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