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Phenomena of trauma to be dealt with scientifically must be based not

on descriptive categorizations, but on etiologic ones. How this is


happening and what it means are discussed in this paper.

THE CHANGING APPROACH TO THE EPIDEMIOLOGY.


PREVENTION, AND AMELIORATION OF TRAUMA: THE
TRANSITION TO APPROACHES ETIOLOGICALLY RATHER
THAN DESCRIPTIVELY BASED
William Haddon, Jr., M.D., M.P.H., F.A.P.H.A.

Background sume they have contributed something.


This, however, is likely to occur de-
APPROACHES to the phenomena of creasingly because of the accelerating
trauma, which are of interest here, transition in concepts and research now
are rapidly becoming more rational and taking place.
scientific. Nonetheless, the field still in- What then, is the essence of this tran-
cludes the only substantial, remaining sition? Very broadly and importantly,
categories of human morbidity and mor- it is part of the increasing awareness
tality still viewed by most laymen and of the relationships between man and
professionals alike in essentially presci- his environment, of human ecology,
entific terms. The traditional wisdom especially of man's relationships with
perpetuates terms and concepts formerly certain potentially or actually hazard-
applied to much of human experience. ous physical and chemical attributes of
"Luck," "chance," "accident," and other his environment.
extrarational notions still survive from At the beginning of the nineteenth
the times when scientific explanations century, man was equally ignorant of
for plagues, earthquakes, "natural dis- both the physical and chemical hazards
asters," and other terrifying phenomena of his environment, on the one hand,
scourged a mankind that had no rational and of the biological hazards on the
understanding, either of their sources or other. In the 150 years that followed,
of the means for dealing with them. he moved disproportionately rapidly
Unfortunately, because of their auto- in unravelling and controlling the bio-
matic subscription to the traditional, logical hazards, but is only now begin-
prescientific wisdom of the field, many ning on the physical and chemical haz-
professionals-physicians, behavioral sci- ards which range from air pollutants to
entists, and others-in coming to this the forces at play on our highways.
field for the first time, still merely trans- The accompanying transition in cate-
late the traditional wisdom and its terms gorizations of the phenomena of the field
into their own scientific framework and has many precedents in medicine. It is
jargon. Building on the result, they as- the shift from descriptive thinking and

AUGUST. 19968 1431


More relevant for our purposes here
is to view the process in reverse; that
is, from the standpoint of the etiologic
sets in picking up pieces of many pre-
existing descriptive sets, as illustrated
in Figure 2.
Thus, syphilis, the etiologic set based
on the infectious agent, Treponema pal-
lidum, picked up parts of previous de-
scriptive sets, such as paresis, gummas,
I penile lesions, rashes, certain gastric
lesions, certain abnormalities of the
growing ends of bone, and many others,
but not all of those in any one of the
Figure 1-An illustration of the parcel- earlier descriptive sets. Again, an im-
ling out to etiologically defined sets of portant point is that there is almost
the components of a descriptively de- never in such transitions
fined set of pathology in nosology
a one-to-one relationship between the
earlier, descriptive ways of looking at
nosology to categorizations in etiologic the phenomena and those etiologically
terms. In the past, this shift has almost based which are substituted for them.
invariably been accompanied by in-
creasingly successful control efforts, as Concepts, Old and New
one would expect, because ability to de-
scribe human morbidity and mortality Those who do not understand this
etiologically requires an understanding typical and long-standing pattern of
of causation. Hence it opens the door transition usually refuse new etiologic
to the possibility of manipulation and categorizations and evidence because
control.
What are a few past examples of this
routine transition from descriptive cate-
gorizations or diagnoses to those etio-
logically based? In illustration, such no-
tions as fever and wasting were once
diseases. As the evolving science of the
past was applied, it did not, however,
find single causes of these, substituting
causally based classifications on a one-
to-one basis for the earlier terms and
the ideas with which the phenomena
were described. Rather, new groupings
etiologically based were constructed
that picked up portions of the earlier,
descriptive groupings or sets, as il-
lustrated in Figure 1. Viewed differently,
for example, the set of phenomena I\/
formerly referred to as "wasting," was
parceled out to such etiologic sets as Figure 2-An illustration of the incor-
tuberculosis, amebiasis, and a host of poration of portions of various de-
others. scriptively defined sets of pathology
into an etiologically defined set

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PHENOMENA OF TRAUMA

they maintain, correctly, that these do ing radiation, mechanical energy, elec-
not account for all of the descriptive trical energy, and chemical energy, each
categories involved, or for all of the in a variety of forms. Since these have
problems associated with them. This been discussed in detail elsewhere,2'3 we
commonplace failure to understand this need not go into them further here, ex-
usual, and necessary, transition has, in- cept to note that in the highway safety
cidentally, especially been a problem in area the problem is almost exclusively
connection with research on descriptively one of mechanical energy reaching
based groupings such as "atheroscle- people at rates that involve forces in
rosis," "chronic bronchitis," "cancer," excess of their injury thresholds. None-
"diabetes," and many others of current theless, some chemical and thermal
concern. This failure in understanding hazards appear to be of increasing im-
has also delayed research and programs portance on the highway; for example,
concerned with what most still refer to in relation to the distribution of hazard-
as "accidents." ous amounts of propane, explosives, and
The notion of an accident is descrip- other hazardous materials, on our roads.
tive, not etiologic. It has a long his- The literature in the over-all field is
tory and close relationship-themselves increasingly divergent. Most of the be-
worthy of the most careful study by be- havioral science literature is highly in-
havioral scientists-to notions of per- bred and concerned almost exclusively
sonal vulnerability and invulnerability. with studies and programs centering on
This is illustrated, for example, by the the use of the descriptive notion of "acci-
themes of the stories of Job and Achilles. dent." Parallel to this literature is an-
Redolent of the extrarational and super- other-substantially based in physics
natural and prescientific, they remind and medicine-already very extensive
one of Malinowski's natives in their and growing much more rapidly, and
approach to the hazards outside the largely derived from De Haven's 1942
reef, which they did not understand, landmark paper entitled "Mechanical
in comparison with those inside which Analysis of Survival in Falls from
they approached in more rational Heights of Fifty to One Hundred and
terms.1 Fifty Feet."4 This second literature, in-
But the old, descriptive, concept of cidentally, is already producing major
an accident is largely giving way in payoffs in injury prevention and ame-
programs and research to an etiologic lioration. It is concerned with the forces
concept which, in turn-as is typical in that produce the injuries to animate
such transitions-is picking up a num- and inanimate structures, the ways these
ber of phenomena not normally included can be avoided, the susceptibilities of
under the term accident itself. As with the animate and inanimate structures in-
the examples I have briefly sketched, volved, and the amelioration of the vari-
neither set includes all of the ingredients ous forms of damage, once they occur.
of the other. An outstanding exception to the pre-
The etiologic basis is the various occupation of the behavioral literature
forms of energy exchange which must with "accidents" is James J. Gibson's
occur in excess of body injury thresh- 1961 paper. "The Contribution of Ex-
olds for the injuries which make the perimental Psychology to the Formula-
field of such current social concern to tion of the Problem of Safety-a Brief
occur. The forms of energy involved in for Basic Research."5 Gibson's subsec-
producing so-called "accidental injuries" tions delineate an ecological and etio-
of all types, and without which they can- logical approach: "a classification of
not occur. include thermal energy, ioniz- dangers" (wherein he discusses, for

AUGUST. 1968 1433


example, the various forms of energy- It is the end results, again, of struc-
thermal, radiant, chemical, electrical); tural damage and death that make the
"exploratory behavior and margins of problem of social concern, and it is
safety" (that is, failure to perceive, fail- these that must be reduced. The prob-
ure to react, the concept of an accident, lem thus is not a priori "to prevent
and the role of motivation); and "ex- accidents" per se. In the case of the
perimental research relevant to perceiv- very parallel situation, where the social
ing and avoiding dangers." Here the objective was to reduce the end result
author's approach is solidly on the sci- of epidemic paralysis, this would have
entific side of the issues, rather than to been equivalent to preventing infection.
translate into scientific terms essen- However, as we subsequently learned,
tially prescientific and extrarational no- preventing infection was not the only
tions. This, in my opinion, is clearly or best way to prevent the end result
the direction that most behavioral re- of injury and death due to the virus
search should and will take. in question.
However, the former still prevalent
notion of an "accident" should continue Phases of Social Concern
to serve as a basis of some research be- Rather, as with polio, there are es-
cause it is so ingrained in our culture. sentially three major portions or phases
Unless we learn the ramifications of this of the sequence of events leading up to
notion, we will not know how the be- the end results, during which causal fac-
haviors to which it relates can be tors are active and countermeasures can
manipulated. This is probably a passing be undertaken.
opportunity and one of great potential The first phase involves, from a
value, especially in relation to ideas countermeasure standpoint, the preven-
of personal invulnerability, subjective tion of the etiologic agent from reach-
probability, and many others. In shift- ing the susceptible host. In polio, this
ing, nonetheless, in Gibson's direction, used to involve keeping children out
research should concentrate on the much of swimming pools and from attending
larger issues involved in the etiologic the movies. In the highway field, this
set since they include concepts related involves an array of measures which, in
to hazards of all kinds, not only physical essence, are designed to prevent mechan-
and chemical, but also whether expected ical forces above injury thresholds from
or not. Moreover, the limitation should reaching vehicles and people.
not be to civilian phenomena alone. A second phase in the interactions,
Control opportunities, in parallel with which lead up to the end results of so-
the handling of problems posed by other cial concern, involves the interaction of
environmental hazards in the past, must the etiologic agents and the susceptible
be solidly based in relation to etiologic structures. In the case of polio, this be-
organization of the field, not on descrip- gins with the arrival in the host of the
tive categorizations. Although I have else- virus and involves its interactions with
where spelled out a much more detailed the cells of his intestinal tract, and,
analysis of ways one can analyze the later, of his central nervous system. In
problems of physical and chemical haz- the case of highway phenomena, it be-
ards, and the prevention of harmful in- gins when mechanical forces, in excess of
teractions with them,2'3 here are a few those the vehicle, occupants, pedestrians,
examples illustrating, with concepts com- and cyclists can tolerate, begin to exert
patible with Gibson's the utility of this themselves on vehicles and people. Here,
approach. too, are many opportunities for the

1434 VOL. 58. NO. 8. A.J.P.H.


PHENOMENA OF TRAUMA

elimination or reduction of the end re- nosology and its penumbra of folklore
sults of injury and death. In fact, as and traditional wisdom.
far as vehicle occupants are concerned,
the knowledge, both theoretical and ap- Technics in Use
plied, is already available. During the For simplicity, most of the prob-
next few years, this will make it en- lems of the field can be sorted out
tirely feasible to design vehicles whose with a two-dimensional matrix, within
occupants need not sustain either any the cells of which one can organ-
injuries at all or, at worst, no very seri- ize a great many more specific issues.
ous injuries at crash speeds under at Figure 3 shows this as done for the
least 60 miles an hour, a range in highway portion of the over-all chem-
which the overwhelming bulk of occu- ical and physical injury problem. Simi-
pant injuries and deaths now occur. (In lar matrices are used for other portions
illustration, Bohlin6 has recently shown of the over-all problem. Doing so is also
reductions in deaths in highway crashes, an important step in sorting out inter-
other factors being equal, of 80 per cent actions between the items covered in
as the result of the use of combination the individual cells and for purposes
lap-and-upper-torso safety belts. In addi- of mathematical modeling. Each of these
tion, no deaths occurred in his series be- cells contains a substantial number,
low 60 miles per hour, compared with breadth, and complexity of factors, cate-
12 miles per hour among the unbelted.6) gories of variables, and opportunities
Without going into further details, the for influencing the end results.
methods applied will, in essence, involve If fully developed here, two ana-
the far better "packaging" of human lagous matrices would be set up: the
cargo, accomplishing with people what first concerned with causal factors in
we long ago achieved with property.2'3 each cell; the second with counter-
A third phase of the sequences, which measures in each. We also use this
lead up to the end results of concern, matrix to identify resource requirements
involves maximizing salvage, once dam- and what is known scientifically.
age has been done to the susceptible It should be noted that this matrix
structures. Using polio again as an identifies the location of all, as far as
example, although there are many we know, that is done in the field to
others in the medical field, the problem reduce the end results of concern. It is
there was to reduce the likelihood of much broader than preoccupation with
death, once paralysis occurred, to lower the causation of accidents (i.e., crashes)
the extent and progression of paralysis, and their prevention. For example, in
to reverse it insofar as possible, and to the precrash phase, the research issues
provide the necessary emergency med- include those of alcoholism, blowouts,
ical, intermediate, and rehabilitative coefficients of friction of road surfaces.
care. Needless to say, the timing and In the crash phase, there are the injury
sequencing of salvage and a good deal thresholds of drivers and others, the
of its substance are identical to those dynamic integrity of vehicle "packages,"
appropriate for those injured on our and highway crash design. In the post-
highways. crash phase, the issues for research and
Clearly, the questions and opportuni- programs include emergency signal
ties, at each point in these etiological generation and other communications,
sequences, are different from those emergency transportation, emergency
likely to be recognized by merely talk- medical care, debris removal, and police
ing about injury control or about "acci- work.
dents," using the old and still traditional The most common and universal fal-

AUGUST. 1968 1435


COMPONENT
DRIVER PASSENGERS PEDESTRIANS BICYCLISTS VEHICLES H IGHWAYS POLICE
PHASE CYCLISTS

PRECRASH

TIME CRASH

POSTCRASH

DRIVER PASSENGER
INJURY INJURY & ____ ---
IPROPERTY DAMAGE --
& DEATH DEATH

Figure 3-A matrix for identifying major areas within the highway portion of the
over-all chemical and physical injury probl em

lacy in the field, whether viewed within pelling the use of appropriate helmets
a descriptive or etiologic framework, reduces deaths and injuries about 65
is one which is ingrained that it is
so per cent, it would have us concentrate,
seldom explicitly recognized. It in- despite our present lack of knowledge
volves the assumption that the prior- of ways to influence crashes, only on
ity rank of countermeasures, in terms the present far less productive manipula-
of their ability to influence the end re- tion of motorcycle drivers.2 In the case
sults of concern, must parallel the rank- of occupant protection, which we know
ing, in order of their relative contribu- has great potential,2 some of it already
tions, of causes influencing those end beginning to be realized, this fallacy
results. In its most common form, it has set back for many years the applica-
states that because drivers cause most tion of such information because of its
accidents, programs correspondingly insistence that the driver was the prob-
must be concerned with drivers. In the lem and, therefore, should be, in essence,
real world, there is no basis for making the only locus of countermeasure ac-
this assumption, especially since in nu- tivity.
merous areas of the field it leads to Earlier it was emphasized that transi-
demonstrably false conclusions. tions from descriptive to etiologic group-
Thus, if applied to the widespread ings of phenomena do not occur on a
thermal and electrical injuries associated one-to-one basis. It has been mentioned
with early house-wiring systems, this that the notion "accident" includes a
theory would have led to concentrating number of things not directly relevant
on attempts to influence human be- to highway or other injuries and deaths.
havior rather than the development of It includes the entire area of "mis-
the fuse. With respect to motorcycle haps," with all their extrarational and
accidents, where we know that com- other overlays, all of which should be

1 436 VOL. 58. NO. 8, A.J.P.H.


PHENOMENA OF TRAUMA

systematically explored by behavioral Similarly, in the third phase, involv-


scientists and other research workers. ing salvage after the injuries have oc-
Similarly, groupings of phenomena curred, the problems related to the fac-
based on the kinds of injurious energy tors that aggravate or increase the suc-
exchanges involved, for example, those cess of salvage are essentially identical,
defined in terms of mechanical energy, whether the issue is injury on the high-
include a number of phenomena not way or in jungle warfare. The injuries,
now considered under the term "acci- the measures that need to be taken, and
dent." Some of these should be of great the time constraints are all virtually
scientific value, if explored in behavioral identical. The response involves prompt
and other terms. These, in turn, are command and control, communications,
quickly discovered to have many things and transportation, with all of the oppor-
in common with problems related to the tunities for research and the application
more traditional highway and other of research findings that this embraces.
"accidents." Also, it should be noted that in the
For example, within the highway past we have ambiguously separated and
area, this broader approach. based on treated, in conceptually different terms,
the etiologic agents which must be in- the acute interactions of man and his
volved, picks up in the first phase* structures with environmental hazards
the occasional murders and suicides from those operating over longer pe-
which many of us working in this field riods, even though the two in many cases
have occasionally come across. The ap- have identical results. Thus, for example,
proach also picks up a number of if sulphur dioxide acutely damages man,
equivalents that involve individual and we have traditionally viewed the inter-
organized violence and aggression, action descriptively and prescientifically
whether on the civilian scene or in war. as an "accident" and emphasized the
Thus, one can identify for study, across unplanned nature of the event and its
all human violence, the roles of alcohol, chance aspects, not the nature of the
views of risk, notions of individual in- agent and the means by which it
vulnerability, and subjective proba- reached or could have been prevented
bility.3 from reaching the susceptible host. To
As another example, in the second the contrary, even though the end result
phase, body tolerance to mechanical might be biologically identical, the in-
injury is the same, regardless of teraction involving the same agent, ar-
whether the body is subjected to me- riving over a longer period of time in
chanical forces deliberately or inad- smaller doses, has been regarded in
vertently on the highway or in the terms of traditional preventive medicine
jungle. Similarly, countermeasures, too, concepts. These emphasize the nature of
are soon discovered to have many com- the agent and the ways to prevent either
mon denominators, whether they in- its generation, its release, or its arrival
volve, for example, the use of military at the person or group to be protected.
and police helmets, or helmets worn by Here we have talked in terms of maxi-
motorcyclists, or the interior padding of mum permissible concentrations in the
windshield header areas in automobiles. working environment and in the air we
Parallel points can be made, of course, breathe in our cities, not in terms of
for a number of the behavioral aspects chance. By emphasizing the nature of
of all of these and related problems. the injurious etiologic agents, involved
* In the highway "safety" field, these phases
in the former "accident" area, we elim-
are termed the "precrash," "crash," and "post- inate this logical inconsistency and open
crash" phases, respectively. the door for success in control.

AUGUST, 1968 1437


Conclusion forces. Such an approach is more ap-
It must be emphasized again that it propriate for primitive tribes than for
is essential that those who would make modem society.
scientific contributions in this field avoid
approaches which, in effect, translate the REFERENCES
traditional, prescientific wisdom into sci- 1. Malinowski, B. Magic, Science and Religion, and
Other Essays. Garden City, N. Y.: Doubleday
tific terms and jargon. We must recog- (Anchor Books), 1954.
nize the conceptual transition in which 2. Haddon, W., Jr. "The Prevention of Accidents"
(Chap. 33). In: Textbook of Preventive Medicine
we are participating and the difference (Clark and MacMahon, eds.). Boston, Mass.: Little
between descriptive and etiologic ap- Brown, 1967.
3. Haddon, W., Jr.; Suchman, E. A.; and Klein, D.
proaches, and that the payoffs for so- Accident Research, Methods and Approaches. New
York: Harper & Row, 1964.
ciety and in scientific understanding lie 4. De Haven, H. Mechanical Analysis of Survival In
chiefly in the latter. We must also recog- Falls from Heights of Fifty to One Hundred and
Fifty Feet. War Med. 2:586-596 (July), 1942.
nize that this area and approach must 5. Gibson, J. J. The Contribution of Experimental
be considered as part of any over-all Psychology to the Formulation of the Problem of
Safety-A Brief for Basic Research. Ibid ref. 3. 1961.
approach to human ecosystems, and that pp. 296-303.
6. Bohlin, N. I. A Statistical Analysis of 28,000 Acci-
we can no longer afford to deal in the dent Cases with Emphasis on Occupant Restraint
terms and concepts of the past, with Value. Proc. 11th Stapp Car Crash Conference.
(Oct. 10-11), 1967. New York: Society of Automo-
their vague emphasis on threatening tive Engineers, Inc., 1967.

Dr. Haddon is Director, National Highway Safety Bureau, Federal Highway


Administration, U. S. Department of Transportation, Washington, D. C. 20591
This paper was presented before the Epidemiology Section of the American
Public Health Association at the Ninety-Fifth Annual Meeting in Miami Beach,
Fla., October 26, 1967.

1438 VOL. 58. NO. 8. A.J.P.H.