract desirable candidates to this special branch, both the Commander Submarine Force Pacific and Commander Submarine Force Atlantic, in October of 1946, suggested to the Chief of the Bureau of Naval Personnel that ten definite submarine medical officer billets be established, as follows: one submarine medical officer on the staff of each Submarine Force, SubLant and SubPac; and one submarine medical officer assigned to each of the four Pacific Squadrons and each of the four Atlantic Squadrons* Nine such billets were subsequently approved (27 January 1947),—the shore-based squadron at Pearl Harbor being the only billet deleted* These nine billets are sea- duty billets, providing desirable submarine duty and sea pay. The assignment of those billets went a long way toward establishing the rightful place of the submarine medical officer within the Submarine Force, and served to formulize the situation which existed to a limited degree during the -war. In the early part of the war, a medical officer was assigned the combination job of Senior Medical Officer at the Submarine Base Dispensary, Pearl Harbor, and duty on the staff of the Commander Submarine Force, Pacific Fleet. However, the Pacific Force Medical Officer job was not operated to the fullest extent, nor to the best interest of submarines, until the arrival of a submarine i trained and submarine-mind Force Medical Officer in March of 1944. Then the program of submarine medicine was activated; distribution of supplies was organized so that every submarine got what it needed and wanted. Carful check-up was made on all submarine crews, both before going on patrol and immediately upon return from patrol. Several special research projects were initiated, and data on these studios were obtained during submarine trial runs. A Warrant Pharmacist was attached to the staff of ComSubPac to assist with the handling of personnel problems, and the maintenance of more complete liaison with the Hospital Corps details officers of CinCPao and ComSerForPac# With this assistance it was possible to keep accurate records of the distribution of all submarine Hospital Corpsmen in the Pacific area, the number of patrols made by each man, etc* This new regime also instituted an aggressive health program, which included conferences with Commanding Officers and extensive work with the pharmacists mates# In addition to this, a pool of submarine pharmacists mates (graduates of the School for Pharmacists Mates Entering the Submarine Service, at New London, Connecticut) was established. This pool was intended to furnish replacements as necessary. And in order to keep the men interested and in best possible trim for transfer to fighting sub- marines, a system of continuous refresher training was made available to the men thus standing by# On 20 April 1942, a medical officer was assigned additional duty on the staff of Commander Submarine Force, U# S, Atlantic Fleet, whose primary duties were the examination and selection of officers and men for the Submarine Service, and the conduct of experimental work in connection with submarine activities# A medical officer was also assigned to each submarine squadron, but unfortunately in many cases these medical officers were not the trained and qualified submarine medical officers. In fact, in almost every case, the Senior Medical Officer at submarine bases or on tenders inherited the designation of Squadron Medical Officer, and was in most instances, neither selected, trained, nor qualified for this task. The actually qualified submarine medical officers serving with the squadrons were in many cases junior to the designated Squadron Medical Officer and thereby considerably hampered in the work they wanted to do for the Submarine Service. A lesson should be learned from this so that such a situation can never again be allowed to exist. Other qualified submarine medical officers were utilized at submarine base dispensaries and in research activities at NMRI, at Bethesda, and at NMRL, at New London, and at the Experimental Diving Unit, Navy Yard, Washington, D.C. There was some agitation during the war period, for attaching a medical officer to the regular complement of all submarines, but both the limitation of space aboard submarines and the shortage of available medical officers precluded the adoption of this arrangement* The greatest number of qualified submarine medical officers existing at any one time during the course of the war was twenty-seven* Three medical officers actually made submarine war patrols, --one such officer was lost with the U. S, S. WAHOO. ' The senior author of this history would like to point out that should another such situation arise, more submarine medical officers should certainly ride the boats, —if for no other reason than to learn submarine problems aid conditions first-hand, and to conduct experimental work actually during patrol conditions. B. The Hospital Corps Officer in the Submarine Service# In the normal course of events, when a qualified submarine pharmacist's mate is promoted to warrant or commissioned rank, he is lost to the Submarine Service by transfer to other activities# However, during the war certain of these well-trained and well qualified Hospital Corps officers were utilized in the following billets: as assistant on the staff of ComSubPao; at subnmrine Base Dispensaries; as the officer heading the School for Pharmacist's Mates Entering the Submarine Service, Submarine Base, New London; and in research programs being conducted at the Naval Medical Research Institute at Bethesda, Maryland, and at the Naval Medical Research Laboratory, at New London, Connecticut. In any future emergency, it is believed that all Hospital Corps officer billets at submarine shore stations or aboard submarine tenders should be filled by Submarine trained personnel. 12 C. The Submarine Pharmacists Mate* No submarine carried a pharmacists mate in the crew until the V-boats, BASS, BARRICUDA, and BONITA, commissioned in 1924, 1925, and 1926, respectively. Until that time the medical officers of the submarine tenders and bases cared for the health of submarine personnel* With the improvement and development of submarine design, longer and longer periods of absence from the tender or base became feasible, and therefore the need for hospital corpsmenS being assigned to independent duty on submarines became increasingly necessary. From the very beginning, the attachment of a pharmacists mate as a regular member of the submarine crew has proved to be a very satisfactory arrangement. A good pharmacists mate, like a good cook, often proved to be one of the most valuable men aboard the boat, from the point of view of morale, quite apart from the specific duties performed. The accomplishments of submarine pharmacists mates during the recent conflict have received high acclaim, in the official patrol reports, in the record of commendations and awards, as well as in press and radio. The initiative and resourcefulness they displayed deserves a chapter all its own. This splendid record and the more-than-adequate service rendered by Pharmacist’s Mates during this war makes it appear that rigid selection and adequate training of the submarine pharmacist’s mates is the answer, rather than assigning medical officers. The submarine pharmacist’s mate, like all other submarine rates, is a volunteer, and at the time of the onset of the war, such volunteers were obtained by direct transfer from the Forces Afloat or shore stations, to the Submarine School for basic training in submarine operation. During peacetime this was a satisfactory arrangement• However, early in the war it became imperative to establish a school for intensive training of pharmacist’s mates prior to their entry into the Submarine School because of the inadequate amount of training possessed by pharmacist’s mates being transferred to the Submarine Service; and also because, as the war progressed, the demand for trained pharmacist’s mates increased far beyond the available supply. Accordingly, the School for Pharmacist’s Mates Entering the Submarine Service was established at the New London Submarine Base in April of 1943, The input to this school continued to be furnished by volunteers from the Forces Afloat and shore activities, but as the manpower situation became more acute, the training of the men being received was found to be so poor that a different arrangement was made early in 1945, whereby this school received a quota bf students from the graduates of the U, S, Naval Hospital Corps School, at Norfolk, Virginia, where pharmacists mates were being trained for independent duty. Thus the volunteer pharmacists mates from the Fleet went directly to the Norfolk School where they received 16 weeks of training, then on to the School at New London, where 8 weeks of additional training were given in the special phases of pharmacist's mates duties aboard submarines. Then the pharmacist's mate went on to the Submarine School at New London for basic training in his line duties. From there he was assigned either directly to a submarine, or to further training for Lockout, Sonar, or Radar duties, and then to a submarine. In November of 1944, a pool of pharmacist's mates was established in the staff allowance of ComSubPac where pharmacist's mates from the Submarine School were not only held actually awaiting assignment as replacements aboard submarines, but also attended refresher courses in the local post-graduate school. Additional numbers of trained pharmacist's mates we re also carried on all submarine tenders and held in pools at various submarine bases and stations, in order to furnish emergency replacements as necessary. In most oases this method of assignment worked adequately, but in some situations the medical officer of either the tender or the dispensary saw fit to hold the specially selected and trained submarine pharmacist's mates and transfer to active duty on submarines the poorer, non-submarine-trained material. This situation would automatically be taken care of in the event of any future emergency, when presumably only a qualified submarine medical officer will ever be designated as the Squadron Medical Officer. It should be pointed out that graduation from the School for Pharmacist's Mates Entering the Submarine Service does not automatically make a man "Qualified in Submarines". Graduation from the School automatically makes a man a submarine technician and his personnel accounting records are so marked, but in order to acquire the designation "Qualified in Submarines", a pharmacist's mat© must have served aboard a submarine until he has completed certain requirements to the satisfaction of the submarine's skipper and have been recommended by him for his designation. ‘ Just as all other ratings on the boat, in order to be designated as "Qualified in Submarines", a man must have completed a notebook, which contains drawings and diagrams of all of the systems through- out the boat, —the ventilating system, the system of tank arrange- ments, the hydraulic system, etc.. This notebook must have been graded and passed by a qualified submarine man. The man must have served from six months to a year aboard a submarine (in wartime. sometimes two war patrols were considered sufficient to qualify a man) and must be recommended by the Commanding Officer* Aboard a submarine, the pharmacist’s mate is responsible for the care of the sick and injured and the maintenance of the health of the crew. He is thus responsible for all of the routine medical duties laid down in the Manual of the Medical Department. However, in addition to this, war experience demonstrated the desirability of the pharmacist’s mate performing general submarine operational duties and other special duties as were assigned, such as sonar operator, radar operator, day or night lookout, librarian, compartment cleaner, oiler of the periscope, etc. Thus, the pharmacist’s mate is an integral part of the crew. He knows his men and his boat thoroughly and is therefore in a position to render the best possible medical service — preventive and clinical. 17 Ill - DEVELOPMENT OF THE USE OF SELECTION PROCEDURES FOR THE J SUBMARINE SERVICE. V One of the most important contributions to the efficiency of the submarine force was that made in the field of the selection of the officers and men best fitted for this duty. At the onset of the war the only examination for entry into submarine duty was the physical examination prescribed under Article 1535 of the Manual of the Medical Department. No mention of intelligence quotient, of psychological fitness, or psychiatric selection was contained therein, although these items became of great importance to the submarine selection system during the war. It is true, of course, that under pre-war condi- tions, some of the factors found in this type of selection were automatically covered by the requirement of satisfactory per- formance of at least three years of sea duty with the Fleet prior to making application for submarine duty* However, this automatic screening became inoperative immediately with the beginning of the war when the manpower needs of the Submarine Service were so suddenly expanded that large numbers of personnel* were received fresh from civilian life, A. Physical Examination: The physical requirements maintained during the war were those of the Manual of the Medical Department, Article 1535, with the exception that certain requirements were modified to meet the demands of the situation* As an example and notable in this regard is the dental examination. It had been found that certain dental officers, unfamiliar with service necessities, had been rejecting as many as 50ft of candidates in the preliminary exami- nation, in some instances making the requirements much more stringent than set forth in the Manual* It has been aptly said that "We’re gonna fight ’em, not bite ’em*’• A statement from a SubLant publication clearly illustrates the policy in regard to the dental requirements* "The strict dental requirements for submarines were specified due to the erroneous impression that the mouthpiece of the submarine escape appliance, the ’lung1, must be firmly gripped by the teeth. Actually, the ’lung’ mouth- piece is properly held by the lips with scant or no gripping of the teeth* Many a man has left his dentures in his locker while taking lung training* Emotional stability is much more important as a factor in learning the use of the lung. Dental requirements in submariner are satisfied by good oral hygiene (no pyorrhea alveolaris, Vincent’s infection, or excessive caries), no marked deformity of mouth or teeth (very marked over or under-bite or dental protrusions make lip-gripping of mouthpiece difficult)* Properly fitting bridges or dentures are not considered cause * "Outline and Discussion of Methods Used in Selecting Enlisted Candidates for Submarine Training", 1943* for rejection* It is required that sufficient opposing teeth be present to perform good mastication." Also, rejection .for venereal disease was modified, not only because of the persennel shortage, but also because of the advent of new types of traatment enabling men to return to duty in a shorter period of time, B* Special Senses: The development of specialized submarine tasks necessitated the introduction of special examinations. In this connection, particular mention should be made of the necessity for testing night vision in order to properly select night lookouts, or at least eliminate the dangerously night-blind. The first work on this problem started in the submarine service in April of 1941 and was continued and greatly developed throughout the war. The experimental phase of this work for the entire Navy was largely done in the Medical Research Laboratory, Submarine Base, New London, and will be discussed in more detail in the chapter on research. Submarine personnel were also tested for their visual ability to become good radar operators. The technique of this testing process was set up and validated by the National Defense Research Committee working in connection with range finders, height finders and radar operators. Requirements were found to be: normal near visual acuity and normal phoria measurements* Also additional tests as well as modification and improve- ment of old tests were found necessary, both in the field of testing far visual acuity and color vision* One of the most important contributions made by the Submarine Force to the Navy as a vhole, was the early development and application of selection procedures for picking sonar operators* The pioneer work was done by the staff of the Medical Research Laboratory at New London* Early recognition of the value of this work came from the Navy as well as from the N.D.R* Committee group, and the work done at New London formed the basis of the selection procedures developed for the selection of sonar operators for all of the Fleet units* The files of the Medical Research Laboratory at the U, S, Naval Submarine Base, New London, Conn*, contain the letters, reports, etc*, T/hich corroborate this state- ment, and will be mentioned again in the chapter on that laboratory* C* Psychological Testing: Paper-and-pencil psychological tests are extensively used in the selection process* The early impetus for the development and application of these tests came from the civilian research groups, such as the NDRCommittee Section - the Brown University Division* Many of these early tests were proven to be of great value in eliminating the psychologically and psychiatrically unfit personnel# Psychometric testing is a part of the psychological testing program# The Submarine Service became interested in intelligence tests early in 1942, in order to assure the selection of individuals of average or better than average intelligence, capable of being trained to handle the complicated equipment of a submarine. Again as in several of the other fields, experimental work on this pro- gram was done at the Medical Research Laboratory at the Submarine Base, New London and will be discussed in the chapter on Research# D# Psychiatric Interview: The first truly psychiatric selection interview for the Submarine Service was conducted in 1943, with the attachment of a trained psychiatrist to the Medical Examining group at New London# Prior to this time, selection interviews were conducted by trained Medical Corps and Hospital Corps personnel who were however non- psychiatrioally trained individuals# Of special interest is the method employed at New London using the combination of paper-and- penoil tests and psychiatric interview to complement each other. Many of the "boot" training camps and other training centers required their psychiatrist to attempt to interview as many as 20-30 men per hour, straight through the day# This obviously was not only impracticabler but literally impossible# In the Submarine Service, by using the psychological paper-and-pencil tests for the original screening, and asking the psychiatrist to interview only those in the bailing* or ‘doubtful1 categories, he was able to render much more effective service. This point should be clearly publicized and established as the procedure for the entire Navy in case of another mobilization. As an indication of the examinations given routinely at Medical Research Laboratory, New London, we list the following: Officer candidates for Submarine School Enlisted candidates for Submarine School — all candidates for Submarine School were given physical, psychological, and psychiatric examinations, and aptitude tests for various special jobs, and those who passed were then given submarine escape training Officer candidates for "Qualification in Submarines" Pharmacist*s Mates for Submarine PhM School Enlisted candidates for qualification as deep-sea diver Special test in Color Vision Special tests in Night Vision Selection tests for Sonar Operation Selection tests for Radar Operation Re-check examination for New Construction crews Basic battery tests for those who were found to lack same in their Service Record# As an indication of the volume of this examination program the following excerpt from Medical Research Laboratory*s Semi- Annual Report for the period duly through December 1944 is indicative: July 1, 1944 to December 31, 1944 Passed Failed Total For Submarine School: Enlisted candidates from Fleet and other stations 4,423 1,099 5,522 Enlisted candidates from this base (including re-exams)•••• 336 147 483 Officer candidates for Submarine School 607 33 640 Physical Exam* of officers for the designation "Qualified in Submarines" 46 1 47 Pharmacist’s Mates examined for entrance into PhM School ••••••• 83 40 123 Physical examination for Divers••••••• 169 28 197 Exam, for duty as instructor in Escape Training Tank**.* 7 2 9 Re-check examination for New Construction submarines•••*.•••••••• 160 0 160 Special Color Vision Tests.. ••• 480 Night Vision Tests. 8,570 711 9,281 Sonar Selection tests 1,544 374 1,918 Radar Selection tests.. 438 89 527 19,387 E, Pacific Reprocessing It should be noted that the Pacific Fleet medical organization found it highly desirable to conduct careful screening and reprocessing of submarine crews in order to eliminate those individuals who due to the pressure of circum- stances in the early days of the war (especially the week following Pearl Harbor), had been inducted directly into the submarine force without previous selection and training* This activity of ComSubPao functioned very effectively and served to eliminate many men who should never have been assigned to the Submarine Service. F* Trips made in the Interest of Submarine Selection. Of particular importance to the Submarine Service was the method of insuring a continuous flow of the best type of officers and men for training for submarine duty* Early in the war, it was found that the personnel situation was suoh as to make it highly desirable to actually go to the source of supply of submarine officers and select those volunteers best suited for submarine duty* Thus early in 1943, the first of a continuous series of interview boards was established, each board consisting of a representative of the staff of Commander Submarines, Atlantic Fleet, a representative of the submarine personnel division of BuPers, and a medical representative from the staff of the Medical Research Laboratory at New London. These boards travelled to the various officer indoctrination units and working in cooperation with the selection and medical depart- ments, studied the records of the volunteers for submarine duty, and interviewed those candidates deemed to be desirable. After the establishment of this system, those individuals sent to New London were found to be much more likely to pass the more detailed and rigid examinations, tests, and interviews, administered by the submarine medical group at New London, than had been the case when groups of unscreened volunteers had been sent. Thus many man-hours were saved as well as much disappointment and resentment which inevitably results from rejection of candidates after arrival at Submarine Base, New London. The same Board served as a Final Review Board for all officer candidates following their entrance examination at Submarine Base, New London. The proficiency of this Board was checked against the final accomplishment of each class and was found to be exceed- ingly high, in fact, the judgment of this Board was considered by the Submarine School to be sufficiently accurate to be the final authority as to whether or not a candidate should enter the School, In so far as the enlisted personnel were concerned,--to actually interview and examine candidates at the various Training Centers, Class-A Schools, and other activities sending men to the Submarine Service, was of course impossible. However, it was found highly desirable for a representative of the Submarine Medical Examining Section at the Submarine Base, New London, to travel to all of these units throughout the U, S, and have indoctri- nation conferences with the medical officers, the dental officers, the psychological, the psychiatric, the classification and selection officers. Following these conferences the input of men to New London consistently improved so that attrition dropped as much as 15% from individual Training Centers and Schools. These conference trips had to be repeated periodically because of the transfer of indoctrinated officers from the various units, but the expenditure of time and effort on the part of the Submarine Medical Examiner was compensated for many times over by the saving of time, money, and good will on the part of the candidates, for no man likes to be okTd at one station, then travel great distances to another, only to be turned down as unfit. Of historical interest in connection with these trips would be some of the almost incredible situations found in the examining units of various organizations. Complete misunderstanding of submarine requirements, as well as complete lack of any organization in the examining group was frequently noted. At one station, it was found that dental officers were rejecting Ql%> of all candidates on the basis of minimum degree of dental defects, such as slight overbite, underbite, a few missing teeth, etc. It was only rarely that the psychologist, the psychiatrist, and the selection officer were found to work together or even know the part played by the other in selection procedures. Physical exami- nations were done by all types of completely untrained personnel. Examining facilities were totally lacking, or completely inadequate in many cases. In fact, the situation generally encountered leads one to wonder how anyone was properly selected for any particular Navy task. Accordingly, a statistical accounting system was set up in 1944, and complete reports were furnished to all stations monthly. G. Submarine Escape Training Tank* Not only was the Submarine Escape Training Tank used as a method of training individuals in the use of the submarine escape appliance, but it was used by the selection group at New London as a measure of identifying the emotionally unstable and psyohiatrically unfit candidates,---it being assumed and at least partially established that men who failed notably in the adjust- ment necessary to proper performance of 'lung1 training, would not be likely to make the adjustment necessaryfor submarine activities, particularly during contact with the enemy, such as depth charging. H. Indoctrination of BuPers Selection and Classification Officers. One of the most effective means of obtaining good submarine personnel was the indoctrination at the Submarine Base, New London, Connecticut, of a group of officers being sent from the Bureau of Personnel to outlying units to act as classification and selection officers. By a carefully planned and executed program, a large group of such officers were indoctrinated into submarine life and into the needs of the submarine service, particularly in so far as 28 personnel were concerned. This job was so well done that by the end of the war, there was hardly a boot camp. Training Station, or Class-A School that did not have a submarine indoctri- nated enthusiast aboard* It can readily be seen that the value to the Submarine Service of such an individual was inestimable, I, Report of Rejections to the Originating Activity: In the course of the trips taken by the Submarine Medical Examiner to the Training Centers and activities furnishing sub- marine quotas, it became apparent that these stations did not know the fate of the candidates for Submarine School, and that a much healthier state of affairs would obtain, if a report were furnished by the New London examining group back to the station of origin,—giving the disposition of each man sent, and the reason for the rejection, if any, J, Summary: In summary, we list the following points considered to be of utmost importance to the Submarine Service in the field of personnel selection during the recent war: (a) Modification of the submarine physical examination to include an intelligence test and psychological and psychiatric testing techniques. As a matter of fact, the latter three are considered to be of a great deal more importance than the straight physical examination. (b) The adoption of paper-and-pencil psychological and psychiatric tests and their combination use to relieve the psychiatrist of the necessity of seeing all candidates. (c) Development of Special examinations for specific submarine tasks, such as night-lookout, radar,and sonar. (d) Selection trips by Boards of Examiners for purposes of pre-selection of officer volunteers for submarine duty. In connection with this, the use of a Board of Examiners at the Submarine Base for the final evaluation and selection of officer candidates. (e) Trips by a qualified submarine medical officer to all activities furnishing enlisted candidates for purpose of indoctri- nation of personnel in examination of men for submarine duty, (f) The establishment of techniques of reporting back to supplying activity all information concerning the success or failure of their candidates. (g) Indoctrination training at Submarine Base, New London, Connecticut, for the BuPers selection and classification officers thus ensuring an informed and interested nucleus of individuals in all Naval activities charged with selection of personnel. IV “ TRAINING ACTIVITY The training program operating within the submarine service during the war reached an unbelievably high level of efficiency* Courses of instruction were developed, and techniques of training we re perfected, new and improved equip- ment for the purposes of training and indoctrination were developed* The center of much of this training was at the Submarine School, New London, Connecticut* However, training activity within the submarine force was located at almost every submarine base, notably Pearl Harbor* The contribution of the medical department of the Hew London Submarine Base to this general training program was heavy and unusual, in that, it included a number of activities normally considered to be under the sole jurisdiction of the Line. A listing of these various training activities and a brief statement concerning the develop- ment of each will be the contents of this chapter,—with the School for Pharmacist’s Hates Entering the Submarine Service occupying its rightful position as the most important single i contribution to training so far as the submarine medical activities were concerned* A. Sohool for Pharmacists Mates Entering the Submarine v Service. The need for a School for Pharmacist’s Mates Entering the Submarine Service had been felt for some time, but became more urgent in the spring of 1943 when a survey of the background of a group of pharmacist's mate candidates for submarine duty revealed that the average PhM volunteer for submarine duty was sadly lacking in experience and knowledge of the Hospital Corps. Most of these men were returned to general service and conse- quently a shortage of pharmacist’s mates qualified for indepen- dent duty aboard submarines developed. Also, at this time, due to the publicity given to several appendectomies performed aboard submarines, there was considerable agitation to have a medical officer placed aboard each boat. This was impossible due to an already acute shortage of Medical Officers, therefore, a school for these submarine pharmacist’s mates was decided upon as the best possible answer to both problems. Authority was granted on 7 May 1943 (BuPers Itr. P-242FJF/No38) by the Chief of the Bureau of Personnel to establish the school with the first class to convene on 15 June 1943. Four Chief Pharmacist’s Mates were immediately ordered from ComSubPac for duty as instructors, and an Ensign in the Hospital Corps, who was exceptionally well trained and qualified in submarines was assigned as the administrative head of the school. The curriculum decided upon was of six weeks duration, with four weeks of theory and two weeks of practical work in the Dispensary* The subjects taught were: First Aid and Minor Surgery; Medical and Diagnostic procedures and Treatment; Hygiene and Sanitation; Nursing; Materia Medica and Toxicology; Clerical Forms and Procedures; Anesthesia; Laboratory and Venereal Diseases; and Pharmacy and Chemistry* Each school day was divided into six one-hour periods, one of these being a lecture by a Medical Officer* As this school was designed to help prepare a man for independent duty aboard submarines, great stress was given to those subjects that have to do with the saving of life and limb* What not to do, as well as what to do and the ability and necessity of thinking each situation through for one's self was emphasized. These conditions peculiar to submarines were also taught, i*e*, gases present and those that may be formed, the effects of increased pressure on health, as well as the effect of those conditions inherent in submarine life, —close confinement, lack of sunshine and fresh foods, etc* Much time was also given to the administration of intravenous medicines and the use of the sulfonamides* Mindful of the great responsibility that a pharmacist's mate assumes when he goes aboard a submarine, this school was from the very beginning extremely rigid in its qualifications* The entrance requirements were strict, and the subject material was concentrated and streamlined. Since this was so, and since the volunteers coming in from the Fleet had woefully meager background of training and experience, a rather high rate of attrition developed. Therefore, in March of 1945 a change was made in the source of supply of the quota for this school. Since that time all students received for this School have been graduates of the U, S, Naval Hospital Corps School at Norfolk, Virginia, where pharmacists mates receive sixteen weeks of training for independent duty. With the inauguration of this system, attrition dropped to normal limits and the arrangement is considered satisfactory for retention. (No pictures available for this copy) There have been a few changes and additions in the curriculum, and shifts in points of emphasis, changes in personnel and hours, but basically the School has not been changed much. There have been over two hundred graduates from this school and there is not one case on record where a man has been reported for not being able to do his job. On the contrary, comment from the Pacific was very complimentary, showing that these men did an excellent job. Many of the graduates wrote back to the School, expressing satisfaction with the instruction received there and sent in notes on conditions encountered, which first- hand material was an interesting and valuable addition to the classroom presentations. Following pictures with attached annotations illustrate certain phases of the Submarine Pharmacists mate's duty. B, Refresher Training for Pharmacists Mates Awaiting Assignment, At one point in 1944, more pharmacists mates were being graduated from the School for Pharmacists Mates at New London, than could be immediately assigned to boats. Therefore, in November of 1944 authorization was obtained from BuPers and BuMed for the establishment of a pool of pharmacists mates at Pearl Harbor, from which periodic and emergency replacements could be made among the pharmacists mates permanently assigned to submarines. With the acquisition of the pool allowance and the personnel therefor, it was possible to proceed with the establish- ment of a local post-graduate school for the pharmacists mates thus held awaiting assignment, in order to keep them busy, interested, and to give them the advantage of every additional day of training possible. Qualified Medical Officers, the Hospital Corps officer assigned to the pool, and experienced submarine pharmacists mates were utilized as instructors. The establishment of this replacement pool was also valuable in that it permitted the replacement of some pharmacists mates vho had not attended the New London School and permitted them to attend this refresher training school. The Radar and Sound Schools were made part of the regular curriculum of this refresher training school, along with instruction in first aid, minor surgery, war instruction in general medicine and surgery, plus a rather vigorous course in clerical procedures* This was in line with the policy of submarine commanders who wished to use the pharmacists mates as soundmen and radar operators, since in so many cases they had demonstrated their ability to readily absorb this technical training, and it was believed that this would not interfere with the performance of the pharmacist's mates regular medical department duties* It might be noted in passing the the pharmacist's mates generally became star pupils in the Radar and Sound courses, even to the point of surpassing the grades attained by officer members of the same classes* It is believed that such measures helped make the pharmacist's mates key members of each submarine crew and helped sustain the idea that submarine pharmacist's are mates/as a rule outstanding. The creation of this pool made possible the establishment of the policy of relieving the pharmacist's mate at the end of his fifth successive patrol, which proved to be an excellent morale factor* Dissemination of the news concerning the inauguration of this policy was sufficient to produce maximum performance for five patrols* -Relief after five patrols could be followed by immediate transfer to a submarine under construction •which meant 3-6 months 'stateside duty* and consequent rest and rehabilitation, or transfer to the pool with duty at a Submarine Base Dispensary until such time as New Construction were available * The attendant periods of decreased operational activity, during fitting out, amply provided for leave and constituted an adequate rest and recuperation interval,and usually involved return to the continental limits of the U,S,A,, which was most welcome and a very efficient form of recuperation. In one or two months, these former submarine pharmacist’s mates usually expressed a desire to return to active patrol status, C, Deep Sea Diving School, Washington, D,C# Although this Navy school was not directly a part of the Submarine Force medical training, yet all of the Submarine Force medical officers took courses of instruction given at this School, As pointed out in the introductory chapter, this training con- stituted the only submarine preparation for many of our submarine medical officers. It is considered that this training was very valuable, but entirely inadequate for proper coverage of submarine duty# Therefore, as will be seen in the next paragraph, training dealing more directly with submarine problems was added# D# Submarine Training of Medical Officers at the Medical Research Laboratory, New London: Much of this material has been presented previously in Chapter II, under the heading of the Submarine Medical Officer, However, at this time it is well to reemphasize the necessity of a medical officer’s having actual submarine training if he is going to work with the Submarine Force. It is felt that the presently planned program of six months training at the Submarine Base, New London, one half of the time to be spent in the regular Officers Course at the Submarine School, and the other half of the time to be spent in purely medical submarine training in the Medical Research Laboratory, is the perfect solution to this problem, As indicated in Chapter II, the course of additional training at the Medical Research Laboratory, which was begun in 1943, at first covered two weeks, then was extended to three weeks of indoctrinational training. In each case, the medical officer trainees expressed a desire for a longer period of this type of training,—"more of the same", A typical schedule of the material covered in this course, as it was given during the war appears below. OUTLINE OF CURRICULUM FOR SUBMARINE MEDICAL CFFICERS 1/ A. Selection of Submarine Personnel, 1, Physical Examination 2, Psychiatric examination 3, Recording data on cards, coding of disqualifications, 4, Aerotitis, Reports by Fowler, Haines and Harris Demonstration of use of radium by Dr. Haines, 5, Night Vision Lectures and demonstrations 6, Color Vision Lectures and demonstrations 7, Visual Acuity Lecture and demonstration 8* Audiometry Lecture and demonstration B, Duties of Squadron Medical Officer !• Property and Accounting 2m Military duties 3* Medical supplies on Submarines 4. Tender Medical Department C, Submarine Escape and Rescue, 1, Present methods (seminar) 2, Analysis of previous escapes (seminar) 3, Air Embolism (seminar) 4, Underway on ASR-PETRaL (a) He02 diving (b) simulated Event-1000 D, Training Tank E, Medical and Miscellaneous Aspects of S/M Operation -(seminar) 1, Ventilation, revitalization, 003, etc, 2, Diseases encountered during patrols. 3, Foul Weather gear, 4, Water and Food 5, Fumigation 39 E* Escape Training Tank* “ The submarine Escape Training Tank was designed to permit the thorough training of all submarine personnel in the use of the flung’ or submarine escape appliance, under conditions which would simulate as closely as possible those conditions that exist during an actual escape from a disabled submarine* This tank contains a vertical column of water 100 feet high and 18 feet in diameter* It has a capacity of about 280,000 gallons of water* Integrated with the tank are escape locks or compartments which duplicate those installed in submarines. These locks are located at depths from the top of the tank of 18 feet, 50 feet and 100 feet, thus permitting escapes under conditions identical to those existing in similar depths at sea. All submarines are supplied with submarine escape apparatus and the crew must be properly trained in the use of the lung, either at the Tank located at New London or at Pearl Harbor. In order to escape from a sunken submarine, it is neces- sary that the pressure within the compartment or ship from which egress is to be made be equalized with the outside water pressure. To equalize the pressure in an escape compartment with the out- side water pressure, the compartment is flooded by admitting water through various valves; as the water rises, it compresses the air in the upper part of the compartment. Yihen the water rises to the top of the escape door or telescopic trunk, it causes a pressure within the compartment equal to the sea pressure or outside water pressure. At this stage it is very easy for the hatch or door to be opened by hand. The occupants of the escape compartment stand in compressed air formed by the flooding referred to above. After the pressure is equalized, the hatch is opened and a buoy with an ascending line is released through the open hatch and an escape is made to the surface with the use of the lung. All officers and men are required to make escapes at the Escape Training Tank, and in addition to providing training in an important safety measure, this program also provides an excellent / indicator of the temperamental qualities of the men concerned. Qualification at the Escape Tank consists of the following essentials: (a) pressure test of 50 pounds per square inch in recompression chamber; (b) a lecture on construction, operation, safety features, and precautions in use of the lung; (c) shallow water training for confidence in breathing under water; (d) 12-foot training to attain proper relaxation and confidence; (e) 18-foot, and 50-foot training to permit the student to become highly trained in the use of the lung so that should he be called upon to use this device to save his life, he would have no fears as to its life- saving qualities. Through the years from September 1930 to the present date, an accurate record has been kept of all lung.escapes as indicated be low t Fiscal Year QUA 18-foot L I F I C A 50-foot T I 0 N S 100-foot TOTALS 1 July 1930-31 556 405 338 1,299 1931-32 770 189 179 1,138 1932-33 490 244 216 950 1933-34 562 252 141 955 1934-35 264 104 104 472* 1935-36 454 84 84 622 1936-37 637 41 41 719 1937-38 1,813 121 121 1,555 1938-39 1,321 62 62 1,445 1939-40 1,375 189 149 1,713 1940-41 3,695 123 13 3,831 1941-42 4,621 2,231 1,405 8,257 1942-43 8,014 6,463 1,882 16,359 1943-44 13,569 12,590 811 26,970 1944-45 8,895 6,710 786 16,391 TOTALS 46,536 29,806 6,332 82,676 * It is interesting to note that more men were trained during the three days January 3, 4, and 5, 1944 (527) than for the entire fiscal year 1934-35 (472), In the month of January 1944, more men were trained than in any single year from 1930 through 1941, 18-ft. 1,352; 50-ft, 1308; 100-ft. 122; total 2,782, 42 The reason for including the account of the Tank training in this report is two-fold: (l) as already pointed out in Chapter III, it was used as one method of personnel selection, and (2) and more importantly, the Tank was actually under the administrative control of the Medical Officer in Charge of the Medical Research Department from 23 February 1944 to 17 January 1946, and it is likely that control of this activity will again be given to that officer, for the reasons outlined in a letter of which we quote the pertinent paragraphs pointing out the reasons why the tank should be under the control of the MO-in-C of the Medical Research Laboratory: "(a) The first phase of the training, that is 50-lb pressure test, is officially part of the submarine physical examination, routinely conducted by medical officers attached to our laboratory. M(b) The tank training is carefully graded and conspicuous failure in training is considered by the Submarine Medical Examiner as a cause for rejection on psychological grounds. "(c) If an accident occurs during training, it is considered to be a medical emergency and the medical officer takes over control and supervision of the treatment. "(d) By order, a medical officer must constantly be in attendance during the pressure test as well as the actual ’lung* escape training. "(e) The Medical Research Laboratory has several official research projects under the management and technical control of the Bureau of Medicine and Surgery which must be accomplished in the training tank under medical supervision, and for which BuMed funds are provided# "(f) Because of the volume of this research as well as use of the Training Tank for various personnel selection validity studies, the Tank is used more than 50% of the time directly by the Medical Research Laboratory#" During the operation of this Tank under Medical Officer supervision 26,997 escapes were made entirely without casualties# F# School for Second Class Divers No detailed description of this activity is included and the only reason for mentioning it in a history of submarine medicine is that this School was organized under the administration of the Medical Officer in Charge of the Medical Research Laboratory, Submarine Base, New London, Conn. A brief history follows: A School for Qualification of Second Class Divers was established at the Submarine Base, New London, Connecticut by letter NB7/P11«1(MR), Serial No. 920 of 8 March 1944 to the Chief of the Bureau of Naval Personnel, as provided for in BuPers Manual Art.D-5327(C)(4), for the dual purpose of (l) training men for the qualification of Second Class Diver, and (2) in order to provide an adequate number of trained personnel to handle all the routine salvage inspections and be ready for any emergency diving. G. Lookout Training School Following receipt of reports from British sources (where a state of war had existed for two years) concerning the importance of training lookouts. Commander Submarines, Atlantic Fleet, became interested in the possibilities of such training for the submarine service and directed that a night lookout training table be set-up similar to that used by the British. Accordingly a trainer was set up in Building at the New London Submarine Base in 1941, where it was used continuously for the training of personnel attached to ships operating out of this Base until February 1943, when this instruction was moved to the newly constructed building fi-126. From the beginning commanding officers were enthusiastic about this training and the program was very popular with the men them- selves, and with the many visitors who were favorably impressed with this stage and the accompanying lecture material. Briefly, this original trainer provided a reasonably realistic horizon with a sea foreground simulating the situation confronting a lookout at sea. It provided varying lighting effects so as to produce the effect of an horizon, and ship models were placed at various sectors for the training of lookouts in the calling of relative bearing and the general duties of a lookout watch. An essential part of this lookout training was the lecture material which served to indoctrinate and motivate the men concerning the value of the lookout’s job. This lecture was put out in printed form by ComSubsLant as a pamphlet entitled handbook of night lookout training. On 15 June 1942, an officer from the Office of the Commander of the Eastern Sea Frontier, visited the New London Submarine Base to see what was being done in night vision, became very much interested in the night lookout training stage, requested blueprints of the existing stage and further details concerning the proposed modifications which were planned. On 10 July of the same year, an officer of the Interior Control Board, visited Submarine Base New London and also became very much interested in the night lookout training stage. Because of the interest at these two sources, a greatly improved version of the Lookout Stage was built at Tompkinsville, S. I., N.Y., embodying several additional improvements. This stage was completed early in October 1942, Following this, arrangements were made to present to the Bureau of Naval Personnel, officially, the idea of constructing similar stages of a "portable" type for distribution throughout the Navy for the training of all personnel. The suggestion was accepted by BuPers and the trainers ordered. A realistic horizon was provided upon which the trainee was required to sight and identify small ship models which were placed upon it, The apparatus provided also for reproduction of distant gunfire, of moonlight, and of recognition lights. Its advantages as a training device lay in its realism, and the interest which it aroused in the men. Its value in indoctrination and preliminary training of beginners was unquestioned. In operation, lookouts were posted in pairs and located and redported in proper phraseology the position of model ships. On 25 November 1942, the Chief of Naval Operations, requested the Submarine Base, New London, to train instructors for the various lookout training centers which it was contemplated would be established, using the night lookout trainers developed by the base, and at that time being prefabricated by BuPers for release throughout the Navy, This training program was assigned to Medical Research Laboratory due to its interest and activity in Night Vision testing and research. Medical Research Laboratory was officially designated by BuPers as the experimental station for the entire lookout training program, —by BuPers Itr. P-2423-RB of 18 December 1942, The first of the prefabricated type of lookout trainers was installed in Building ?,c126. Submarine Base, New London, and instructor training started there on 22 February 1942. The first group of 30 instructors finished training there early in 1942. This group of instructors were assigned to train men in the technique of setting up a lookout stage and teaching classes, therefore they were given all the information necessary to start from the packing boxes and continue on to the completion of an adequate course of instruction for lookouts. In March 1943, Commander Submarine Force, Pacific Fleet, recommended the establishment of the Renshaw Recognition training system at submarine activities. Following investigation and conferences, this training was adopted, modified to fit submarine service needs, and included as a part of the night lookout training program already in operation at the Submarine Base, New London• As the work in visual, night visual, general lookout, and recognition training began to increase, it was obvious that a regular school should be organized. Accordingly, in May of 1943 letters were submitted by the Commanding Officer, requesting the establishment of such a school. By ComSubsLant Itr. to Commanding Officer, Submarine Base, Pll-1,Serial 2172, dated 15 June 1943, the establishment of a Lookout School was directed, A new building was requested to provide adequate space for this School. Authori- zation was granted; the building (#156) was constructed, and first occupied in February 1944. There the Lookout School continued throughout the remainder of the war period. In the same correspondence referred to above, it was suggested to the Bureau of Naval Personnel that lookout training schools be established for the general service similar to the one being established at Submarine Base, New London, which resulted in the eventual establishment by the Bureau of Personnel of general lookout training schools in conjunction with recognition training at all of the various training centers. In order to facilitate the establishment of these combi- nation lookout-recognition schools, it was found necessary to give the recognition officers in the field additional training in lookout work# Therefore, they were ordered to the Medical Research Department, Submarine Base, New London, for temporary duty, additional instruction, in order to enable them to train lookouts -when assigned either to basic training schools or the "L" divisions aboard ships. This activity trained around 200 line officers, all of whom had previously graduated from the U, S, Naval Training School (Recognition) at Ohio State University, Since the advantages of this additional instruction were acknowledged by all hands, a course in lookout procedures'was added to the curriculum of the Naval Training School (Recognition) at Ohio State University early in July of 1943, so that all graduates of this School would be trained in both lookout and recognition pro- cedures and would not have to be sent to New London for additional instruction. A detailed account of the curriculum, statistics on numbers of men trained, and other developments in the Lookout Training School are contained in the History of the Medical Research Laboratory.* During a typical period of six months, the following instructional program was carried out in organized classes: a) 5,141 enlisted men received a three-hour course in Night Lookout training in Building 126; - 1,068 of these used the NLOT Stage twice# b) 939 enlisted men from New Construction attended the three-day course# c) 1,931 enlisted men from Basic School and Advanced Schools attended the six-day course# d) 40 recognition officers attended a six-day course# e) 508 Submarine School student-officers attended a two-day course. f) From 10 April 1944 to 22 June 1944, a varying number of student-officers were received for Recognition Training# These officers were the overflow from the Attack Teacher. Each officer received from three to fifteen hours of instruc- tion --the average being about nine hours. g) Eight hours of aircraft recognition are given to each class of the Quartermast-Signalman School# ♦"History of the Medical Research Laboratory - 7 Dec. 1941 to 7 Deo. 1945" by J. Vv# Kohl, and annual supplements to same published as of 1 July of each subsequent year. Because of the intensive interest in and pioneer research in techniques of night vision and night lookout training in this laboratory, a variety of new equipment was developed, tested experimentally, and added to the School’s training devices; important modifications were also made on existing equipment. All during the period of the conduct of this School, it was constantly being visited by interested individuals from all branches of the armed services and from various allied countries, therefore the School was constantly acting as a center for dis- semination of knowledge concerning the latest methods of night vision testing and night lookout training. In summary, it is considered to be of particular interest in a medical history of submarines to realize that the submarine service was the first in the U. S. Navy to inaugurate night lookout training and that this training was developed under the auspices of the Medical Research unit at Submarine Base, New London, Connecticut* It is also of particular significance to realize that this unit was utilized to train not only submarine personnel, but that it was also the experimental center for all of the Navy’s official activity in the field of lookout training, and that it was, perhaps even more importantly, utilized as the center for 51 training all instructors sent out through the Navy to conduct the general program of lookout training. In addition to this, the Navyfs Recognition Program at Ohio State University was taken under study at the Medical Research Laboratory and through its advice was so modified that night look- out training was combined with and added to all recognition train- ing being done by the Navy, Actually, many of the Recognition School officers received additional training at the Lookout Training School, Submarine Base, New London, and upon their return, acted as instructors of the combined lookout and recognition courses* Here again, a medical unit of the submarine force made a major contribution to the efficiency of the submarine service and, in addition, to the general efficiency of the entire Navy. H. Interior Voice Communication School, The Medical Research Department of the Submarine Base, New London, Conn*, through its liaison with the Applied Psychology Panel of the Office of Scientific Research and Development, had been interested for some tine in the general problem of telephone talker selection and training. On 1 May 1944, a Bureau of Personnel directive authorized the establishment of telephone talker schools in all Class A, B and C Schools. The Medical Research Department immediately began the necessary preliminary negotiations for the organization of a telephone talker classification and training program for the Submarine Service. Following a long series of conferences and official letters concerning personnel, equipment, and curricula, the "Telephone Talker School" was finally officially established by the Bureau of Personnel Director of Training in confidential letter Pers-41218-vm of 17 July 1944 and assigned for operation to the Medical Research Department, A study of the needs of the Submarine Service was at once undertaken with the assistance of the National Defense Research Committee - Project N-118. This preliminary study of the situation indicated that a course in Telephone Talking alone would not be sufficient to eliminate on our boats the inefficient voice communications ■which made this training necessary. It was determined, and this determination was approved by Commander Submarines, Atlantic Fleet, that training was necessary in all of the following basic subjects, if the desired ends were to be accomplished* a. How to increase intelligibility in use of all communi- cation instruments, over noise. b. The formulation of brief, efficient, and standard orders, commands, and reports of execution of orders. o# Efficient operation and handling of equipment in order to reduce casualties# d# The use of Standard Phraseology and Procedures for all types of interior communications# e. Suggested organization for sound-powered and broad- casting circuits under various battle and operational conditions• f# Examples of Standard Terminology for various stations on submarines requiring any form of voice communication with another station# g# For Officers; Methods of Shipboard Instruction to be used for advanced training# With the aforementioned facts in mind, the name of this School was properly changed from the "Telephone Talkers School" to the "Interior Voice Communications School", in order to assist in its taking over a broader field of instruction# Work on teaching the seven subjects listed above continued with the instruction modified and changed frequently as new data became available# It is considered that a most valuable contri- bution was made in this field to efficient submarine operation# In collaboration with if.D.R.C. personnel and with assistance from Submarine officers representing the Training Officer, Staff, ComSubsLant, the following publications were drawn up and approved for publication: a, Submarine Telephone Talkers1 Manual* b, Suggested Ship*s Organization; Chapter on Interior Voice Communications for fleet type submarines, c, Pamphlet: Standard Submarine Phraseology, d, Classroom Pamphlet: Standard Submarine Phraseology and Procedures, e, A complete Instructors Handbook for instruction in Submarine Interior Voice Communications. Much work was done toward the development of effective means of classification of all men. However in the final analysis all men were trained and following an evaluation of their ability records were stamped and checked as to vhether a man was ’’Well Qualified", ’’Qualified", or ’’Not Qualified", The following instruction schedules are illustrative of the activity of the school, a. Basic School; 210 men each two weeks; each man 5|r hours of instruction* Classes in units of 30 men each, b. Advanced Schools: 200 men each two weeks; each man 2 hours of instruction. Classes of 30 men or less, o* Student Officers: 150 officers every four months and give 12 hours of instruction to each officer - in classes of 15 officers each. d. New Construction Submarines: (1) Basic Course: Approximately 250 men per month. - 8 hours instruction per man. Class: 30 men. (2) Advanced Course: Officer instructor accompanies boat during shakedown as often as requested by Commanding Officer. During a six months period of time, the School gave approximately 25,100 man-hours of instruction to 4,400 officers and men. In addition to training students, it was necessary to train instructors for the increased submarine training program. The parent school gave a one month’s course to six officer instructors for the schools being set up at advanced submarine bases. Instruction was also given for approximately twenty enlisted instructors assigned to these various bases as the first instructor units. Equipment was also assembled for transfer to other submarine activities. An entry in a history of the school clearly shows this activity: "Including the set of equipment sent to Pearl Harbor recently, a total of seven IVC training rooms have now been established and equipped for submarine advanced training bases. Utilizing the officer and enlisted instructors trained and the curriculum prepared in New London, the advanced schools are also now in operation." One of the most important parts of the training program of was the teaching/the use of standard procedures, a type of practi- cal drill developed which greatly facilitated the instruction in voice communication procedures, phraseology and terminology for the submarine crow. These drills, by the use of scripts made up of leading orders and messages, forced the student to utilize correct procedures, phraseology, and terminology while simulating the actual operations and speaking the actual words involved in the conditions of the drills. During the course the student participated in practical drills simulating the maneuvering watch, general drills, torpedo approach, battle surface, and other standard patrol operations. All officer and enlisted students from the schools and from boats undergoing training became thoroughly familiar with the actual voice communication installation of the submarine. Intensive lecture periods, utilizing visual training aids facilitated this job as well as teaching the organization of communications during the various types of operations. Some minor differences were necessary between the courses of instruction for enlisted students and officers, and for sub- marine crews. The average course, however was lengthened to twelve hours and followed the schedule listed below: Period One - (55 minutes) Lecture: Importance of Interior Voice Communications, Introduction to Submarine IVC Equipment and Organization* Basic Principles of Intelligibility over Sound Powered Phones, Drill: Proper Handling and Stowage of Sound Powered Phones, Simple messages and Acknowledgements, Period Two - (80 minutes) Lecture and Demonstration: Basic Voice Communication Procedures, Period Three - (40 minutes) Drills: Basic Voice Communication Drills — Simple Application of Rules of Procedure, Period Four - (60 minutes) Lecture: Description and Location of IVC Equipment, Operational Organization and Use, Period Five - (90 minutes) Practical Drill: The Maneuvering Watch General Drills , Period Six - (90 minutes) Practical Drill: The Torpedo Approach Period Seven - (90 minutes) Practical Drill: Patrol Drill* Period Eight - (90 minutes) Practical Drill: Battle Stations Surface* Test* Three additional periods were added to this schedule for training of student officers: an instructional tour of a new construction boat to study the IVC installation (preceding period four), and two hours instruction and drill in methods of ship- board instruction* In carrying out instructional schedules during a six months period the IVC School gave the following man-hours of instruction: To Amount Submarine School - Enlisted 23,925 Submarine School - Officers 2,760 Submarine Crews 39,000 Total 65,685 In the early stages of the development of this school it became apparent that it was necessary to standardise the use of voice communications in the various submarine schools, new construc- tion boats, and training boats. Continued efforts were made to accomplish this. All instructors in the enlisted submarine school were processed by this school* practically all training submarines were sent here for IVC training; and through the device of extensive pre-training conferences with boat’s officers, all new construction submarines set up almost identical communications organizations and utilized the standardized set of procedure as recommended. In order to further standardize the training given in all submarine areas, an IVC instructions training kit was prepared and distributed consisting of: 1, A complete Instructor’s Handbook for Submarine Interior Voice Communications• 2, Interior Voice Communications Training Records; a. The Maneuvering Watch Drill b. The Torpedo Approach Drill c. The Thames Patrol Drill d. The Battle Surface Drill 3, Interior Voice Communications Training Charts, a. Typical Submarine bound Powered Installation b. Typical Submarine Broadcast and Talkback Installation, c. Interior Voice Communications Organization for Normal Cruising, Diving and Surfacing, and Maneuvering Watch. d. Interior Voice Communications Organization for Battle Stations Torpedo and Battle Stations Surface. A determined effort was made to maintain a close liaison with all outlying schools which was partially successful. From July 1, 1945, this activity continued to function in the training of all classes of submarine officers and men, but with the cessation of hostilities, and consequent reorganization, it was felt that the logical place for such training was in the Basic Course of the Submarine School, It was therefore transferred 31 December 1945 from the Medical Research Department to the Submarine School, as directed by the Commanding Officer of the Submarine Base. It was the almost unanimous opinion of all of Commanding Officers that the training given in this School was of real importance in the improvement of interior voice communication aboard submarines. This improvement was dramatically demonstrated on many occasions and for training purposes wire recordings were made showing ’’before’' and "after” examples very effectively. The role of the medical department in this activity is one that deserves an additional note. We believe that the reason that the program was so well developed and handled was that in general medical and psychological personnel have a keener under- standing of the potentialities of the individual for as simulation of material and also have a better understanding of the require- ments of a training program. This and other training programs handled by psychologist personnel, we believe clearly indicate that Naval training courses in many instances could be immeasure- ably improved, were they taken out of the hands of traditionally- trained line officers and put in the hands of those trained specially for instruction and design of programs of instruction. Because of the real success of this program, it is to be hoped that it will not be dropped from the curriculum when Lookout Training School is transferred to the auspices of the Submarine School. 62 V - SPECIAL CARE CF SUBMARINE PERSONNEL V As was pointed out in Chapter II on Selection, great care was exercised in picking proper personnel to man the submarines during World War II. In addition to careful screening and selection, every effort was made to insure adequate and proper training of all of the submarine personnel. Also, every effort was made to properly indoctrinate all personnel into the submarine service,. —a unit notably for its esprit de corps, so that they would realize that they were in the very best possible specialty of any of the military services* All of this was exceedingly important and very new, but none of it would have been successful, were it not for the special care exercised in maintaining this highly selected and trained personnel at a very high point of readiness both physically and in matters of morale* As part of this maintenance of physical fitness, the Pacific Submarine Force conducted pre-patrol examinations of all personnel to make certain that no one was permitted to go on a wartime patrol, who was in any way physically or emotionally below par* In addition to special examination of the crew, the pharmacist’s mate vras called in for pre-patrol conferences in order to supply him with additional late information relative to new approaches to the treatment of various diseases and also to talk over any special personnel problems presented by any members of the crew. In addition to these very excellent approaches, the Pacific Force Medical Officer also established the custom of holding brief conferences with the Commanding Officer and Executive Officer and Pharmacist’s Mate of each vessel prior to its departure on patrol. An excerpt of a report from the Pacific Fleet Medical Officer, entitled "Submarine Medicine, Health, and Morale", will servo to amplify this statement* "Each submarine prior to departure on patrol received a briefing by conference with the Force Commander, on natters of change in tactic, policies and doctrines referrable to the conduct of operations. Medical department activities were likewise affected by changes in phases of warfare, so it was considered advisable to arrange a conference briefing, attended by the Commanding Officer and, or Executive Officer, and Pharma- cist’s Mate of each vessel, in which the Force Medical Officer covered subjects orally that were difficult to accomplish by directives. The oral discussion was supplemented by written or mimeographed instructive material. These conferences were particularly used in the final war phases when targets became increasingly scarce and when many vessels had life guard duties for air craft strikes as primary missions. On other occasions rescue duty was assigned as an additional mission. After having departed on a routine patrol, other vessels performed rescue missions simply by accidental encounter or in picking up prisoners of war from their own destroyed targets. In all these instances it is evident that survivors likely to be encountered would require medical attention for any or all of the hazards of warfare at sea. Much briefing was directed toward the care of survivors but also included other items. "Vitamins were included in the discussion in an attempt to survey the different methods of usage and to make suggestions that bottles of vitamin tablets placed near drinking fountains in such a position as to be unavoidable by the drinker was an additional reminder and incentive to insure usage* Personal attention on the part of the pharmacists mate was advised to insure daily ingestion by all lookouts." Actually, aboard submarines we find that again great emphasis is placed upon special care given to officers and men of the submarine crew, A brief listing of measure taken to insure both health and a high state of morale will serve to illustrate this point. Submarines were air-conditioned and actually more habitable than any other type of ship of combat type. Berthing space was adequate and of excellent quality, much better than even some of our largest battleships. Food was not only of highest quality and great quantity, but offered a variety not encountered on any other type of ship, and in addition to this, was well prepared, for cooks were carefully selected for submarine duty. The icebox was open and snacks available at any time. Ice-cream was served the crews daily. Every effort was made to insure catering to the appetites of submarine personnel* Not only was there ample drinking water available; water was also available for bathing and laundry and all other uses in much greater quantity than was found on larger ships. Smoking was allowed, except in most unusual circumstances. Vitamin tablets were provided for all members of the crew. Ultra-violet lamps were included in each medical allowance for use by the crew; in short, every effort was made to make certain that every- thing was done that could possibly contribute to the maintenance of both health and morale. One of the most important innovations put into effect by the Pacific Force Medical Officer was the careful post-patrol examinations which were conducted in order to ascertain which individuals might need medical or dental treatment, or who might be candidates for transfer to a Rest Camp. In this connection, it is believed of sufficient interest to again quote verbatim from "Submarine Medicine, Health and Morale", reporting the procedure used in conducting the post-patrol activity. "The usual succession of events was about as follows for the Pearl Harbor refits: All Force and Squadron Staffs as well as the Base Heads of Departments were notified of the arrival from the signal tower, approximate arrival data having been distributed by the Force Commander on the preceding day. The above array of officers gathered as a greeting party at the arrival berth along with the band rendering appropriate exhilaration, mingled with the hails and greetings from the large attendant gathering of officers and men who did not form part of the official greeting committee. Two other conspicuous items of the greeting- party were two trucks, one laden with accumulated mail and the other stacked with fresh fruits and ice-cream. Obviously all these are morale factors, even though the ravenous manner in vhich fruit disappeared might indicate the presence of some food deficiency. At present, it is the opinion that this is merely a "sight hunger1' augmented by youthful over-enthusiasm. The fruit and mail were put aboard only second to the gangway and the most senior Staff officers, the latter greeted the commanding officer and the remainder of the shipfs company with congratulatory remarks upon the success of their late mission. Of first concern to the medical department of course, were the immediate emergencies, for which an ambulance was kept in readiness near the berthing area. Immediate arrangements were made for physical and dental examination of the entire shipfs company, officers and men. Experience had taught that these examinations must be arranged for at the earliest possible time after arrival because once the crew has been dispersed to the recuperation area, it was next to impossible to congregate them subsequently. Prudence dictated that prompt examination was necessary to elicit minor changes likely to disappear quickly. The usual scheme was to have the Pharmacists Mate appear with the crew at the Sickbay about 0830 on the succeeding morning. All health records ivere transported to the Sickbay in a specially made container furnished by tho base, for minimizing record loss. ’’First and foremost, the entire crew was transported to the Photo-fluoroscopic Unit for chest x-rays. It sufficies for the present that any evidence of acid-fast infection resulted in removal entirely from the submarine service. "The next item on the program was a complete physical examination including checkage of weight, conducted in a special examining room. Qualified submarine medical officers only conducted the examinations, the crew being stripped and conducted through the examining room on almost a production line basis. These examinations were accomplished on both officers and men. The dental department was the next recipient of the crews vhere each man received a complete dental examination, and the needed dental repair was made a matter of record. "Results of both the physical and dental examinations were entered upon 6 by 7 inch cards* These cards thereafter became the property of the boat and formed a continuous history of the major and minor illnesses of each individual as long as he was a member of the ship's company. Upon transfer to any other submarine force activity the card was likewise transferred to the receiving unit and the reason, if any, for transfer indicated there- on, If transferred out of the submarine service, the card was returned to Sub Base, Pearl Harbor, and placed in the dead files. It is realized that the standard Health Record is a continuous history, but it failed to serve the intended purpose in that only conditions sufficiently grave to warrant admittance to the Sick List find entry therein* Also, at each reenlistment much of the pertinent history details were removed and transmitted to the Bureau of Medicine and Surgery* "Upon completion of the examination, those individuals who needed no attention had their cards returned to the Pharmacist’s Mate of the boat concerned. Cards of those needing treatment were retained by the examining officer for further study, treatment and disposition entries* "Inasmuch as the entire crew was to be transferred to the Rest and Recuperation Annex located in the Royal Hawaiian Hotel, a distance of some 12 miles from the base, immediately upon com- pletion of the examination, it was evident that most of the treatment and dental repair work would be accomplished at the Annex. It was therefore necessary to establish a medical and dental dispensary in the Annex. Naturally those individuals who had very minor ailments were allowed to proceed to the Annex, where they were treated by a medical officer regularly stationed in the Annex Dispensary and furnished by the Sub Base, Pearl Harbor, complement. The Annex medical officer was advised of this condition and treatment needed on the history card. Graver ailments were either retained at the base and treated in the base ward or as the occasion demanded, transferred to the hospital. Concerning those latter individuals, those not likely to be fit for the next patrol, the Commanding Officer of the boat was so advised in order that early replacements were possible. "The dental department transferred the information con- cerning the dental repair needed on a special card to the two dental officers regularly stationed at the Annex and furnished by the base complement. Dental repairs were accomplished during the rest and recuperation period. "Mien all medical and dental treatment needed was complete, such was indicated on the cards and the latter returned to the base for preparation of a summary report. The completed cards were then returned to the boat's Pharmacist's Mate along with the summary report. The original summary report was sent to the Squadron Commander conducting the refit, one copy was retained in the boat file, one copy was sent to the Force Record Office, and one copy was retained for presentation along with the completed cards to the next refitting agency. "These provisions resulted in the exact medical status being a matter of knowledge to the Squadron Commander, the Com- manding Officer of the boat, as well as the Pharmacist's Mate, and the Force Medical Department, Also, the next refitting agency had an individual history of each crew member prior to his appearance for the next refit examination# The Pharmacists mate of the boat was required to bring the individual history cards up to date by addition from a rough log any conditions occurring while on patrol. Cards, summary report copy and rough logs were together presented to the medical officer of the next refitting agency for examination, information and guidance. Condi- tions occurring on patrol are made known to the Force Medical Department by preparation by the boat Pharmacists mate of a Form "A" and transmitted when mailing facilities were available," Of all of the measures used to insure the utmost in caring for the welfare of the Submarine Force, we believe that the sub- marine rest and recuperation program leads the list in importance. It is amply and rather interestingly discussed by the previous mentioned report from which we quote: nMen, like machines, require refitting for peak efficiency, when required to experience continual daily physical and emotional strain as imposed by submarine wartime patrols. Patrols usually occupied a period of 30 to 60 days, exceptions occuring of both longer and shorter duration. Factors determining the length of the patrol period were expenditure of fuel and ordnance materials in the majority of instances. Battle or engineering casualties constituted a smaller group of patrol terminating factors. The need for rest and recuperation for the crews during the shipfs refit was recognized early in the war and a program was formulated and put into operation. "The refit periods, usually, were of two weeks duration followed by a training and reloading period of 7 to 10 days* Under this regime each vessel was able to make four to five patrols per year* Owing to the enormous size of the operational areas and the large number of submarines in the Force, it was necessary 1b establish a number of refitting points being located in the fol- lowing places! Midway, Majuro, Guam-Saipan Area, Milne Bay, Manus, Fremantle Area, Brisbane Area, Subic Bay, Pearl Harbor and Mare Island. These refitting areas, because of their location, divided the refit periods into two general classes. One type might be entitled the "glamorous" type, of which Mare Island, Pearl Harbor, Fremantle and Brisbane were the composite members. The second type might be known as the "athletic" recuperation period, with Midway, Majuro, Guam-Saipan Area, Manus and Milne Bay as the composite members. Obviously, each of these types was so named because of the kind of recreation afforded. In type one, opportunity was afforded for recreation offered by more or less well populated areas, where mixed community social life formed a large part of the recreational program. Type two, in the remote forward areas, by location limited the recreational period program, mainly to individual and competitive sports. Despite the classification into the two general types mentioned. all of the refit points cannot be described as having only the type characteristic under which they were classified* "Naturally, the Mare Island refits, with the opportunity for leave and visits to home and relatives, were the most popular from the personnel standpoint. This type of refit had only been granted when vessels were in need of Navy Yard overhauls, occur- ring once per five or six patrols. In general, these Navy Yard overhauls, afforded the best rest period of any of the refit locations. The crews appeared refreshed and eager for resumption of combat patrol duty. In a few instances the return to the Continental limits revived the memory of the comforts of Mainland duty to the point of producing reluctance to resume patrol status. Notably among the latter exception were the young individuals who had ventured into matrimony during the overhaul period. At each stop on the outward journey to the patrol areas, the recently wed were frequent visitors to the medical departments with imagined or exaggerated illness being projected as the basis of their lost motivation, "The Brisbane and Fremantle areas were extremely popular to submarine personnel as refit and rest points. The novel experi- ence of a new and strange land, plus the cooperation and generosity almost to a fault, of a friendly people amplified the opportunity of social intercourse and recreational activity, to the extent of removing entirely from the fields of memory the recent life aboard during patrols. "A unique refit plan was initiated and maintained at Pearl Harbor* The nationally famous Royal Hawaiian Hotel was leased and converted into a rest camp. This elegant hostelry with its awe-inspiring and ample grounds was esthetically and terrestrially ideal to rest and relaxation* The opportunity for water sports at the adjoining Waikiki Beach was unlimited# All possible types of sports equipment were procured or constructed# Beer gardens and soft drinks facilities were provided. Motion pictures, stage plays, libraries, boxing matches, photographic equipment, orchestra recitals, and si$it-seeing tours, were all parts of a recreational plan, which had as its motive to be complete to the point of lacking in appeal to no one regardless of their tastes# In addition, the adjacent city of Honolulu furnished opportunity for contact with activities of urban community life to include female companionship and alcoholic beverages# The use of alcohol at this rest camp was confined to beer# "The Midway, Majuro, Guam-Saipan, Manus and Mine Bay rest and recuperation camps stressed athletic games, interest in the flora and fauna of the locale, bathing and water sports, recreation halls with suitable inside games, amusement machines and beer# Motion pictures and occasional stage shows were available# "In all the rest and recreational camps there seemed to be two basic ideas, first, the idea of compulsory participation was entirely dispensed with, the facilities were provided, but the initiative was dependent upon the individual and his desires of the moment. Every effort for additional appeal was made by procure- ment of adequate and diversified equipment. In the field of sports, athletic specialists were employed, who, when interest was exhibited coached and explained, in an endeavor to create greater interest. Notable was this opportunity for participation with or against the specialists, some nationally famous in athletic events# The motive of voluntary participation was also maintained in those who were not athletically inclined, as a rule, or for the moment# The individual himself dictated his method of rest and recuperation# "The second basic idea of the rest and recuperation plan was to create a period with as oomplete disassociation from the submarines themselves as possible# This plan was inaugurated by removal of the crews from the boats and transfer to the rest camps as soon as possible after arrival from patrol# Relief crews were provided to board the ship upon arrival and conduct the material refit of the vessel. Rest camps were as a rule located considerable distance from the berthing areas to increase the reality of the separation. Crews did not return to their vessels until the refit was complete and time for the training period was at hand. "If it is necessary to answer the question as to which type of rest and recuperation period is most efficient, the answer is not apparent. Inasmuch as all the refit establishments were not purely of one type or another, but rather having characteristics of both types of recreation, it is possible that a mixed type of program is most ideal. It was a matter of observation that in both the so-called "glamorous" and "athletic" recreation period, after the initial eight or ten days, there was a noticable lag in participation in either social life or sports, whichever pre- dominantly offered by the camp. Some individuals shift from sports to social life or vice versa, others prefer quiet relax- ation or sleep. This observation may be interpretated as indication that the rest status was obtained in a shorter time than thought necessary or that the mixed recreation was most efficient. "Despite the lack of a clear indication as to the nature of the most desirable rest and recuperation plan, the operational results, the low incidence of physical and mental disease, the minimal attrition, were ample evidence to warrant the program as enacted." VI - SUBMARINE MEDICIAL FACILITIES AND EQUIPMENT Facilities for medical care of submarine personnel during the period of World Wa** 11, consisted of: dispensaries, located at the various submarines bases; the submarine tenders and their medical staffs and large medical spaces and storehouse of medical supplies; and the submarine medical department itself, consisting of one Pharmacist’s Mate and his supplies and equipment, No detailed discussion is believed necessary or desirable concerning the dispensaries available for the care of submarine personnel, as they were in no way significantly differ- ent from other dispensaries organized for the care of other Naval personnel, however, the writers of this history would like to point out that they believe that in any future emergency every effort should be made to have as many as possible of the medical personnel, from the Senior Medical Officer on down, qualified in submarines. This would in a 1: rpe measure provide for the necessarv understanding of submarine problems and insure a more sympathetic handling of submarine personnel. With the submarine tender, as with the dispensary, it is not believed that a detailed discussion of all the facilities and equipment and supplies is in order in this type of history, such information being available elsewhere. It may be stated that in general these medical facilities, equipment and supplies were adequate for submarine needs. One distinctive feature of the equipment of the sub- marine tender was the inclusion of a pressure chamber for the handling of decompression for any diving, rescue, or salvage operations that might be necessar}', This of course required that some member of the medical de ertment have additional knowledge of handling of problems connected with high pressure air. Again, as in the case of the dispensaries, it was abundantly shown, as pointed out in previous chapters, that the Senior Medical Officer of the tender should, if possible, be a Qualified Submarine Medical Officer, If this is not possible, then the Qualified Submarine Medical Officer aboard, even though he be junior in rank, must be designated as the Squadron Medical Officer, in order to have a proper functioning of the submarines attached to the tender. In the case of the submarine, it is well to be remind- ed that the medical department consists of one specially selected and specially trained Pharmacist's Mate, and that only in rare instances is there a medic; 1 officer ever carried aboard a submarine. It is believed desirable to include in this dis- cussion of the submarine medical department, the allowance list of supplies and equipment issued to each vessel upon its commissioning. It should be pointed out that this list is changed from time to time officially, and that the actual list of materiel aboard changes even more frequently as individual Pharmacists Mates add to or subtract from this allowance accord- ing to their own individual preferences and desires. The typical wartime commissioning allowance follows: SUBMARINE COMISSIONING ALLOWANCE Glcss 1 - Drugs, Jhemicrls and Biological Products Stock No. Item Unit Issued 1-106-245 Acetophenetidin, Acetylsalicylic Acid and Caffeine Tab, 1000s Bottle 1 1-010-000 Acetylsalicylic acid Tablets, 0.324 Gm. (5 gr.), 1000s Bottle 2 1—048—010 Alcohol, g gal., (Ethyl) 1-054-750 Alkaline Aromatic Solution Tablets, 100s Bottle 1 1-061-075 Ammonia Spirit, Aromatic, 2cc,, 4s Pkg 4 1-061-100 Ammonia Spirit, Aromatic, J pt. Bottle 4 1-068-605 Amphetamine Sulfate, Eacemie, Tablets, 0.01 Gm(l/6 gr»)l00s Bottle 1 1-098-502 Benzedrine Inhaler, 250 mg. Each 10 1-099-082 Benzoin Tincture, Compound, 1 pt. Bottle 1 1-104-000 Bismuth Subcarbonate, 1 lb. Bottle 1 1-106-640 Boric Acid, 1 lb. Bottle 1 1-106-647 Boric Acid Ointment, 4 oz. Tube 24 1-106-712 Brendy, 2 oz. Bottle 20 1-108-470 Butacaine Sulfate, 5 Gm. (Butyn Sulfate) Bottle 1 1-108-485 Butacaine Sulfate Ophthalmic Ointment, 12 tubes (Butyn Sulfate) Box 1 1-109-500 Caffeine and Sodium Benzoate Injection, 0,5 Gm (7igr.), 2cc., 12s Box 1 1-111-000 Calamine, Prepared, 1 lb. Bottle: 1 1-121-220 Camphor and Soap Liniment Powder, 57 Gm. Jar 2 1-124-511 Capsule, Gelatin, Pharmaceutical, No.l, 100s Box 1 1-129-010 Cascara Sarreda Tablets, 0.25 Gm. (4 gr.) 100s Bottle 6 1-137-310 Chloroazodin Saline Mixture Tablets, 0,55 Gm.(8j Grs.), 100s Bottle 1 1-148-985 Codeine Sulfate Tablets, 0.032 Gm, (4 gr.) 100s Bottle 1 1-160-100 m-Cresylacetate, 1 oz, (Cresatin) Bottle 1 1-165-000 Dextrose and Sodium Chloride Injection, lOOOcc,, 6s Box 1 1-175-300 Epinephrine Hydrochloride Injection, 1:1000, lee., 12s Box 1 1-175-330 Epinephrine Hydrochloride Injection, 1:1000, 1 oz. Bottle 1 1-204-005 Foot Powder, 4 oz. Can 40 1-218-000 Glycerin, 1 lb. Bottle 2 1-223-000 Glycyrrhiza and Opium Compound Tablets, 1000s Bottle 1 1-227-000 Hexavitamin Tablets, 100s (Multivitamins)Bottle H 1-229-000 Hydrogen Peroxide Solution, 1 pt. Bottle 2 1-235-000 Iodine, £ lb. Bottle 1 1-235-120 Iodine Tincture, 10 cc, 3 vials Pkg, 6 1-240-995 Ipecac and Opium Tablets, 0,324 Gm. (5 gr.) 100s Doverrs Powder) Bottle 1 1-245-200 Jelly, Lubricating, 4 Oz, Tube 1 1-263-020 Magnesium Sulfate, 2g lb. Can 1 1-273-915 Mercuric Oxide, Yellow, Ophthalmic Ointment 1$, 1/8 oz, 12s Box 1 1-278-700 Mercurous Chloride, Mild, Compound Ointment 50 tubes Box 2 1-285-705 Merthiolate Tincture, 1 pt.(1:1000) Bottle 1 1-295-510 Morphine Tartrate Syrettes, (0,032 Gm, (i gr.), 5s(l,5cc) Pkg, 7 1-300-810 Neosynephrine Hydrochloride Solution, 1$, 1 pt. Battle 2 1-301-805 Nikethamide Injection, 25$, ij cc, 5s Box 1 1-323-030 Opium Tincture, Camphorated, 1 pt, (Paragoric) Bottle 1 1-336-000 Petrolatum, Liquid, 1 q. Can 2 1-338-025 Petrolatum, White, 1 lb. Gan 2 1-339-600 Phenobarbital Tablets, 0.032 Gm, (i gr,), 100s Bottle 4 81 1-386-585 Quinacrine Hydrochloride Tablets, 0.1 Gnu (l|gr.) 100 s (Atabrine) Bottle 5 1-391-000 Quinine Sulfate Tablets, 0.324 Gm, (5gr) 1000s Bottle 1 1-404-675 Silver, Mild Protein, Tablets, 0,299 Gm (4,6 grs), 100s Bottle 1. 1-404-740 Silver, Strong Protein, Tablets, 0,150 Gm. (2.3 gr.),100s Bottle 1 1-415-000 Sodium Bicarbonate, 1 lb. Can 1 1-417-020 Sodium Bicarbonate Tablets, 0.648 Gnu (lOgr.) 1000s Bottle 1 1-429-500 Sodium Chloride Isontonic Solution, lOOOcc, 6s Box 1 1-429-520 Sodium Chloride Tablets, 2,25 Gm, (34.7 gr.) 100s Bottle 1 1-445-000 Sodium Salicylate Tablets, 0,324 Gm. (5 gr.) 1000s Bottle 4 1-462-100 Sulfadiazine, 1 oz. Bottle 4 1-462-140 Sulfadiazine Ointment, 5%, 1 lb. Jar 1 1-462-200 Sulfadiazine Tablets, 0,5 Gm. (7i gr) 1000s Bottle 1 1-462-300 Sulfadiazine Sodium Injection, 5 Gm, 20 cc, 6s Box 1 1-463-490 Sulfanilamide, £ lb. Bottle 2 1-463-975 Sulfathiazole, 1 oz. Bottle 4 1-464-100 Sulfathiazole Tablets, 0,5 Gm, (7i gr), 1000s Bottle 1 1-467-050 Sulfur Ointment, 1 lb. Jar 1 1-471-755 Tetracaine Ointment, 1 oz.(Pontocaine) Tube 1 1-472-600 Thiamine Hydrochloride Injection, 0.05 Gm (1/12 gr.) 500s Bottle a 1-501-000 Zinc Oxide, 1 lb. Bottle x 1-502-000 Zinc Oxide Ointment, 1 lb. Jar i 1-607-104 Plasma, Normal Human, Dried, 500 cc. Pkg, 4 Glass 2 Surgical Dressings 2-002-185 Bandage, Cotton, Elastic, 2 ins by 5g yards, 12s Pkg, 1 2-002-200 Bandage, Cotton, 3 inches by 5g yards, 12s, Elastic Pkg. 1 2-006-204 Bandage, Gauze, Roller, Camouflages, 2 inches by 6 yds. 12s Pkg 11 2-006-206 Bandage, Gruze, Roller, Camouflaged, 3 in, by 10 yds. 12s Pkg, 4 2-013-500 Cotton, Absorbent, 4 oz, Pkg, 60 2-014-000 Cotton, Absorbent, 1 lb, . Roll 4 2-017-425 Dressing, First Aid, Camouflaged, Large. Each 14 2-017-430 Dressing, First Aid, Camouflaged, Medium Each 50 2-017-435 Dressing, First Aid, Camouflaged, Small Each 24 2-017-5B5 Dressing, Gauze, and Adhesive Plaster, Camouflaged, 1” x 3n, 100s Pkgi 4 2-017-680 Dressing, Head, Adjustable, Compressed, Camouflaged Each 6 2-022-000 Gauze, Plain, % inches by,25 yards; Pkg, 4 2-034-510 Plaster Adhesive, Surgical,. 2 inches by 5 yards Spool 11 2—035-500 Plaster, Adhesive Surgical, 12 inches by 5 yards. Roll X 2- Suspensory, 12s Pkg, 1 Class 3 Surgical and Diagnostic Supplies 3- Applicator, Wood, 1/8 by 12 inches, 500s Pkg, 1 3-070-100 Atomizer, Hand, Glass Each 2 3-070-140 Bulb, Rubber, Hand Atomizer Each 1 3-096-500 Bath, Eye Each 3 3-104-100 Blower, Powder Each 2 3-176-500 Catheter, Urethral, Rubber, Nelaton, lOFr, Each 1 3-176-520 Catheter, Urethral, Rubber, Nelaton, 14Fr, Each 1 3-176-540 Catheter, Urethral, Rubber, Nelaton, 18Fr. Each 1 3-212-800 Cot, Finger, Large, 12s Each 1 3-245-500 Depressor Tongue, Wood, 100s Box 3 3-333-600 Forceps, Dressing, Straight, 5j inches Each 1 3-379-800 Forceps, Tissue, Spring, 5 inch Each X 3-390-700 Gag, Mouth Screw Type Each 2 3-397-880 Gloves, Surgeons, Size 8 Pair 2 3-419-200 Holder, Needle, Hegar-Mayo, 7 inch Each 1 3-447-100 Blade, Operating Knife, No,10,6s Pkg, 1 3-447-120 Blade, Operating Knife, No,11, 6s Pkg, 1 3-447-800 Handle, Operating Knife, No. 3 Each 1 3-465-900 Loupe, Binocular Berger Each 1 3-495-400 Needle, Hypodermic, 23 rage, 3/4 inch, 12s Box 1 3-497-980 »/ire, Hypodermic Needle, 4 inch, 12s Bundle 1 3-524-420 Needle, Suture, Surgeons Regular, 3/8 Circle, Pkg. Pkg, 1 3-524-540 Needle, Suture, Surgeons Regular, 3/B Circle, Cutting Edge, Size 16, 6s Pkg. X 3-540-200 Otoscope, Electric Each 1 3-594-800 Razor, Safety Str. Each 1 3-599-940 Resuscitor, Portable Each 1 3-594-BOO Blade, Safety Razor, 5s Pkg, 1 3-683-800 Scissors, Bandage, Lister, 5h inch Each 1 3-649-100 Scissors, Operating, Curved, Double Blunt 5j inch Each 1 3-670-420 Shield, Eye, Single Each 12 3-713-100 Sphygmomanometer, Aneroid Each 1 3-721-200 Splint, Bass\*/ood, 12s Pkg. 1 3-732-800 Splint, Wire Mesh, 5j inches by 1 yard Rolls 2 3-739-800 Spud, Eye, Dix Each 1 3-742-300 Stethoscope, Ford Each 1 3-75B-380 Suture, Den .al. Size 0, 12s Pkg. 1 3-767-900 Suture, Silk, Braided, Single Armed, Size 0.12s Pkg, 1 3-767-940 Suture, Silk, Braided, Single Armed, Size 2, 12s Pkg. 1 3-774-600 Suture, Silk, Twisted, Size 000, 12s Pkg. 1 3-782-920 Suture, Surgical Gut, Nonboilable, Type A Plain, Size 0, 12s Pkg. 1 3-782-940 Suture, Surgical Gut, Nonboilable, Type A Plain, Size 1, 12s Pkg. 1 3-782-960 Suture, Surgical Gut, Nonboilable, Type A, Plain, Size 2, 12s Pkg. 1 3-795-850 Syringe, Ear, Pomeroy, 2 oz. Each 1 3-796-600 Syringe, Irrigating, Urethral, 1/8 oz. Each 12 3-803-800 Syringe, Luer, 2 cc Each 3 3-804-100 Syringe, Luer, 10 cc Each 2 3-829-400 Tourniquet, Elastic 2 l/8 inch Each 14 3-853-100 Tube, Colon, 300Fr. Each 1 3-865-800 Tube, Stomach, 30Fr. Each 1 3-876-715 Tubing, Rubber, Red 1/4 inch Foot 12 3- Tubing, Rubber, Latex, l/8 inch inside diameter, l/32M wall Foot 15 Class 4 ~ Laboratory and Pharmacy Equipment and Supplies 4- Box, Ointment, Tin, 1 oz., 12s Pkg, 1 4-090-300 Box, Powder, Dispensing, 3 in nest, 12s Pkg, 1 4-097-000 Bulb, Rubber, 3 ml., 12s Each 1 4-102-820 Burner, Alcohol (Barthel) Each 1 4-187-525 Corkscrew Each 1 4-228-120 Dropper, Medicine, 12s Pkg. 1 4-276-100 Funnel, Glass, Ribbed, 16 oz. Each 2 4-275-120 Graduate, Glass, 125 ml. Each 1 4-311-120 Label, Direction, 100s Pad 1 4-361-000 Paper, Filter, Qualitative, 250 nun*, 100s Pkg, 1 4-365-030 Paper, PH indicator 100sBottle 1 4-395-000 Slide, GL, Micro, 72s 25 by 75 nun Box 1 4-397-350 Spatula, 3 inch Blade Each 1 4-401-200 Stand, Apparatus Support, Base 6g by 9 inches Each 1 4-401-315 Ring, Sup. inches W/SC, Clamp Each 1. 4-401-325 Ring, Sup, 3>\ inches w/SC. Clamp Each 1 4- Ring, Sup. 5 inch W/SC Clamp Each 1 Class 5 - Dental Equipment and Supplies 5- Blower, Chip Each 1 5-019-000 Bulb Each 1 5-142-200 Cement, Temp, Antiseptic Fkg, 1 5-182-000 Cotton Roll, J inch, 100s Box 1 5-189-000 Jup, Drinking, Paper Ctn, 10 5-235-050 Dispenser, Paper Cup Each 1 5-266-050 Excabator, Darby-Perry, 21 Each 1 5-280-000 Explorer, No. 6 Each 2 5-3H-0OO Floss, 100 yds, wfxed Spl, 2 5-365-405 Instr. Plastic, Woodson 2 Each 1 5-375-010 Lamp, Alcohol, Metal Each 1 5-375-O2O Wick, Alcohol Lamp, Small Each 1 5-419-005 Mirror, No. 5, Magnifying Each 1 5-419-350 Handle, Mirror, Gone Socket Each 2 5-426-150 Pliers, No. 6, Dressing Each 2 5-513-250 Bag, Paper, Waste Recple Pkg, 5 5-541-150 Scaler, B, SSW Each 1 5-547-150 Scaler, Zerfing Each 1 5-562-000 Slab, Mixing, Glass Each 1 5-568-000 Spa-tula, Cement, No. 324 Each 1 Glass 7 - Hosp. Equip, and Sup. Furniture and Fixtures 7-OB4-525 Sterilizer Inst. 13 by 5 by 3 inches 110 V aO-DG Each 1 Physical Therapy Equip, and Sup. 7-129-B15 Lamp, Ultraviolet SP. Des. 110V 60 G, AC Each 1 7-352-465 Pitcher, 1 qt. GRS Each 1 7-706-425 Bag, Hot Water or Ice, Combination Each 2 Ward Nursing and Miscellaneous Equipment and Supplies 7-709-220 Basin, Pus, GRS Each 1 7-710-945 Basin /ash, 4i qts. GRS Each 1 7-717-025 Bedpan, GRS Each 1 7-725-925 Brush, Hand Each 1 7-800-656 Flashlight, Hand Each 1 7-819-000 Hone, Oil, Arkansas Stone Each 1 7-822-075 Irrigator, 2 qt. CHS Each 1 7-807-000 Glass, Medicine, 1 oz, Each 3 7-827-075 J&r, Dressing, CRS Each I 7-837-705 Litter, Semi-rigid, Canvas Each 1 7-877-000 Pins, Safety, Large, 12s Card 1 7-932-000 Thermometer, Clinical, Oral Each 4 7-938-945 Tray, Instrument, 2 by B by 10 inches Each 1 7-944-090 Urinal, Male, CRS Each 1 Class 9 - Field Equip, and Sup. Kits etc. 9-207-125 First Aid Kit, Gun Crew Each 10 9-214-775 First Aid Kit, Life Boat Each 1 9-219-175 F-A Kit, Mo, and H.C,, Large Each 1 9-235-875 Forceps Set. Herao, Forceps Each 1 9-565-825 Surg. instr. Kit, Dressing Each 1 9- vfater Test, and Screening Kit Each 1 Class 10 - Professional Books 10- Handbook, Hosp, Corps, 1939 Ed. Each 1 10-167-600 ManMed Dept. USN Each 1 10-308-000 Treat. Cas. Chem. Mar, NM220 Each 1 10-443-030 Prin, Nursing, Harmer, 4th Ed, Each 1 10-567-120 Man Naval Hyg. Navraed 126 Each 1 10-747-570 Outline Treat. Frac,, ACS 3 Ed, Each 1 10-748-275 Spl, App, Bandages, US Army Each 1 Class 14 - Blank Forms 14-101-100 Annual Syphillis Report, 20s Pad 1 14-103-300 Report of Allotment Expenditures and Obligations, 25s Pad 1. 14-105-500 Individual Statistical Report of Patient Card 36 14-106-600 Individual Statistical Report of Patient Card 36 14-107-700 Hospital Ticket 50s Pad 1 14-108-800 Health Record, Cover Each 6 14-109-900 Health Record, Physical Examination, Set of 2 Set 6 14-110-000 Health Record, Immunization Record Sheet 14-113-300 Health Record, Abstract of Service Sheet 6 14-116-600 Health Record, Medical History Sheet 50 14-123-300 Certificate of Death 50s Fad 3 14-130-000 Med. Stores Ledger Sheet 100s Pad 3 14-136-600 Receipt, Transfer and Status Card, H.C, 75s Pad 1 14-137-700 Roster Report of the Hospital Corps, 100s Pad 1 14-285-500 First Aid Battle Casual, Man, Each 1 14-289-900 Electric Shock First Aid Treatment Each 1 14-291-100 Venereal Disease Contact Reports, 25 sheets Pad 1 14-293-300 Emergency Medical Tag 25 sets Pad 1 14-296-600 Emergency Medical Tag, Poster Each 1 14-297-700 Indiv, First Aid Packet (Poster) Each 1 14-309-900 Monthly Morbidity Report, 50s Pad 1 14-310-000 Immunization Record, U.S, Navy, 500s Pad 1 14-311-100 Report of Burial, 50s Pad 1 14-344-400 Prosthetic Laboratory Card Each 1 14-500-100 Catalog of Navy Material, BuMed Section Each 1 There is real need for a complete and exhaustive study of the entire medical allowance aboard submarines. This need is fold, but among the phases which need study can be listed the following: (a) Revision of the commissioning allowance in the light of the above recommended study, (b) Revision of the method of obtaining replenishment supplies. (c) Designation of the activity from which the supplies are to be obtained. In this connection we might note that there has been many changes during the past several years. We believe that all replenishment supplied for submarines should be obtained either from the Submarine Tender or Submarine Bases, in case of shore-based squadrons. The submarine Pharmacists mate should not under most conditions have to obtain supplies from a Medical Supply Depot, because in general the quantity that would be the smallest amount supplied is too large a quantity for submarine where storage space is an acute problem. (d) The entire problem of medical supplies must be ev- aluated in the of acute problem of storage space, particularly as we look forward to newer types of submarines, such as the guppy-snorkel, v;hose modifications further limit the already critical storage problem, (e) Of paramount importance is the preparation of a real Handbook for use of the pharmacists mate, giving not only general medical diagnosis and minor surgical care, but specifically covering the use of each item of equipment and supplies which he carries. The Hand- book available during the war period did not in any sense meet the requirements and it was found necessary to mimeograph and distribute all types of instructive material. This should definitely be corrected prior to any future mobilization, (f) One item that we believe it is imperative to clarify is the dental first-aid kit. None of an official nature was furnished from the Supply Depot during the war period. Several unofficial versions were con- structed in an attempt to meet this need. In the Pacific area, such kits were obtained by directing a letter to the Force Medical Officer; in the Atlantic, such kits were supplied at the Submarine Base, New London and also at the Portsmouth Navy Yard. No general agreement could be found as to what should be carried in the kits and therefore no general training program could be instituted covering the use of either the equipment or the medicaments. VII - ANALYSIS OF SUBMARINE PATROL REPORTS During each submarine war patrol, a complete running account was kept of all pertinent information. This report, made by the Commanding Officer, included whatever medical information was considered pertinent. In this instance fmedical* is used in its broadest sense to include personnel problems, food, habitability, as affected by temperature, humidity, air-conditioning, etc., as well as in the more strictly medical sense, including such things as accidents, injuries, illnesses and psychiatric difficulties. There were approximately 1520 submarine patrols made during World War II, the reports of most of which were available for study of the medical problems encountered, A complete study of these patrol reports was completed in the Research Division of Bureau of Medicine and Surgery, where all pertinent information likely to be of any value or interest to medical officers was abstracted and compiled by Comdr. Ivan F, Duff, USNR in a very complete report, entitled "Medical Study of the Experiences of Submariners as recorded in 1471 Submarine Patrol Report of World Lar II", This study (class- ified CONFIDENTIAL) analyzed all phases of medical interest in exhaustive detail and is available to authorized personnel from the Research Division of Bureau of Medicine and Surgery, Present plans call for its publication in a permanent form. At the Medical Research Laboratory, Submarine Base, New London, Connecticut, a similar study was made, in which 1489 patrol reports were carefully studied. The procedure at New London was first to prepare typed excerpts from patrol reports of all information of possible medical in- terest, This was a time-consuming operation, but was a necessary preliminary to the second phase of the work, which was the further reclassification of the material under ap- propriate headings, for example, all of the original material was separated under such headings as: medical conditions occurring; accidents and injuries; psychiatric casualties; surgical conditions; abdominal surgery; habitability, from the standpoint of air-conditioning, temperature, humidity, etc,; Food; Water; specific .mention of PhM, including com- mendation, etc,; and general personnel problems of signif- icance to those interested in personnel selection. The two individuals primarily interested —one from Res. Div. in Washington and one from MRL, New London, col- laborated on a series of papers, based on the above material. Although these papers have been, or are being published elsewhere, it is believed that it is worth while reporting them in this history, because they distilled out a consider- able amount of the valuable information contained in the above rather voluminous study of the patrol reports. These papers will be presented in the following:order: (1) Surgical Care on a Martime Operating Submarine, (2) Medical Aspects of Submarine Warfare - The Human Factor as Reflected in War Patrol Reports, (3) Psychiatric Casualties in Submarine Warfare, (4) Lung Training Pays Off - (a semi-popular article) (5) Analysis of Submarine Food Problems in World War II. (6) Upper Respiratory Infections and Contagious Diseases aboard Submarines, SURGICAL CARE ON WARTD.E OPERATING SUBMARINES By C. W. Shilling, Captain, Medical Corps, U, 3, Navy and Ivan F, Duff, Commander, Medical Corps, U, S. Naval Reserve Introduction In order to properly appreciate the submarine surg- ical problem it is necessary to understand that although a submarine does not ordinarily carry a doctor, its complement does include a Pharmacist’s Kate, whose training is akin to, though more extensive than, that of a skilled civilian first- aid man; but who, on a submarine, is necessarily the medical officer, the dentist, the nurse, and the chaplain all roiled into one. A rigorous selection program chooses a trained Pharmacist’s Mate from the general service who is at least 20 years old, is a high school graduate, is above average intelligence, and, as nearly as can be determined, is an emotionally stable, psychiatrically and physically sound adult. His additional training is designed to so equip him that he can diagnose and treat the more common ill- nesses, perform routine minor surgejyand in the absence of a medical officer, care for major surgical emergencies which nay arise. There were under his care in the Sub- marine crew approximately B officers and 75 men. To a civilian doctor this must sound impossible of achievement, and echo of charlatanism, V.'e are confident, however, that the following performance report will speak for itself and require no apology. The qualified submarine Pharmacist’s Kates were a credit to the Kedical Corps; and they were often, by all odds, the most valuable, and at the same time, the best liked men on the "boats". As complete a story as possible of surgical care on a wartime operating submarine will be considered in this paper. The primary source of material, admittedly in- complete and sometimes inadequate for statistical study, is the official patrol report made by the Commanding Officer of each submarine at the conclusion of a war patrol. Of the more than 1500 war patrol reports, 1489 were studied in pre- paring material for this article. Additional material has been gathered from official medical records, from personal experience of the authors, and from discussions held with many returned officers and Pharmacist’s hates of the submarine force. Injuries and Occasion for Traumatic Surgery Aboard Submarines Injuries were very common aboard combat submarines as substantiated by the fact that on 685 patrols, some 1203 in- juries were considered sufficiently important to justify men- tion in the official patrol report. In order of frequency there were: lacerations, contusions, sprains, abrasions, burns, shrapnel and gun shot wounds, fractures and heat exhaustion. Injuries were commonly sustained by personnel of the bridge watch, particularly in the lightning-like maneuvers necessary to clear the bridge in the relatively few seconds that elapse between the time the diving signal is given and the submarine is actually submerged. Smashed fingers, broken ribs, dislocations, bruised shoulders, and lacerations of various degrees were the result of this mass exodus of eight or so men from the bridge through a twenty-four inch hatch, and down the slippery and precipitous ladder into the conning tower. The bridge of a submarine affords scant protection against heavy weather, and not infrequently, it may be in- undated to waist depth. Personnel frequently sustained pain- ful and serious injuries when thrown about the bridge and against the periscope shears by the rough seas. To a lesser degree, all hands below deck were subject to the fury of the weather. Men were sometimes thrown from their bunks. Burns, caused by the spilling of hot coffee and soup, were commonly reported. The routine checking of torpedoes during rough weather was accompanied by the hazard of painful bruises, smashed fingers and in one case, by a fatal intracranial injury. The accumulative effect of continual harassment in severe storms was such that often commanding officers submerged the ship to weather out the storm and rest all hands. Some of the most stirring chapters of submarine war- fare concern gun engagements, literally duels to the death between enemy surface craft and submarines. Exciting though these encounters always were, they sometimes exacted their price in terms of painful shrapnel and bullet wounds. Ten submariners lost their lives in these engagements. In addition, exposed to the force of the sea, men were some- times thrown about the deck, against the gun mount, and on occasion were washed over the side. On three occasions, personnel on the bridge of submarines were seriously wounded (two fatally) when the ship was strafed by enemy planes. Pharmacists Mates were also called upon to treat in- juries which could be attributed to other sources than these hazards on wartime operating submarines. Japanese taken aboard, as prisoners, were frequently found to be seriously injured. It can be pointed out with pride that the care furnished them by the representatives of the medical pro- fession aboard submarines was always adequate and often- times brilliant. The thoroughness of the training and caliber of the performance of submarine Pharmacist's 1-ates is nowhere more apparent than is the care afforded survivors recovered in air- sea rescue operations. Throughout the war, 110 U. S. Sub- marines in 200 separate pick-ups recovered a total of 542 American and Allied airmen downed in Pacific waters in operations extending from Tokyo Bay to the Solomon Islands, Of these survivors, 259 (48$) when rescued required medical care, essentially for exhaustion and primary shock consequent to over-exertion and over-exposure. Ten percent were suf- fering from severe wounds with severe secondary shock, wine aviators, when recovered, were dead. Only two aviators died aboard submarines under the care of Pharmacist's Mates. Excerpts from Patrol Reports Dealing with Injuries j In order to illustrate some of the conditions described above, the following authentic excerpts from patrol reports have been selected; "One man received a severe laceration of the forearm which required seven stitches. Two men were injured by misfire of the 201'.M gun. In one of these cases it was deemed necessary to amputate two toes of the right foot. Due to a shortage of surgical instruments, (Editor's Note: this was early in the war) a pair of sterilized side cutters were used to cut portions of the shattered bone. Because the "phalanges,.....were completely shattered, they were not sutured bjit left open to allow free drainage. A generous amount of sulfanilamide powder was used. The other man was wounded in the shoulder but no lead or foreign body could be located. This man was back to duty in three days with no complications." "The medical department in the person of the Chief Pharmacist’s Rate did a particularly capable job in handling the Jap prisoner of war recovered after his plane was shot down. Though suffering from shock, second degree burns of the face and hands and several other serious wounds from gunshot and the crash, he was brought around very well and will probably arrive in port almost fully recovered," "Two wounded men were in excellent hands under the care of the Chief Pharmacist's tiate. Their recovery from wicked flesh wounds caused by a Jap,,50 caliber machine gun bullet is a tribute to his skill and ability. Two men with multiple shrapnel wounds were admitted to the sick list for a total of 50 man-days," "An injured German prisoner was treated for a dis- located left knee, broken right collar bone, badly lacerated mouth and nose and three missing teeth. Re- covery to date is satisfactory except that he succeeded in mis-aligning his clavicle after it was lined up properly." "The price of sinking one sampan, damaging one and learning the use they are put to (Editor's note: Submarine traps) was three men wounded. One man re- ceived two .25 caliber hits in the left side just beneath the floating ribs, the bullet ranging upward, fracturing the rib and puncturing the left lung, the other bullet lodged in the diaphram above the stomach, A second man received five hits in the right shoulder over the scapula: the third was struck in the right hip by a piece of flying metal as the target exploded. In view of the nature of the wounds, left the area 24 hours early, setting course for kidway at best speed. The Chief Pharmacist’s Mate is particularly com- mended for his quick and efficient action in caring for these three wounded shipmates. By his proficient skill and painstaking efforts he prevented complications of severe wounds and enabled return of his patient to the facilities of a hospital, well on the road to recovery. He has been recommended for promotion and the Bronze Star Medal," "Two men were knocked unconscious by heavy seas while standing lookout watch and suffered minor contusions of the shoulder, chest, and kidney areas, /mother man suffered lacerations of the scalp when he hit his head on the conning tower ladder while clearing the bridge in rough weather," "One man suffered a compound fracture of his right ring finger and a simple fracture of his index finger when a storeroom hatch cover fell on his fingers. The boat was dived to a hundred feet to furnish a stable platform for sewing up the fingers and setting the bones, khile the finger tips are still stiff one month after the accident, they have healed nicely and Fhklc is to be commended for his efficiency and skill," "The , on her second patrol, established an all time record for the recovery of friendly aviators when in five rescues she picked up a total of 30 men. The first man was recovered on 25 kay 1945 with severe lacerations and second degree burns. Five days later five more were recovered, all in good condition, 18 minutes after their plane had crashed. On 29 kay, sixteen were rescued, two of whom were seriously in- jured, one with severe head and body injuries, the second with a possible fracture of the back and skull. One man of this group died about six and a half hours after recovery and was buried at sea on 30 kay. On the afternoon of the same day 7 survivors from an Army bomber, clinging to a life raft buffeted in tremendous sea with waves at least 30 feet high, were brought aboard. One of these men had a bullet wound of the foot, a second a fractured clavicle." (Editor's note: the problems which confronted the CPhM during this 6 day period must have been at times overwhelming. On 1 June, a medical officer from a destroyer boarded the submarine; on the same day the survivors were transferred at Iwo Jima I Another Pharmacist’s hate had an entire surgical clinic on his hands with three women and three civilian men seriously wounded out of a group of 14 individuals rescued at sea. There were shrapnel wounds in all parts of their bodies re- quiring surgical treatment. In his own words, the Pharmacist’s Hate so described one case: ’’This woman had a piece of shrapnel at the bottom of her breast; there was a wound about three inches long and about two inches deep. First I stopped the bleeding. Then I cleansed it thoroughly with alcohol and put sulfanilamide powder in the wound. Then I put in 14 stitches and applied sterile dressings, 3he also had minor,wounds which I cleansed with merthiolate." (Editor’s note; when this boat finally put its passengers ashore fourteen days later, not a single case had be- come infected, Lhat trained surgeon could have done any better?) Appendicitis Aboard Combat Submarines in World War II Probably no other single disease is cause for more anxiety to Submariners than is appendicitis. Since medical officers could not be carried on submarines, it became doubly important to formulate a policy governing the treat- ment of all cases of appendicitis, and to promulgate it as widely as possible. To accomplish this, all officers at the Submarine School, U. S, Naval Submarine Base, New London, Conn,, both in the basic and prospective commanding officers’ classes, and of course, all Pharmacist’s Mates in the Submarine service and those in the "School for Pharmacist's Mates Entering the Submarine Service" were carefully indoc- trinated along the following lines: The diagnosis of appendicitis, without laboratory facilities and in relatively untrained hands is difficult and the errors in diagnosis might exceed the correct diagnosis. Gastric and gastro-intestinal disturbances and constipation are common in submarines and add difficulty to diagnosis. For these reasons conservative rather than surgical treatment should be instituted. Moreover, even if the diagnosis is certain, with modern conservative treatment more cases will recover than will go on to rupture —the percentage again is against surgery. They were also taught that even though their patient might turn out to belong to the small percent that would go on to rupture, the odds were still in the patient's favor — that he would wall off the infection and develop an abscess which could be drained at a later date. Realizing all of this, and most importantly, taking into account the relative inexperience of most of the Pharma- caist's Mates and the almost impossible conditions under which an operation would have to be undertaken, the final obvious order was —"Never resort to surgery." This order was put into effect toward the end of the first year of the war. The conservative medical treatment recommended was: NO food by mouth; the smallest sips of water by mouth (any evidence of dehydration treated by intervenous fluids); NEVER give a cathartic to a case of suspected appendicitis; a low gentle enema repeated, if necessary, until results are satis- factory (many of their cases of "acute appendicitis" were cured this way); absolute bed rest; sedation until resting quietly; icebag over right lower quadrant; sulfa drugs in adequate dosage and with proper safeguards; and, as it be- came available, penicillin. The Incidence and Mortality Rates of Appendicitis in Civilian Personnel in a group of comparable size and age to the one with which we are dealing in unknown. However, according to the Public Health Service in some 8,758 families of all ages who were under observation in 18 states during 12 consecutive months, appendicitis developed at a rate of 6,6 per thousand in males and 12,3 in females. For males, the incidence per age group is presented in Table 1, These figures are of interest because they indicate that between the ages of 15-35 appendicitis is very common —"the most common major surgical disease". Table 1 INCIDENCE OF ACUTE APPENDICITIS IN MALES* Age Per Thousand Under 5 years 1*8 From 5 to 9 years 5.0 From 10 to 14 years 3.3 From 15 to 19 years 9.3 From 20 to 24 years 10*1 From 25 to 34 years 12.1 From 35 to 44 years 7.0 From 45 to 54 years 2.7 From 55 and over 2.4 * From the Public Health Reports, Reprint No. 1981, Vol. 53, Ho 36, Sept. 9, 1938. Incidence and Mortality Hates of Appendicitis in Personnel Aboard Combat Submarines. The average complement aboard sub- marines on war patrols was approximately 75 enlisted men and 8 officers. The average age of the officers was 26.7 years and of the men about 22 years. At the conclusion of the war, in a group of 318 submariners picked at random, the average man had made 6.17 war patrols* The average strength of the submarine force in 1943 was about 8,755 men, in 1944 it was about 13,345 men. At no time during the conflict did the entire Submarine force exceed a strength of 25, 433 men. According to the statistical division of the U, S. Navy Bureau of Ledicine and Surgery, the diagnosis of acute appendicitis was made 78 times in 1943 (or 8.9 cases per thousand) and 124 times in 1944 (or 9.2 times per thousand), among personnel attached to submarines, but not necessarily on war patrols. It will be noted that this percentage is slightly under that to be expected according to Table 1, which argues in favor of the correct diagnosis having been made by the Pharmacist’s Mates. From information available in the submarine patrol report, it appears that Pharmacist's Mates made the diagnosis of Appendicitis (acute, chronic, or Diagnosis Undetermined, admitted for observation) on 116 war patrols in 127 instances during the entire war. On eight patrols more than one man was admitted with the diagnosis. In sixteen instances one case of appendicitis was reported from the same submarine on two successive patrols, presumably by the same Pharmacist’s Mate. The authors know of instances in which, during a two week period spent at a rest camp between war patrols, the diagnosis of acute appendicitis in more than one individual from the same boat was verified surgically. And although there is no doubt that submarine crews were sometimes "appendicitis conscious" a few Pharmacist’s Mates were plagued on successive patrols, by different individuals who undoubtedly had appendicitis. In the majority of instances from information available in patrol reports, the diagnosis as made by the Pharmacist's Kates cannot be verified. There can be no doubt, however, that in thirty-four instances their patients were sufficiently ill to warrant eventual transfer for medical treatment, fre- quently at sea from one submarine to another for further transfer. In eleven instances acute appendicitis was the cause for submarines to either leave their areas of operation, their formation, or terminate their patrol. Twelve cases of appendicitis occurring on patrol, upon arrival at port, are known to have been followed by surgical treatment. Ten of these were either definitely stated to have had or likely to have had a ruptured apoendix. This series of cases accounted for a total of almost 578 sick or man days lost —while on patrol —an average of about 4.6 sick days per case. In a few instances following return to port, prolonged hospitalization was necessary. To the best of our knowledge and experience, throughout the War in the Submarine Force, in not one single instance had death been reported due to, or related to acute appendicitis arising on a submarine war patrol. Commanding Officers and higher authorities were so impressed by the performance of Pharmacist’s Kates in handling these truly acute emergencies that in twenty-two instances they were especially commended in official patrol reports. Patrol report excerpts with reference to acute appendi- citis show this problem and how it was handled on our sub- marines on war patrols, "The most disconcerting thing that happened during the entire patrol (early in 1942) was a case of acute appendicitis that fortunately turned out to be some- thing else. The patient had all the symptoms of acute appendicitis. The decision was made to operate. Pre- parations were being made when the patient was seized with a violent spell of vomiting and cramps. The pain subsided and the temperature increased to 104° F. with symptoms indicating the appendix had ruptured. Further observation indicated a gastro-intestinal disorder and at the end of four hours the temperature had decreased to 101° F. where it remained for eight days. At the end of two weeks the patient was able to be up and around," "The third day out of 'Pearl1 a signalman came down with an acute attack of appendicitis. The 'doctor' was ordered (Editor's note: by the Commanding Officer) not to operate, and was instructed to keep the patient quiet, start treatment and get him well (This order might be difficult to carry out). It seems to me that there had been too much publicity lately about such cases and we thought we'd do our best to lick it and try and prevent an epidimic of appendicitis. The patient was confined to his bunk and ice packs were given continuously for four days. The morning after the initial attack, sulfathiazole was administered every four hours for the next four days. The patient had no more sharp attacks but the area remained tender for the next two days, after which the tenderness sub- sided and he was allowed up and about. No recurrent symptoms during the remainder of the patrol. The Pharmacist's Mate is to be commended for his devotion to duty and his efficient handling of this case." "The quick diagnosis and correct treatment of a case of acute appendicitis, by is deserving of particular attention and commendation. When the patient was turned over to the Medical Officer at Darwin, he was well along the road to recovery. This reflects credit not only on the individual but the Medical Service and to the medical course at Mew London, Connecticut." " had an attack of acute appendicitis, commenced ice packs and sulfadiazine treatment (May 1944). Temperature varied from 101.5 to 99.6 for next two days and pain became progressively worse. A Medical Officer from a destroyer came aboard to check patient's condition. Because of better facilities and probability of operation prior to arrival in Majuro, patient was transferred to the destroyer." "Shortly after reaching the patrol area, one man was suspected of acute appendicitis. The treatment used was preventative with the aim of minimizing the pos- sibility of the appendix rupturing, or in the event that it did rupture, this man was made a strict bed patient. Daily treatment consisted of ice bags to abdomen, frequent administration of morphine tartrate to relieve the pain and control intestinal peristalsis, sulfathiazole and sodium bicarbonate 4 daily doses of each, and a 5% dextrose saline injection and no food by mouth. Sulfathiazole wras discontinued after three days as it brought on vomiting. On the fifth day the ice bag was replaced with a hot water bottle. This continued for six days. The Chief Pharmacist's Mate is commended for his quick diagnosis and application of preventative measures. His professional ability is considered to be outstanding." Appendectomies Performed Aboard Submarines on War Patrols Although sufficient publicity has been given those appendectomies performed by Pharmacist's Mates at sea aboard submarines, for the sake of completeness and because of their interest the authors verify these cases as follows: The first was done aboard the USS SEADRAGOM, on 11 September 1942, concerning which little technical information is available. Subsequent to the operation, which lasted about 110 Three hours, the patient was on the sick list for fourteen days. The second man, who had been ill for about forty-eight hours, was operated upon aboard the US3 GRri.YBA.CK, on 14 December 1942. At the operation, which lasted about lg hours, the appendix was discovered to be ruptured; sulfanila- mide powder was instilled locally, drainage was instituted (an elastic rubber band) and the abdomen was closed. Ether was used as an anesthetic, tl e first assistant was a Motor Machinist’s Mate First Class. "Spoons were flattened and used for retractors, long nose pliers from the engine room were utilized. A submarine escape ’lung’ mouthpiece was used for administering the ether." The third and last case was performed aboard the USS SILVERSIDES on 22 December 1942* The patient had been ill for about twelve hours prior to the operation, which was per- formed on the wardroom table, with the submarine submerged at 100 feet. The effectiveness of the spinal anesthesia having worn off, "Ether wras administered, following the directions on the can. This anesthetized the operating staff as well as the patient. One hour after completion (the operation lasted about four hours) we tangled I’dth a destroyer. The patient convalesced the following morning —to the tune of torpedo firing, two depth charge attacks, two ’crash dives’ and an aerial bombing which knocked him out of his bunk. The conduct of the patient,, was exemplary throughout the operation and the period following," Comments made by the Conmanding Officer of one submarine concerning the operation performed aboard his ship are highly pertinent and, in the light of the above circumstances, understandable: "It is recommended that all men who have a previous history of, or indications of chronic appendicitis not be sent out on patrol until their appendix has been removed. This also applies to any other ail- ment which may require an emergency operation at some future date." Higher authority observed in connection with the operation on the SEADRAGON: "The incident.,.is believed to be the first of its kind in submarine history. While this case had a happy ending it is pointed out that this particular Pharmacist’s hate had had considerable experience in assisting at surgical operations...it is hoped that his success will not encourage others to take ..•.risks." One point of great interest to doctors charged with planning for any future emergencies is to be emphasized. With the remarkable history of NO mortality in the 127 cases of appendicitis recorded in the Patrol Reports and with the low morbidity, there appears to be no cause for the undue alarm which was experienced at least early in the war. Medical Officers can, with confidence, continue to teach conservative measures for the treatment of acute appendicitis with the assurance that the best possible treatment is being given to the men of the Submarine Service under the circum- stances. In not a few instances submarine personnel returning from war patrols on which they had had attack of acute appendi- citis were completely recovered when seen by Medical Officers. The decision as to whether such men should be permitted to remain aboard submarines once having had an attack of appendi- citis and without surgical treatment must be governed by local circumstances. In general, if conditions permit, an interval appendectomy is believed a wise decision. Summary On submarines, injuries were frequently sustained by above deck personnel in foul weather and in clearing the bridge. Major wounds were sometimes sustained in surface engagements with the enemy. Pharmacist’s Mates were frequently called upon to treat serious wounds sustained by prisoners of war and rescued aviation personnel. Of a total of approximately 542 American and Allied aviation personnel rescued by submarines throughout the war, only two of the many seriously wounded, died while under the care of submarine Pharmacist's Mates. Submarine Pharmacist's Mates were carefully indoctrinated in the conservative medical treatment of acute appendicitis. They made this diagnosis in 127 instances aboard operating sub- marines. Ten cases likely had a ruptured appendix when seen by medical officers. As far as is known, in not one single instance was a death reported due to, or related to acute appendicitis arising on a submarine war patrol. This is a fact which should be of considerable interest to all sub- mariners and physicians charged with planning for possible future emergencies. Submarine Pharmacist’s hates may well be proud of their performance record throughout World War II, These men, carefully chosen, patiently and thoroughly trained, aptly and often times brilliantly shouldered the immense responsibili- ties that were theirs. That they performed so excellently is a significant indication of what can be done in training lay personnel to handle medical problems. MEDICAL CARE ON WARTB.dE OPERATING SUBMARINES V by C. W* Shilling, Capt,(MC) USN and Ivan P, Duff, Comdr. (MC) USNR Introduction In order to properly appreciate the submarine medical problem, it is necessary to understand that although a submarine does not ordinarily carry a doctor, its complement does include a Pharmacist’s Mate, whose training is akin to, though more extensive than that of a skilled civilian first- aid man; but who, on a submarine, is necessarily the medical officer, the dentist, the nurse, and the chaplain all rolled into one. A rigorous selection program Chooses a trained Pharmacist’s Mate from the general service who is at least 20 years old, is a high school graduate, is above average intelligence, and, as nearly as can be determined, is an emotionally stable, psychiatrically and physically sound adult. His additional training is designed to so equip him that he can diagnose and treat the more common illnesses, perform routine minor surgery and in the absence of a medical officer, care for major surgical emergencies which may arise. There were under his care in the submarine crew approximately 8 officers and 75 men. To a civilian doctor, must sound impossible of achievement, and echo of charlatanism. We are confident, how- ever, that the following performance report will speak for itself and require no apology. The qualified submarine Pharma- cist fs Mates were a credit to the Medical Corps; and they were often, by all odds, the most valuable, and at the same time, the best liked men on the "boats”. As complete a story as possible of medical care on a wartime operating submarine will be considered in this paper. The primary source of material, admittedly incomplete and some- what inadequate for statistical study, is the official patrol report raady by each submarine pommander at the conclusion of a war patrol. One section of these reports deals specifically with features of health and habitability as they were encountered.♦ Additional material has been gathered from official medical records, from personal experience of the authors, and from dis- cussions held with many returned officers and Pharmacist’s Mates of the submarine force. Preventive Medicine Preventive medicine on a submarine includes the usual shipboard problems of supply and purity of food, and water, the proper stowage, refrigeration, and preparation of food ♦1489 patrol reports have been available for study. the inspection of food handlers, the disposal of garbage and other waste material, the sanitary condition and adequacy of the toilet and wash room facilities, the general health of the men, and instruction in first aid. In addition to these routine measures, the submarine Pharmacists Mate must be familiar with the medical aspects of the air conditioning problem, such as the oxygen supply, carbon dioxide removal, temperature and humidity control, and the potential hazards of noxious gases. He must also be familiar with the submarine escape problem and capable of instructing others in the use of the submarine escape appli- ance, the "lung” General Incidence of Medical and Surgical Conditions Reported from Combat Submarines. Pharmacists Mates attached to submarines on war patrols reported the four or five most commonly encountered medical conditions as acute communicable diseases, injuries, disturb- ances of the digestive tract, diseases of the skin, and diseases of the urogenital system. The incidence (per thousand) of diseases and injuries reported from submarines and destroyers in 1944, according to the statistical division of the U.S.Navy Bureau of Medicine and Surgery, is presented in Table I, Table I INCIDENCE OF DISEASES AND INJURIES BY CLASS OF DISABILITY, DESTORYERS AND SUBMARINES* 1944 CLASS SUBMARINES DESTROYERS Injuries • »••••••••••••• 39.9 39.6 Communicable Diseases Transmissable by Oral and Nasal Discharges • • • • • 33.9 40.8 Venereal Diseases 24.1 23.4 Other Diseases of the Infectious Type* 16.9 22.1 Exclusive of Combat Injuries Cold statistics cannot tell the true story however, for the illness of even one man in so closely integrated a crew prevents flexibility of the organization and often produces considerable inconvenience. This was particularly true when it was necessary to engage in prolonged periods of contact with the enemy with a crew whose efficiency and endurance had already been reduced by prevalent colds, etc. Upon occasion in this last war the incidence (sick or ntan-days lost) and cumulative effect of acute respiratory diseases aboard submarines on war patrols assumed military significance. Installation of germicidal lamps in the ventila- tion system of submarines was considered. Actually, a battery of such lamps was installed on one submarine, but unfortunately, loss of the ship prevented an adequate and complete evaluation of its efficiency. Medical Conditions Acute Communicable Diseases Aboard Submarines. As is evident from Table I, acute communicable diseases were common aboard operating submarines, having been reported in over 400 patrols, on 211 of which they accounted for 1068 sick or man-days lost. Despite the obvious incompleteness of the reporting, some details in regard to these illnesses are per- tinent and of interest. Colds (including "Acute Catarrhal Fever*1) and "Sore jy Throats", As in any branch of the service, these tw© diseases were very common, and relatively speaking, few submarine patrols were made without a varying incidence of them. In some 140 patrol reports they were thought sufficiently important to justify special notice. Because of their interest and for the sake of completeness a few of these comments have been taken from the patrol reports and will be quoted and discussed in the following paragraphs• It is quote natural to assume that men returning from leave brought the germs and viruses of these infections aboard the sub- marine which, as the following excerpts indicate, could be traced to unavoidable contact with shore based personnel, lowered individual resistance, inclement weather during the training periods, etc, "There were numerous colds aboard when we left Australia" "The epidemic of mild *Cat Fever* (Editors Note: Short for the official navy diagnosis of Catarrhal Fever, Acute which is really a severe acute "cold" with fever) that started prior to leaving Pearl Harbor continued throughout the patrol involving 20 men, seven of whom were turned in from three to eight days." "On departure, two thirds of the crew had colds which per- sisted for several days with noticeable redaction in efficiency". "Shortly after leaving Pearl Harbor, several cases of severe septic throats occured—believe contracted from an epidemic raging at the Submarine Base upon departure". As the following excerpts indicate, submarines on patrol commonly reported "epidemics" of colds, sore throats, etc, within the first one to three weeks of the cruise, not in- frequently before the submarine reached her operating area "A small epidemic of colds (16 colds, 4 tonsillitis. 2 ear-aches, 2 fCat Fever’) occured in the first two weeks", "A mild epidemic of colds and sore throats occured in the first week involving Q0% of the officers and crew", "The usual run of sore throats and minor colds in the first two weeks#" "As the patrol prgoressed, the cold germs gradually re- treated. " Generally these infections were short lived, reaching peak in the first and second weeks and disappearing thereafter. Upon occasion, however, as noted below, they persisted through- out the patrol, "Approximately 70foof the crew suffered from colds and ’Cat fever*# The combination of colds, lack of sleep, and lifeguarding (Air-Sea Rescue patrol for downed aviators-Editor*s note) resulted in a certain nervousness and irritability which fluctuated in intensity with the magnitude of the three items mentioned.” ”A mild epidemic of colds occured in the latter part of the patrol, believed due to lowering of resistance because of the length of the run,” ”There were four cases of mumps, one case of measles, and two cases of *Cat Fever1 —the latter being on the sick list on arrival at Midway at the end of the patrol," Patrols made in northern areas of operation, particularly in in winter, were especially apt to be handicapped by these acute infections. As indicated by the following excerpts the operating conditions encountered in these areas were extremely unfavorable. "With 27 days spent submerged, the boat was cold and damp| health was only fair, 50% of the crew had colds." "The temperature in the conning tower varied between 28 to 32° F; bridge personnel were constantly drenched with salt water spray, hail, and snow; ice accumulated two inches thick on the boat at night," "Operating in a cold climate with an average temperature of 54°F, eliminates the generally encountered fungus in- fection but reciprocates with an increase in the number of minor colds,- Also, colds were commonly experienced, as observed in 26 reports, with the passage of the ship from warmer climates to cooler operating areas, particularly if the three weeks refit period had been conducted at a tropical or semi-tropical base* "An epidemic of colds broke out—as the result of the sudden change in climate from Guam to the cold damp- ness of the weather in the Japanese Sea made in little more than a week." "Ninety percent of the crew had colds due more or less to the sudden change of climate from Pearl Harbor to Dutch Harbor." Interestingly enough, however, the reports of 43 patrols made in tropical waters were concerned with the in- cidence of acute respiratory infections. "It was uncomfortably hot on all day dives. Health was fair with many colds. Two were admitted to the sick list with !Cat Fever*," "A high incidence of coughs and colds and two cases of *Cat Fever* coincided with our passage across the equator". In a few instances the onset of colds was related to submerged operations, as noted in the following excerpts, "After the first all day dive of thirteen hours duration, twenty men developed colds," "A severe epidemic of common colds was experienced at the start of daylight submerged patrolling," Ample evidence exists, however, that once the colds had run their course, everyone became more or less immune to the common offending organism. Should, however, a new strain of organism be introduced, difficulty was again experienced t "Four cases of fCat Feverf were observed to develop after a short stop over (Editor’s note: a matter of hours) at Saipan," One submarine, having sunk an enemy submarine, rescued one survivor: "The German had a cold when captured. He brought a new variety of cold germs aboard resulting in another epidemic of colds and sore throats," Another submarine participated in the mass rescue of British and Australian prisoners of war. Some of these men developed an acute bronchitis within a few hours after they were taken aboard the submarine. Nine, when X-ray facilities were available, showed evidence of acute broncho-pneumonia. Other Acute Jommunicable Diseases Aboard Submarinest Other types of acute communicable diseases (classified accord- ing to Navy diagnostic nomenclature) reported were: Influenza (23 cases). Mumps (21 cases). Measles (20 cases). Pneumonia (12 cases), Jhicken pox (2 cases). Meningitis (2 cases), and Scarlet Fever (1 case). The fact that submarines on patrol were relatively free of mass illnesses such as these can be credited to luck, and to the sagacity of the Pharmacist’s Mates in treating and isolating, so far as possible, their patients from the rest of the crew,. Fifteen cases of Malaria and 5 cases of Dengue Fever occured - which developed following re- fits in tropical ports, A number of submarines experienced varying incidence of what was apparently Acute Infecious Jaundice —22 cases having occurred on fourteen patrols. It would appear that some of these cases were contracted during refits on Guam, The Tuberculosis Problem Aboard Submarines. The gen- eral problem and the incidence of tuberculosis aboard sub- marines was of concern to interested doctors throughout the war. Some of their comments taken from official Submarine Force documents may be of interest, "The expansion of personnel brought into contact many individuals with quiescent or minimal tuberculous lesions not readily discernable on routine physical examination." '•Prolonged residence in specialized craft such as sub- marines, where sunlight is nil and outside ventilation is reduced to only parts of each day were ideal for activation of quiescent tuberculosis and the close association in sleeping and working spaces, was even more ideal to droplet srread of disease, enhanced by the presence of increased heat and humidity," "Recognition of the problems involved led to the in- auguration of periodic chest x-ray examinations of submarine personnel." These surveys were accomplished at Pearl Harbor, Mare Island, Calif, and New London, Conn. Table 2 is a summary of such examinations at Pearl Harbor, T.H. Submarine Base, Table 2* TUBERCULOSIS The following summary shows the results of x-rays of all sub- marine force personnel between 1 November 1944 and 1 October 1945. The complement as of 1 July 1945 "was 21,522 enlisted men and 3,9U officers (including Submarines, Tenders, Bases, etc,). 23,232 men were examined by photofluorograms, The incidence of tuberculosis (per 1000) in the Submarine Force was 0.43$, class- ified as follows: Primary Type Transferred 1. Stable 11,411 0 2. Unstable 2 0 Re-Infection Type 1* Minimal (a) Active 61 61 (b) Inactive 41 18 2. Moderately (a) Active 20 20 Advanced (b) Inactive 1 1 3. Far Advanced (a) Active 1 1 (b) Inactive 0 0 Total 101 ** Through the courtesy of the Force medical Officer, of the ' Submarine Force, U, S. Pacific Fleet, Gaptain 0, D, Yarbrough, (MG) USN, ** Commander R, S, Henry, (MG) USNR, the medical officer who installed and directed the local fleet unit, cannot be praised too highly for the excellent way in which he has conducted the phot ©fluorographic program• Excerpts from the Pacific Submarine Force Medical Officers report add interesting sidelights to the facts presented in the table; "In only one vessel, where an open case v;as found, were there any additional cases that were considered to be infected from the open case*” "Results of the program , , are very gratifying to the Force Medical Officer, especially after the misgivings that accompanied reliance on tuberculin tests for crews in which tuberculosis was found prior to the establishment of the photo-fluorographic unit," "It is regrettable that two of the tuberculosis cases occured in medical personnel, one in a medical officer and one in a submarine Pharmacists Mate," "The incidence of tuberculosis in the entire fleet (based upon 185,000 photofluorograms) was 0.32$." The incidence of tuberculosis in submarine crews and in surface craft crews is presented in Table 3> and it was found in a survey taken at the Mare Island Naval Shipyard, California, TABLE 3* TUBERCULOSIS Submarines Month Number X-Rayed Hospitalized for TB Indications for Clinical Study Aug. 246 1 2 Oct. 275 1 0 Dec. 451 0 0 Total 972 2 2 Editorfs Note: Incidence 0.41) TABLE 3* ** (Cont *d) Surface Craft Month Number X-Rayed Hospitalized for TB Indications for Clinical Study Aug. 2,978 12 4 Oct. 865 1 0 Dec, 1,071 . 3 1 Total 4,924 16 5 Editor!s i Note: Incidence 0.42) * Through the courtesy of Commander J, E, Gompson (MG) USNE, Senior Medical Officer, Mare Island Naval Shipyard, Mare Island, California, ** The three months shown in this report were taken at random from. 1945 records. The statistical division of the Bureau of Medicine and Surgerv has reported the incidence of all forms of tuberculosis officially reported as occuring in submarine personnel as seven cases in 1943 (08 per 100), and eight cases in 1944 (06 per 100), These figures, in combination with those shown in Tables 2 and 3 indicate that the incidmce of tuberculosis among submarine personnel was very low. The incidence of the disease among incoming university students — presumably never subject to previous screening— is "said to be about 0.7 per 100. Diseases of the Digestive System Aboard Combat Submarines, As noted in Table 1, diseases of the digestive system accounted for 24,1 admissions per thousand to the sick list. According to the war patrol reports the four most commonly en- countered conditions of this class were acute gastro-enteritis, chronic constipation, acute appendicitis, and Undeter- mined (Abdominal Pain)", Most cases of gastro-enteritis, and practically all cases of constipation were not admitted to the sick list. The bulk of sick days attributed to this class (57S of a total of 995) were due to acute or chronic appendicitis, which will be discussed under the section of this paper dealing with Surgical Conditions, Gastro-Enteritis and Food Poisoning. Careful analysis reveals notations concerning food poisoning in only 34 patrol reports. In only nine of these was food definitely incriminated. Offending agents were listed as canned orange juice, canned sardines, custard pie, beef, surveyed "Avoset" (stabilized cream), spoiled chicken (2), tinned hash and tinned salmon. The remaining reports mentioned the occurence only in general terms. That mass food poisoning aboard an operating submarine may, by incapacitating the crew, cripple the striking force of the ship is illustrated by the experience of one submarine, where, at least in part such a mass illness was responsible for the submarined 129 inability to carry through a successful attack against a Japanese carrier. Food poisoning occurred on 7-9 July believed due to frozen chicken (which was spoiled) served for dinner on 7 July. Two-thirds of the crew and all of the officers were in- volved with diarrhea and vomiting. Two men were still vomiting after five days and were not fully recovered ten days after they had been stricken. The submarine sighted a carrier on 10 July and the following com; ent concerning the attack was made; "Loss of depth control on the one attack made was most unfortunate in that it prevented firing at carrier. Ihe order to make ready the tubes was given rather late; this was combined with personnel errors in hurriedly preparing all tubes. At this time nearly all of the crew was handicapped by sickness from the food poisoning," Constipation, Constipation being considered almost an v.- * ' ' . * • occupational disease among submarine personnel is generally taken for granted. The following excerpts from patrol reports will illustrate its frequency. "Constipation was the most common complaint, being most prevalent in the first two weeks of the cruise; after this period the requests for laxatives dropped off to the level observed in normal operating (peace time) conditions." "The most common complaint was constipation, involving 90% of the crew," This Pharmacists Mate stated that on a 56 day patrol with a crew of approximately 75 men he had dispensed three quarts of mineral oil, one pint of castor oil, two pounds of Seitlitz powder, three bottleiS of cascara and twenty soap and water enemas I (First patrol of the ship early in the war. Admittedly over-emphasized and over- treated! Eds Note.) Constipation, in submarine personnel, is associated with the problem of diet (the small amount of available roughage, insufficiency of fresh fruit, excess of carbo- hydrates); improper eating habits; irregularity of meals; lack of sleep; lack of exercise; motion of the ship; and heads (toilets) which are sometimes difficult to operate. When intelligently managed by the PharmacistTs Mate, con- stipation was not, however, an insurmountable problem, Venera 1 Disease, Manual of the Medical Department of the U. S, Navy states that a man with an active venereal disease shall be disqualified for entrance into the submarine service and that a proven history of syphilis shall be sufficient to disqualify. Men already serving aboard sub- marines who contract venereal diseases are to be transferred to the tender or hospital facility ashore as soon as possible. The occurence of diseases of the urogenital system among submarine personnel on war patrols has been summarized from the official patrol reports and is presented in Table 4* Table 4 DISEASES OF THE UROGENITAL SYSTEM DISEASES NO.PATROLS NO. CASES NO. SICK REPORTING REPORTED DAYS REPORTED Gonorrhea Urethra, Acute 37 109 45 Urethritis Acute, non- venereal 33 6? 26 Gonorrhea Urethra (DU)*- 25 56 31 Prostatis,Unclassified 8 24 6 Penile Lesions (DU)*- 18 20 28 Syphilis 11 16 52 Renal Disease (DU)** 10 15 22 Calculus, Urinary System 12 13 35 Epididymitis; Acute and Orchitis, Acute 10 11 25 Cystitis, Acute 5 5 29 Balanoposthitis 1 1 0 Total 170 337 299 * DU stands for Diagnosis Undetermined, indicating that it was impossible to be absolutely certain or to prove the diagnosis. It should be pointed out that the reporting, especially for Gonorrhea, Urethra, is undoubtedly incomplete as medical facilities of submarines do not include microscopes. The following excerpts from patrol reports concerning venereal disease aboard submarines are quoted for their interest: MFour men with gonorrhea were taken to sea (Editor’s note; early 1942) and given a short course of sulfa- thiazole tablets orally as prescribed and furnished by a Dutch doctor at Soerabaja. The treatment was apparently 100$ effective in 3 of the cases and partially effective in the other case," M0ne case of gonorrhea appeared shortly before arriving at Saipan enroute to the patrol area„ Sulfa drugs were administered aboard and he was treated with penicillin upon arrival at Saipan, The patient continued the patrol with no apparent ill effects.” "There is one suspected case of chancroid which developed about three weeks after departure on patrol. Subject man has been isolated to the extent necessary to prevent cont- amination of other personnel," "One case of venereal disease developed after departure Fremantle that required transfer at Darwin enroute north due to the fact that his health record contained the statement that he should not be given sulfa drugs for treatment of any illness." "One case of Diagnosis Undetermined (Syphillis was noted and precautionary measures were used until a positive diagnosis could be established," "The presence of pediculi and scabies among the crew caused further discomfort," Upon one occasion a submarine, at the conclusion of a long patrol, underwent a two weeks refit period at an advanced base. When the ship arrived post-patrol physical examinations were confined to a discussion with the Pharmacist’s Mate, A few weeks before the termination of the next patrol one man who had made all patrols advised the Pharmacist*s Mate of a venereal disease which he had concealed for a period of at least six weeks and during the last refit. Examination dis- closed the presence of multiple penile and perineal lesions. When the submarine finally came alongside another tender-ship these lesions were easily proven to be syphilitic. In addit- ion, the patient had an acute cerebro-spinal syphilis. The entire crev/ were given blood seriological tests for syphilis, all of which were negative. This incident is reported in such detail to emphasize two points; (1) Apparently, aboard sub- marines, the hazards of contacting a venereal disease by casual contact are at a minimum, despite the necessity of sharing bunks and the markedly limited lavatory facilities; and (2) Post- patrol physical examinations while admittedly a chore, and often productive of but in the way of pathology, were none-the- less worth doing well for the occasional time they did pay dividends. Such cursory "Examinations" as described above may well, upon occasion, prove embarrassing to the examining physician. Skin Diseases as Related to Air Conditioning Aboard Submarines. Most fleet-type submarines were equipped with two, four-ton air conditioning units installed in the ventilation supply lines. As the war progressed these were supplemented by additional cooling and blower units. Without air condition- ing and adequate ventilation (Lack of installations, lack of refrigerant, insufficient or mal-functioning cooling units, etc.) the habitability of a submarine on an active war patrol may become so poor that through material defects and/or lack of personnel endurance and efficiency, the safety and ability of the submarine to carry out her mission may be seriously com- promised, The following excerpts from reports of war patrols made without, or with inadequate air conditioning, have been selected to emphasize this point and to show the relation of excessive heat and humidity to skin disease and heat exhaustion. Actually, only a very few patrols were made under such harrowing conditions, "Shortly after midnight the dove at nearly full speed on four engines,.. .the interior of the ship being as hot as a fireroom that has been secured. Noisy air conditioning equipment was secured as we went in across the bow of the escort. Temperature in the maneuvering room was 130° F. and the engine rooms were about the same At about 2 A.M. men in these two compartments were near prostration from the heat; one man was already receiving treatment. The men on the wheels and planes were being rotated every 5 to 10 minutes by which time they were totally exhausted. Men had never before been seen to sweat so profusely. There was cheerful chatter by the men on station about how much Tojo had to pay for his high grade of depth charging but response was slow and acuity dull. Errors were prevalent. It was evident that the ship was no longer in condition to fight or to defend itself,.,. At 2,35 A.M. the Executive and the Engineering officers advised me to surface before dawn to rehabilitate 135 the ship and crew if at all possible." "Due to faulty air conditioning units the boat was oppressively hot and humid. ,After two weeks of all day submergence all the bunks were wet and sticky. Clothing in lockers ... were green with mildew. Temperatures well over 100° F, with high humidity levels made it practically impossible to get any rest while submerged. There were two cases of heat exhaustion. The entire crew had prickly heat. Seme cases covered the entire body. Thirty percent ... developed some type of fungus infect- ion," Following repair of the air conditioning system on the succeeding patrol the commanding officer commented; "At last we have found out that submerged time need not be a taste 'of hell— this is the first patrol this boat has been anywhere near livable. General improvement in the condition of personnel and reduction of heat rash and skin diseases was quite notice- able in comparison with previous patrols," "On another boat on which it is presumed the aid conditioning must have failed completely we find that "90$ of the officers and crew had ’prickly heat1, 68$ ’Guam blisters* (Editor’s note: probably dermatophytesis), 20$ had boils and 12$ had fungus infections of the ears," Psychiatric Casualties Aboard Combat Submarines. A complete and detailed report concerning psychiatric casualties aboard submarines on war patrols has been accepted for publication in The American Journal of Psychiatry. In the present report, for the sake of completeness the authors would like to briefly review so:;e points which they made in that article. The frequency of psychiatric cases was unbelievably low, with only 56 occuring in submarine v/ar Patrol Reports avail- able for study. Only two cases of epilepsy were recorded, and five cases that could be classified as true psychosis. This is truly a remarkable record. The cases which did occ \t were handled efficiently: "On one patrol a esse of mental derangement occured, with repeated attempts at suicide. The Pharmacists Mate handled the case with skill, restraining the patient with sheets, giving sedatives, and bringing him to port v/ithout mishap, in spite of the patient’s acute depressed state," • It is believed that this remarkable record may be attributed to: (l) Careful selection of candidates for the submarine service; (2) Thorough training of submarine personnel and elimination of the unfit; (3) Morale, or Esprit de Corps of the submarine service; (4) Pre- and Post-patrol physical examinations to determine fitness for continuance on patrols; (5) Generous use of rest camps, and rotation to the "States" for leave and to pick up "New Construction" submarines; and (6) Confidence in the submarine, their officers, and their shipmates. Surgical Conditions. Injuries and Occasion for Traumatic Surgery Aboard V Submarines Injuries were very common aboard combat submarines as sub- stantiated by the fact that on 685 patrols, some 1208 injuries were considered sufficiently important to justify mention in % the official patrol report. In order of frequency these were: lacerations, contusions, sprains, abrasions, burns, shrapnel and gun shot wounds, fractures and heat exhaustion. Injuries were commonly sustained by personnel of the bridge watch, particularly in the lightening-like maneuvers necessary to clear the bridge in the relatively few seconds that elapse between the time the diving signal is given and the submarine is actually submerged. Smashed fingers, broken ribs, dislocations, bruised shoulders, and lacerations of various degrees were the result of this mass exodus of eight or so men from the bridge through a twenty-four inch hatch, and down the slippery and precipitous ladder into the conning tower. The bridge of a submarine affords scant protection against heavy weather, and not infrequently, it may be inundated to waist depth. Men were sometimes lost when washed overboard, and personnel frequently sustained painful and serious injuries when thrown about the bridge and against the periscope shears by the rough seas. To a lesser degree, all hands below deck were subject to the fury of the weather. Men were sometimes thrown from their » bunks. Burns, caused by the spilling of hot coffee and soup, were commonly reported. The routine checking of torpedoes during rough weather was accompanied by the hazard of painful bruises, smashed fingers and in one case, by a fatal intracranial injury. The accumulative effect of continual harassment in severe storms was such that often commanding officers submerged the ship to weather out the storm and rest all hands. Some of the most stirring chapters of submarine warfare concern gun engagements, literally duels to the death between enemy surface craft and submarines. Exciting though these encounters always were, they sometimes exacted their price in terms of painful shrapnel and bullet wounds. Ten submariners lost their lives in these engagements. In addition, exposed to the force of the sea, men were sometimes thrown about the deck, against the gun mount, and on occasion were washed over the side. On three occasions, personnel on the bridge of submarines were seriously wounded (two if at ally) when the ship was strafed by enemy planes. Pharmacist's Mates were also called upon to treat injuries which could be atrributed to other sources than these hazards of wartime operating submarines, Japenese taken aboard, as prisoners, were frequently found to be seriously injured. It can be pointed out with pride that the care furnished them by the representatives of the medical profession aboard sub- marines was always adequate and oftentimes brilliant. The thoroughness of the training and caliber of the performance of submarine Pharmacist's Mates is no where more apparent than in the care afforded survivors recovered in air- sea rescue operations. Throughout the war, 110 U. S, Submarines in 200 separate pick-ups recovered a total of 542 American and Allied airmen downed in Pacific waters in operations extending from Tokyo Bay to the Solomon Islands. Of these survivors, 259 (4&fo) when rescued required medical care, essentially for exhaustion and primary shock consequent to over-exertion and over-exposure. Ten percent were suffering from severe wounds with severe secondary shock. Nine aviators, when recovered, were dead. Only two aviators died aboard submarines under the care of Pharmacist’s Mates, Excerpts from Patrol Reports Dealing with Injuries. In order to conclude the section and in order to illustrate some of the conditions described above, the following authentic excerpts from patrol reports have been selected: "One man received a severe laceration of the fore- arm which required seven stitches. Two men were in- jured by misfire of the 20MM gun. In one of these cases it was deemed necessary to amputate two toes of the rifht foot. Due to a shortage of surgical instruments, (Editor’s Note: this was early in the war) a pair of sterilized side cutters were used to cut portions of the scattered bone. Because of the phalanges were completely shattered, they were not sutured but left open to allow free drainage. A generous amount of sulfanilamide powder was used. The other man was wounded in the shoulder but no lead or foreign body could be located. This man was back to duty in tiiree days with no complications.” 140 "The medical department in the person of the Chief Pharmacist’s Mate did a particularly capable job in handling the Jap prisoner of war recovered after his plane was shot down. Though suffering from shock, second degree burns of the face and hands and several other serious wounds from gunshot and the crash, he was brought around very well and will probably arrive in port almost fully recovered." "Two wounded men were in excellent hands under the care of the Chief Pharmacist’s Mate. Their recovery from wicked flesh wounds caused by a Jap ,50 caliber machine gun bullet is a tribute to his skill and ability. Two men with multiple shrapnel wounds were admitted to the sick list for a total of 60 man-days," "An injured German prisoner was treated for a dislocated left knee, broken right collar bone, badly lacerated mouth and nose and missing teeth. Recovery to date is satisfactory except that he succeeded in mis-aligning his clavicle after it was lined up properly," "The price of sinking one sampan, damaging one and learning the use they are put to (Editor’s note: Submarine traps) was three men wounded. One man received two ,25 caliber hits in the left side just beneath the floating ribs, the bullet ranging upward, fracturing the rib and puncturing the left lung, the other bullet lodged in the diaphram above the stomach. A second man received five hits in the right shoulder over the scapula: the third was struck in the right hip by a piece of flying metal as the target exploded. In view of the nature of the wounds, left the area 24 hours early, setting course for Midway at best speed. The Chief Pharmacist’s Mate ,,,,.is part- icularly commended for his quick and efficient action in caring for these three wounded shipmates. By his profic- ient skill and painstaking efforts he prevented complica- tions of severe wounds and enabled return of his patients to the facilities of a hospital, well on the road to re- covery#. He has been recommended for promotion and the Bronze Star Medal," "Two men were knocked unconscious by heavy seas while stand- ing lookout watch and suffered minor contusions of the shoulder,, chest, and kidney areas. Another man suffered lacerations of the scalp when he hit his head on the conning tower ladder while clearing the bridge in rough weather." "One man suffered a compound fracture of his right ring finger and a simple fracture of his index finger when a storeroom hatch cover fell on his finger. The boat was dived to a hundred feet to furnish a stable platform for sewing up the fingers and setting the bones. While the finger tips are still stiff one month after the accident, they have healed nicely and PhMlc is to be commended for his efficiency and skill," "The , on her second patrol, established an all time record for the recovery of friendly aviators when in five rescues she picked up a total of 30 men. The first man was recovered on 25 May 1945 with severe lacerations and second degree burns. Five days later five more were recovered, all in good condition, 18 minutes after their plane had crashed. On 29 May, sixteen were rescued, two of whom were seriously injured, one with severe head and body injuries, the second with a possible fracture of the back and skull. One man of this group died about six and a half hours after recovery and was buried at sea on 30 May. On the afternoon of the same 7 survivors from an Army bomber, clinging to a life raft buffeted in tremendous sea with waves at least 30 feet hirh, were brought aboard. One of these men had a bullet wound of the foot, a second a fractured clavicle. The problems which confronted the CPhM during this 6 day period must have been at times overwelining. On 1 June a medical officer from a destroyer boarded the submarine; on the same day the survivors were transferred at Iwo Jima, Another Pharmacist’s Mate had an entire surgical clinic on his hands with three women and three civilian men seriously wounded out of a group of 14 individuals rescued at sea. There were shrapnel wounds in all parts of their bodies requiring surgical treatment. In his own words, the Pharmacist’s Mate 142 so described one case; •'This woman had a piece of shrapnel at the bottom of her breast; there was a wound about three inches long and about two inches deep. First I stopped the bleeding. Then I cleansed it thoroughly with alcohol and put sulfanilamide powder in the wound. Then I put in 14 stitches and applied sterile dressings. She also had minor wounds which I cleansed with merthiolate," When this boat finally put its passengers ashore fourteen days later, not a single case had become infected. What trained surgeon could have done any better? Appendicitis Aboard Combat Submarines in World War IIc Probably no other single disease is cause for more anxiety to Submariners than is appendicitis. Since medical officers could not be carried on submarines, it became doubly important to formulate a policy governing the treatment of all cases of appendicitis, and to promulgate it as widely as possible. To accomplish this all officers at the Submarine School, U, S, Naval Submarine Base, New London, Conn,, both in the basic and prospective commanding officers' classes, and of course all Pharmacist's Mates in the Submarine service and those in the "School for Pharmacist's Mates Entering the Submarine Service" were carefully endoctrinated along the following lines: The diagnosis of appendicitis, without laboratory facilities and in relatively untrained hands is difficult and the errors in diagnosis might exceed the correct diagnosis. Gastric and gastro-intestinnal disturbances and constipation are common 143 in submarines and add difficulty to diagnosis. For these reasons conservative rather than surgical treatment should be instituted. More over, even if diagnosis is certain, with modem conservative treatment more cases will recover than ’/ill go on to rupture— the percentage again is against surgery. They were also taught that even though their patient might turn out to belong to the small percent that would go on to rupture, the odds were still in the patient’s favor— that he would wall off the infection and develop an abscess which could be drained at a later date. Realizing all of this, and most importantly, taking into account the relative inexperience of most of the Pharmacist’s Kates and the almost impossible conditions under which an operation would have to be undertaken, the final obvious order was — "Never resort to surgery," This order was put into effect toward the end of the first year of the war. The conservative medical treatment recommended was; NO food by mouth; the anallest sips of water by mouth (any evidence of dehydration treated by intervenous fluids); NEVER give a cathartic to a case of suspected appendicitis; a low gentle enema repeated, if necessary, until results are satisfactory (many of their cases of "acute appendicitis" were cured this way); absolute bed rest; sedation until resting quietly; icebag over right lower quadrant; sulfa drugs in adequate dosage and with proper safeguards; and, as it became available, penicillin. The Incidence and Mortality Rates of Appendicitis in Civilian Personnel in a group of comparable size and age to the one with which we are dealing is unknown. However, according to the Public Health Service in some £,758 families of all ages who were under observation in IB states during 12 consecutive months, appendicitis developed at a rate of 6,6 per thousand in males and 12,3 in fanales. For males, the incidence per age group is presented in Table 5* TABLE 5 INCIDENCE OF ACUTE APPENDICITIS IN kALES* Age Per Thousand Under 5 years 1.8 From 5 to 9 years 5.0 From 10 to 14 years 8.3 From 1$ to 19 years 9.8 From 20 to 24 years 10.1 From 25 to 34 years 12,1 From 35 to 44 years 7.0 From 45 to 54 years 2.7 From 55 and over 2.4 * From the Public Health Reports, Reprint No. 1981, Vol,53, No. 36, Sept, 9, 1938, 145 These figures are of interest because they indicate that between the ages of 15-35 appendicitis is very common — "the most common major surgical disease". Incidence and Mortality Rates of Appendicitis in Personnel Aboard Combat Submarines. The average complement aboard sub- marines on ?;ar patrols was approximately 75 enlisted men and 8 officers. The average age of the officers was 26,7 years and of the men about 22 years. At the conclusion of the war, in a group of 318 submariners picked at random, the average man had made 6,17 v;ar patrols. The average strength of the sub- marine force in 1943 was about 8,755 men, in 1944 it was about 13,345 men. At no time during the conflict did the entire Submarine force exceed a strength of 25,433 men. According to the statistical division of the U. S, Navy Bureau of Medicine and Surger , the diagnosis of acute appendicitis was made 78 times in 1943 (or 8,9 oases per thousand) and 124 times in 1944 (or 9.2 times per thousand), among personnel attached to submarines, but not necessarily on war patrols. Frequently men were transferred directly to the submarine tender where the diagnosis was made or they were picked up while in rest camp or on leave and thus the case was not counted in the actual submarine war patrol report. It is assumed that -these diagnosis followed surgical treatment of the disease. For information available in the submarine patrol report, it appears that Pharmacist’s Mates made the diagnosis of Appendicitis (acute, chronic, or Diagnosis Undetermined, ad- mitted for observation) on 116 war patrols in 127 instances during the entire war. On eight patrols more than one man was admitted with the diagnosis. In sixteen instances one case of appendicitis was reported from the same submarine on two successive patrols, presumably by the same Pharmacist’s Mate, The authors knew of instances in which, during a two v/eek period spent at a rest camp between war patrols, the diagnosis of acute appendicitis in more than one individual from the same boat v;as verified surgically. And although there is no doubt that submarine crews were sometimes "appendicitis conscious" a few Pharmacist’s Mates were plauged, on successive patrols, by different individu- Is who undoubtedly had appendicitis. In the majority of instances from information available in patrol reports, the diagnosis as made by the Pharmacist’s Mates cannot be verified. There can be no doubt, however, that in thirty-four instances their patients were sufficiently ill to warrant eventual transfer for medical treatment, frequently at sea from one submarine to another for further transfer. In eleven instances acute appendicitis was the cause for submarine to either leave their areas of operation, their formation, or terminate their patrolc Twelve cases of appendicitis occurring on patrol, upon arrival at port, are known to have been followed by surgical treatment. Ten of these were either definitely stated to have had or likely to have had ruptured appendicitis. This series of cases accounted for a total of almost 578 sick or man days lost—while on patrol—an average of about 4,6 sick days per case. In a few instances following return to port, prolonged hospital- ization was necessary. To the best of the authors knowledge and experience, throughout the War in the Submarine Force, in not one single instance has death been reported due to, or related to acute appendicitis arising on a submarine war patrol, "For the Navy the statistics vary little from year to year, the figures for the last five years available show the number of deaths from appendicitis of all types to be well under 1 percent of operations for the disease,” (U,S, Naval Medical Bulletin, Vol, 35.1937, The Navy and Appendicitis, L,W, Johnson, Captain (MC) USN, H.R. Boone, Commander (MC) TJSN.pp, 44), Commanding Officers and higher authorities were so impressed by the performance of Pharmacists Mates in handling these truly acute emergencies that in twenty-two instances they were ©specially commended in official patrol reports. Patrol report excerpts with reference to acute appendi- citis show this problem and how it was handled on our submarines on war patrols, "The most disconcerting thing that ahppened during the entire patrol (early in 1942) was a case of acuto appendicitis that fortunately turned out to be some- thing else. The patient had all the symptoms of acute appendicitis. The decision was made to operate. Pre- parations were being made when the patient was seized with a violent spell of vomiting and cramps. The pain subsided and the temperature increased to 104° F, with symptoms indicating the appendix had ruptured. Further observation indicated a gastro-intestinal dis- order and at the end of four hours the temperature had decreased to 101°Fo where it remained for eight days. At the end of two weeks the patient was able to be up and around,” ”The third day out of ’Pearl1 a signalman came down with an acute attack of appendicitis. The ’doctor’ was ordered (Editor’s note: by the Commanding Officer) not to operate9 and was instructed to keep the patient quiet, start treatment and get him well (This order might be difficult to carry out- Editor’s note) It seems to me that there had been too much publicity lately about such oases and I thought we’d do our best to lick it and try and prevent an ’epidemic’ of appendicitis. The patient was confined to his bunk and ice packs ’were given con- tinuously for four days. The morning after the initial attack, sulfathiazole was administered every four hours for the next four days. The patient had no more sharp attacks but the area remained tender for the next tifo days, after which the tenderness subsided and he was allowed up and about. No recurrent symptoms during the remainder of the patrol. The Pharmacist's Mate is to be commended for his devotion to duty and his efficient handling of this case,11 "The quick diagnosis and correct treatment of a case of acute appendicitis, by is deserving of particular attention and commendation. When the patient was turned over to the Medical Officer at Darwin, he was well along the road to recovery. This reflects credit not only on the individual but the Medical Service and to the medical course at New London, Connecticut," ''••....chad an attack of acute appendicitis, commenced ice packs and sulfadiazine treatment (May 194-4), Temp- erature varied from 101,5 to 99,6 for next tv;o days and pain became progressively worse, A Medical Officer from a destroyer came aboard to check patient*s condition. Because of better facilities and probability of operation prior to arrival in Majuro, patient was transferred to the destroyer." "Shortly after reaching the patrol area, one man was suspected of acute appendicitis. The treatment used was preventative with the aim of minimizing the possibil- ity of the appendix rupturing, or in the event that it did rupture, this man was made a strict bed patient. Daily treatment consisted of ice bags to abdomen, fre- quent administration of morphine tartrate to relieve the pain and control intestinal peristalsis, sulfathiazole, and sodium bicarbonate 4 daily doses of each., and a 5% dextrose saline injection and no food by mouth, Sulfath- iazole was discontinued after three days as it brought on vomiting. On the fifth day the ice bag was replaced with a hot water bottle. This continued for six days. The Chief Pharmacists Mate is commended for his quick diagnosis and application of preventative measures. His profess- ional ability is considered to be outstanding*" Appendectomies Performed Aboard Submarines on Yrar Patrols. Although sufficient publicity has been given those appendect- omies performed by Pharmacist*s Mates at sea aboard submarines, for the sake of completeness and because of their interest the authors verify these cases as follows* The first was done aboard the USS SSADRAGON on 11 September 1942, concerning which little technical infor- mation is available. Subsequent to the operation, which lasted about three hours, the patient was on the sick list for fourteen days. The second man, who had been ill for about forty-eight hours, was operated upon aboard the USS GRAYBACK, on 14 December 1942, At the operation, which lasted about 1-g- hours, the appendix was discovered to be ruptured; sulfanilamide powder was instilled locally, drainage was instituted (an elastic rubber band) and the abdomen was closed. Ether was used as an anesthetic, the first assistant was a Motor Machinist’s Mate First Class, "Spoons were flattened and used for retractors, long nose pliers from the engine room were utilized. A submarine escape ’lung’ mouthpiece was used for administering the ether,1* The third and last case was performed aboard the USS SILVERS IDES on 22 December 1942. The patient had been ill for about twelve hours prior to the operation, which was performed on the wardroom table, with the submarine sub- merged at 100 feet. The effectiveness of the spinal anesthesia having worn off, "Ether was administered, following the directions on the can, This anesthetized the operating staff as well as the patient. One hour after completion (the operation lasted about four hours) we tangled with a destroyer. The patient convalesced the following morning— to the tune of torpedo firing, two depth charge attacks, two !crash dives1 and an aerial bombing which knocked him out of his bunk. The conduct of the patient,,,, was exemplary throughout the operation and the period following," Comments made by the Commanding Officer of one submarine concerning the operation performed aboard his ship are highly pertinent and in the light of the above circumstances9 under- standable : "It is recommended that all men who have a previous history of, or indications of chronic appendicties not be sent out on patrol until their appendix has been removed. This also applies to any other ailment which may require an emergency operation at some future date," Higher authority observed in connection with the operation on the SEADRAGON: "The incident,,, is believed to be the first of its kind in submarine history. While this case had a happy ending it is pointed out that this particular Pharmacist’s Mate had had considerable experience in assisting at surgical operations.,, it is hoped that his success will not encourage others to take •••• risks." One point of great interest to doctors charged with planning for any future emergencies is to be emphasized. With the remarkable history of NO mortality in the 127 cases of appendicitis recorded in the Patrol Reports and with the low morbidity, these need not be cause for the undue alarm which was experienced at least early in the war. Medical Officers can, with confidence, continue to teach conservative measures for the treatment of acute appendicitis with the assurance that the best possible treatment is being given to the men of the Submarine Service under the circumstances* In not a few instances submarine personnel returning from war patrols on which they had had an attack of acute appendi- citis were completely recovered when seen by Medical Officers, The decision as to whether such man should be permitted to remain aboard submarines once having had an attack of appendicitis and without surgical treatment must be governed by local circumstances. In general, if conditions permit, an interval appendectomy is believed a wise decision. Summary On submarine war patrols the most common medical conditions which the Pharmacists Mates were called upon to treat were acute communicable diseases, injuries, disturbances of the digestive tract and diseases of the skin and urogenital system. The incidence of these conditions aboard a submarine when compared with surface craft (destroyers) appears to be about the same. Relatively few submarine patrols were made without a varying incidence of acute upper respiratory infections commonly experienced in the first two weeks of operations. These could be traced to contact with shore based personnel, inclement weather conditions during training period immeidately preceding the patrol, and rapidly encountered changes in climate. Such immunity thereafter afforded the crew did not necessarily protect them from strains of organisms introduced from the "outside” world. The incidence of tuberculosis among submarine personnel is low (0,43$) and does not vary significatnly from the general fleet (0*52#), That the overall method of selecting, training, and hand- ling submarine personnel was satisfactory, is evidenced by a very low rate of psychiatric break downs. Venereal diseases, when sulfanomid drugs and penicillin becomes available, present no special problems aboard sub- marines, Despite the necessity of sharing bunks and markedly limited lavatory facilities the hazards of contracting syphilis by casual contact are at a minimum aboard this type of craft. Injuries, which are common aboard submarines, were frequently sustained by above deck personnel in foul weather and in clearing the bridge. Major wounds were sometimes sustained in surface engagements with the enemy#. Pharmacists Mates were frequently called upon to treat serious wounds sustained by prisoners of war and rescued aviation personnel. Of a total of approximately 542 American and Allied aviation personnel re- scued by submarines throughout the war, only two died while under the care of submarine Pharmacistrs Mates, Submarine Pharmacists Mates were carefully indoctrinated in the conservative medical treatment of acute appendicitis. They made this diagnosis in 127 instances aboard operating submarines. Ten cases likely had ruptured appendixes when seen by medical officers. As far as is known, in not one single instance was a death reported due to, or related to acute append- icitis arising on a submarine war patrol. This is a fact which should be of considerable interest to all submariners and physicians charged with planning for possible future emergencies. Submarine Pharmacists Mates may well be proud of their performance record throughout World War II. These men, carefully chosen, patiently and thoroughly trained, aptly and oftentimes brilliantly shouldered the immense responsibilities that were theirs. That they performed so excellently is a significant indication of what can be done in training lay personnel to handle medical problems. MEDICAL ASPECTS OF SUBMARINE WARFARE THE HUMAN FACTOR AS REFLECTED IN WAR PATROL REPORTS* by Ivan F, Duff, Comdr,(MC) USNR Although World War II produced a tremendous volume of literature on the many phases of military medicine, little information is available in the unclassified literature con- cerning the medical problems of submarine warfare. It is the purpose of this paper to discuss some of these problems in the light of personal experience and material available in submarine combat patrol reports. During the war American submarines made over 1500 patrols. The commanding Officers’ reports of 1471 patrols wsr? r~'v* 1 ht air activity necessitates frequent night dives. The attendant nervous tensions coupled with prevalent rough seas interfered materially with the sound sleep of the crew* A 21-year old machinist’s mate with no previous war patrol experience developed a partial paralysis of the left side of his face following the above bombing. He appeared otherwise normal,” There were five cases reported which were undoubtedly in the nature of frank psychoses* One of these occurred on an Aleutian patrol early in the war and was apparently the cause of considerable apprehension aboard the submarine, it being written: ”One man suspected of being mentally unbalanced was put under close observation and removed from the watch.” ”Our patient is defin- itely unbalanced and a menace to the safety of the ship. Confined to the Ward Room, guard posted,” It was necessary to recall this sub- marine from patrol nine days after she reached her area of operation to remove this patient* Transfer of a second psychotic patient was made at sea from one submarine in emeny controiled waters to another in order that he might be returned for medical care. His management en route to Base proved difficult and restraint was necessary, —"His obstreperous behavious demoralized every compartment in which he was confined," A third case involving a pharmacist’s mate was later hospitalized with a diagnosis of dementia praecox. The fourth case, a man who had made many previous war patrols, committed suicide aboard the boat en route to the area of operations and was buried at sea. The following information is available concerning the fifth psychotic episode reported aboard submarines on war patrols: "During the close depth charge attack one man, a chief commis- sary 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 pharmacist’s mate 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 and kept bothering the pharmacist’s mate 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 disqualification for sub- marine duty. His presence aboard is a definite hazard to our morale and he will be temperamentally disqualified and transferred upon arrival for mental observation," No mention of homosexual behavious occurs in these patrol reports, however the authors know of nine cases, of which only three either oc- curred aboard combat submarines or in men who had ahd submarine duty. All of the cases which could possibly be diagnosed as neuro- psychiatric or emotional casualties are presented in the following table according to standard Navy nomenclature. Diseases of the Mind and Nervous System Classes XV and XVII Diagnosis* No. of Patrols Reporting No. of Cases Reported Psychoneurosis, anxiety*** 23 25 Psychcneurosis, Hysteria 8 9 Psychoneurosis, unclassified 6 6 Psychosis, unclass. 5 5 Neuritis, Unclass. 6 6 Paralysis, unclass. 2 2 Paralysis, facial nerve 2 2 Epilepsy 2 2 Migraine 2 2 Diagnosis Undetermined - syncope 2 2 - vertigo 1 59“ 1 62 * U.S.Navy Medical Department Nomenclature - 1945 ** Classified as nearly as possible from sometimes inadequate case histories from patrol reports, *** It has been pointed out that this diagnosis (psychoneurosis, anxiety) is too low, and that a trained and emotionally neutral observer during almost 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 re- actions interfering with performance of duty were recorded, ’'The depth charge attacks had little effect on personnel. They came to be expected and accepted as routine and to all appearances were ignored. The experience of the heavy grapnel banging against the Ship’s hull at 340 feet caused some raised eyebrown, the Commanding Officers’s being as high as any," It is painfully apparent to t he authors that the Medical Officers on the submarine tenders at the various submarine bases and rest camps missed a golden opportunity in not carefully studying and reporting these cases when on return from the submarine patrol adequate histori- cal material was readily available. To evaluate the true significance of this total of 56 possible psychiatric casualties (neuritis not counted), it is necessary to have information concerning the number of men Exposed to the emotional trauma so vividly described in the patrol reports and so indelibly recorded in the memory of all submariners. There were, as noted earlier, 1520 war patrols (all areas) and there was an approximate average of 75 men aboard on each patrol, making a grand total of 114,000 man-patrols. In the same way there were 12,160 officer-patrols, and human nature being what it is, they were as likely to break as the men; and perhaps more so, because they more fully realized the dangers and responsibilities that were theirs. This total of 126,160 man-patrols and 56 possible psychiatric casualties give the amazing percentage of ,00044 casualty cases of a psychiatric nature oc curing per man-patrol. Another method of approach would be to take the average number of patrols per submariner, making at least 1 or more patrols. From the thousands of questionnaires returned after the war in connection with a survey which was conducted on submarine personnel, we picked a random sample of 318 returns. In this group 14 was the largest number of patrols made by one man and the average number was 6.17 patrols per man. Thus, if we divide the man-patrols (126,160) by the average patrol per (6,17) we have 20,447 men making an average of 6,17 patrols. Again, 56 cases is an amazingly low figure, "It is interesting to note that during the six war patrols made to date and in spite of the severe depth charging on each patrol in- volving a total of over 500 depth charges, only one man has cracked up. This was on the first patrol and the man was a veteran of several war patrols on another vessel," Another approach would be to consider that the maximum number of men attached to submarines, relief crews, rest camps, and on staffs, at any one time was 19,000, Even if we made the erroneous assumption that these men were the only ones attached for the duration of the war, we would have an admission rate of only 2,94 per thousand. Even though these figures may be somewhat incomplete and therefore lead us to an underestimate, nevertheless, it must be obvious that the Submarine Service had a very enviable record so 4ir as emotional or psychiatric breaks are concerned. The reasons for this record are important, particularly in the light of planning for ary future national emergency. The authors believe they may be completely summarized under the following general headings: (1) Selection of the candidates for the Submarine Service, Qev Oe>/u.K\ i(ff (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 continuance on patrols, (5) Generous use of Rest Camps and Rotation to the States for leave and pick up "New Construction" submarines, (6) Confidence in the submarines, their officers, and their shipmates. (1) Selection: Foremost in a discussion of selection for the submarine service is the fact that every man is a VOLUNTEER. He may have been drafted into the Navy, but he goes into the submarine branch of his own free will. This only is a selective process in itself, but also a motivating force for the man to continue in this activity. Much has been written about the process of selection for the Submarine Service, Here we will be content with simply mentioning that all the men had to meet rigid standards both as to educational, psychometric, and psychiatric, as well as physical fitness standards. An attempt was made in this screening process to eliminate all those with obvious defects and in addition an attempt was made to eliminate those who had latent defects, as indicated by the psychological and psychiatric evaluations. That there were reported as occurring only one case of Dementia Praecox and two of epilepsy on submarines during the War indicates that this screening was of an extremely high order. None of the other reasons—training, morale or rest could account for this • (2) Training: Training was conducted in an exceptionally proficient manner by the Submarine School, which is an established activity of long standing and known excellence. "Refresher" training and "New Construction" training courses were also conducted in order to keep both officers and men up to standard. A man who is sufficiently trained and drilled in his job has a maximum of confideaoc in himself and is most likely to withstand the trauma and rigors of warfare. He knows what to do and how and when to do it, and reacts automatically in times of emergency. (3) Morale: There is no question that from start to finish the submarine engenders in the men a special spirit which undoubtedly served to carry them over many a tough spot and caused them to realize fully that they were a part of an organization which has a high reputation to live up to. They were a group that lived together as one family and they real- ized that if one man failed, all would fail in their mission. For this reason there was less likelihood that they vjould allow themselves to give way to the pressure of the moment. (4) Pre-and Post-Patrol Physical Examinations for Continuance on Patrol Pre- and post-patrol physical examinations undoubtedly served to pick up men who were in need of a period of rest and rehabilitation, prior to the time when they would actually have experienced an motional break. (5) Rest Camps and Rotation; The generous use of rest camps, we believe, proved to be the greatest single factor in the excellent record achieved by the submarines. It was the general policy that no man made more than two consecutive patrols without a period in a rest camp. Again, an equally important factor was the rotation to the U.S, to pick up a new boat and of course the incidental leave was an effective form of rehabilitation. (6) Confidence in Submarines, Officers, and Shipmates: The construction of the submarine, the demonstrated ability to withstand enemy counter-attacks, and the demonstrated effectiveness of their weapons could not but engender confidence in all the men. In addition to this, they were well aware that both their officers and shipmates were not only very carefully selected but highly trained, thus attuning the maximum in efficiency and mutual protection, (7) The lessons that one can learn for application to the planning of any future conflict have been amply covered in this series of reasons showing why the submarine service fared so well in contrast to other services insofar as psychiatric breaks are •oncerned. It is apparent that by selection, by training, by building morale, by frequent examinations, by generous use of rest camps, and by instilling confidence, the breaking point was indefinitely deferred and psychiatric casualties were largely eliminated under conditions which submarines encountered in World War II, SUBMARINE ESCAPE ("LUNG") TRAINING PAYS OFF BY T. L. WILEMON, Captain (MC) USH, I, F, DUFF, Commander (MC) USNR, AND C. W. SHILLING, Captain (MC) USN. One of the most colorful and interesting parts of the training of submarine personnel is found in connection with the use of the Submarine Escape Device, commonly called the '•lung". This device (•e-ecHEllustration -No-.-lr) was developed iin in by Lieutenant Charles B. Momsen, USN, (now Admiral), Chief Gunner Tibbals, and Lr. Hobson of the Bureau of Ships. After the experimental work on this device had been completed in the Deep Sea Diving School in Washington, the first train- ing was conducted in the swimming pool of the Y.L.C.A. in New London, Connecticut. The Escape Training Tank at the U. S. Naval Submarine Base, New London, Connecticut, was constructed at a cost of v120,000. and completed on the 20th day of August 1930. The principal characteristics are an overall height of 138 feet, 6 inches, which provides a vertical column of water 100 feet high and 18 feet in diameter. It has a capacity of about 280,000 gallons of water. Integrated with the Tank are escape locks, or compartments which duplicate those installed in submarines. These locks are located at depths from the top of the Tank of IB feet, 50 feet, and 100 feet. Thus per- mitting escapes to be made under conditions simulating those existing in similar depths at sea, and with identical pressure factors. This Submarine Escape Training Tank was designed to permit the thorough training of all submarine personnel in the use of the "lung", or submarine escape appliance, under conditions that exist during an actual escape from a disabled submarine. All submarines are equipped with submarine escape apparatus, but the crew must be properly trained in the use of the "lung", either at the Tank located at New London, or at Pearl Harbor, T.H. With the advent of World ,.ar II, "lung" training took on new impetus, in order to keep pace with the large numbers of men being trained for the Submarine Service. The proportions of this increase in the number of men trained wall be seen by reference to the accompanying table (TABLE I), In spite of this great expansion in training, many men who entered the Submarine Service at advanced bases did not receive "lung" training. Although it w;as considered unlikely that the "lung" would be used for escape in wartime disasters, training in TABLE I QUALIFICATIONS SUBMARINE ESCAPE TANK Fiscal Year 18-foot 50-foot 100-foot TOTALS 1 July 1930-31 556 405 338 1,299 1931-32 770 189 179 1,138 1932-33 490 244 216 950 1933-34 562 252 141 955 1934-35 264 104 104 472* 1935-36 434 84 84 622 1936-37 637 41 41 719 1937-38 1,813 121 121 1,555 1938-39 1,321 62 62 1,445 1939-40 1,375 189 149 1,713 1940-41 3,695 123 13 3,831 1941-42 1,621 2,231 1,405 8,257 1942-43 8,014 6,463 1,882 16,359 1943-44 13,569 12,590 811 26,970 1944-45 8,895 6.710 786 16,391 TOTALS - 46,536 29,806 6,332 82,676 *It is interesting to note that more men were trained during the three days, January 3, 4, and 5, 1944 (527) than for the entire fiscal year of 1934-35 (472), In the month of January 1944, more men were trained than in any single year from 1930 through 1941, 18-ft. 1,352; 50-ft, 1,308; 100-ft. 122; total 2,782. its use was continued throughout the war period for several reasons. It was considered to be an excellent morale factor for the men; and it was known to afford a sense of security and comfort for the families of the men. But more importantly, it was used by the Kedical Research Department of the Submarine Base, New London, Connecticut, in their selection program, as a means of selection from the standpoint of emotional stability, Ken who became excessively nervous, or actually went to pieces during the training were disqualified for Submarine Duty on the grounds of emotional instability. If so simple a task as "lung" training was too much for them to take, what could one expect when the depth charges were rolling? And it was felt that no possible factor of safety should be omitted. There was always the off-chance that some men might be saved through their knowledge of the use of the "lung". The British used "lung" in escaping from the THETIS in 1939. Also, during the war, there was evidence of German escapes made with their "lung". In one recorded instance, twenty-one survivors are known to have escaped from a disabled German submarine at a depth of approximately 120 feet; nA few used lungs, but the majority came up without them". As noted earlier, most of those responsible for the training of American submarine personnel in the use of the escape device felt that there probably would not be any opportunity to use the "lung" for actual escape under wartime conditions. In this assumption they were mistaken, however, for the "lung" was used by the men of one disabled submarine for a very dramatic escape, and the training given at Mew London enabled two of the men to make a successful "free escape" (without a "lung"). A description of this incident follows,* One of our U.S. Submarines, while conducting a most successful attack against the enemy in the shallow waters off the coast of Formosa, in 1944, was struck by one of her own torpedoes, when that torpedo, —the last one to be fired, made an erratic run. Maneuvers to dodge the torpedo failed, and"the ship was struck abreast of the after torpedo room with a violent explosion. The tops were blown off the only regular ballast tanks aft and the after three compartments flooded instantly. The ship sank by the stern, much as you would drop a pendulum suspended in a horizontal position, there being insufficient time to carry out the last order to close the hatch." Of the nine men on the bridge at the time of the ex- plosion, three men (The Commanding Officer, a Radar Tech- nician, and a Chief Boatswain’s hate), were thrown clear of *The sources of this material are the official Patrol Report, and personal interviews and correspondence with four survivors. the ship and managed to stay afloat until picked up by the Japanese along with other survivors, about eight hours later. ho details are known concerning seven of the nine men who were in the Conning Tower at the time of the explosion, and were lost. Information concerning two others follows in the account of an exciting "free escape” by one of them, as related by that officer after his return to hew London. (We might add that he felt very strongly that the importance of "lung” training could not be overemphasized.) Excerpts from Lieut, S 's account follow: "The boat seemed to bounce up and down, I didn’t lose my footing. I heard the order to close the hatch and the Skipper wanted to know if we had any propulsion. I started forward to look at the pit-log which I remember seeing, - then the lights went out. The conning tower filled almost immedi- ately with water. I was hanging on, leaning against the No. 2 periscope shaft, which was down. With the sudden down- ward angle of the boat, men and loose gear were bumping and falling by me with the rush of water. I apparently rose up along the periscope shaft. Ly nose and mouth were out of water, - in an air bubble in the overhead of the conning tower, where the No. 2 periscope goes through and where there is an indenture between the cork and the hull. I remained there, in the quietness, with my nose and mouth cramped up against the cork to breathe. I thought that I had better figure out what else I should do - wanted to know where I was. For some reason, I thought the boat was upside down - I had a fear of going up the periscope well and being caught in the pump room. I ducked out and began to feel around, treading water all the time, then I seemed to rise and come up into a real big bubble with my whole head and face out of the water, I felt around and found the engine order telegraph and knew that I was in the forward end of the conning tower. The air must have been trapped between the hatch and the forward bulkhead. I thought that I’d better get out - felt around and located the ladder and the trunk circling the top of the ladder at the hatch. I figured that I might be able to hit into another air bubble, so I went through the hatch which opens up underneath the cowling on the bridge and found another pocket of air trapped there. In popping out of the water I must have made a noise for there was a voice asking, "Who is it?" I answered with my name, and asked "Who are you?". It was the soundman who had been opposite the TDC in the conning tower. He said, "Do you know where we are?" and I said, "I think we are under the bridge," Then he asked, "What are you going to do?", and I told him that I thought we'd better get out of there and try to get to the surface. He said, "Can I go with you?" I answered, "Sure." He asked, "How?," I told him to hold on and ducted down under the cowling with him holding my legs - but as soon as I pushed down, he let loose. I didn't see him again. I began to swim up, using both hands, as hard as I could - the whole idea was to get up - I wanted air and lots of it. I had no sensation of being under pressure, but I thought of my lung training lecture about letting the air out ana knew that as I came up I would have to force the air out - so I heaved it out - all at once - and then just as I thought I'd have to swallow some salt water, I burst out on the surface and began swimming. I could see the bow of the boat sticking out of the water ahead to about the windlass which is just forward of the hatch, (the hatch to the forward torpedo room thus being under water.) Lieutenant S is of the opinion that the angle of the boat at this time was such that his free escape from the bridge to the surface was a distance of approximately fifty feet. Events as they befell those men still alive and occupying the unflooded portions of the ship appear to have been as follows: "In the explosion —which was very violent, whipping the boat, breaking high pressure airlines, lifting deck plates, etc,, numerous personnel as far forward as the Control Room sustained broken limbs and other injuries. The immediate re- sults to the ship was to flood the three after compartments. Even the forward engine room was half flooded before the after door could be secured. When the survivors from here and the after battery reached the mess room, they found water already above the eye-port in the door of the control room. Testing the bulkhead flapper, and finding that the water had not yet reached this high, they opened the door, letting the water rush past them as they proceeded through to the control room and the forward torpedo room. Personnel in the control room had succeeded in closing the conning tower hatch which had been sprung in the explosion and was leaking badly. Dur- ing this time, all secret and confidential publications were destroyed —first by burning in the control room and then in the forward battery compartment as the control room was flooded." One survivor, in describing what occurred in the forward torpedo room, stated, "Vie fired the last two fish on the sur- face and approximately 45 seconds later the submarine shook with a hit aft, We knew we'd been hit severely, but didn't know where, or with what damage. We lost forward motion in a few seconds. The bow remained buoyant as the stern dropped to the bottom leaving the submarine at a very steep angle. All loose gear fell to the forward battery bulkhead and the men held on to anything they could reach. Almost immediately after the stern struck bottom, I heard air rushing through the main ballast tank blowers and knew the men in the control room were trying to blow us to the surface, but we didn't budge We closed the water-tight door between the forward room and the forward battery so we could secure our compartment. There were about ten men in the room at this time. One Chief Torpedoman in charge of the forward room made his way up into the escape trunk, opening the lower hatch," "Since it was quite possible the conning tower might be flooded and we were sure the after-torpedo room was, that left only the forward torpedo room for escape purposes. Therefore, we couldn't escape without waiting for everyone left alive to get to the forward room. Fifteen minutes later a group of about fifteen men had made their way into the forward room. When we opened the door there was such a dif- ference in air pressure between the compartments that it literally blew the men into the forward room and when it had equalized, there was quite an increase in pressure. These men had come from the control room. It had been apparent to them that the ship must be levelled off before the mechanical lungs could be used. Hydraulic power no longer existing, they had finally succeeded in turning the vents by hand. The ship slowly sank and rested on the bottom at 30 fathoms," "We found out from these men that the boat was flooded up to the forward engine room. There were about 45 men in the torpedo room now, and the angle of the boat had lessened quite a bit. We were secured in the forward room and knew the boat would never run again, but were confident we could escape, "Lungs were passed to everyone and strapped on. In- structions on how to use them were reviewed. Over half of the men didn’t seem to remember how to use one. Life jackets were distributed and those who didn’t get them were instructed to use their lungs as such when they reached the surface. At this time Jap patrol boats evidently picked us up again and dropped about ten depth charges which shook us severely, but did no real damage. Everything came to a dead stand-still until they had left and there was no danger of them picking up our sounds. "One officer decided that there might be a chance to blow the boat to the surface, thereby making it much easier and quicker for everyone to escape. He was going to lead a party of six men back to the control room to see what they could do. When they started to open the watertight door to the forward battery, a terrific blast of black smoke came into the forward room from a fire in the forward battery. Although the door had only been cracked for a second, the smoke completely filled the compartment and the lights became only dim gloom. Almost immediately some of the men began to gag. They were instructed to take a few breaths through their "lung" when the irritation became too severe. "The men lay on the bunks discussing ways and means of survival. They knew or had a good idea of the depth of the water and that they were only about ten miles from the Formosa coast. It was decided that an officer and three men should attempt the first escape. "They went up into the escape trunk and we handed them a rubber lifeboat that they were going to try to get to the surface. They were to rig the trunk, escape, and the last man out was to signal by tap- ping when he had left, then I would pull down on a lever in the overhead which would close the door and then drain the trunk for another party, (with rupture of the air lines they were lacking the required pressure to blow the trunk down.) After waiting about 40 minutes with no signal what- ever, I closed the lever anyway and drained the trunk. We knew there were men in it before it was drained, but de- cided to find out from them what had gone wrong. The officer had escaped, but the other men were still in the trunk, A difference of opinion among them as to how the trunk operated had caused the delay, and after it was finally rigged, they had difficulty getting the life buoy attached to the line on the reel. The officer hadn’t waited for them to rig the buoy, but dove out the hatch. It was right after that that I had closed the door from below, locking it, and making it impossible for the others to escape, "One of the three men came down into the forward room stating he didn’t care to attempt it again. They decided not to attempt to take the life boat to the surface because it was too bulky and heavy. Another officer and three men went into the trunk. Then it was decided to try five men, so a second officer entered the compartment. The same arrangements were made for rigging and draining. After another 40 minutes, we began to worry about them having been unable to signal, and I listened close to the hatch. I could distinctly hear moaning, but nothing else. After draining the trunk, it was found that the three men had escaped; one officer was in a stupor as we took him down and the other officer had been pinned to the trunk bulkhead by the line attached to the buoy. He was cut loose, lowered to the deck, and wrapped in blankets...The first officer said he would not attempt another escape, but that there was no reason why every other man in the compart- ment shouldn’t escape. Japanese ships patrolling the area began dropping charges within a one-mile radius, so we stopped operations till they secured." Our narrator led the next escape. The group this time consisted of himself and three other men. He says, "We had cut the buoy line to get the officer down and not knowing that it had also been secured outside the trunk, we took a life-ring with us to use as a buoy. This ring had been taken off a Jap ship on a past patrol. I had no difficulty flood- ing the trunk to equalize the pressure, but when I tried to open the door, it was stuck, but finally swung open. When I attempted to charge my lung from the manifold, I found there wasn’t any oxygen, "This worried the other men, even though I explained they could blow up the lungs with their own breath and that it would serve the purpose. I felt very exhausted —like I v. couldn’t get any air into my lungs, and began to get dizzy, so I knew I had better get out while I could. It took me about 15 minutes to rig the trunk, including preparing the life-ring as a buoy, I would have let the ring go to the surface and then gone up the line, but I was so near passing out I went up with it. The other man in the trunk could have e.scaped if they had only stepped out the hatch. They didn't want to try the escape without oxygen, although I explained how they could. Two of the men went back down to the com- partment, A torpedoman remained in the trunk after it was drained and had the men below turn on the remaining oxygen valve. Thus, I was the only one of my group to leave the ship on this try. However, the torpedoman led the next es- cape. "I took the life-ring that had been attached to the line and stepped out the hatch, and started rapidly to the surface holding on to the ring, I had no difficulty breathing through the lung other than for the pressure. After about twenty feet, the line began jerking badly. The torpedoman, still in the trunk attempted to slow me down, but in doing so, I lost my lung; so I blew air out all the way to the surface trying to equalize the expanding air, the way the lung would have done. Upon reaching the surface, I was very exhausted and sick and vomited for about a half hour. "After floating around a few minutes, I heard a machinist's mate who had escaped previously, calling me. He was hanging on to the life-buoy about 50 yards away. He cut the line and we tied the buoy and ring together. He had been unable to reach the only other man he had seen in the water, before the tide carried him from sight, be could easily see the coast of Lormosci, also the masts of two ships we had sunk, and the bow of our last target was only about a mile from us. The tide was never constant, or we could have attempted swimming to the nearest ship. We were unable to do anything else but hang on to the buoy and wait for someone else to come to the surface, "In about 45 minutes, an officer (the one who had been caught in the line) and two other men reached the surface, at about three minute intervals. They were all very exhausted, "We could see two destroyers slowly sweeping the water between us and the coast and realized they were either trying to find us or pick up survivors of their own ships sunk the night before. One of them finally spotted us after 2 hours and came by within a hundred yards dropping a buoy, then sweeping around in a circle. At this time another man, came to the surface, and I swam over and pulled him to us, as he was evidently unable to keep his head out of the water. He seemed in a stupor and kept gasping, as if he couldn't breathe, and couldn't understand anything, and soon died," It appears likely, from available information, that thirteen men left the submarine via the escape trunk. Five of these, as described above, reached the surface and were able to cling to the buoy until picked up. These men are known to have been physically exhausted from their ordeal in the submarine (smoke, pressure, heat, and accumulated carbon dioxide). Two of them are known to have been nauseated and to have vomited for half an hour or so while clinging to the buoy. Three others reached the surface but were unable to hang on or breathe and floated off and were drowned. One of these apparently had an air embolism. The other five were not seen after leaving the trunk. It is not inconceivable that perhaps they lost their mouthpieces, held their breath, and died of air embolism, or drowning, Ir appears likely that approximately forty-five men were alive in the forward torpedo room of the submarine at the time plans were made for escaping. Two of these men are known to have been seriously injured and were conceivably unable to escape. Concerning the twenty-eight or so men remaining, who perished in the torpedo room, the Commanding Officer has stated: "At the time the last party escaped, the fire in the forward battery had reached such intensity that the paint on the bulkhead of the forward torpedo room was scorching and running down. Considerable pressure had built up in the forward battery making it difficult to secure the after torpedo door sufficiently tight to prevent the acrid smoke from seeping by the gasket. It is felt that this gasket blew out, either due to pressure or an ensuing battery ex- plosion and that the remaining persons were asphyixiated. Our narrator stated: "Even if conditions hadn’t gotten any worse than when I was last there, I would say the men left below were all dead or unconscious from pressure, lack of oxygen, or the smoke, within an hour after the last twro men escaped." The practical lessons concerning submarine escape that may be learned from the experiences related above appear to be as follows: 1, The submarine escape "lung" and the standard escape gear appears to have well accounted for itself under practical trial in war time. All of the lungs had been checked, aired out, counted and restowed prior to departure of the submarine from Pearl Harbor. There were enough for every man in the crew and 10$ more. 2. Provision must be made for vocal communication between the escape trunks and adjacent compartments, —as by sound-powered telephones. Under strain and in confusion signals by hammer are not effective. Moreover, as in this case, they may well have led to increased enemy anti-submarine activity. One of the major difficulties encountered was the lack of proper means of communication between those in the escape trunk and those below in the torpedo room. They didn't know what was going on or what trouble they were having. 3. A redesign of the oxygen supply for the escape trunk is apparently needed, for on this submarine and on other repre- sentative submarines examined subsequently, the oxygen flask for charging the "lung" was in the adjacent compartment with the charging manifold in the escape trunk. The valve governing the flow of oxygen was thus in the compartment and could not of course be operated from the trunk once locked inside. 4. In similar manner, the emergency lights were controlled from below, instead of being turned on from within the trunk. 5. It should be pointed out clearly to all submarine per- sonnel that in the absence of oxygen compressed air can be safely used, and in the absence of compressed air, the "lung" can be safely filled with the individuals own breath. 6, It should be pointed out more forcefully that in the absence of a ’’lung", or in the event of its loss, "free escape” from considerable depths is not only feasible but was done with success by two men on this submarine, and has been done by several Germans from equal or even greater depths, during this war. The authors believe that at least all officers should be required to demonstrate their ability to make a '‘free escape" from the 100-foot lock in the Escape Training Tank. 7* It is urged that the 100-foot escape be made manditory, for as noted in this episode, confidence engendered by this escape will be of great value. 8, All personnel should be given additional instruction in the operation of all of the current submarine escape trunks and compartments. It is felt that perhaps this type of intensive training in the procedure of submarine escape, the use of the "lung", the operation of the escape trunk, upon the part of Submarine officers, would have resulted in this case in a more positive and adequate leadership under the conditions of stress as were encountered. Differences of opinion among the first men attempting escape wasted valuable minutes. The men weren’t sure of escape procedure and were afraid they would make a mistake that would be fatal to those below. Escape procedure is very simple on paper, but somewhat different where every man’s life depends on it. 9* There is apparently still room for some improvement in the mouthpiece of the "lung" so that it will not be so easily lost, and in the harness, in order that it may be held more firmly to the body. 10. Ample evidence exists of the extreme toxic qualities of smoke from fires aboard submarines. This is particularly true of fires in the main batteries. It is recommended that all personnel be more thoroughly indoctrinated in the dangers and mitigation of the effects of this smoke, 11. In this connection, more thorough dissemination of the facts concerning the effect of increased atmospheric pressure, oxygen lack, carbon dioxide increase, and the effects of other toxic gases than smoke, is definitely indicated. 12. Wide dissemination of the events as they occured aboard this submarine is recommended as being of value to the entire submarine service. This brief review of the lessons to be learned from this tragic episode is not intended to detract in the least from the remarkable display of courage, judgment, and resource- fulness in the face of almost insurmountable odds. Not only is there ample evidence of how well "lung" training paid off in general, but there are numerous specific references in the statements of the submariners showing how individual memories of details of the "lung" training lecture and training escapes saved their lives. The authors will, I am sure, be forgiven for taking pride in such statements as the following: "We were secured in the forward room and knew that the boat would never run again, but we were confident we could escape. Lungs were passed to everyone and strapped on. In- structions on how to use them v/ere given." "Life jackets were distributed and those who didn't get them were instructed to use their lungs as such when they reached the surface." "A terrific blast of black smoke came through the door and completely filled the forward room. Almost immediately some of the men began to gag. They were instructed to take a few breaths through their "lung" when the irritation became too severe," "We were able to breathe through them without their being inflated." "When I attempted to charge my lung from the manifold, I found there wasn't any oxygen. This worried the other men even though I explained they could blow the lungs up with their own air and that it would serve the same purpose," "I felt at ease using the lung and knew it would work after I tested it under the v/ater before leaving the trunk, I had made the 100-foot escape before." "After about twenty feet, the line began jerking..,.I lost my lung. So I blew air out all the way to the surface, trying to equalize the expanding air, the way the lung would have done." "Suddenly I realized that I must be way down under the water, under pressure, though I never felt it. Remembering that when I was in the Diving Tank at the Sub School, they cautioned us about holding our breath when we were escaping from under water because our lungs would burst as the external pressure decreased and that we must come up slowly,,.,I reasoned.,,.that I would relax my lips completely and that as I came up the air would force itself out. The officers and men of the Submarine Service, should take justifiable pride in this escape which was one of the outstanding highlights of the entire submarine campaign, which, as all know, is replete with examples of unparalleled heroism. ANALYSIS OF SUBMARINE FOOD PROBLEMS IN WORLD WAR II C. W. Shilling, Capt. (MC) USN and Ivan F. Duff, Comdr. (MC) USNR. Ordinarily physicians are not greatly concerned with the details of food supplies. In the Navy the Supply Department has cognizance of commissary matters. The Naval Medical Officer, however, ff in carrying out his responsibility related to food", is specifically charged with the duty of "inspecting, as to quality, all fresh provisions issued an authorized mess". A study of patrol reports leads to the conclusion that this duty too often was not assumed by medical officers associated with the Submarine Force, and that, specifically, submarine squadron medical officers should actively concern themselves not only with the quality of food issued to submarines but with the planning of menus to provide a dietetically acceptable ration. It is well known that an adequate and palatable diet is necessary for the smooth functioning of any military organization. Recognition of the many inherent limitations and discomforts of life aboard sub- marines makes it imperative to exert a special effort to provide a good ration. This is necessary for health, personnel, endurance, and morale. In general, the food served aboard subnanines in World War II was excellent and well deserved the reputation which it came to have among other less elaborately fed branches of the Armed Services, The Submarine Ration The ration provided a submarine needs to fulfill certain requirements. It must have been selected to occupy a minimum of space and evidence excellent keeping qualities under sometimes adverse conditions of stowage. From it a daily well- balanced menu incorporating a maximum of food value and variety and a minimum of waste should be easily prepared. Submarines have always had a more generous ration allowance than other ships or stations with a similar complement. At the outbreak of the war the allowance was 85$ per man per day. As the war progressed and costs increased, the ration allowance was increased until at the end of the war submarines were allowed $1,00 per man per day when based in the Continental United States, and £1.05 in foreign ports. In addition to more money, submarine commissary officers and stewards have complete freedom in the type and quantity of foods they may draw within the limitations of availability. They may draw fresh or fresh frozen fruits and vegetables as desired. They never have to use "unit loads". The only exception to this freedom is in the case of beef. In most places, submarines were officially required, throughout the war, to draw the standard f proportions of steaks and roasts (2), stewing beef (l), and ground beef (l). Planning of menus and of the quantity and distribution of stores to be carried was the prerogative of the submarine commis- sary officer and commissary steward either working alone or in conduction with the tender or base commissary officer. No overall master menu was developed during the war. However, several of the bases and tenders worked out sample menus for two or three months which could be used as a guide if the submarine wished. Patrol Information In order to evaluate accurately the food problems as they existed aboard submarines during World War II, the authors have thoroughly studied all of the available submarine patrol report comments concerning food and water. Of the 1520 patrols made, reports of 1489 were available for study. The known excellence of the food aboard subnu rines was undoubtedly the reason that many commanding officers made no mention of it. However, 286 paused in their busy routine to make favorable comments concerning either the food, its preparation, or the cooks and bakers. The adverse or constructive criticisms made by a few of the commanding officers will be more thoroughly studied in the following sections of this paper, * (One section of the official report made at the conclusion of each submarine war patrol dealt specifically with the health of the crew and encountered conditions of habitability (food, water, ventilation, etc.) Stowage Space The anount of space aboard a submarine which may be allotted for food stowage has military significance. For like the fuel, oil, and ammunition capacity, it is definitely one of the factors limiting the length of a submarine patrol. In World War II this was particularly trub for the smaller and older "S" class submarines. The amount of food which they could carry to provide a well-balanced menu did not, in general, extend over a 30-35 day period* Although these boats made patrols lasting longer than 30 days, the majority of them so doing turned in comments such as follows: "Very little reserve is left in this class of ship after 35 days on patrol. Provisions for all practical purposes are exhausted. The base of the icebox loomed very large during the last week. No one went hungry, but there was a decided reduction in the quantity and variety of food," Fleet-type submarines commonly departed on patrol with A' food supplied calculated to provide for 70 to 90 days. In the early days of the conflict, especially in the active war zone, it was sometimes difficult to obtain food and supplies. Shortage of provisions occurred on a few occasions giving rise to comments such as these; "Inexperience in planning and procurement for such a long patrol made the diet unsatisfactory. Difficulty in obtaining food at Soerabajo prevented getting a full larder. Food had to be rationed,” Or again "Food supply was low, the decision to remain on station was based on a 5 day supply of food. The patrol could not have continued for a longer period without a serious reduction in efficiency and health —due to an unbalanced ration." Occasionally, as the war progressed, deficiencies in the quantity and variety of food were reflected in a monotonous diet. This was due to different factors—unusually long patrols or un- expected extension of operations, inexperience in loading, poor quality of available food before departure, refrigeration failure, and sometimes accidental flooding of supplies while on patrol. At the end of an 80 day patrol, one of the longest made by any sub- marine during the war, it was reported: "It was very fortunate that we had taken on a 90 day supply of food (83 men aboard)— by the 77th day choice and variety had disappeared and all food came out of cans. Planning menus was difficult. Five days of provisions were left at the end of the patrol," Another such long patrol was unexpectedly extended; at the time the ship left her area "food stocks had been reduced to the level that cabbage and asparagus were served for Breakfast." On a third patrol, of 60 days* duration, largely due to the in- experience of the commissar',’ officer and the poor quality of food available, "Supplies were entirely expended except for the two cans of catsup," A fourth submarine after completing an arduous 6l-day patrol stated that on about the 30th day, due to the necessity of securing refrigeration during a severe and prolonged depth charging attack, "All fresh meat, vegetables, and fruit had to be surveyed, , The diet from then on consisted of canned food. In view of the possibility of refrigeration failure, it is necessary to carry a good reserve of canned food," Stovya'-e space aboard fleet-type submarines varies with the’ make of the boat. Some of the newer ships are provided with double store rooms, others have a single compartment for dry storage with additional locker space in the torpedo rooms. All boats have an icebox and a chill room. Anyone who has ever been aboard a submarine at the time supplies are being loaded has marveled at the ingenuity evidenced by the crew in making stowage space available. Literally, every inch of space was used. Ice- boxes were crammed, potatoes were stored in hatches, under the deck grating of the cool room; showers were piled high with crates of vegetables and fruit, cases of food were stacked in the pump and engine rooms, in passageways, and pushed under benches. When this space was reduced, individual cans were tucked between the hull and the torpedoes, under bunks, behind manifolds and in indiv- idual personal locker. It is estimated that an enterprising commissary officer can carry sufficient food, with a complement of 90, to last for 100-150 days, depending on the type- of the boat. These figures would assume particular importance in any plan for transporting large numbers of personnel, as troops, by submarine. Commissary Personnel Considerable difficulty was sometimes experienced, and especially at advanced bases, in the satisfactory procurement of food. In part, as indicated in a number of these reports, poor or unsatisfactory food, while on patrol, was due in some instances to lack of experience of members of the submarine's commissary department. Typical comments were; ’’Food was lacking in variety—a deficiency which probably may be traced to the inexperience of commissary department personnel.” ’’Inexperience in planning and procurement for such a long patrol made the diet unsatisfactory.” ’’Quality of the food was good but ran out of several items due to carelessness in loading.” ’’Provisioning for the next patrol will be undertaken with the assistance of more experienced base or tender personnel,” In loading a submarine with supplies there was and is defi- nite need for skilled assistance from shore-based supply activities. As the veteran commanding officer cf one submarine wrote; •’Fresh frozen foods and ’’Avoset” ran out too early on the patrol because of the decision to load the refrigerator with an ex- cessive amount of meat at the expense of other foods. As a result, we arrived in Saipan with a certain amount of meat but low in certain canned foods. There should no longer be any necessity to load to the hilt with the old staples, missing out on taking aboard the more desirable items of food that are available. At any rate, the Commissary Officer and steward should be furnished a sample list of provisions listing the items—with alternatives and quantity— that are recommended to be carried by submarines on war patrols. There has never been anything published to guide the commissary officer to the best of my knowledge although unlimited information must be available. The only system has been the ordering of food carried on previous patrols, which often goes amiss when certain items are not available. It is felt that this haphazard ordering of provisions could be eliminated by preparation of a standard provision list for submarines that would be mandatory on their part to follow. This list could be prepared with alternatives to give it sufficient flexibility to satisfy any boat,1’ Meat The one article of the submarine ration most frequently the subject for comment was meat, its quality and quantity. Early in the war, for reasons of space economy, boneless beef was made available to submarines. It comes as steak and roasting, stewing and boiling, and chopped beef. Current regulations of the Bureau of Supplies and Accounts for all ships require that 30$ of the meat be drawn in inferior quality. In practice, at times, submarines starting on patrol were issued beef in the following proportions: roasts and steaks 50$, hamburger 25$, stewing and boiling meat 25$. This regulation resulted in considerable criticism, particularly with reference to Australian beef, which is inferior in quality to beef from other sources. Various observations may be of interest: "Steaks and roasting beef though a bit tough are satisfactory; stewing and boiling beef is 60% waste and, like hamburger, is tough, stringy, and unpalatable," "All of the boned beef taken on this patrol was tough and could have been put to better use in a shoe factory," "When meat loaf is too tough to eat, that is a new low," "This is a satisfactory proportion but since stewing and boiling meats are not considered worth the icebox space, it is generally left at the base and other frozen items, as shrimps, frozen foods, and sausage are taken in quantity to fill the space," "It is understood that commonly submarines draw their in- ferior meat (and pay for it) and immediately survey it." "One commanding officer recommended that ground beef be re- moved from the mandatory items for Submarines." "There is only one icebox in which must be stored various kinds of food and which must be entered daily on two or three month patrols. Ground meat absorbs odors quickly and becomes un- palatable after a few weeks at sea. Arrangements should be made so submarines going on war patrols can increase the percentage of roasts and steaks but reduce the percentage of ground meat. It be- comes the practice of tenders to store meat turned in by submarines returning from patrol and re-issue these same meats when submarines draw stores for succeeding patrols," It is felt, in all fairness that this latter practice, was certainly not common. It must be emphasized again that more un- favorable comments were made concerning the quality and proportion of issued beef (and not always Australian) than any other single item on the submarine ration. In view of this, the authors are of the opinion that Bureau of Supply and Accounts regulations should be reviewed with the possibility of making a satisfactory adjust- ment in the currently allowed percentage of meat issue provided operating submarines. At any rate, "At no time should meat of inferior quality be issued sub- marines for use on war patrols. Various cuts of good meat care recommended," "Limited storage space makes it necessary that every piece of meat be usable in some manner," Ice dream appears to have been the most popular so-called luxury item served on the boats, A few quotations will serve to reinforce this statement; "Once again, (10th patrol of this ship) and despite the cold and bitter weather, ice cream was the most popular dish." ",.,,and frequent ice cream was enthusiastically received." "The ice cream machine being very popular with the crew." "The ice cream freezer paid for itself many times over, it being estimated that one ton of ice cream was cons .med during the patrol, cold weather notwithstanding." "The ice cream maker turned out a fine produce,...this device should be placed on all boats." "The ice cream maker continues to be worthy of its weight in gold." "On long hot dives, ice cream is really appreciated and easy to take," "Generally found that near the end of the patrol, ice cream was the food that did not suffer with repetition," Staple Items of Food Like meat, potatoes are basic in the diet of the average American. It is exceedingly interesting, in view of this fact, that few unfavorable remarks appear in these reports concerning this vegetable. Most submarines were £ble to carry a large enough supply of fresh potatoes to last for a variable period well into the patrol. Early in the war a ”spud” locker was made out of the trunk of the mess hatch for extra stowage space aboard many boats, augumenting, by about 50$, the supply which could be carried. Widespread alternations to the hatches eventually eliminated this stowage space. (To supply potatoes every day for 90 men on a 60-day submarine patrol, approximately 2800 pounds are required.) By ingenious stowage (beneath the deck grating in the coat room in one of the crewTs showers, under mess tables, benches, etc.) it is said that a total of 3>000 pounds can be loaded aboard. Canned, water-packed potatoes were frequently available. Some submarines regarded then superior to regular fresh potatoes; certainly they were more con- venient to use. Dehydrated potatoes and onions were recommended on long cruises to save space. One pound of dehydrated potatoes makes ten pounds of mashed potatoes. Two submarines observed: •'Rice is an excellent substitute for potatoes and was served frequently.” "In the last two weeks when potatoes ran out, rice, spaghetti, macaroni, and increased consumption of bread and cake filled our need for starch." About 2600 pounds of flour are required for a 70 da}?- patrol. This, which comes in ten pound cans, was commonly stored in the engine rooms. Some boats had special storage racks in the torpedo rooms for flour and coffee. Bagged flour is unfit for patrol use due to the lack of proper stowage facilities; and the everpresent danger of oil contamination. Remarkably enough, considering the universality of coffee drinking in the Navy, coffee was only the subject of two unfavor- able comments in all of these reports, "Food was excellent and well prepared with the exception of coffee. Any resemblence between the stuff we have and real coffee is pur el y coincidental. It was either burned in roasting and is very stale, or both." "The food was generally very good, well prepared, and plentiful. The only exception being the coffee which was pretty bad, causing many to give thanks for Nescafe," Canned and evaporated milk was used aboard these ships. One boat reported; "Klim" makes very good cocoa and chocolate milk and is satisfactory on cereal but is not recommended for use as whole milk for drinking," Another commanding officer suggested that powdered milk be provided in small containers to prevent spoilage. Souring of con- densed milk, especially an Australian brand, was not uncommon. "Avoset", stabilized cream, was very popular aboard submarines and was used in coffee and on cereal and fruit. Many cooks used it to fortify canned and powdered milk, serving it as a beverage. It must be kept at an even temperature and sours quickly when opened and left at room temperatures. Fresh eggs were a boon and much appreciated: "Eggs for breakfast was one of the most popular items served." "It was a distinct pleasure to have fresh eggs at the start and end of the patrol instead of the usual spam end dried egg ome]3t." If available in quantity, enough eggs could be carried to last throughout the patrol. Freshness of eggs was hard to guarantee, especially at advanced bases. Powdered eggs were used with some success in cooking but generally they were not greeted with enthusiasm in taking the place of the "strictly fresh egg," Difficulty was not uncommonly experienced in keeping butter sweet and palatable, "Eight cases of eggs and 100 pounds of rancid butter were surveyed—brought from the States." "Butter went bad after the first week," "After two weeks at sea found that all the eggs were rotten and the butter rancid," One submarine experiencing rancid butter "despite excellent refrigeration" recommended a separate butter locker be installed in the cool room. Another commanding officer reported: "Butter as usual became unpalatable, A special sealed wrapper should be provided to prevent the absorption of all the odors in the refrigerator space." This, it seems to the authors, is an important suggestion. Some boats used and recommended canned butter; another boat recommended that all contracts for a special brand of canned butter be cancelled. "No boats should be stocked with it." "Tinned butter should be chilled to avoid running." In some reports excess spoilage of certain staple articles of food was reported—particularly due to the presence of weavils, as in the rice, wheat flour, cereal, macaroni, noodles and cocoa. Some commanding officers reported that certain brands of canned foods (particularly Australian) were unsatisfactory—as canned carrots, balogna, salmon, and orange juice. In five reports it was stated that the yeast taken aboard was entirely unsatisfactory. Supply of Vegetables and Fruit Carried by Submarines During the war the quantity of fresh vegetables and fruit that could be carried aboard submarines was limited not only by the amount of available space but by the available supply at re- fitting bases. Mention has been made of the importance of potatoes in the submarine diet. Other fresh vegetables and fruit, as onions, tomatoes, lettuce, carrots, cabbage, applies. Granges, etc., were especially appreciated for the variety and interest they lent to meals which otherwise became very monotonous. One commanding officer observed: "Fresh provisions of an excellent and superior quality should be made available for the crews of submarines on patrol—the importance of this is hard to overestimate. We had tomatoes for two weeks, onions and cabbage for four weeks, lettuce for three weeks, and potatoes for five weeks," "Loading the icebox with fresh lettuce and tomatoes paid dividends for the first two weeks of the patrol." "About the 50th day fruit and fresh vegetables became the usual topic of conversation." "Fresh provisions taken on at Tulagi were a great help. The lack of frozen foods was ffset by an abundance of fresh fruit," "A quantity of locally produced (Soerabaja, Java) con- centrated lime and lemon juice was carried and proved a delicious and refreshing drink. Since this product was fresh, it is con- sidered to have supplied, in part, the vitamin deficiences of our ration due to our inability to stock sufficient fresh food for the entire patrol." The advent of quick-frozen fruits and vegetables was a boon to the submarine cook and crew. They are convenient, simple to prepare, cook with a minimum of waste, and can be easily stowed. Unfortunately, however, they require refrigeration, the amount of which space aboard a submarine is definitely limited. Comments re- garding this type of commodity were, on the whole, very enthusiastic: "Quick-frozen foods are excellent," "The value of such items as frozen strawberries, corn, beans, peaches, and vegetables cannot be too strongly stressed," "Even a small quantity enlivens an otherwise drab bill of fare," "Are worth their weight in gold toward the end of the patrol," "It is unfortunate that the space available restricts the amount of fresh frozen foods that can be taken aboard," "By the institution of rationing, quick frozen straw- berries, peaches and peas were served throughout the patrol." Unfortunately, and especially at advanced bases, it was not always possible to supply operating submarines with resh vegetables and frozen foods in adequate quantities. "The absence of frozen foods was heavily felt and was a great disappointment in view of all the correspondence during the past year regarding the desirability, benefit, etc., of supplying submarines on long patrols with them." "A small selection and quantity of frozen foods were available; supply officers should keep the stock of these items high at all times Jf "Highly recommend that the high priority assigned this type of food be rigidly enforced—that shore stations and tenders do without to- such an extent that operating submarines may benefit," Special Submarine Foods Several different articles of food, often called "special submarine foods", were especially appreciated because, like fresh and frozen vegetables and fruit, they served wonderfully to re- lieve the monotony of the regular diet. Moreover, they provided "a maximum of food value in a minimum of space with great keeping qualities and little waste." Inasmuch as many submarines served only a lunch as the noon meal during submerged operating, canned luncheon meats were highly desirable—as canned ham, meat spreads. Spam, Vienna sausages, canned boned chicken and turkey, roast beef, potted deviled meats, lamb and beef stew, meat loaf, sardines, shrimps. crab and lobsters* "Our irreplaceable community stock of canned tuna* shrimp* and crab disappeared during the last refit and was missed by all hands, particularly for the nnon meal on all-day dives," Canned bacon was found very convenient. Tinned soup, mush- rooms, peanut butter, pickles, jelly* preserves, mustard, etc,, went far in stimulating appetites which* sometimes on long patrols* became dispirited. Fruit juices of all kinds were much appreciated, and, as indicated above, were very important in supplying the vitamin requirements of the ration. An ample supply of fruit juices is believed responsible for the marked decline in the number of bleeding gums among the crew. Canned orange juice in a few instances was reported as being bitter and unpalatable. Many submarines carried blends of orange, tomato, and grapefruit juices; lemon, lime and orange concentrates were available, as were powdered lemons. Other preparations in- cluded apple, currant, prune, and sauerkraut juice, etc. On© commanding officer pointed out the tendency of submarine personnel to consume liquids—one patrol it might be coffee, another might find the same crew consuming large quantities of tea. On some boats* "Coca Cola" was very popular, "Coca Cola" mad© with water and put in the cold room to 'ice up* was a delicious drink at any and all hours of the day. at any and all hours of the day. Two other suggestions concerning the stocking of submarines with these various food items have belli made: "It is not considered advisable to stock fresh ffozen vegetables or fruits, as tinned vegetables and fruits are always available, more economical, easier to store, taste as well, save cold storage space for essential items and have all the nutritional advantages of frozen items. "Most yards and bases have standard items in small pack, such as Nos. 2 or 2-g- tins, suitable for use on small submarines. By using this small pack, greater variety of vegetables and fruits can be stored and some waste avoided. Spices, sauces, catsup, etc,, are available in small cans or bottles. A wider variety can be carried to season food so it is more appetizing." Dehydrated and Concentrated Foods Dehydrated foods—potatoes, onions, cabbage, carrots, eggs and soup stock—were available to operating submarines, being re- commended to save space on long cruises. As pointed out, one pound of dehydrated potatoes makes ten pounds of mashed potatoes. De- hydrated potatoes are palatable when mashed or french-fried. They do not approach the fresh variety. Powdered eggs were used in cooking and baking with success. When prepared, as scrambled or in omelets, they were not greeted with enthusiasm. Only four patrol reports out of the 1458 reviewed showed any enthusiasm for dehydrated foods. Vitamin Capsules During the war multiple vitamin capsules were supplied to the submarines* A capsule per day supplied one half the minimum daily requirements. About 85 patrol reports mentioned having used these capsules, particularly for the lookouts. In general, it was felt that the varied submarine ration contained all of the required vitamins. However, in order to be certain there were no deficiencies, the use of the multiple vitamin capsules was recommended. That the vitamin intake was ample was evidenced by the fact that only in two patrols in the earliest months of the war, and then only under the most unusual circumstances, was there any evidence of avitamosis, / Refrigeration Odors and Taste in Foods As pointed out above, submarines are equipped with a chill room and an icebox. These, unfortunately, must be entered many times in a patrol. Food especially meat and butter, crowded into this refrigerating space, absorbs various odors and becomes ”strong.” "Towards the end of the patrol food begins to acquire an 1 icebox* taste,” "Fresh meat although kept at F again acquired a most unpalatable taste early in the patrol in spite of every effort to locate and remedy the cause. This condition has existed on every patrol. Ventilation was increased, a charcoal filter was installed and the icebox was inspected by a medical officer--," Another submarine reported, "The objectionable icebox odor was eliminated by careful observance of cleanliness, stowage and ventilation of the refrigeration spaces. In two refits the spaces have been scrubbed with soap and water, wiped down with alcohol and aired out with portable blowers for two days® Meat and provisions have been stowed in such a manner as to allow the circulation of air* An electric fan was installed to provide circulation of air and temperature was maintained at a low level by limiting the frequency of opening the door to an absolute minimum/1 A few boats obtained deodorizing equipment. One commanding officer reported most enthusiastically concerning the use of "Ozonelite" procured from an Australian firm* "The usual odor of an objectionable nature observed when the cool room door was opened disappeared. There was no discolora- tion of the meat#" In these patrol reports sometimes considerable meat and, in some instances, fresh frozen vegetables were surveyed while at sea. In part, this was undoubtedly due to the poor quality of food issued the submarine prior to her departure on patrol. It should be pointed out in this connection that potatoes which have bean frozen, meat which has been thawed and refrozen or which has been removed from a submarine upon the completion of a patrol should never be reissued to submarines. It is true that iceboxes were commonly loaded beyond their capacity, "The present arrangement of the icebox is not satisfactory. Either a rearrangement of the coils, shelves and ventilation or a compromise of each is required to utilize the present refrigeration space. The excessive amount of meat spoilage (1000 pounds) shows the necessity of an improvement inasmuch as the icebox was never out of commission," "Feel that the increase in personnel over the designed complement necessitates carrying more food so that proper cir- culation is not obtained near the bottom of the icebox," Again, "Inasmuch as all running equipment, including refrigera- tion machinery, was commonly secured during * silent running1 in evasive tactics, impressive amounts of meat, etc,, spoiled due to temporary rise in the temperatures of the refrigeration spaces,” Cooks and Bakers Unless care is taken in its preparation, the finest of food may prove unsatisfactory, "We had one inexperienced cook. Constant effort and the use of the Navy Cook Book was required on the part of the commissary officer to keep the food palatable,” The commanding officer of another submarine pointed out ”a cook with enthusiasm for his job and inspiration can do much to improve the food situation," Another stated: "Three unimaginative cooks and the Navy Cook Book are a bad combination for even the hardest working commissary officer," "Only the best cooks obtainable should be assigned to the exacting cooking duties aboard a submarine and between patrols it is believed that a brief course of instruction in diet and preparation of healthy menus should be given to all submarine cooks by a qualified medical officer," "The practice that some ships followed while in the Bay Area of permitting the ship*s cooks to take part time work in the galley of the St, Francis Hotel was followed *>y this command and has paid ample dividends. This is the first good commissary department that we have had in five patrols," By and large, however, it is believed that most cooks and bakers aboard submarines performed their duties with satisfaction if not aplomb, for they were commended by their commanding officers in 47 of these reports in glowing terms: "The cooks and bakers made meals a pleasure," "The unsung heroes of these patrols are the cooks—their1 s is a difficult task and one that is always well done," "The abundance of fresh bread, cakes, rolls and cookies provided by a conscientious cook went a long way in making this a fine ship," An effort should be made to provide all submarines with a good baker,'1 .who are responsible for the particularly high morale around chow time," Meal Time When there is a break in the normal conditioned routine, some men react unfavorably, A submarine on patrol certainly en- forces many violent changes. Some patrol comments relative to this were: "Night was turned into day for meals," "Two meals were served, one in the morning and one in the evening, with soup and sandwishes at noon and midnight," "During the period of all-day dives, breakfast was either cold or cooked prior to submerging, lunches were cold, and a hot meal was cooked and served after surfacing at night," "Meals were served at the regular times with hot soup and crackers available at midnight. This midnight snack became more and more popular as the patrol progressed," The majority of the boats maintained normal meal hours. That the problem of meal time was not considered important is evidenced by the fact that only 12 comments were made in patrol reports. Yet we know that every officer and man who served aboard submarines was affected. It is interesting to conjecture how much bearing this break in the long established meal time routine had on such problems as gastric distress, peptic ulcers, constipation, and even general fatigue. "Night was turned into day for meals,” Food Poisoning On© of the ever present worries of every conscientious cook or baker is the occurrence of group food poisoning. Such episodes may be not only incapacitating but definitely dangerous. Careful analysis of the patrol reports reveal notations concerning food poisoning only 34 times. Many of these reports mention the occurrence only in general terms, as: "Sixty-five percent of the crew were mildly affected on one occasion by food poisoning," Some of the reports listed the offending agents: canned orange juice, canned sardines, custard pie, beef, surveyed "Avoset," spoiled frozen chicken, tinned hash and tinned salmon, THht mess food poisoning aboard an operating submarine may not only be incapicating but cripple the striking force of the ship is illustrated by the following excerpt: "Food poisoning occurred on 7-9 July—-believed due to frozen chicken (which was spoiled) served for dinner on 7 July, Two-thirds of the crew and all of the officers were involved with diarrhea and vomiting. Two men were still vomiting after five days and were not fully recovered ten days after they had been stricken," The submarine sighted a carrier on 10 July concerning which it was observed: "Loss of depth control on the one attack made was most un- fortunate in that it prevented firing at a carrier. The order to make ready the tubes was given rather latej this was combined with personnel errors in hurriedly preparing all tubes. At this time nearly all of the crew was handicapped by sickness from the food poisoning," The incapacitating nature and serious military significance of this illness may be recognized when it is further explained that -237- mass illness, in part, may have been responsible for the submarine’s inability to carry through a successful attack against a Japanese carrier# For the benefit of medical officers studying the etiological agents causing a general poisoning on a submarine, it is well to bear in mind two possibilities in addition to food— the drinking water and a volatile chemical such as carbon tetrachloride# At the risk of seeming to belabor the point, the following pertin- ent quotation is presented* "The period November 6th to November 10th contained the greatest amount of sickness, about twenty people being sick enough to vomit at this time, and it was necessary to turn two men in# These latter two men were never able to resume their normal duties# This particular period occurred soon after a particularly bad tast- ing batch of water was put in use and is believed to be the cause of the illness. The taste of this water was distinctly like iodine and samples were taken for analyzation# The two more seriously sick men were subject to cramps and pain in the stomach and they were unable to retain any foods or liquids for a period of five days in spite of the use of amphojel, soda, paregoric, and rhubarb and soda mixture. Intravenous feeding was finally resorted to in the case of one of these men and after two days we wore improved sufficiently to go on a liquid diet and two days later on a soft diet#" Next patrol of the same ship says: "No evidence of stomach upsets experienced on the two previous patrols was noted# This condition had been attributed to contaminated drinking water. During the last refit period the senior medical officer advanced the opinion that it was caused from inhaling carbon tetrachloride fumes* This liquid had been carried below decks for cleaning electrical appliances. All carbon tetrachloride was removed from the ship and nothing was done to the fresh water system. It now appears that the trouble had been remedied," Re wish again to emphasize that operating submarines, as judged by the record of the patrol reports, were singularly free from "food poisoning", with a record of only 34 instances out of 1489 patrol reports studied; and in only 9 of these 34 was food actually incriminated. Miscellaneous A few interesting and largely unrelated comments concerning food habits of submariners, etc., were observed in these patrol reports. One submarine, early in the war, reported that an average of 1,5 pounds of meat had been used per man per day. Total food consumed averaged 5,6 pounds per man per day; this was a 47-day patrol, thirty-one days of which were spent submerged in the vicinity of Truk, One commanding officer was of the opinion that serving a light lunch at noon "curbed the tendency to overeat from boredom, with a beneficial effect on the crew," Aboard another submarine, also early in the war, "food consumption was observed to fall off noticeably, the decline being most noticeable during the fourth week”. Others reported a decline in appetitie after prolonged periods of silent running and depth charging. Two commanding officers, following cold weather patrols, reported an increase in food consumption, A third reported that cold weather operations were accompanied by a marked increase in the consumption <3f coffee (tripled). Others observed difficulty in b aking under conditions of in- creased humidity within the ship. More than one cook on a war patrol has experienced and complained bitterly of collapse of his cakes during depth charge attacks. Two commanding officers encouraged the chewing of gum by their crew, one of whom was convinced of its beneficial effects in that it reduced the amount of smoking during depth charging and was believed to account for a "noticeable reduction in the usual number of gastro-intestinal complaints usually observed during the course of a long patrol," SUMMARY 1, The ration provided submarines in World War II succeeded in meeting their somewhat specialized requirements, namely: case of stowage, excellent keeping qualities and case of preparation in providing a well balanced daily menu incorporating a maximum of food value, variety, and a minimum of waste* 2, More active participation of submarine squadron medical officers in the problem of supplying men on submarine patrols with a satisfactory ration is indicated, 3, It is urgently recommended that this entire problem be re- studied in the less hurried atmosphere of peacetime with a view toward constructing a master ration plan for the Submarine Service, sufficiently exact to be helpful as a guide and at the same time flexible enough to allow for satisfying individual preferences* 4, The need for more thorough schooling and training of the en- tire team (commissary officer, commissary'- steward, cooks, bakers and supply officers) is apparent and will go far toward eliminat- ing some of the problems of the submarine ration, 5, The one single item of food most common cause for unfavorable comment by commanding officers of combat submarines was the qual- ity and percentage issue of boned beef, A review of this situation, with a view to possible corrective measures, may be in order. 6, With reference to individual food items provided submarines, the following points appehr Worthy of emphasis* (a) The significance and importance of ice-dream in providing variety in the diet as well as nourishment is apparent. In addition, it rates high as a recognized morale builder aboard submarines, (b) Submarines should be given a high priority in the obtaining of available supplies of frozen fruits and vegetables, the importance of which, in the submarine ration, has been amply demonstrated, (o) Certain luxury foods ("Avoset", canned luncheon meats, sea foods, fMescafet, jams, etc.), particularly when available in small pack size, are important in providing variety and enlivening what may otherwise be a monotonous diet, 7. The foregoing comments are intended not as a criticism of the commissarydepartment of the submarines or the supplying organization, but as suggestions designed to make more perfect an already smoothly functioning organization. In fact, from all information available, it is apparent that the Submarines in World War II amply earned their reputation of being ’’the best feeding ships in the Navy,” UPPER RESPIRATORY INFECTIONS AND CONTAGIOUS DISEASES ABOARD SUBMARINES' IN WARTIME 1942-1945 There has always been a great deal of speculation concerning the incidents of upper respiratory, infectious and contagious diseases and their transfer from one to another in submarines. A study of this nature would certainly be of value in any attempt to determine the need for such equipment as Ultra violet lights for the control of bacteria in the air or for any other air purification equipment. With this in mind, the students in the school for Pharmacists Mates Entering The Submarine Service were given as an assignment, the review of all the submarine patrol reports, with a view toward pulling out every mention of inciddnts of upper respiratory, in- fectious and contagious diseases and their transmission from one to anothe r. The material which follows are these extracts quoted verbatim from the patrol reports, and we believe it is amply indicated that there is a problem yet to be answered so far as the submarine service is concerned, in the matter of removal of bacteria from the air. U.S.S. ALBACORE, 4th Patrol, 4-6-43 to 5-26-43, Bismarck Sea Area Numerous colds at start of patrol were aggravated by wet weather. U.S.S, ALBACORE, 6th Patrol, 8-23-43 to 9-26-43, Bismarck Sea Area Numerous colds wore prevalent at the start of the patrol but they cleared up on reaching warmer climate. U.S.S. ALBACORE, 7th Patrol, 10-12-43 to 1-25-44, Truk, New Hanover Area. One man had catarrhal fever throughout the run and was in a rundown condition. He is being transferred for a rest. U.S.S. ALBACORE, 8th Patrol One case of DU (Sinusitis) retained on the sick list for seven days and returned to duty, two cases of Catarrhal Fever. U.S.S. AMBER JACK, 2nd Patrol Twenty-six cases of colds, seven hundred and eighty treat- ments • U.S.S, APAGON, 2nd Patrol, 1-15-44 to 3-9-44, Mariannas Area Three cases of common colds and some sore throats and five cases of Vincentfs Agina, U.S.S. ARCHERFISH, 2nd Patrol, 3-16-44 to 4-27-44, Palau Area There was a small epidemic of common colds during the first two weeks after departure of p&trol, Number of cases sixteen, days lost none. U.S.S. ARGONAUT (SMl) (First), 1st Patrol After forty-one days without sunlight in the tail end of the patrol, the number of colds and sore throats have increased, 40/b of the crew, U.S.S. BaLAO, 3rd Patrol, 12-8-43 to 1-15-44, Bismarck Sea Area A few colds noted, especially among the bridge personnel, U.S.S. BALAO, 9th Patrol, 5-3-45 to 6-7-45, East China & Yellow Seas, Colds wore prevalent especially among the bridge personnel, U.S.S. BARB, 3rd Patrol, 2-1-43 to 3-9-43, Off Spain Twelve cases of colds. U.S.S. BaRB, 4th Patrol, 4-1-43 to 5-14-45, Norway & Ireland Thirteen cases of colds. U.S.S. BECUNA, 4th Patrol, 4-15-45 to 5-24-45, South China Sea Our last leave period was spent in an unhealthful surround- ings, since that time, until almost the end of the patrol, an unusually high number of cases of sore throat, severe head end chest colds and associated illnesses, including two abcessed throats were experienced. Eleven man days were lost among the crew because of illness and one officer was on the sick list for one day, U.S.S. BESUGO, 4th Patrol, 5-24-45 to 5-20-45 The usual colds were experienced upon leaving port. The GERI/AN POW had a cold when captured. He brought a new variety of cold germ aboard, resulting in another epidemic of sore throats and colds. U.S.S. BLUEGILL, 5th Patrol, 5-12-45 to 4-18-45, Java Area Colds were unusually numerous in the early part of the patrol but cleared up as the patrol progressed. -243- U.S.S, BONEFISH, 7th Patrol, East China Area The health of the crew was, in general, fair with only five mild cases requiring treatment# These men developed compli- cations resulting from colds# U.S.S# BOWFIN, 6th Patrol In general the health was excellent after overcoming the initial epidemic of colds and sore throats that prevailed from Pearl to Midway# U.S.S. BOWFIN, 9th Patrol Quite a number of colds developed in the damp Japan area# U.S.S. CABRILLa, 1st Patrol After our first day dive about twenty-men developed colds, but the epidemic was of short duration. U.S.S. CAVALLA, 5th Patrol, 4-20-45 to 5-27-45, South China Sea Health of the crew has been fair. There were two admissions to the sick list due to Catarrhal Fever, and many cases of head colds. U.S.S. CERO, 8th Patrol, 6-27-45 to 7-30-45, East of Honshu The health of the crew during the patrol was very good# There were a few slight colds contributed to change in climate # U.S.S. COBIA, 5th Patrol, 5-9-45 to 6-18-45, Gulf of Siam A minor epidemic of colds and Catarrhal fever commenced during the training period and persisted through the first two weeks of the patrol. U.S.S. CREVALLE, 7th Patrol, 5-27-45 to 7-5-45, Sea of Japan An epidemic of colds broke out but was not to severe. This was expected as the change in climate from Guam to the cold dampness of the weather in the Japan Sea was made in slightly over a weeks time# U.S.S. CROAKER, 1st Patrol, 7-19-44 to 8-31-44, East China Sea A mild epidemic of colds and sore throats occurred during the first week, about eighty percent of the officers and crew were affected, U.S.S. CROAKER, 3td Patrol, 12-13-44 to 2-12-45, Luzon Straits Because of consistently damp weather in this area numerous colds developed. U.S.S FLYING FISH, 5th Patrol Three cases of mumps with complications in two cases. U.S.S. GABILAN, 5th Patrol It was noted that after irwo or three hours of silent running that fifty percent of the crew caught colds. U.S.S CATO, 5th Patrol Carrying over one hundred men (non-naval) the crew developed over forty-five colds. U.S.S. GRAMPUS, 3rd Patrol Epidemic of catarrhal fever one day after departure involving over seventy percent of the crew. U.S.S. GRENADIER, 1st Patrol, 2-4-42 to 3-23-42 A number of the officers and crew developed colds, some of which were severe. U.S.S. GROWLER, 1st Patrol, 6-20-42 to 7-17-42 There were eighteen cases of slight colds; no one was incapicated for duty. The ship was kept comfortably warm except when running silently. Heaters were secured then and naturally the ship became cold and clammy. U.S.S. GUARDFISH, 12th Patrol, 5-8-45 to 6-26-45 Minor colds were prevalent due to the cold damp weather encountered but all responded to treatment. In general the health of the crew was excellent. U.S.S. GURNARD, 6th Patrol, 7-8-44 to 9-5-44, Mindano Sea There were six man days lost due to Catarrhal Fever, Acute, U.S.S. HADDOCK, 3rd Patrol, 12-28-42 to 2-13-43 During the first three weeks about forty percent of the officers and crew had colds which were probably due to the change in climate. U.S.S. MINGO, 1st Patrol, 6-25-43 to 8-21-43, Palsu Area Numerous colds at the start of the patrol but were all gone in two weeks. U.S.S. NAUTILUS, 1st Patrol During the first two weeks about twenty-five percent caught colds, none of which were serious. U.S.S. NAUTILUS, 5th Patrol Ninety percent of the crew had chest colds at one time or another. The more or less sudden change from tropical to Artie area is the obvious cause. U.S.S. PAMPONITO, 6th Patrol There were several colds the first week after leaving Subic Bay. One man was on the binnacle list for two weeks with a fever from a cold. U.S.S. PETO, 2nd Patrol, 6-10-43 to 8-4-43 There were numerous members of the crew with colds when the patrol started and three mild cases of influenze. This cleared up during the second week. U.S.S. RAY, 4th Patrol, 4-23-44 to 6-14-44 Numerous colds the first two weeks. U.S.S. RAY, 7th Patrol, 4-30-45 to 6-16-45 Approximately thirty-five men contracted common colds and five cases of mild tonsillitis occured. U.S.S. REDFIN, 3rd Patrol, 5-26-44 to 7-14-44 Many of the crew suffered from colds contracted during leave and training period. U.S.S. SARGA, 8th Patrol, 8-1-43 to 9-15-43 Besides a bad seige of colds that made the rounds, only minor complaints were encountered. U.S.S. SAWFISH, 12-17-44 to 2-4-45 A great number of common colds was encountered due to sudden change in weather conditions. U.S.S. SEADPvAGON, 9th Patrol, 12-14-43 to 1-30-44 At the start of the patrol there was an epidemic of common colds, leasting about two weeks• U.S.S. SEAL, 2-19-42 to 4-9-42 An epidemic of colds made the rounds the first two weeks. U.S.S. SEGUNDO, 3rd Patrol, 2-1-45 to 3-26-45 Colds were prevalent during the first week in the area, but attribute this to the fact that the ship had operated in the tropics for the previous seven months. U.S.S. SHAD, 2nd Patrol There were fourteen cases of colds and sore throats, the greatest amount of these occured during the first half of the patrol. U.S.S. SHAD, 8th Patrol Half of the crew had colds* Epidemic naturally ascribed to sudden passage from a warm climate to a cold one* U.S.S. SNAPPER, 1st Patrol, 12-19-41 to 2-10-42 While up in the cold area neqr Hongjcong, several men had colds vhich cleared up -when we reached warmer weather. U.S.S. SNAPPER, 2nd Patrol, 3-6-42 to 4-25-42 At the start of the patrol four officers and many men had heavy colds which gradually cleared up as we got into warmer climate. U.S.S. SNAPPER, 8th Patrol Epidemic of common head colds approximately seventy-five percent of the officers and men were affected with these and while disagreeable none were sufficiently serious to require men to be taken off duty. It is felt that this epidemic was caused by the difference in weather conditions between Pearl Harbor and this area. U.S.S. SPEARFISH, 2nd Patrol. The health of my crew is beginning to wane as evidence by an enormous increase in colds. More than half of the officers and men were affected. U.S.S. SPEARFISH, 7th Patrol About twenty percent of the crew and three officers suffered from prolonged coughing spells which had the effects of whooping cough, but without nausea and vomiting. U.S.S. SPEARFISH, 9th Patrol Other than a rather severe epidemic of common colds at the start of daylight submerged periods the health in general was excellent. U.S.S. SUNFISH, 6th Patrol, 1-15-44 to 3-7-44 A continuous epidemic of mild Catarrhal Fever that started prior to leaving Pearl. Continued throughout the patrol. U.S.S* SUNFISH, 7th Patrol, 6-22-44 to 8-1-44 We had expected several colds due to the cold and damp weather, especially as several members of the crew still had colds and coughs hanging on that they had contracted in the states. Surprisingly all colds cleared up and no new ones were started* U.S.S. S-31 Health of the crew was good, except for common colds and epidemic of sore throats thought to be caused by improper disinfecting of mess gear* U.S.S. S-32, Attu A marked lowered resistance of the personnel resulting in an increase of colds and apparent coughs. The fact that only one week was spent in port for refitting between the last patrol and the present one, plus an increasing time spent submerged may account for this condition# U.S.S. S-33, 3rd Patrol Health and hability was only fair. Fifty percent of the crew suffered from colds of varying durations# U.S.S. S-41, 5th Patrol. 9-2-42 to 10-14-42, New Caledonia Area Numerous colds were experienced. Commanding Officer confined during last four days with severe cold and sore throat. U.S.S. TARPON, 10th Patrol. 12-4-43 to 1-14-44 The general health of the crew v/as good. At the start of the cruise about one third of the crew had severe colds and several cases developed into catarrhal fever which gradually cleared up without any admission to the sick list. U.S.S. TRITON, 1st Patrol. During first weeks on station, there were a large number of colds, probably due to change of conditions. Only one serious case developed and that could not be diagnosed. The patient ran a high temperature for two days and was transferred to the Marine Camp at Wake Island for treatment. A good portion of the crew had submarine coughs upon return to Pearl Harbor# U.S.S. TRITON, 3rd Patrol Numerous colds, however, were experienced about Midway during the daily submerged running periods, considerably more colds than on the last patrol# U.S.S. TRITON, 4th Patrol. During early stages of the patrol, numerous colds were experi- enced mainly due to change in climate# During latter part of the patrol bad colds and coughs increased and personnel resist- ance was lower* Probably due to eighteen hours submerged daily# U.S.S. TUNNEY, 3rd Patrol. Numerous colds developed early in the patrol# Three cold cases developed into Catarrhal Fever, acute# This tendency was quickly checked by adding small quantities of creosol to dish- water# The epidemic of colds also subsided after two days of this precaution# VIII - RESEARCH ACTIVITIES WITHIN THE SUBMARINE FORCE Research accomplished anywhere in the Navy was eagerly utilized by the Submarine Force, wherever found to be applicable. Historical accounts of the full research program and its develop- ment and utilization will be published elsewhere and no attempt is made there to even outline the field. Within the Naval laboratories, the work at Naval Medical Research Institute in Bethesda is notable, in that at times certain phases of the program there were designed to answer directly certain submarine problems. Such research was of course utilized by the Submarine Force to the fullest extent. Examples of such projects are listed below: Project X-189 (Bio-3) - Protective Clothing for Subjects immersed in Cold Water# Project X-191 (Sub 31) - Application of Body Fat Measurements to the Study of "Bends” Suscepti- bility* Project X-337 (Sub 62) - Oxygen Poisoning - Reaction of men Breathing Pure Oxygen Under Water at Depths usually of 60 feet or less# Project X-427 (Sub 87) - Preparation of a Classified Biblio- graphy of Submarine Medic ine * Project X-436 (Sub 88) - Oxygen Poisoning in Man. Effect of Drugs and Alterations in pH of the Blood and Tissue. Project X-443 (Sub 89) - Physiological Factors Underlying the Prevention and Treatment of Compression Sickness. Project X-540 (Sub 113)- Design and Modification of Oxygen Breathing Equipment for Use in the Treatment of Caisson Disease. Project X-570 (Sub 121)- Evaluation of Effects of Experience During Decompression on the Incidence of Bends. Project X-589 (Sub 125)- Table for Surface Decompression Utilizing Oxygen, Calculation and Testing of. Project X-605 (Sub 130)- Physiological Effects of Pressure Changes in Relation to Submarine ''Snorkel" Operations. Project X-755 (Sub 156)- Effects of Silicone Vapor Emanating from Insulation on Electrical Equip- ment of Submarines. There were from time to time within the Submarine Force minor researches of an applied or development nature undertaken by medical officers in various parts of the world* These are usually of such a minor nature or such short duration that again no attempt has been made to list them here. It can be truthfully stated that the only continuous concerted and organized effort of any magnitude in so far as submarine research performed by submarine personnel is concerned was that done by the Medical Research Laboratory, Submarine Base, New London, Conn. A history of this laboratory for the period from Pearl Harbor to the end of the war, and its development from a two man team of a medical officer and chief pharmacist’s mate to an organization occupying three buildings and having 27 officers, 4 civilians, 11 waves, and 100 enlisted men at the height of the war, has been prepared and is available from the Medical Research Laboratory. However we believe that it is in order at this time to at least briefly set forth certain phases of the research activity of this organization. In doing this it should be constantly borne in mind that the research staff at New London had many additional routine duties in connection with the examination and general processing , screening and selection of officers and men for the Submarine Service and also in connection with the activities of the various schools giving instruction under the cognizance of the Medical Research Laboratory, so that research was only a part of the effort of the group working at the laboratory during the war. With this in mind, the following has been bodily lifted from the report entitled HISTORY OF THE I EDICAL RESEARCH DEPART- MENT OF THE SUBMARINE BASE, dated 7 December 1945: ”E stab1ishment as a Base Department, 23 February 1944: The Medical Research Department was officially set up as a separate department of the U. S. Submarine Base, New London, Connecticut, by Base Order No. 2-44, under date of 23 February 1944, signed by the Commanding Officer of the Base. However, this department had been functioning as a separate unit, for all practical purposes, for at least two years prior to that date, although it was still, officially, an appendage of the Medical Department, —some of the personnel (i.e. Lookout and Recognition Officers) were carried on the complement of the Submarine School, and the rest (Medical Corps and H(S) officers and pharmacist’s mates) being part of the Medical Department. "Previous Recognition by BuMed and BuPers: Recognition of the work of this department by the Navy Department, that is, both BuPers and BuMed, had come in 1942, with the appointment of the Submarine Medical Examiner, on 11 September and 9 December respectively, as assistant liaison officer between BuMed and N.D.R.C. Committee for the Selection and Training of Sound Operators, and liaison officer between BuPers and the Committee on the Selection and Training of Service Personnel, (lator transformed into the Applied Psychology Panel of N.D.R.C.). On 25 April 1943, additional duty orders as Medical Officer in Charge of the Medical Research Laboratory were issued by the Bureau of Personnel to the Submarine Medical Examiner. During all of this formative period 1942-44 and continuing through the present writing, numerous Bui'fed, BuPers, and BuShips experimental projects have been assigned to this department for investigation, study, and comment# "Early Work? During the two years prior to Pearl Harbor the medical officer attached to the Submarine Escape Training Tank and serving in the Medical Department as Submarine Medical Examiner, had initiated several interesting pieces of research on Sub- marine Sound problems* He was assisted in this work by a Chief Pharmacists Hate who was a submarine man of long experience* In collaboration, they wrote a series of articles on "Auditory Acuity among Submarine Personnel", which was later published in the Naval Medical Bulletin# The first of the series appeared in January 1942, The others followed in April, July, and October of that year# They also had begun some experimental work leading to the development of tests and techniques for the selection of men for sound listening duties on submarines. Many of these tests were later adopted officially for use throughout the Navy. "Status at the Outset of the Wars At the onset of the war (December 7, 1941) what was to become the Medical Research Department was in its embryonic state. The two-man team mentioned above v/as the staff and the working space was an office, a soundproof testing room, and one large classroom and/or examining room in the south wing of the dis- pensary, Building 86. Both men spent a part of each day at the Escape Training Tank. Then, as now, the primary function of the department was the examination and selection of submarine personnel. This constant stream of candidates for Submarine School and submarine duty, plus their training in the use of the submarine escape appliance, and the complete and accurate records kept on this testing, made available a wealth of data for analysis and study. As we have pointed out, the two were at this time preparing the first reports on their studies in auditory acuity and audiometric testing at this time. (As an almost forgotten angle of the situation in those days, we might point out that the Dispensary building was sand-bagged up to the level of the second storey windows, hence, all the work done in this basement wing of the Dispensary was necessarily carried on under artificial lighting and under conditions of very poor ventilation.) "Assistance from National Defense Research Committee: From the very modest beginning outlined above, several related studies developed, such as, night vision, color vision. and lookout training, and as the volume of work increased, assistance became necessary. Such assistance was secured from several sources, notably N.D.R.C. As early as January 1941, the Division of Preventive Medicine of the Bureau of Medicine and I Surgery, became interested in the research on sound problems and put the laboratory in touch with members of the National Research Council who became and continued throughout the war active sup- porters of the efforts at New London. Further contacts with these and other forward-looking scientists brought active assist- ance from the N.D.R.C. group, as we11 as from the Research Division of BuMed, and financial assistance from the Bureau of Ships. Through the assistance of N.R.C., N.D.R.C., Coordinator of Research and Development, Columbia Division of War Research, Underwater Sound Laboratory, Fort Trumbull, and Brown University Division of War Research and numerous other contacts, the staff was rapidly augmented by a number of civilian scientists. "Acquisition of Additional Space: It was soon apparent that more space was necessary and that it would make for greater efficiency and progress if all our activities could be housed in one building, —not one on the Upper Base and one on the Lower Base. Accordingly, a new build- ing was requested and plans drawn. The request was approved and the building (tt126) was built, immediately behind the Dispensary, and first occupied on 2 February 1943. This is a two-story frame building, rectangular in shape. In order to procure a higher priority for the construction of this building, and in response to the Dispensary’s need for more beds, the first deck of this building was converted into Dispensary wards (Wards G and H), however, the entire second deck was occupied by the Medical Research Department# This area contains 20 rooms. In one there is an area designed to facilitate the physical examination of submarine candidates (a series of small examining rooms around a central waiting space) and at the other end there is a large dark-room for giving Night Lookout Training and an adjacent dark-room for Night Vision testing# The remaining rooms are classrooms, offices, and laboratory spaces# '’Building #156: With the further development of the department and the addition of other activities (training as well as research), still another building was found necessary# This was requested, planned, and constructed during the latter half of 1943. Build- ing 7/-156, a three-story brick construction, adjoining Rock Lake, was first occupied on 17 February 1944, and houses the Lookout Training School, the School for Pharmacist’s Mates Entering the Submarine Service, the Interior Voice Communication School and the Sound Laboratory* ”Building #70: By the Base Order creating this department, the Escape Training Tank was included, and therefore Building was added to the Medical Research Department# This attachment was a very logical one, since the medical officers of this department (all qualified in submarine $nd diving medicine) had always been attached to the Tank and supervised the escape training, the satisfactory completion of which is a part of the submarine physical examination* The performance of candidates in the ’’lung" training program constitutes a further valuable check on the emotional stability of men requesting submarine duty. "Training Aids Shop, Basement of Bldg* y!06: A need for a shop for the Research Unit for the constr- uction of training aids, and various experimental "gadget" as well as the repair of models and research devices soon became apparent. First plans called for construction of such a shop in the basement (the unexcavated part) of Building rrl56, but this plan was not approved* For a while, space for this purpose was made available in the Mess Hall in Building i'-150, and when it became necessary to move from there, space was made available in the basement of Building 7,-'106 on the Lower Base (this base- ment being reserved as an air-raid shelter in case of emergency and being otherwise unsuitable for occupancy because of the flooding in of water). Construction of this shop was started on 31 January 1943. This department had previously constructed night vision testing facilities (temporary testing booths and alleys) in an adjacent area in the basement of f,:1069 to accom- modate the mass testing of night vision for the entire comple- ment of this Base, as will be mentioned in the section concerning the development of that section of the department* The Training Aids Shop was located in -7/-IO6 until October 1945 when it was moved to the first deck rr'156 because it became necessary to use this space for storage of spare parts for submarines* 11 Summary: Buildings In summary then, as of 15 November 1945, the Medical Research Department occupies Building No. 156, the second deck and one half of the first deck of =}flZ6 (South wing), and all of Building No, 70* Staff The staff has constantly grown until at the present time it includes: 26 officers (three having been recently released to civilian life --replacement being received on only one.) 22 chief petty officers 35 enlisted men 11 enlisted WAVES 4 civilians - Group IV-b I - examination Officer candidates for Submarine School. Unlisted candidates for Submarine School, —all candidates for Submarine School are given physical, psychological, and psychiatric examina- tions, and aptitude tests for various special jobs, and those who pass are then given submarine escape training. Officer candidates for "Qualification in Submarines" Pharmacist's mates for Submarine PhM School Enlisted candidates for qualification as deep-sea diver Special test in Color Vision Special tests in Night Vision Selection tests for Sonar Operation Selection tests for Radar Operation Re-check examination for New Construction crews Basic battery tests for those who lack same in their Service Records. II - RESEARCH Auditory - Sound, including project on aero-otitis media. Visual - Color Vision Night Vision and Lookout Training General ophthalmological research Training Aids Shop Personnel Selection Submarine and Diving Problems, III - INSTRUCTION Submarine Escape Training School Lookout Training School School for Pharmacist's Mates Entering the Submarine Service School for Second Class Divers Interior Voice Communication School "Sound Section This activity was the first to be undertaken beyond the routine work of the department, —physical examination for sub- marine duty and "lung" training. Work on tests for the selection of sound operators was well underway prior to the war. Recognizing this valuable pioneer work, the N,D,R*C, Sound Section agreed to forward the work and assigned in January of 1942, a secretarial and statistical assistant, A short time later, a psychologist was attached as an additional statistical and technical assistant. He later transferred to Underwater Sound Laboratory and was re- placed by a psychologist serving in uniform (Ensign H(S) USNR,| "The first working space was the one large classroom and two small sound-proof testing rooms in the South wing of the Dispensary basement. Work continued there until 2 February 1943 when the Sound Laboratory moved into the newly constructed Bldg, where there were two small sound-treated testing rooms and a classroom and an office. The sound selection work continued in Bldg. 7,-'126 until February 1944, when it was moved to Bldg, 7r'156, its present location, where on the first deck really sound-proof testing space was available for the first time. This space contains a sound-proof classroom capable of seating 20 subjects and an audiometry room, capable of seating 12 subjects, and a large office. "The routine activity of this section was the selection of personnel for training as sound operators for the Bound School of the Submarine School at this Base, Close liaison with the Sound Department of the Submarine School was maintained constantly. However, from time to time, similar selection was accomplished for the Coast Guard, the Inshore Patrol, and the Underwater Sound Laboratory, the U,S,S, SYLPH Sound School, and the Maritime Service, and the Harbor Defense at Fisher's Island, and for the Naval Training Division at the Coast Guard Station at Avery Point, and the West Coast Sonar School. This volume of testing made possible the trial and standardization of many experimental tests and devices. This section cooperated with N.D.R.C. repre- sentatives, with the Harvard Psycho-Acoustic Laboratory and with the University of California, Division of War Research, in running trial tests and various comparative studies. "Experimental work included studies of protective devices for the ears; the development of a group audiometer test; the development and standardisation of a Propeller Noise Injector, and the constant development of tests end equipment to aid in the selection of better men for sound listening assignments on our submarines. Other projects were: a comparison of various measures of auditory acuity and an extensive study of Aero-Otitis Media in Submarine Personnel, —its prediction, prevention, and treatment. A rather extensive report on the Group Audiometer, as well as numerous shorter research reports on other projects were made to the Bureau of Medicine and Surgery and distributed to other interested activities. The Officer in Charge of the laboratory delivered reports both on and work in sound selection and on the auditory acuity studies and aero-otitis media project before the American Academy of Ophthalmology and Otolaryngology, the Association of Military Surgeons, and other groups. "On 14 and 15 June 1945, a Sound Conference was held at this Base, sponsored by the Research Division, Burned, with the Sound Section of the Medical Research Department acting as host* Fifty-two representatives were present (in addition to 26 officers from this Base attending) from the following organizations and activities: The British Admiralty Delegation; the British Navy; the Canadian Navy and Air Force; the D, $, Army, Navy and Air The Veterans Bureau; the Service Rehabilitation Centers at the U,S,Naval Hospital, Philadelphia, and the Deshon General Hospital, Butler, Pa,; the Office of Research and Inven- tions, the Research Division of tho Bureau of Medicine and Surgery; the Bureau of Ships; the Bureau of Standards; and the Standards and Curriculum Section of the Bureau of Naval Personnel; the Naval Medical Research Institute at Bethesda, Md, the Medical Field Research Laboratory at Hew River, N.C., and the Naval Research Laboratory at Anacostia, Md., and civilian representatives from 0,S,R,D. and N,DJR,C, groups at Harvard University, Princeton University, and University of Pennsylviania, Yale University, the West Coast Sonar School, Johns Hopkins University, and the State University of Iowa, A very profitable two-day period was spent in discussing mutual problems in connection with methods of testing hearing; standard clinical tests, audiometer tests, phonograph record tests, monitored live-voice tests; and several newly developed tests, such as the Sound Recognition Group Trainer, the Propeller Noise Injector, and the Target Discrimi- nation Test and Pitch and Loudness Tests, "During the final afternoon session of this conference, a proposal was made that a permanent organization be formed to continue work similar to that of the Sound Conference. This committee would continue on into peace time and be the clearing house for all auditory problems and the coordinating group for research projects. This proposal was unanimously approved and arrangements were made for working out the practical details. It was suggested that this committee should include representatives from all of the organizations at the Sound Conference and provide for inclusion of any others who may be interested or valuable to its progress. (This committee was finally organized as of 1947 with Array, Navy and N.R.C. representation.) "Research in Personnel Selection Research in Personnel Selection was undertaken on a large scale at the Submarine Base with the advent of the N.D.R.C, personnel research program in April 1942, For fifteen months a series of tests of enlisted personnel we re investigated by this organization for their relationship to factors in submarine success. Finally, in June 1943, the Office of Scientific Re- search and Development (OSRD Report #1770) recommended a battery of tests for selecting enlisted submarine candidates. One of the tests (the Enlisted Personal Inventory) which this program was instrumental in developing has since been adopted for general Navy usage. Research on the original battery of tests continued. "In July 1943, the first research on officer personnel selection was undertaken. With the assistance of the Test and Research Section of the Bureau of Personnel and of NDRC a selection program was developed, and established in the latter part of the year. By January 1944, officer selection was standardized in what is basically its present form; but research on tests continued until demobilization of the officer personnel in 1946* "As the attention of the Bureau of Personnel became directed to this work, by letter Pers-4162c-FBH of 6 March 1944 the Chief of Naval Personnel established submarine personnel as a field for study and improvement of selection procedures# "Two consequences grew out of the interest of BuPers. First, in May 1944, various representatives from BuPers col- laborated with this activity in establishing a system of selection for submarine duty which integrates medical, psychi- atric, and personnel selection at Training Centers (Pers-6374- hmg, NC of 22 May 1944). This system was effected by Selection Officers, and was judged generally satisfactory* Very shortly the program expanded so that Selection Officers became charged with all assignments from Class A Schools and Training Centers for which requirements were established by BuPers (Pers-6374-EN- NC of 4 July 1944), A second consequence was that field research was undertaken jointly by the Submarine Base and the Bainbridge Naval Training Center, under the joint cognizance of the Bureau of Medicine and Surgery and of the Bureau of Naval Personnel (Pers-1011 NBH of 30 October 1944) to the end that a practical system of personnel selection involving mental, psychological, psychiatric and physical fields be developed. "Following the establishment of uniform BuPers standards for all submarine personnel, selection research centered to a considerable extent upon developments and refinements of BuPers procedures. For example, accounting practices were developed in order to identify weaknesses and strong points in personnel pro- grams of the various stations supplying men for submarine service. And all enlisted personnel leaving the station were examined with a complete program of tests and scores recorded in order that aptitudes might be identified to the fullest extent. Beginning in 1945* all Submarine School graduates and all enlisted men received for assignment to New Construction, were given a com- plete set of aptitude examinations and the test scores recorded on Qualification cards inserted in the Service Record. 1 ’Development of Visual Research Program* U.S. Submarine Base * Visual research at the U, S. Submarine Base, New London, Connecticut, may be divided into four sections: (a) Night vision testing and research - which will be discussed under four sections: (l) general running history of night vision section. (2) write-up of the part the night vision section played in the development of the Army-Navy-OSRD Vision Committee, (3) an account of the history of the development of the Navy Radium Placque Adaptometer and of the training of personnel for the Bureau of Medicine and Surgery for the administration of night vision testing with the R,P,A, throughout the Navy, (4) listing of reports prepared in this section and current projects, (b) Night lookout training research; (o) Color vision testing and research; (d) General ophthalmological research, / (a) Night Vision Testing and Research; (l) General running history of night vision section. Following receipt of British reports concerning night blindness encountered upon long submarine patrols, local interest in the subject was aroused. In compliance with verbal orders, in April of 1941, the squadron medical officer began a search of available literature on the subject of night vision. Official orders from the Commanding Officer of the Submarine Base followed on 12 May 1941, to "commence investigation and research for the purpose of detecting and control of night blindness,—this to include the development of a device to test, and a suitable diet to minimize night blindness"• After numerous conferences with specialist in relevant fields and the exploration of all possible sources of information, testing was begun under the supervision of a Board of Medical Examiners for Night Vision, which was established on 3 June 1941, by confidential letter S24-1 (0237) from ComSubsLant to Submarines Atlantic, --subject: "Night Lookouts; Testing and Training of". This letter directed that personnel attached to the addressed forces for their night vision; set up a Board of Night Vision to accomplish this, and also directed that special reports on this testing be submitted. "After careful investigation of the Wald Adaptome ter, the Admiralty Adaptometer, and the Hecht-Shlaer .adaptometer, it was decided to adopt the Kecht-Shlaer for use at this activity as the testing device for night vision. "In addition to supervising the routine testing of night vision, the Board of Medical Examiners for Night Vision also supervised the night lookout training being given. Because of the close relationship between the two activities,—night vision testing and night lookout training, and because the continuing members of ihe Board of Night Vision were attached to the Medical Research group, it was logical that the Lookout School which developed from this activity should be a part of the Medical Research Department# "As the testing program proceeded, it became apparent that the testing of night vision is a very complex problem, involving many controversial issues and angles. Each of these phases had to be investigated and tried out. It was obvious that not much had been known on this matter and that much confusion and misinformation had existed. Obviously, it was necessary to decide upon a standard adaptometer for military use and to standardize the testing procedure. "As the volume of testing increased and additional experimental studies became necessary to provide the answers to some of these problems, the procurement of additional assistance in the way of trained personnel became urgent. In answer to this need, the National Defense Research Committee, through its Brown University Division, furnished the survices of a trained perceptual psychologist* who arrived in April of 1942, and continued with the night vision research in his civilian capacity until 31 June 1944, at which time he came to active duty as Ensign H-V(s) USNR, was assigned to the Medical Research Department, and continued this research work as his Navy assignment. "The night vision testing and research continued in Building in three rooms made available on the first deck, from May of 1942 until February of 1943, when the completion of the construction of Building provided new and more convenient quarters. The civilian assistant made possible a more extensive research program and more complete statistical analysis of the results obtained. An investigation was undertaken of a series of adaptometers for suitability for adoption by the Navy, "A comprehensive report was issued under date of 25 April 1942 from the Board of Night Vision to the Chief of the Research Division of BuMed, via ComSubsLant, This contained a detailed statement of the problem involved, as well as a report of the progress to that date, and gave an outline of the plan for future investigation. Under date of 18 May 1942, S24-1 WSV/AE, a Report of Test of Six Pairs of Night Adaptation goggles was issued. Routine testing of night vision continued, modified from time to time in accordance with new experimental findings, "The urgent need for an adaptometer bettor adapted to the needs of the service situation led to the development and trial of several different adaptometers, One of these was developed through the combined efforts of several members of N,D,R,C,, N,R.C,, and Army and Navy representatives. It was known as N.D.R.C, Mod, II, and one of the first of these adapto- meters to be completed was delivered to this activity on 3 July 1942 for testing prior to putting this device into production. Following test runs here, certain modifications were made in the instrument, A report on the Reliability Test of this adaptometer was issued on 28 July 1942, As a result of this work, a pilot model of NDRC Mod, II was constructed and used in testing the NEW JERSEY crew. In October 1942 the first comprehensive experi- ment was run and the pilot model of the present Navy Radium Plaque Adaptometer was recommended for approval, (See Division (3) of this section for complete account of the development of the Navy Radium Plaque Adaptometer,) "Simultaneously with these developments along the line of night vision testing, the night vision training phase of the activity was receiving wide attention and causing repercussions discussed elsewhere in this history. "On the basis of the Medical Research DepartmentTs basic work in night vision and night lookout training, this activity was officially designated by BuPers as the experimental station for the entire lookout training program - (BuPers Itr, P-2423d-RB of 18 December 1942.) "The Bureau of Medicine and Surgery assigned research projects to this activity from time to time on the Project "X" Forms of its Research Division, and other projects were instituted by ourselves and approved by the Bureau by means of these Project Forms, (as per example those listed under Division (4) of this section)• "The NRG Subcommittee on Visual Problems, including re- presentatives from many activities, met at this Base on 15 December 1942, This meeting indicated the need for a permanent committee on vision with broad interests and membership, (see Division (2) of this section for an account of the organization of such a committee*) At this meeting plans were made for the preparation of a manual on Night Vision. This plan as it developed finally resulted in the preparation of several official manuals, both for the submarine service and for the general Navy* "Throughout 1942 and 1943, a series of adaptometers were tested for suitability for the Navy. This series included the Wald, the Admiralty, the Miles Four-Plaque, the Beals Adaptometer, and the Wright Adaptometer, "In May of 1943, an extensive project was undertaken in connection with the testing and classification of the crew of the battleship U.S.S. NEW JERSEY, using the NDRC Model III Adaptometer, Work was completed during the first week of June and a Preliminary Report dealing with Equipment used was sub- mitted to idle Bureau of Medicine and Surgery on 7 June 1943. On 25 June 1943, a general report concerning the night vision testing of the crew of the U.S.S. NEW JERSEY was submitted, and on 3 July 1943, a final report presented the incidental data of interest in connection with this project. "By CominCh confidential letter FFl/Pll-1, Serial 03473, of 6 October 1943, the cooperation of the Medical Research Laboratory of this base was requested, with N.D.R.C. in a program of selection and training of night lookouts, as desired by the Bureau of Naval Personnel, The program as arranged called for a study of the predictive value of various tests for night lookout duty, involving an analysis of various adaptometers and the ability of men to see ship targets at sea at night. "Accordingly in October and November 1943 a compre- hensive experiment vxas undertaken, involving 150 men specially ordered by BuPers to the Submarine Base to serve as subjects* Extensive field runs were made with the 150 men serving as lookouts* The field tests were conducted aboard the U.S.S* SaRDONYX. DSHD confidential Report No* 3357, "A Study of the Prediction of Night Lookout Performance", under date of 15 March 1944 contains the detailed report of this experimental study. "In November 1945, the first official Navy Radium Plaque Adaptometor was delivered and this was one of the adaptometers studied in the experiment mentioned above. "In order to establish norms and refine the testing procedure, it was decided that mass night vision testing of large numbers of personnel would be helpful. Therefore during February of 1944 all personnel of the Submarine School and of the Submarine Base were tested on the Radium Plaque Adaptoraeter* A total of 5,750 were tested at this time. "The very complete records of the night vision section of the Medical Research Department reveal that more than 23,000 individuals have been tested for their night vision acuity during the period of this report. "Further studies were made on the Radium Plaque Adaptometer, e.g., the effect of altering the difficulty, and the reliability of results over a period of time. Other experimental work in the field of night vision and binoculars has been conducted, as follows: the effect of certain drugs on night vision was determined; a test of fixed-focus binoculars was run at the request of BuShips, in the spring of 1943; a series of studies of submarine illumination were made. In the summer of 1944, a representative of this department travelled on a new construction submarine to the Submarine Base, Pearl Harbor, T.H., to observe the use and adequacy of red-illumination. Again through the spring of 1945, a study of conning tower illumination was made in the Hark IV Attach Trainer, Research results of both studies consist- ently showed the satisfactorinoss of red illumination. Numerous other studies will be indicated by the list of reports and projects appearing in Division (4) of this section. "The procedure developed at New London was adopted by BuMed and accepted as the basis of comparison for results from other activities. Since February 1944, all submarine personnel have been given the RPA test as a routine part of their physical examination for submarine duty. In December 1944, the entire personnel of the Submarine Base were again tested, --this con- stituted a retest for many, a first-test for some. (2) Development of the Army-Navy-OSRD Vision Committee As soon as the visual experimental work was well under way in the Medical Research Department, Submarine Base, New London, an almost constant procession of visitors began to arrive from Army activities, other Naval activities, and from N.D.R.C., N*R.C* and other civilian organizations, as well as from Allied liaison activities, especially Canadian and British. It seemed that it would certainly be valuable to have a group of such representatives get together for an exchange of information and viewpoints. "Accordingly, this activity was host to a meeting of the N»R.C. Subcommittee on Visual Problems* This meeting was held at this Base on 15 December 1942, and was attended by twenty-three representatives; six from N.R.C., five from N.D.R.C., six from Navy* one from U.S.Army, two from Canadian Army, one from Canadian Navy, one from U. S, Public Health Service, and one from Columbia University* Numerous visual problems were discussed, but as the group had no authority, no decision was reached* It was considered that this group did not serve the purpose believed desirable. "This early meeting led to the definite conviction in the minds of many that a regular committee should be formed having power to make decisions and allocate research. Numerous small committees interested in visual problems met from time to time, an example of which is the Joint Night Vision Committee of Supers and BuMed, which met on 23 September 1943 in Washington to decide certain problems of testing and of policy. The Subcommittee on Visual problems of the N.R.C, Committee on Medical Research, Committee of Aviation Medicine, is another example. In addition to these meetings, numerous conversations were held with various official representatives of the Army and the Navy, and finally a meeting was held with the Coordinator of Research and Development, resulting in the letter from the Coordinator to the Chief of Bureaus, announcing a meeting on 5 January 1944 to plan for a committee representing the Army and the Navy and N.D.R.C,, which would deal with all sorts of visual problems, maintain a library of pertinent information, and coordinate the necessary research. At this meeting the organization was tentatively formed. Continued work on the committee on the part of this department in coordination with various representatives of the Navy Depart- ment finally led to the organization of the Army-Navy-OSRD Vision Committee, The first official meeting was held on 7 April 1944 in Room 0144 of the Navy Department • "This Committee held monthly meetings and continued to function throughout the war in a most satisfactory manner and has now been organized to continue into the peace. "The Officer-in-Charge of the Medical Research Department and the members of the visual section of the Medical Research Department were actively interested in the joint Army-Navy-03RD Vision Committee from the time of its inception, and served on many of its committees and subcommittees. The third meeting of this group was held at the U. S, Submarine Base on 16 June 1944 with a large representation of service and civilian organizations present* This activity also acted as host to the Fourteenth Meeting, which was held on 11 and 12 September 1945. "Detailed information as the matters handled by this committee is available in the Reports of the Proceedings of these meetings which have been bound in pamphlet form. (3) Account of the Development of the Navy Radium Plaque Adaptometer and of the Training of Personnel for the Bureau of Medicine and Surgery for the Administration of Night Vision Tests throughout the Navy, using the R.P#A. In the latter part of 1941, two members of the Medical Research Department visited the Yale Medical School, and demon- strated the use of A radium plague with superimposed figure which it was thought might be valuable in ni$it vision testing# Again, on 14 July 1942, at a conference at ihe Submarine Base, the Yale representative told of a radium plaque which he had developed and which he was trying out as a night vision testing device. "The next step in the development of this adaptometer cannot be documented from the files of the Medical Research Depart ment, but it is understood that the Johnson Foundation was given the Yale Adaptometer and made some modifications on it. It was then taken to the Research Laboratory at the Naval Air Base in Pensacola, where a movable disc was added in front of the radium plaque and called the device the self-luminous telesilhouette adaptometer* This was first officially brought to our attention by the Research Division, in a letter dated 19 September 1942, in which it was suggested that a representative report to New London with the instrument for testing at this station. "A conference was held in Washington on 25 September 1942 with numerous representatives of the Research Division of BuMed, at which time the Pensacola modification of the telesil- houette adaptometer was discussed. On 12 October 1942, the telesilhouette adaptometer was brought to Medical Research Department, New London, Conn. Dur..ng the long conference and testing period which ensued, the adaptometer was converted back to a self-luminous plaque with a plain block T of standard Snellen type superimposed upon it. This change was made after conferences in order that it could be made comparable to the NDRC* Mechanical revision was made at this station, and after field testing done under Bulled Research Division Project X-68 (Av-VI-16). The model and our report on it were sent to Washington for final work by Special Devices Division# A long period of time elapsed in which nothing was heard from this model. "In the period vhich ensued, a methodological research program was undertaken at this activity, in an effort to deter- mine the most efficient testing procedure for night vision, based upon a device like the R,P,A. "Following receipt of confidential letter from Commanding Office, U, S, Fleet, dated 1 July 1943 (FFl/L5-2/P2-5, Serial 02162) addressed to the of Naval Operations, concerning procurement of an adaptometer for night vision testing, the Officer in Charge, Medical Research Department was called to Washington for a conference with CominCh and BuMed representatives. At this meeting it was decided that the modified telesilhouette adaptometer should be used and it was stated that BuMed had already placed an order for 500 of these devices. The name was changed to Radium Plaque Adaptometer, The first units of R.P.A.s were delivered to the Medical Research Department in October 1943, and were immediately subjected to rigorous field tests. This department continued to work with this device as woll be seen from perusal of the list of reports found in Division (4) of this section# A few of the reports are listed here for cohvenience: Report of Five Hundred Subjects Tested and Retested for Fifty Trials each on the foavy Radium Plaque Adaptometer 8 March 1944, 6 pp, Verplanck and R, H, Peckham, A Report on the Might Vision Testing of 5750 Men* 12 August 1944, 12 pp, The Reliability of the RPA Over Long InterTest Intervals. (In preparation) Report: Comparative Study of Adaptometers• 1 December T94’2V$’l pp. A Rapid Procedure for Testing of Night Vis ion. 5 March 1943, 15 pp. Field Tests of the Radium Plaque Adaptometer* 26 November 1943, 30 pp. Instruction for Operations and Maintenance of Radium Plaque 1 February 1944, 2 pp vdth D.T.Reed. "Because of the continued interest in this work and following a series of discussions, the Bureau of Naval Personnel and the Bureau of Medicine and Surgery issued a joint letter, Pers-423h-mjj of 5 January 1944, directing the assignment of Hospital Corps officers to the Medical Research Department, U, S, Submarine Base, New London, for a period of intensive training so as to prepare them to handle the night vision testing program in the various naval districts and activities. "In February of 1944, the first class of warrant pharmacists arrived for instruction in the technique of the Radium Plaque Adaptometer test. The Medical Research Department, New London, developed and administered the course of instruction. 1/hile here these pharmacists were trained to be technicians capable of setting up and maintaining in operation a standard procedure for night vision testing. Their training schedule was designed to train them to be expert operators of the Navy Radium Plaque Adaptometer themselves and to be able to train pharmacist's mates to operate it; to set up a mass testing program; to understand the operation of several other adaptometers and the principles on which they work; to be able to answer with authority questions on night vision and night vision testing which migjit be directed to them; to cooperate fully with the Lookout-Recognition Training program; and to be able to check on the accuracy of the testing results obtained. This was accomplished by a comprehensive series of lectures; by group preparation of a handy reference book for all hands; by participation in all phases of the extensive testing program then underway at this base; and by having each pharmacist test a minimum of 300 men. At the termination of this large-scale testing program, using the services of the R.P.A. technician, the final testing procedure was adopted by BuMed, on the basis of Report 5 above. This incorporated the features of testing methods developed here. "After six weeks of instruction here, these men were ordered to various stations to set up the night vision testing program throughout the Navy. Three additional classes arriving later brought the total number of men so trained up to approxi- mately fifty. "This department continued to keep in touch with these individuals and by close liaison kept them informed on all the latest developments in night vision testing techniques. "(4) List of Reports prepared and Current Projects in Night Vision. The following list of the reports prepared in Medical Research Department indicates the type of work done by the Visual Section, The type and volume of the work still underway is indicated by the list of current projects, which also follows. Reports prepared; The following reports cover large scale testing programs which required considerable organization and handling of personnel: Program: Selection of Lookout Division of U,S,S. NEW JERSEY, 1. A report on the NDRC Model III Adaptometer. 7 June 1943, 9 pp. 2, Night Vision Testing of Members of the Crew of the U.S.S. NEW JERSEY. ‘ 3# Report on Night Vision Testing of the Crew of the Battleship N'T.I JERSEY, Incidental Data of InterestT 3 July 1943, 15 pp. Program: A Field Test of Binoculars Conducted upon a Request Originating in the Bureau of Ships* 4. A Report on Sample Binocular Serial 6268 Mark I Model 2, £3 July 1943, 21 pp. Program: Training of approximately 50 Pharmacists as RPA tech- nicians, and testing of all personnel of the Submarine Base, 5. RePor~fc Five Hundred Subjects Tested and Retested for Fifty trials each on the Navy Radium Plaque Adaptometer. 8 March 1$44, 0 pp, 6. A Report on the Night Vision Testing of 5750 Men. 12 August 1944, 12 pp, 7• The Reliability of the R,P.A, Over Long Intertest Intervals. (in preparation). Programs Study of the "Validity" of a Series of Adaptometers by Field Experiment with 150 Men Trained as Lookouts. Collaborated with NDRC in execution of the program - "A Study of the Prediction of Night Lookout Performance", 15 March 1944, 37 pp. The following reports, training material, and so forth concern lookout and recognition training: 8, Handbook on Night Lookout Training. Submarines, Atlantic Fleet, 1 May 1943, 51 pp. 9, Handbook on Night Lookout Training, Revision I. 10, Report on Night Lookout Training Procedures. 7 August 1943, £2 pp. 11, Report of Conferences on Lookout and Recognition Training Held at Section Base. San Pedro, California, 1-4 September 1943 • ITppT 12, Night Vision Testing and Training Program, 28 December 1943, 12 pp, 13, Report on Field Observations of Submarine Lookouts. 30 September 1944, 8 pp, 14, Memorandum on Lookouts. 2 October 1944, 8 pp 15, Performancerof Submarine Lookouts. 12 October 1944. pp 33-35 Minutes 6th Meeting ANOSRD Vision Committee, 16, Submarine Lookout, Commander Submarines, Atlantic Fleet, 17, First draft of Lookout, A Manual for Lookout Officers. Ncm being published by BuPers, 18, A Report on Standardization of Night Lookout Stages. 24 May 1945, 7 pp, ~ 19, Modification of Procedures of Sky Scanning for Lookouts Aboard Ship. July 1945 Minutes 13th Meeting A&OSRD Vision Committee. 20, Experimental Evaluation of the Ship Recognition Trainer, ( in prepar ation) Reports and other material on research in night vision testing. 21, Report on Reliability Test of NDRC Adaptometer I'lode 1 II, Conducted at Submarine Base, 'New London. 28 July 194-2, 2 pp, 22, Report: Comparative Study of Adaptometers. 1 December 1942, 3l p pl 23, Further Report on the Testing of ■Efficiency of Night Vision: Comparative Reliability and Validity Measures on the -h-dapto- meter and the Self-Luminous Telesilhouette Adaptometer, January 194-3, 38 pp, 24, A Rapid Procedure for Testing of Night Vision. 5 March 1943, 15 pp, 25, A Report on the Test-Retest Reliability of the Admiralty Mark I Adaptometer. 1943, 4 pp, 26, A Report on the Test-Retest Reliability of the Miles Four- Plaque Adaptometer, 1945, 4 pp, 27, A Report on the Test-Retest Reliability of the Wright Adapto- meter . 1943, 3 pp."- 28, The New London Hand Dark Adaptometer. 3 pp, 29, Field Tests of the~lTadium Plaque Adaptometer, 26 November 1943, SO pp. 30, Instruction for Operations and Maintenance of Radium Plaque Adaptometer. 1 February 1944, £ pp. 31, Instructions for Administering the Night Vision Test with the R.P,a. 1 March 1944, 5 pp, 32, Adaptometers forNight Vision Select!on and Classification, 18 June 1944, pp S8-43 of minutes 3rd meeting ANOSRD Vision Committee, 33, The Lffect of Increasing the Difficulty of the R.P.A. Test of Night Vision. 25”September 1945, 18 pp. Reports on Submarine Illumination. 34, Submarine Lighting Requirements for Night Operations, August 1944, 4 pp, 35, Preliminary Report on Conning Tower Illumination, April 19-4£), 18 pp, 36, Final Report on Conning Tower Illumination. (in preparation) Miscellaneous Topics. 37, Binoculars with Treated Surfaces. 21 August 1S42, 4 pp. 38, Determination of Sky Brightness (A) a Table of Sky Brightness Measurements• 9' August 1944, 2 pp, 39, tJse of Binoculars at Night. 31 August 1943, 11 pp, 40, Visual Acuity and Contrast Discrimination through Neutral and Color Filters"! I2 June 194 5"! Confidential supplement to minutes of 12th meeting of ANOSRD Vision Committee, 41, Some Notes on Visual Devices and Procedures on New German Submarines. September T945, Minutes of"13th Meeting of ANOSRD Vision Committee, 42, The Effects of Paradrine on Night Vision Test Performance. 25 May 13pp. 43, Report of Test of Six Pairs of Night Adaptation Goggles. 18 May 1942, 2 pp. Current Projects X-268 (Av-156-a) Field Test of Radium Plaque Adaptometer, X-270 (Av-158-c) Preparation of Lookout Training; Manuals* X~271 (av-159-c) Construction and Experimental Testing of Recognition Training~Pevices. X-550 (Av-197-c) Predicitive Value of the Navy Radium Plaque Adaptometer and Other Physiological Treasures of Night Vision for Score on a Performance Approximating the Standing of a Night Lookout Watch. X-519 (iiy-375-p) A Study of the Illumination of the Submarine ffonn:in6 ‘Tower. X-612 (Av-314-p) Field Test of Optical Equipment. X-662 (Av-547-p) Field Test of Optical Instrument and Auxiliary Experiments. X-638 (Av-330-p) Field Test of the Use of Filters and Goggles ' in Penetrating Haze~l X-663 (Av-541-p) Field Test of Lark Adaptation of Divers. "The three projects X-612, X-662, and X-638 constitute one comprehensive project being conducted for the Bureau of Ordnance covering the field testing of optical equipment. This experiment is a large scale undertaking designed to answer many of the critical problems with respect to the relative importance of magnification, exit pupil and field size. Begun in July 1945, it has involved the full-time operation of a Destroyer Escort, for three and one-half months, and a supervisory observation and statistical staff of four officers and sixty to seventy enlisted men. Preliminary results indicate that the project will be successful and that, on the basis of the results obtained, decisions with respect to optical design may be made on a practical as well as a theoretical basis. Certain phases of the experiment, originally designed for shipboard study, have been transferred to land and will be performed in January, February, and March. (b) Lookout Training Research; It should be noted that research in this field included the development and field testing of equipment; introduction and trial of techniques of teaching; coordinating of the recognition training and lookout training programs with the night vision research developments. Discussion of training is reported else- where in this history, (c) Color Vision Testing and Research: This section of the department really had its origin at a conference held on 11 May 1942 at the Bureau of Medicine and Surgery, concerning the need for re-evaluation of color vision testing and color vision standards. Following this conference, research was initiated on the Royal Canadian Color Vision Lantern, the American Optical Company’s Pseudo-Isochromatic Plates, and laboratory tests of color vision which were used for validation. Representatives of Yale Medical School and of New York University, and officers of the Inter-Society Color Council acted as consultants, "In order to forward this color vision research, a research associate in the Psychology Department at New York University, was commissioned as Lieutenant H-V(S) USNR, and called to active duty in the Medical Research Department, He reported for duty on 10 Hay 1943 and began a job analysis of color vision in the submarine service, A battery of color (Duo to clerical error there is no Page 285) vision tests was selected and standard procedures were adopted for testing candidates for submarine service. The following year the reasons for the failure of the standard Navy test, the a-0 plates, were investigated and reported to the Bureau of Medicine and Surgery and a total of over thirty tests for color vision ■ were investigated for reliability. It was decided that the most valid of these tests was a lantern type test, Early in 1944, a lantern was designed by this laboratory for Navy use which was intended to incorporate all the necessary characteristics of a serviceable Navy lantern# ’’During the first half of 1944, the Color Vision Labora- tory cooperated extensively with the printers of the revised A-0 test plates and an experimental purchase, incorporating a number of suggestions by the New London laboratory, was authorized by the Surgeon General in June# "In the years 1943 and 1944 the Color Vision Laboratory aided the Camouflage Section of the Bureau of Ships in many projects tested at the Submarine Base. In August 1944, a con- ference was held at the Coordinator’s Office which resulted in a request that the Color Vision Section of the Medical Research Department design and build a working model of a permanent Camouflage and Visibility Theater# A staff drawn from the Bureau of Ships, the David Taylor Model Basin, and the Naval Research Laboratory worked over the plans for this Visibility Theater submitted by Medical Research Laboratory* The Medical Research Department ms requested to construct this working model, by BuShips confidential letter X-S19-7 CBjvob of 23 October 1944* Construction was begun in the Training Aids Shop in December 1944 and completed in time for demonstration as one of the features of the Array-Navy-OSRD Vision Committee meeting which was held at this Base on 11 and 12 September 1945* This model was dismantled, transported to the David Taylor Model Basin and reassembled there in November 1945* "As an example of the type of activity of the color vision section, we quote in its entirety the section of the Semi-Annual Report of Activities of the Medical Research Department concerning that laboratory; (July 1944 through December 1944). "’The activities of the Color Vision Laboratory consist of (a) routine examination, (b) research, and (c) development* "*As has been mentioned under Section I, the Submarine Examination section of this report, screening tests for vision and color vision were given to 640 officers and 6,005 enlisted men* In addition, batteries of special selection tests for color vision were given to 480 officers and men. "'Research was continued under Bureau of Medicine and Surgery project assignments as follows; X-457 (Av-241-k) - Two prototype models of a Navy Lantern built by Macbeth Daylighting Corp. and are undergoing trials for reliability, validity, and mechanical efficiency. X-480 (Av-255-p) - The second edition of the American Optical Company*s Pseudo-Isochroraatic Test Plates was printed from color specifications furnished by this laboratory and a copy of the new edition is being tested on 400 men in accordance with the directions in the project form. X-493 (Av-263-p) - Testing was begun with the first two visual screening devices received, —the Tele- binocular and Ortho-Rater, and the scores are being compared with ophthalmological diagnosis. "development of special devices was undertaken at the request of other branches of the Service, as follows: "‘Permanent Camouflage or Visibility Theatre, After extensive conferences conducted by the Coordinator of Research and Development, BuShips requested that the Medical Research Dept., New London, build a large-scale working model of the proposed theatre. Plans for the model have been drawn and submitted to the committee. "‘Submarine Identification X-paint, Substantial aid was given to BuAer, BuShips and other interested parties in the trial of a special identification paint for submarines. "1590-Milli-micron Cut-Off Goggles. At the request of the Experimental and Flight Test Department, U, S, Naval Air Station, Lakehurst, a goggle was developed for checking night lighting installation in blimps. The goggles provide a visual, qualitative check on the presence of non-red light. "‘At the invitation of the Aero-Medical Association, convening in St. Louis, an extensive exhibition, made up of charts, instruments and demonstrations, was shown of color vision tests and color standards. "‘When requested for specific problems, aid, by way of specifications or materials, was furnished to many activities, including: "‘Medical Field Research Laboratory, Camp Lejeune, Specifications for night running lights* "‘Camouflage Section, BuShips, Field reflectance scales. n,R,C,N. Medical Research Unit, Toronto, Dichroic filters for tracer goggles. "*National Bureau of Standards, Analysis of Color Vision test scores. "*U. S, Naval Air Station, Lakehurst, Colorimetric transmissions of sample lamps. M,U. S, Naval Air Station, Quonset Point, Filter design re; air-bourne searchlights. ,f,Naval Ordnance Laboratory, Navy Yard, Washington, D.C, Plotting charts. New London RUGS Diagrams ?,-38. If,Army Service Forces, Engineering Board, Ft. Belvoir, Blueprints and filters for testing lantern.T MIn order to bring the report on the Color Vision Section up to date, we quote from the Semi-Annual Report on .activities of the Medical Research Department from January to July 1945: ntThe routine testing and research activities of the color vision laboratory were augmented by extensive collaboration with the Camouflage Section of the Bureau of Ships on problems of visibility and concealment* This culminated in a project look- ing toward the eventual establishment of a Visibility Theater for the study of general problems in vision in addition to those of camouflage and ship design. The building of a large scale wrking model was assigned to this department, Good progress has been made, in spite of the delays and difficulties incident to pro- curement of some of the materials needed* It is expected that the model will be finished in about two months, at which time it will be moved to Washington and set up at the David Taylor Model Basin, where the actual theater is to be built. "'Information and assistance on special color problems were furnished to several near-by Naval activities, and to repre- sentatives of the Engineer Board of the War Department, represent- atives of the Medical Field Research Laboratory, Field Units of the Bureau of Ships, the Navy Ordnance Department, and the Royal Canadian Army Medical Corps. "'In addition to the Model of the Visibility Theater, which has required considerable time and study, the following research projects are in active status: X-265 (Av-151-C) - The Critical Hue Regions of Transmission of Illuminant A for Deuteranomalous and Protanomalous• Data completed on one of the two hue regions to be studied* Material still not available for completion of second region necessary to be studied. X-265 (Av-155-C) - Comparative Reaction Times of Submarine Candi- dates to "Christman Tree" Signal Lights, Work was inter- rupted because the subject instrument was required in combat service and procurement problems have prevented further work on this study* X-266 (Av-154-C) - A Field Test of the Ability of lien with Various Degrees of Color Anomaly to Distinguish Code Colors used Inside of Submarines. Insufficient data taken for report. X-547 (Av-192-p) - The Critical Hue Regions of Confusion of Pig- ment Colors Under Illuminant A and Illuminant C for the Color Anomalous, Extensive data taken. Awaits analysis. X-548 (Av-195-p) - Retention of Discriminable Hue at a Distance for Ten Colors Against the Color of Water, This proved to be a study of color at small subtense and a preliminary report was submitted under date of 20 April 1944 (Interval Report No, 1), Further analysis was made in response to BuShips' request and transmitted as an addenda on 22 April 1944. X-457 (Av-241-k) - Development and Trial of New London Navy- Lantern as a Selection Test for Serviceable Color Vision* Models completely developed and await testing on un- selooted population. X-480 (Av-255-p) - Comparison and Evaluation of the Pseudo- Isochromatic Plates for Testing of Color Perception (American Optical Company, Second Edition) with the First Edition of these Plates Now in General Use by the U, S, Navy, Final report submitted under date of 19 March 1945, Request has been made for termination of project and for permission to distribute. X-502 (Av-515-p) - Effect of Tinted Lenses on Color Vision. This work has been completed and is in process of being issued as Color Vision Report No. 9. X-613 (Av-315-p) - Development and Trial of Screening Devices for Detection of Anomalous Color Vision for Use in Ophthalmic Instruments, Filters have been examined for use in pros- pective instrument. "!The staff of this laboratory includes Lieutenant Dean Farnsworth, H(S) USNR, J, D. Reed, PhMlo, USNR, P, Foreman, Y3c, WAVE, and Jerome Nathan, Sic, USNR,1 (d) Qphthalmological Research: When in October 1944, the Medical Research Department was ordered to undertake the testing of personnel for radar operation, a study of visual aptitudes was required. A project was set up for the purpose of determining the "validity and reliability" of visual screening devices. ’’When the visual reliability phase of the work was approached, it was found that ophthalmological research was in a rudimentary state, that clinical procedures were not standardized, and that insufficient data were available with which to evaluate any of the vision tests used in the instruments. Consequently, research and standardization were begun. "Snellen letter charts were found so unsatisfactory that construction was begun on new ones. Research was therefore directed toward equating the difficulty of letters and dis- covering natural step intervals. "As a result of reports before the Army-Navy-OSRD Vision Committee on 10 April 1945, a Subcommittee on Procedures and Standards for Visual Examinations was set up for the purpose of issuing a standard manual of instructions for testing visual acuity and to investigate more reliable test charts for visual acuity, methods of testing phorias, and physical conditions surrounding the tests. "The writing of the Manual for Testing Visual Acuity was undertaken by Medical Research Department, During the subsequent weeks, a draft of a proposed manual was prepared, and revised at NAOSRD Committee and Subcommittee meetings." Following the cessation of hostilities, the demobilization process began and personnel losses were heavy throughout 1946, However, in order to compensate for this and insure the continuation of the research program at New London, the civilian complement of the Medical Research Laboratory was increased and additional civilian personnel were added to the laboratory staff particularly in the Professional and Sub-Professional classifications. There was some delay while the new members of the staff became indoc- trinated and picked up the threads and continued the program, however, as this is being written, in May of 1947, there are six officers, 13 civilians and 18 enlisted personnel in the research activity. Most of the schools have been assigned to the cognizance of the Submarine School, the exception being the Pharmacist's Mates. As an indication of the type of continuing work, the following is the list of projects active as of this date: X-263 (Av-151-C): "The Critical Hue Regions of Transmission of Illuminant A for Deuteranomalous and Protanomalous". X-266 (Av-154-G): "A Field Tost of the Ability of Men with Various Degrees of Anomaly to Distinguish the Color of Signal Lights at Nigjit". X-347 (Av-192-p): "The Critical Hue Regions of Confusion of Pigment colors under Illuminant A and Illurainant C for Color Anomalous"• X-613 (Av-269-p): "The Development and Trial of Screening Devices for Detection of Anomalous Color Vision for Use in Ophthalmic Instruments"• X-721 (Av-377-w): "A Study of the Distribution of Degree of Color Anomaly in an Unselected Population by a Battery of Pass-Fail Tests", X-729 (Av-318-e): "Investigation of a Method of Physical Speci- fication of Filters in Relation to Perceptual Dif- ferentiation of Color". X-764 (Av-391-k): "Specification of Polychromatic Plates for Use in Screening in the Military Services". X-423 (Av-277-k): "Variations in Visual Acuity Under Conditions of Low Illumination; Possible Use as Selection Procedure and in Assignment to Duty". X-493 (Av-263-p): ’’Comparison of Various Screening Devices with Standard Medical Procedure". X-638 (Av-330-p)s "Field Test of the Use of Filters and Goggles in Penetrating Haze", X-662 (Av-347-p); "Field Test of Optical Instruments and Auxiliary Experiments". X-757 (Av-387-k): "Comparison of Three Measure of Night Vision". X-243 (Sub,No.47); "Relationship of Personnel Selection Devices to the Behavior Criteria of School Per- formance and Performance on Submarine Patrol". X-566 (Sub,No.119)‘."Analysis of Rejections in Submarine School". X-596 (Sub,No,128):"Analysis of Examinations of Personnel Received for New Construction and for Reassignment". X-329 (Sub.No,58 ):"Relationship between the Audiogram at High Frequencies and Proficiency in Sonar Performance X-487 (Sub,No.100);"The Comparative Efficiency of the Whispered Voice and Pure Tone Audiometry for Testing Auditory Acuity"• X-619 (Sub.No,134):"A Study of the Relationship of Certain Auditory Selection Tests and Proficiency in Sonar Performance". X-745 (Sub,No,152);"The Psychophysiology of Loudness Dis- crimination for Complex Tones". X-746 (Sub,No,153);"The Estimation of Percentage Hearing Loss from Pure Tone Audiogram". X-747 (Sub.No,154);"The Psychophysiology of Pitch Discrimi- nation in a Noise Background". X-761 (Sub,No,163);"The Incidence of Deafness among Navy Veterans". X-606 (Sub,No.131):"Preliminary Study of the Effect of Schnorchelling on Submarine Personnel", X-713(Sub.Ho.l45): (a) "Investigation of Adrenal Cortical Functions in Relation to Stress Situations". (b) "Investigation of the Relation of Androgen Excretion to Body Type, Physical Fitness, and Psychiatric Status". (c) "Investigation of the Relation of Rorschach Scores to Psychological Stress and Tension Factors as Indicated by Urine and Blood Analyses". X-752 (Sub.No, 155): "A Study of Prosedure for Training Person- nel in the Making of Free Submarine Escapes". X-753 (Sub,No. 156): "Field Study of the Effects of Sohnorchel- ling on Submarine Personnel". X-707 (Biodyn.53); "Comparison of Flotation Characteristics of Various Types of Life Preservers", Special note should be given to the work more specifically related to submarine operational problems. Of primary interest in this field are listed the following: X-752 (Sub.No* 155) - Study of Procedure for Training Personnel in Making Free Escapes. A visit of the British Submarine Escape Committee to Submarine Base, New London, in July of 1946 stimulated renewed interest in the practicability of training submarine personnel in the procedure of making "free" escapes from submarines. A review of the finding of the British Committee’s survey of all recorded submarine disasters showed that more men have escaped from sunken submarines without the use of submarire escape devices than with the use of such equipment. It is believed that many more could have survived had they been trained in making free escapes• It had been standard practice for over five years for all instrudtors at the Submarine Escape Training Tank, New London, to make free escapes from all depths to 100 feet during Tank operations. Over 15,000 such free escapes had been made by trained instructors without a casualty. The method used in making these free escapes had been to slowly exhale during the ascent, these being free floating escapes (without buoyancy apparatus or ascending line), the speed of ascent being regulated by the amount of air exhaled at a given depth. A project was therefore proposed and approved in August of 1946 for the study of the time required for training submarine personnel in making such free escapes. It was also proposed to study -whether or not preliminary "lung" training would facilitate "free escape" training, and to ascertain the practicability of training all submarine personnel in making "free" escapes, and perfect techniques of making this type of ascent. Volunteer subjects have been used throughout. To date approximately 250 men have received this type of training and results are most promising. Yfork has been begun on an immersion suit which it is hoped will be suitable for protection to the escapee and will provide added positive buoyancy. X-753 (Sub.No. 156) - Field Study of the Effects of Snorkelling on Submarine Personnel. When German submarines fitted with the schnorchel (a retractable breathing tube for procuring air from the surface for engines of a submarine remaining submerged) first became available to us at the close of the war, very little information was available concerning the effect of personnel and living conditions within the boats. Some reports had been made of serious difficultie resulting from the use of this device. Since the snorkel is fitted with a head valve which closes automatically to prevent intake of water when the top of the snorkel tube is ducked, and the sudden closure of this main air intake to the boat causes a sudden and violent change of pressure within the submarine, reports of ear pain and even ruptured ear drums were prevalent, as v/ell as some reports of nausea, disturbance of sleep and other difficulties. Accordingly a preliminary study of effects on personnel was requested and approved as of 12 June 1945. A paraHel study was assigned to NMRI and the investigators cooperated closely in their investigation and collaborated on some of the formal reports* Members of the crews of the captured German boats were interviewed at Portsmouth, N.H., in 1945. Medical officers making this study rode the snorkel boats on experimental runs. Some delay was inevitable due to the engineering problems in connection with installation of this snorkel device in U. S, submarines and conversion of several of our submarines. After the completion of two reports, the original project X-606 was terminated and a new, more, comprehensive study outlined and approved as X-753. Studies so far indicate that the effects on personnel are not as serious as at first anticipated, but due to priority of operational considerations, it has not yet been possible to assign a boat to the exclusive investigation of this problem. It seems likely that with maximum pressure fluctuations con- tinuing over extended periods of time sufficient discomfort may be experienced by sleeping personnel that construction of a pressure constant sanctuary may be necessary. X-713 (Sub.No. 145) - the so-called "Keto-Steroid project* which has three phases: (a) Investigation of Adrenal Cortical Functions in Relation to Stress Situations, (b) Investigation of Relation of Androgen Excretion to Body Type, Physical Fitness, and Psychiatric Status, (c) Investigation of the Relation of Rorschach Scores to Psychological Stress and Tension Factors as Indicated by Urine and Blood Analyses. The so-called "17-ketosteroid project" (BuM&S Research Project NM-003-017) was instituted to investigate the 17-keto- steroid excretion and blood lymphocyte changes in connection with stress situations, especially that of the Escape Training Tank. Other areas of investigation such as anthropometric measurements and body typing, physical fitness tests, psychological and psychiatric tests and blood cellular alterations were included in the program. A total of some 400 variables were obtained on each of 120 subjects. For purposes of convenience in handling the large quantity of data, results were grouped into thirteen sub studies and each area or matrix subjected to a factor analysis in order to reduce the 400 variables to some 10 to 15 independent and significant factors* It was hoped that on the basis of this study it might be possible to establish a simple selection battery consisting of the primary physical, physiological and psychological data which would then be validated on a second large independent population. The results of this second study, simpler in design and consequently larger in scope, could then be employed as the means of selecting future candidates for submarine school. It is believed that this is the first time in research history that such data has made available the possibility of inter-relating in a single population measures from a number of related but distinct scientific fields - the medical, the anthro- pometrical, the psychological, the psychiatric, the physiological, and the biochemical, and we are proceeding carefully and cautiously with the first comprehensive examination of the interrelationships in these areas. From the basic measurements obtained on a population of 120 enlisted submarine candidates, some 57,630 correlation coef- ficients were possible* Since many such comparisons would be of little interest, the variables were broken into natural sub- divisions in an attempt to find the number of basically different yet reliable types of measurements within each sub-division or area, and to study the inter-relationships among these more stable measurements. The basic measurements vfere divided into 8 sub- sections, 3 of which were in turn sub-divided again to provide a total of 13 sub-sets of data which were adapted for handling by I.B.M, methods. The areas of study selected were: 1, Physical Fitness 2, Ketosteroid 3, Psychiatric 4, Physical Characteristics 5, Anthropometric 6, Rorschach (l) 7, Rorschach (2) 8. Blood Data 9* Blood Ratios 10. Blood Mean Percentages 11. Absolute Blood Count 12. Blood Differential Ratios 13. Psychological Tests. It is planned to devote a separate report for each of the thirteen areas into which the data have been divided. IX RECOMMENDED ORGANIZATION FOR .-NY FUTURE EMERGENCY Following the close of the war the Medical Research Laboratory Submarine Base, New London, in compliance with a request from the Navy Department, wrote a chapter on "Sub- marine Medicine" for inclusion in * SUBMARINE WARFARE INSTRUC- TIONS, 1946,* in which recommendations were made concerning the organization believed to be essential so far as the med- ical needs for any future emergency are concerned. This chapter is included in its entirety and in exactly the same form as submitted to the Navy Department, We believe that it serves as a fitting climax and summary to this history and in addition outlines the organizational set-up which ill funct- ion most efficiently for routine peacetime operation, as well as in case of any future emergency. SUBMARINE MEDICINE (As submitted for Chapter XI of Submarine Warfare Instructions 1946) 1100 Organization Submarine Medicine is a distinct medical specialty, re- quiring special selection and training of medical personnel. The submarine medical officer works in close unison with the entire submarine force, therefore, the medical facilities require special treatment and separate organization from the general medical department organization of the Navy, 1101 The Submarine Force The submarine force should include one qualified submarine medical officer and one Hospital Jorps officer qualified in submarines. Either or both of these officers might be carried in additional duty status, with their primary duty being on a Base or Tender, 1102 The Submarine Squadron or Division One qualified submarine medical officer should be attached to the staff of the squadron, serving aboard an operating submarine, with additional duty on a tender or Base serving the Squadron. The Division should have one #Hospital Jorps officer qualified in submarines attached to the Division staff, or with additional duty to the staff and primary duty on a Submarine Tender or Base serving the Division. 1103 The Submarine The experience of the recent war indicated that the ideal medical organization for a submarine should be com- posed as follows. (a) One well qualified submarine pharmacist’s mate should be aboard at all times, (b) One additional pharmacist’s mate should be carried whenever possible, for purposes of training and indoctrination. (c) One qualified medical officer should ride one of the submarines of the Squadron, for purposes of training, (d) The medical equipment of each submarine should be standardized as supplied by the Naval Medical Supply Depot and as augmented by the desires of the individual medical officer or pharmacists mate. 1104 The Submarine Tender The medical department of a submarine tender is the facility from which the submarine derives all med- ical aid, medical personnel, and medical equipment. It should be organized as follows: (a) The squadron medical officer shall have add- itional duty on a tender. The light of our war experience has shown that the squadron medical officer must be a qualified submarine medical officer and not simply the senior med- ical officer of the tender, (b) A pool of pharmacists mates qualified in sub- marines shall be maintained aboard each sub- marine tender, so as to allow rotation from submarines to surface craft tender duty. This rotation of duty allows for continuous training. 302 keeps qualified men with the submarine force, and makes them available for assignment to submarines by the squadron medical officer. (c) The submarine tender shall carry additional medical supplies for issue to submarines. (d) The submarine tender shall maintain sick bay fac- ilities and other medical and dental services. 1105 The Submarine Base The medical department of a submarine base should be organized as follows: (a) The submarine base shall have at least one qualified submarine medical officer attached. (b) The submarine base shall maintain a pool of qualified pharmacists mates, so as to allow rotation from sea to shore duty, thus keeping well qualified men within the submarine service, and integrating the training and assignment program with that of the squadron. (c) The submarine base shall act as a supply depot for medical supplies and equipment, as replacements for the original allowance. (d) The submarine base dispensary shall furnish hospital- ization for patients transferred from submarines or from tenders, and any other medical or dental service required. 1106 The Submarine Escape Training Tank The medical problems to be expected during training of submarine personnel in the use of the submarine escape appliance are such as to require; (a) Two qualified submarine medical officers attach- ed to the Submarine Escape Training Tank, or with additional duty to the Submarine Escape Training Tank, (b) One of these qualified submarine medical officers shall be present at all times during operation of the pressure chamber. (c) One of these medical officers shall examine cand- idates prior to and determine their fit- ness for training at that time. He shall super- vise the giving of the 50-lb. pressure test, which is one of the requirements of the physical examin- ation specified in the Manual of the Medical Depart- ment, Par. 211334. He shall be present during the actual 11 lung" training and be responsible for the treatment of any casualties which may occur; and observe the performance of candidates under train- ing, in order to determine their emotional stability under stress conditions and shall review, or refer for review and possible disqualification any candidate showing questionable emotional traits, as brought out by lung training. (d) The experience of the last war clearly indicates that because of the numerous responsibilities under medical cognizance in connection with submarine escape training, it is advisable to have this act- ivity under the jurisdiction of a qualified sub- marine medical officer. Such an arrangement worked ideally at the Submarine Base,New London, Connecticut throughout the war period. 110? Submarine Medical Research Submarine medical research proved to be of such value, prior to and during the war period, that it is imperative that it be continued during the peace in such a way as to allow easy expansion during any possible future emergency. The organ ization of the Medical Research Department at the Submarine Base, New London, Connecticut, could be used as an example and, based on it experience, it is felt that anjr active submarine medical research unit should include the following personnel:— (a) Three qualified submarine medical officers, the senior of whom could be the staff medical officer for the submarine force of that area and the other two could have additional duty at the submarine escape training tank, if the unit were based near such a tank. (b) A medical officer specializing in ear, nose, and throat. (c) A medical officer specializing in psychiatry. (d) Two Hospital Corps officers, qualified in submarines. These officers could have additional duty in a Division, if indicated. (e) Hospital (Specialists), Civil Service employees, and technical specialists, as necessary to conduct the research program. (f) As many Pharmacists Mates as may be necessarv for the specific research program, —25% of whom should be qualified in submarines. 1110 Medical Personnel, Their Qualification, Training and Duties As noted in Paragraph 1100 under organization, submarine medicine is a distinct medical specialty and therefore, the special qualifications and training required to carry out the duties of submarine medical personnel are herein defined. 1111 The Submarine Medical Officer, The submarine medical officer shall meet the follow- ing qualifications: (a) He shall be qualified in accordance with the Bureau of Naval Personnel Manual, Par, E-1314 (rev.). In addition to this, the experience of the last war demonstrated that it is hi?hly desirable for him to serve at least twelve (12) months "attached to and serving aboard" an operat- ing submarine. He would then be well qualified as both a submarine and diving medical officer. (b) The training of a submarine medical officer is out- lined in the listed qualifications for entrance into the Navy Medical Corps and for his designation as a qualified submarine medical officer. 1112 The Submarine Medical Officerfs Duties. In addition to the duties of a medical officer of the Navy, as outlined by the Manual of the Medical Department and Navy Regulations, the submarine medical officer shall comply with the following; (a) He shall keep himself fully informed of the progress of current research and developments which may have medical significance applicable to the submarine service. (b) He shall carefully examine and determine the fit- ness of officers and men for the Submarine Force, in accordance with existing regulations and stand- ards prescribed by BuFers and Burned. It is highly desirable that only a qualified submarine medical officer shall determine the fitness of officers and men for submarine duty# (c) He shall conduct physical examinations of divers and candidates for training in diving and super- vise the administration of the 50-lb. pressure test in accordance with the Manual of the Medical Depart- ment, Par. 21134. He shall be present at diving and salvage operations as prescribed in the Diving Manual, (d) In addition to the regular duties described above, the submarine medical officer shall have certain special duties as outlined below; (l) When serving on the staff of the Submarine Force, —duties as outlined by Bulled direct- ives and as organized by the force command. (2) When serving with the squadron, —as outlined by BuMed directives and as organized by the Force and Squadron commands. (3) When attached to and serving aboard a sub- marine, —either on practice war patrols, or actually on combat patrols, he shall act as an observer for the purposes of his further training and indoctrination, and in order to establish complete liaison and coordination between the submarine line officers and the medical officers. (4) '-'/hen assigned special research projects, he shall carry out the investigation assigned. (5) He shall constantly observe and report upon con- ditions of a medical nature requiring investigation or change. (6) When attached to a Squadron or £ Submarine Base, with additional duty to a Submarine Tender or Base, he shall perform the primary medical duties as re- gularly assigned, and duties as outlined or assigned for a squadron medical officer. He shall be res- ponsible for the Sanitary and Safety inspections and for First Aid and Venereal instruction for the sub- marines of the Squadron. He shall be responsible for the training of the pharmacist's mai.es of the Squadron and for the proper conduct of the Medical Department, He shall keep the squadron con.under informed concern- ing the detailing of the pharmacist's mates. (e) Rotation of Duty, An attempt should be made to keep quali fied medical officers in the Submarine Force by rotating them to one of the following duties: Submarine duty; sub- marine base dispensaries; Deep Sea Diving School; Experi- mental Diving Unit, tyash, D.G.; Naval Medical Research Institute, Bethesda, Md,: Research Division, Bureau of Medicine and Surgery; Medical Research Dept., U,S, Sub- marine Base, New London; and to Submarine Tenders and to Diving and Salvage units. 1113 The Submarine Hospital Corps Officer. The qualifications of the submarine Hospital Jorps Officer and his duties are outlined belows (a) The submarine hospital corps officer shall have been a qualified chief pharmacists mate v.dth at least two years service in submarines. (b) Duties: wartime experience demonstrated that it was highly desirable that one HO officer be ass- igned to each submarine force and to each sub- marine tender and base. In addition to those assignments, they are required in research units in such numbers as may be indicated by the volume of the work assigned. Their duties in all of these promulgated in the Manual of the Medical Depart- ment or as directed bv other competent authority; and they shall in all cases act as the assistant to the submarine medical officer of that activity to which he is attached. mu Qualification of the Submarine Pharmacists Mate The submarine pharmacists mate must have the following qualific ations: (a) The submarine pharmacist’s mate must meet the require- ments set by Bulled and PhM’s on independent duty and in addition, be specifically trained for duty in sub- marines, after having passed the entrance examinat- ions for enrollment in the School for Pharmacist’s Mates Entering the Submarine Service, (b) Training: The submarine pharmacist1 s mate must successfully complete the School for Pharmacist’s Mate Entering the Submarine Service; or have previous- ly served on an operating submarine for at least a year. He must successfully complete the Basic Sub- marine School, Submarine Base, New London, Connecticut or have previously served successfully on an operating submarine for at least a year. He should have at least a week of special instr action in the u.se of the submarine escape apparatus end related safety appli- ances, including knowledge and treatment of caisson disease. 1115 Duties of the Submarine Pharmacist’s Mate The duties of the submarine pharmacist’s mate shall be as follows: (a) The submarine pharmacists mate shall be responsible for the care of the sick and injured and for the in- stitution and observation of all safety regulations. He shall work closely with the Squadron Medical Officer, his immediate medical superior, keeping him informed on medical problems. He shall keep complete records; make proper entries in the Health Records, and complete such records to BuLed and force commands as required. He shall be responsible for the immun- ization, vaccination, and prophylaxis, of officers and crew, as required. He shall make sanitary in- spections and keep the Commanding Officer advised as to conditions, —in galleys, heads, washrooms, refrigerator spaces, etc. He shall make necessary safety inspections. He shall be responsible for maintenance of the "lungs'1, oxygen, etc, in proper working order and that the crew are familiar with the method of escape and the handling of the necessary locks and equipment. War experience demonstrated the desirability of the pharmacist’s mates performing general submarine operational duties and such special duties as were assigned, such as sonar operator, radar operator, day or night lookout, etc. (b) Rotation of Duty, Pharmacist’s mates should be kept within the jurisdiction of the Submarine Service by rotation to a Submarine Base, either in the States or foreign shore, to Submarine Tenders and to Research activities. 1120 Medical Aspects of Submarine Operation Due to the highly technical nature of the medical aspects of submarine operation, a detailed discussion is presented below: 1121 Medical Aspects The purely medical activities may be considered under the heading of medical treatment and medical records. (a) Medical treatment shall be conducted as laid down in the Manual of the Mediccl Department and the various Burned directives, and in accordance with the best medical and surgical judgment of the medical personnel involved. Due to the limitations of space, and problems of ventilation, air purification, etc,, patients should be trans- ferred for treatment and/or hospitalization to a tender or to the nearest Base or Naval Hospital, whenever possible. T e submarine pharmacist’s mate shall avail himself of the guidance and assistance of a medical officer whenever possible. (b) The Jommanding Officer shall include in the patrol report pertinent information concerning all illnesses and injuries and shall be responsible for the admis- sion to the oick List of the personnel involved (even if no Sick Days are involved), and shall see that suitable entry is made in the Health Record. Appropri- ate entry shall also be made in the Ship’s Log concern- ing all such occurences. 1122 Medical Fbcaminations Various special physical, psychological and psychiatric examinations and evaluations are required by the Manual of the Medical Department, Par. 21133 and 21134, and by Bureau of Per- sonnel directives, and these s’’all be conducted under the super- vision of a qualified submarine medical officer. (a) He shall determine the fitness of all candidates for submarine service in accordance with Bureau of Medicine and Surgery directives. (b) Special examinations shall be conducted, as required by E-1306, BuPers Manual, to determine the physical fit- ness of officers for qualification in submarines. (c) Wartime experience has indicated that pre- and post-patrol physical examinations of all officers and men are highly desirable. These examinations should be carefully conducted and should include a psychiatric examination in order to determine the necessity for treatment or rest. Before and after each patrol, the squadron medical officer shell submit a written report to the Squadron Commander concerning t’-e physical fitness of the Commanding Officer and all officers and men of each submarine crew. (d) Any submarine personnel referred by the Commanding Officer or b- other medical activities, or by any competent authority shall be examined for fitness for retention in the submarine service. (e) Physical examination for entrance into, or con- tinuance in deep-sea diving shall be conducted in accordance with existing instructions. (f) Physical examination shall be conducted prior to submarine escape training, particular reference being made to otological, circulatory, and respiratory conditions. 1123 Dental Aspects The dental aspects of submarine medicine may be considered under the following heads: (a) It shall be the duty of the dental officer to assist the submarine medical officer by conduct- ing the dental part of all of the various examin- ations mentioned above and authorized by existing directives, (b) Experiences of the recent war demonstrated very clearly that it is imperative that each man going to sea on a submarine have all necessary dental vork accomplished, and his mouth in as perfect a condit- ion as possible, prior to his departure. The dental officer shall exert every effort toward taking the proper care of submarine personnel immediately prior to a war patrol. (c) The dental officer shall assist with tne training of submarine pharmacist's mates so that they will be qualified to diagnose and treat any dental conditions that may develop at sea. 1124 Hygienee and Sanitation In each submarine force activity, the assigned submarine medical officer and the submarine pharmacist*s mate shall be responsible for seeing that all hygiene and sanitary regulations which are promulgated by competent authority are strictly complied with* (a) They shall be especially responsible for seeing that proper conditions exist in regard to: water supply, food and food storage; heads and general toilet facilit- ies; gallie?; living spaces; including bed- ding; and noxious gases. (b) They shall familiarize themselves with the medical problems of the geographic area in which the submarine force is operating and bring to the attention of the proper authorities any necessary facts contributing to, or hazardous to, the health and comfort of the men. (see Manual of the Medical Dept. Section IV, Par. 35D14 and 15, Page 425) 1125 Special Submarine Problems Special submarine problems may be considered under the followinr heads: (a) Air Purification. The Submarine medical officer and the submarine pharmacist fs mate will determine that the proper conditions and facilities exist in regard to: oxygen supply, carbon dioxide removal, temperature and humidity control, control of noxious gases, such as chlorine, carbon monoxide, etc,, and will report any deficiencies to the proper authorities. They will conduct a program of ed- ucation for officers and men in the problems of air purification and the physiology of air pressure. Lectures and .literature should be utilized. (b) Submarine .Escape, Rescue, and Salvage, The medical officer and the pharmacist’s mate on independent duty will take an active interest, and shall partic- ipate in all drills, training and educational activity related to submarine escape or "lung” training; shall stand by during pressure test and actual training in the Training Tank, When aboard ship, he shall be responsible for indoctrination end training of the officers and crew of the sub- marine in escape procedures and in the use of the "lung”. He shall be responsible for inspection of the "lungs" and oxygen fittings, etc., to see that they are in working condition. All Qualified med- ical officers shall keep themselves completely fam- iliar with all of the literature and techniq.ies and shall be present during the practice drills, and during any actual s ibrnurine rescue or salvage operat ions which may occur. 1126 Submarine Medical Research. This vitally important subject is presented as a separate unit, as paragraph 1130. 1130 Medical Research Submarine medical research will be discussed under the headings of: location, personnel; and the Medical Research Department of the Submarine Base, New London, will be discussed as an example of such a s 'brrarine medical research activity. 1131 The Location for Submarine Researc} The ideal locations for submarine medical research are considered to be as follows; (a) The Submarine Base, New London, is ’well located for the principal submarine medical research unit, since it is there that most of the person- nel enter the service for the first time, and it is there that the new submarines are comm- issioned, outfitted, and the crews trained for their wartime missions. In order to properly coordinate all of the submarine medical re- search, it has been shown to be highly desir- able to have the head of the Medical Research Department of the Submarine Base, New London, designated as coordinator of all submarine medical research activity. (b) In the recent war, the Submarine Base, Pearl Harbor, proved to be the logical site of various phases of field research. However, the location of this type of research unit would depend upon the sphere of naval operations in any future conflict. (c) Research of certain types must be conducted aboard the submarine tenders, and submarine rescue ships, and war experience has indicated that more should have been conducted aboard operating submarines,— even if such work might detract somewhat from the military efficiency*- of an operating submarine. (d) Certain types of research work associated with the general submarine medical research program can best be conducted at Naval Medical Research Institute, Bethesda, Maryland; at the Experimental Diving Unit, Naval Gun Factory, Washington, D.G.; and the Naval Research Laboratory, Anacostia Station, 'Washington, D*Cfc, and other areas as may be indicated by the nature of the situation which may develop* 1132 Personnel Due to the uncertainty as to the type of naval personnel envisioned for the ipeacetirne Navy, the following discussion of personnel will be patterned after the organization during the recent war. (a) Medical Officers, The majority of medical officers assigned to any of the submarine medical research activities shall be qualified submarine medical officers; others should be specialists in psychiatry, ophthalmology, otology, etc., in such proportions and numbers as necessary for the conduct of an) particular type of experimental work undertaken. These medical officers should be furnished by the Bureau of Medicine axnd Surgery. (b) Hospital Corps Officers Hospital dorps officers should be supplied in num- bers required to handle the billets as personnel officers, property officers, and general administra- tion officers, as veil as to serve as officers in their technical specialties. (c) Hospital (Specialist) Officers, H(S) officers, (a wartime designation which may or may not be retained), shall be assigned in sufficient numbers to each submarine research group to handle such special duties as required in the fields of physiology, chemistry, physics, bacteriology, statistics, etc. (d) Phamac ist * s Mates, At least 25$ of the pharmacist's mates should be qualified subm