DEATH FROM WOUNDING

The relative proportion of deaths among those who are hit (the killed and the wounded) is important in recognizing the relative lethality of the various types of weapons used by the enemy; in reflecting the expected effects of the kind of combat in which troops are engaged; and for indicating areas of possible development of protective measures and, devices, as well as for devising improved surgical techniques. The latter reason, however, places the greatest emphasis on the proportion of wounded who die of their wounds.

The official Adjutant General counts of killed and wounded are summarized in table 38 for World War II experience (8) compared to the official Adjutant General counts (3) for the Korean War. For all of World War II, 28 died among an average 100 killed or wounded. This ratio was 25 deaths in the European Theater of Operations in World War II and 22 of 100 for Korea. Obviously, the method by which the distinction is made between the killed and the wounded has a marked effect on the number determined to have died of wounds. Of the two major sources, the number died of wounds (1,957) processed by The Surgeon General, from individual medical records of admissions to medical treatment facilities, is more reliable in this respect. In addition, the inclusion of the slightly wounded CRO cases provides a broader base for determining fatality among all men hit, rather than just among the killed in action and wounded admissions. In view of this, the data from the Office of the Surgeon General are given in table 39.

There were 19 deaths among an average 100 hit (including wounded CRO cases) and 81 survived in Korea. Of the 83 who were wounded, 13 were treated and immediately returned to duty while 70 required admission for treatment on an excused-from-duty basis. Two of the 70 wounded admissions died of wounds. When distinction is made between division and non-division units, certain differences are apparent. The relatively fewer deaths (14 of 100 non-division hit) show that nine were killed in action and five died of wounds. The larger ratio for died of wounds might tend to prove the principle of classification of the mortally wounded between killed and wounded. It would appear that mortally wounded individuals from non-division units, operating in the vicinity of medical support, are more likely to be seen alive and, therefore, recorded as having died of their wounds. In addition, 28 of the 91 non-division wounded were carded for record, and only 63 required admission to medical treatment. These ratios compare to 19 deaths among 100 division troops hit (including CRO cases), of which 18 were recorded as killed in action. Seventy of 82 division wounded required admission for treatment on an excused-from-duty basis, while only 12 were carded for record only.

 ¹Based on The Adjutant General Casualty Reports

36Table 39.- Killed-in-action and wounded-in-action admissions and CRO cases,
¹ by type of unit and type of case, U.S. Army, Korea, July 1950-July 1953

 ¹Based on medical records and reports of death recieved by The Surgeon General.

CAUSATIVE AGENT AND NATURE OF TRAUMATISM

Two important elements relating to fatality of hits and the lethality of weapons are the causative agent and the nature of traumatism. When comparison is made between the various agents causing wounds and deaths in World War II and in the Korean War (table 40), lower proportions were caused by explosive projectile shells (artillery, mortar, and bazooka), rockets and bombs, and boobytraps in the Korean War than in World War II. Conversely, relatively higher proportions in Korea were caused by small arms, grenades, land mines, and other fragments and explosions. The differences are more pronounced among the wounded than among the deaths. In Korea, 27 percent of the nonfatal wounds were from small arms (bullets) compared to 20 percent for all of World War II. The proportion from explosive projectiles (51 percent) was lower in Korea than the 58 percent for World War II, while the proportion from grenades (9 percent) was markedly higher than the World War II figure.

When data on the lethality of weapons are assembled, and those with the causative agent unknown or unrecorded are excluded, it still is difficult to assess lethality even in the simplest terms of the relative proportion who die among those hit (killed or wounded excluding CRO). Apparently, even the killed in action who are seen by medical personnel are not routinely stripped and examined for the specific lethal agent. The relatively high fatality rates shown in table 41 for "all other" agents undoubtedly, result from this lack of specificity. For example, included in the "all other" group are such categories as "other fragments, or explosions," "unspecified instruments of war," and "accidents involving own weapon n.e.c. (not elsewhere classified)," none of which identify the particular weapon involved. Obviously, the fatality

 ¹Excluded are cases where the specific causative agent was not recorded or was unknown.

37

¹Denotes less than 50 killed or wounded in action.
²Between 50-99 killed or wounded in action.

percentages of death among all those hit, by a specific agent are biased to whatever degree these more or less ambiguous categories obscure a specific causative agent. This problem does not exist for the died of wounds who are treated by medical personnel and, consequently, the case fatality percentages included in table 42 are not affected by "unknowns" to any significant degree.

From these data on lethality, it is apparent, that small arms (bullets) produced the highest fatality rate (13.5 percent) among those hit, when the "all other" group is not considered. Land mines, with a 12.9 percent fatality rate was second and explosive projectile shells (artillery, mortar, bazooka, and so forth) ranked third with a rate of 10.9 percent. Although rockets and bombs were almost identical (10.6 percent), the fatality percentage was based on only 85 hits and any determination of lethality is uncertain at best. For this reason, data based on less than 50 hit or wounded are excluded and those with at leat 50 but less than 100 hits or wounds are separately identified. When the nature of traumatism is considered, traumatic amputations resulted in a relatively high rate of death. The highest fatality percentage (35.9 percent) resulted from traumatic amputations due to explosive projectile shells. Land mines produced a 19.5-percent fatality rate among all those hit who suffered a traumatic amputation. Wounds of all types had the highest fatality rates from small arms (20.4 percent) and also from land mines (16.1 percent). Land mines produced a fatality rate of 14.8 percent for concussions as well. Fractures had the lowest fatality percentages by nature of traumatism among those hit, with land mines (6.3 percent) and explosive, projectile shells (4.8 percent) being the most lethal of any causative agents for fracture wounds.

Of more, immediate concern to the surgeon is the proportion of wounded admissions to medical treatment facilities who die of their wounds. Table 42 shows a total case fatality rate of 2.2 percent

¹Denotes less than 50 killed or wounded in action.
²Between 50-99 killed or wounded in action.

38

when the unknown or unrecorded causative agents are excluded. This latter percentage compares with the overall case fatality of 2.5 percent for the U.S. Army in the Korean War. Land mines, with a case fatality rate of 3.1 percent, was highest. Small arms (2.7 percent) had the next highest case fatality rate for wounded with rockets and bombs (two deaths among 78 admissions) showing an almost identical rate (2.6 percent). Wounded patients with traumatic amputations suffered an overall case fatality rate of 5.4 percent, with those resulting from explosive projectile shells experiencing a case fatality rate of 7.5 percent. Land mines causing traumatic amputations resulted in patients dying of wounds at a rate of 5.0 percent, while wounded admissions with traumatic amputations resulting from small arms (bullets) had a case fatality rate of only 1.5 percent. Fractures, wounds of all types, and burns all had case fatality rates ranging from 2 to 3 percent, depending upon the specific causative agent involved. Concussions, with an overall fatality rate for killed and wounded hit of 7.0 percent, produced a case fatality of only 0.9 percent for wounded admissions.

CAUSATIVE AGENT AND TACTICAL OPERATION

Perhaps a better indication of lethality might be obtained from an examination of the use of weapons in particular tactical situations, where one weapon or another may be given particular advantage. When causative agents are reviewed for the different types of division tactical operations, even the relative proportion of the unknown or unrecorded causative agent among these killed in action is seen to vary considerably. For example, while 57.5 percent of the killed in action was unknown for all operations, markedly higher proportions appeared for operations of pursuit (72.9 percent), defensive operations (82.7 percent), and withdrawal operations (85.8 percent). The balance reflected lower proportions of unknown causative agents, but still were on the order of one-third to two-fifths of all KIA cases by type of tactical operation. The relative ratios between small arms (bullets) and fragments, as determined from table 43, were approximately 2 to 1, in favor of fragments for all operations, 3 to 1 for static defense lines, and 4 to 1 for limited operations. For major offensives and defensives, a 1-to-1 ratio resulted. For operations of pursuit and withdrawal, the situation was reversed, with bullets 2 to 1for pursuit and almost 6 to 1 over fragments for withdrawals. It should be noted, however, that the latter type of operation also had the highest percentage of unknown causative agents.

Causative agents by type of tactical operation are much more complete for wounded admissions to medical treatment facilities, and are shown in table 44 and figure 6 for U.S. Army divisions and separate regimental combat teams in the Korean War. Although neither aviation nor land transport vehicles were significant factors in wounding, it is interesting to note that the highest proportional distributions for land transport occurred during pursuit and withdrawal operations, respectively, while offensives provided the highest ratio for aviation. The majority of wounds, of course, resulted from bullet and fragment type weapons, regardless of the type of division operation experienced. Even so, differences do exist between the relative proportions of these two major weapon groups, not only for the various types of ground operations but also for different periods of time as well, during the Korean War. Figure 6 graphically depicts these differences by type of operation and shows that operations of pursuit and operations of withdrawal resulted in the highest relative proportions for bullet wounds (43.3 percent and 45.6 percent, respectively) and were the only division operations in the Korean War where fragments were exceeded its the causative agent. Fragments caused 41.4 percent of all wounds in operations of pursuit and 35.0 percent during withdrawal operations. Fragments, of course, were the leading cause of wounding in all other types of tactical operation and show a ratio of 58.1 percent for major offensive operations, 54.6 for defensives, and highs of 77.6 percent and 79.2 percent, respectively, during static defensive line operations and during limited offensive operations from these lines. One might consider that these latter distributions are to be expected since they reflect the static nature of the defense of fortified lines where shelling by the enemy was a daily occurrence. Bullet wounds, by tactical operations other than for pursuit and withdrawal, ranged from 34.7 percent of a1l wounds during major offensive operations and 36.1 percent during defensives to a low of 15.2 and 15.7 percent, respectively, during static defensive lines and limited operations from these lines.

Any relationship of wounding by causative agent and type of ground operation must necessarily identify the weapons that are used by the enemy or become available to him over time. Figure 7 graphically shows that, during the early part of the

39

¹Excludes redeploy and reserve.
²Consists mainly of instruments of war, the exact nature of which was unrecorded or unknown. There possibly may be a few known cases included if due to flame thrower, bayonet, sword, or direct secondary effectsof known instruments of war; however, their numbers, if any, would be very small.
³Includes water transport; machinery, tools, and related agents; poisoning; falls and jumps; environments; and other miscellaneous wounds which were not directly due to instruments of war.

40

¹Wounded in action and admitted to a medical facility
²Excludes redeploy and reserve.
³Includes flame thrower; bayonet; sword; direct secondary effects of known instruments of war; the exact nature of which was unknown.
⁴Includes water transport; machinery, tools, and related agents; poisoning; falls and jumps; environments; and other miscellaneous wounds which were not directly due to instruments of war.

41

42

These relative percentage distributions by causative agent indicate that some differences do exist between the relative proportions of wounds for various causative agents when considered by type of division tactical operation or for different periods of time. The data show some measure of uniformity in that fragments were the leading cause of both KIA and WIA cases, with the exception of operations of pursuit and withdrawal. Obviously, both of these latter types of tactical operation, involved swift movement of forces which denied the enemy whatever advantages positional type warfare presents for artillery barrages. The planner, however, might be able to project, from these basic data, certain expected distributions of wounds, based on knowledge of the enemy's weapon system and the type of tactical operations to be employed against the enemy.

ANATOMICAL LOCATION OF WOUND

Distributions of anatomical location of hits and wounds are fundamental data to any medical investigation of battle casualties and are perhaps, the most important; element involving the chance of death. The available data by anatomical location of wound for World War II and the Korean War (table 45) show large differences between the two wars for wounded admissions (nonfatal and died of wounds) and only slight differences for the killed in action, except for "body generally" which undoubtedly includes multiple wounds. The relative proportions of the died of wounds for the Korean War nvolving the head (25.4 percent) and face (5.4 percent) were higher than the World War II percentages of 19.7 and 3.2 percent, respectively, for these two body regions. All of the other anatomical locations for the Korean War died of wounds had slightly lower percentages than did the World War II died of wounds distribution. Nonfatal wounds, on the other hand, showed higher percentages for face, neck, abdomen, and upper extremities in the Korean War, with wounds of the head and lower extremities being proportionately smaller. Nonfatal wounds involving the thorax and the body generally were about the same for both wars.

Since direct aimed fire is infrequent in battle, any differences in the location of hits and wounds which might exist among weapons should result only from chance depending upon the mix of weapons and rate of fire, as well as on the relative frequency and extent of exposure of the various parts of the body. Nevertheless, differences do exist among weapons, especially in relation to fatal wounds among the

44

¹Denotes less than 50 killed or wounded in action.
²Between 50-99 killed or wounded in action.

body regions hit, regardless of the reason for a specific weapon causing a wound to a particular region of the body. Table 46 shows fatality among all those hit, (killed and wounded, excluding CRO) was highest, for bullets for every region of the body except the upper and lower extremities. This would indicate that when small arms are used (usually in close combat), the velocity of their hits to vital areas is highly lethal. Small arms (bullets) hits to the head resulted in the highest fatality rate (59.9 percent), with bullet hits to the neck (40.3 percent) second. Head wounds among those hit by explosive projectile shells had a fatality rate of 37.7 percent, with wounds of the thorax and abdomen from explosive projectile shells experiencing fatality rates of 21.8 percent and 21.2 percent, respectively. Bullet wounds, however, produced higher fatality rates among those hit in these two locations, on the order of 34.7 percent for thorax and 32.8 percent for abdomen. Land mines produced fatal head wounds to 34.5 percent of those hit and resulted in high fatality percentages of 26.1 percent and 24.5 percent, respectively, for thorax and abdomen wounds. The extremely high fatality rate for "body generally" and "all other" undoubtedly results from multiple mortal wounds among those hit. These large differences observed in the fatality rates for hits from the various weapons by anatomical location of wounds are highly significant statistically.

From the medical viewpoint, however, the percentage of wounded who died of their wounds is of prime importance. Wounded admissions, with wounds of the head and abdomen which were caused by relatively high velocity small arms bullets, experienced the highest case fatality rates. These rates (table 47) were 14.9 percent died of wounds for abdominal wounds and 14.7 percent died of wounds for head wounds. Wounded admissions caused by land mines produced case fatality rates of 12.1 percent for abdomen and 8.3 percent for head wounds, while wounds caused by explosive projectile shells had case fatality rates of 7.3 percent for head wounds and 6.8 percent for abdominal wounds. Those patients admitted to medical treatment facilities with wounds of the thorax experienced

¹Denotes less than 50 killed or wounded in action.
²Between 50-99 killed or wounded in action.

45

¹Denotes less than 50 killed or wounded in action.
²Few survivors obviously involved small areas of scalp or skull.
³Between 50-99 killed or wounded in action.

case fatality rates of 7.2 percent from bullet wounds, 4.9 percent from wounds caused by explosive projectile shells, and 5.3 percent from land mines. Grenades, producing relatively low velocity fragments, experienced lower overall fatality rates among the total hit (killed and wounded, excluding CRO) as well as lower case fatality rates among the wounded admissions. Abdominal wounds among wounded caused by grenades resulted in the highest case fatality rate (3.5 percent) of any body region hit by these particular fragments.

Similar data for anatomical location of wound and nature, of traumatism are given in table 48 for fatalities among the total killed and wounded excluding CRO (hit) and in table 49 for case fatality rates among the wounded admissions to medical treatment facilities in Korea. These distributions show that wounds of the head, regardless of the type of traumatism, resulted in relatively more mortal wounds among those hit than any other body region. Traumatic amputation of the head region (not necessarily the complete area) produced almost 100 percent deaths among those hit (killed or wounded). Obviously, the few survivors undoubtedly involved the, ears or small areas of scalp or skull. While fracture wounds of the head had the highest fatality rate (31.2 percent) for those hit resulting in fractures, other fractures involving the thorax (ribs and spinal column), the face, and the abdominal region (pelvis, generally) produced fatality rates of 6.3 percent, 5.6 percent, and 4.5 percent, respectively, for the next highest rates by anatomical location of hits for fracture wounds. Wounds of all types, however, produced the highest fatality rates among killed and wounded (hit) involving the anatomical locations of the face, thorax, and abdomen. Concussions show a fatality rate of 10.9 percent for wounds of this type which involved the thorax and represent the highest fatality rate for concussions of any body region.

When deaths are limited to those who died of wounds among the WIA admissions to medical

¹Denotes less than 50 killed or wounded in action.

46

treatment facilities, marked differences are noted. Although fracture wounds to the head show the highest case fatality rate (18.3 percent), abdominal wounds from wounds of all types (penetrating, perforating, puncture, and incised) with a case fatality, rate of 10.3 percent, were highest for these wounds regardless of body region. Traumatic amputations involving the lower extremities had a case fatality rate of 10.9 percent, while burns and concussions produced relatively low case fatality rates regardless of the anatomical location of wound.

ANATOMICAL LOCATION OF WOUNDS AND TACTICAL OPERATION

Among the most important elements at work in the stochastic process involving hits to the various regions of the body are the frequency and extent to which various parts of the body are exposed in combat. Apparently, differences in the types of division tactical operations would be fundamental to any examination of the anatomical location of wounds, especially since this factor is often, the chief determinant in dictating which parts of the body are exposed. Distributions for the killed in action by anatomical location of wound for division tactical operations the equally incomplete, as are the causative agent data, and for the same reasons. The available figures are given in table 50 and indicate the highest number of unknown were recorded for operations of pursuit (74.8 percent), defensives (85.6 percent), and withdrawals (90.0 percent); the average unknown anatomical location for all tactical operations was 55.8 percent. Offensive operations, static defensive lines, and limited operations were all lower than the average with unknown proportions of 41.1 percent, 27.2 percent, and 33.4 percent, respectively. Table 50 shows that, regardless of the proportion of unknown by type of operation, the head, face, and neck area was the anatomical location for the largest number of fatal wounds recorded. Both static defensive lines and limited operations from these lines, with the smallest proportion of unknowns, resulted in 34 percent of all fatal wounds to the head, face, and neck region. Head, face, and neck wounds for other types of tactical operations vary in proportion to the size of this unknown location of wound. The thorax and abdomen were the next two vital areas for killed in action in that order, and both upper and lower extremity wounds showed relatively slight proportions as sites of fatal wounds among the killed in action.

Distributions of the anatomical location of wound for WIA admissions by type of division ground operation are more complete and should be more relevant to the problem. These data are presented in table 51 and figure 8. Static defensive lines and limited operations from them resulted in relatively higher ratios of wounds to the head, face, and neck area- approximately 20 percent of all wounds for both types of tactical operations. Major offensives show 18 percent, pursuit and defensives 15 and 16 percent, respectively, while withdrawal operations had only 13 percent of wounds involving the head, face, and neck. The upper extremities were involved in about 30 percent of all wounds, regardless of type of operation, with operations of pursuit and limited operations from defensive lines being slightly lower- 27 and 26 percent, respectively- and withdrawal operations slightly higher at 32 percent. The thorax was the site involved in 7 percent of all wounds, as was the abdomen, for all tactical military operations except withdrawals. During operations of withdrawal, the thorax was involved in only 5 percent of all wounds while the abdomen was involved in about 8 percent of the wounds. The lower extremities were the site of approximately 36 percent of all wounds by body region in all but two types of tactical operations. Operations of pursuit and operations of withdrawal, both with about 39-percent lower extremity wounds, were the only variants in this respect. When the extremity wound is considered as being either of the knee-and-above or below-the-knee, withdrawal operations and defensive operations had slightly higher proportions of below-the-knee wounds; 59 percent and 57 percent, respectively. All other operations had between 54 and 55 percent below-the-knee wounds; the balance, of course, represented knee or above. When distributions of the various anatomical locations of wound are compared for different time periods (fig. 9), the head, face, and neck area shows relative increases over time, and wounds of the upper extremity show relative reductions. During the period July-November 1950, in action against the North Korean Army, the head, face, and neck area was the wound site reported in 16 percent of all wounds, increasing to 17 percent by July 1951 in action against the Chinese Communist Forces, 19 percent between July and October 1951, and, finally, to 21 percent during the period of maintaining static defensive lines, from October 1951 through July, 1953. Wounds of the upper extremity decreased from about 30 percent of all wounds during the first two periods

47

¹Excludes redeploy and reserve.

48

¹Wounded in action and admitted to a medical treatment facility.
²Excludes redeploy and reserve.

49

50

51

to 29 pereent and then to 27 percent during the last period (October 1951-July 1953). The thorax and abdomen combined were involved in approximately 16 percent of all wounds during the July-November 1950 period, dropping to 14 percent between, November 1950-July 1951, returning to 16 percent during July-October 1951, and dropping back to about 15 percent from October 1951-July 1953. Wounds of the lower extremity show offsetting fluctuations, being 36 percent, increasing to 37 percent, then dropping to 35 percent during the July-October 1951 period, and, finally, increasing to 36 percent again during the last period of time.

From these data by anatomical location of wound, no significant variation, or major shift is apparent between body regions in the relative distributions, either by type of operation or for different periods of time. Some increases do appear, however, in the head, face, and neck, largely attributed to the characteristics of the tactical operation of maintaining static defensive lines for the last 21 months of the war, where a man might be expected to expose his head relatively more often. The absence of any significant shift of wounds from the thorax and abdomen to some other body region does not permit any evaluation, from these data, of the efficacy of body armor, which was introduced on a limited basis during the Korean War. The data might tend to indicate, however, that all men hit (killed plus wounded) must be considered, due to the probable shift from killed to wounded, some of which, undoubtedly, tend to offset any shift in distribution of wound sites among the wounded alone. The paucity of wound location information among the killed in action, however, precludes any such investigation from these data. The data, however, do tend to prove the theory that relative ratios of wounds by anatomical location result from more random forces and are affected more by the area of the body exposed (vital areas in the killed in action) as well as by items of individual protection, such as the helmet and body armor.

NONBATTLE INJURIES AND TACTICAL OPERATION

Similar percentage distributions by type of division ground operation for causative agents and by anatomical location of nonbattle injury are given in tables 52 and 53. Operations of pursuit showed the highest proportions of nonbattle injuries were caused by land transport (21.5 percent). All other tactical operations were about, equal, showing ratios between 10 and 13 percent for land vehicles. Accidents in the use of own weapons ranged from a low of 11.5 percent during withdrawal operations to a high of 28.7 percent during limited operations from main battle positions on the defensive lines. Offensives were 20.9 percent, pursuit 16.5 percent, static defensive lines 19.2 percent, and defensive 14.7 percent, respectively, for accidents involving use of own weapons. The elements and the effects of heat and cold caused almost 60 percent of all nonbattle injuries during withdrawal operations (largely from cold injury since both of the major withdrawals occurred during winter) compared to 33.1 percent (the next highest) shown for defensive operations. Effects of the elements and heat and cold for offensive operations were 31.5 percent, for operations of pursuit 19.1 percent, and for defensive lines 12.5 percent. The lowest ratio for these causative agents was experienced during limited operations from defensive lines, with only, 3.3 percent of nonbattle injuries being caused by the elements: weather, heat, and cold.

Nonbattle injuries show large differences between the distributions by anatomical location when related to type of division tactical operation. These data, included in table 53, show large variations for the relative ratios of head, face, and neck injuries between the various tactical operations. Offensives, defensives, and withdrawal operations show only 5- to 6-percent head, face, and neck injuries, whereas all other types of ground operations show twice this relative ratio. Nonbattle injuries involving the upper extremities do not vary so widely by type of operation-with the exception of withdrawal operations. These latter operations experience a relative proportion of but 13 percent upper extremity injuries, compared with an average of 22 percent for all operations. The other tactical military operations show a range from 18 to 25 percent for nonbattle injuries of the upper extremity. Injuries involving the thorax and abdomen are also lowest for withdrawal type operations (4 percent) and highest for operations of pursuit (10 percent), all other operations ranging from 6 to 9 percent. Nonbattle injuries of the lower extremity range from a low of 44 percent during limited operations to a high of 70 percent for withdrawal operations. Unlike wounded in action where the knee-and-above and below-knee distributions were approxi-

52

¹Injured due to nonbattle causes and admitted to a medical facility.
²Excludes redeploy and reserve.
³Includes clothing; electricity, except lightning; objects, not elsewhere classified; mechanical suffocation; drowning; fights and brawls; other miscellaneous and unknown agents.

53