History

Battle Casualties and Medical Statistics

Surgical, Medical, and Logistic Considerations

SURGERY AND THE WOUNDED

Information on surgical operations is fundamental knowledge for a varietyof medicologistical problems. It points up the need for surgical specialistsand for ancillary personnel. It indicates the need for plasma and wholeblood and for preoperative and postoperative care. It forms the basis forstaffing, supply, and for supporting requirements for committing surgicaland evacuation hospitals as well. And those most in need of surgery establishthe priority for swift evacuation of the wounded from the battlefield,since, in wartime, emergency surgery cannot be postponed with the samedegree of freedom that might be applied to other medical support considerations,such as alternate methods of treatment or optional means of evacuationand hospitalization.

In Korea in 1950, hospital support was austere and adequate surgicalcare could not always be rendered in country, especially because of theshortage of highly qualified surgeons. Early evacuation of the woundedeither before or after their surgery was necessary under the circumstances.Not until October 1951 were sufficient skilled surgeons available to enablethe Eighth U.S. Army Surgeon to organize professional specialty teams (9).Despite these handicaps, U.S. Army patients received life-giving surgeryin Korea and Japan along with other improved medical procedures to theextent that the case fatality rate for wounded achieved a new low of 2.5percent compared to the 4.5 percent experienced in all of World War II.

When surgical operations are related to the number of wounded requiringsurgery (table 75), and when surgery such as debridement of wounds is excluded,59 percent (46,024) of the 77,788 admissions to medical treatment facilitiesrequired one or more surgical operation. There were 89,974 surgical operationsperformed, for an average of 1.2 operations per total wounded or an averageof two surgical operations per wounded patient for whom an operation wasperformed. When the number of operations are considered by type of surgeryperformed, genitourinary surgery averaged 4.5 operations per wounded whoreceived genitourinary surgery; oral surgery averaged three operations,and neurosurgery and gastrointestinal and abdominal surgery averaged slightlyover two operations for these specialties. All other specified types ofsurgical operation averaged two operations or less. With regard to anatomicallocation of wound and surgical specialties associated with the variousbody regions, the thoracoabdominal region averaged 1.4 operations per totalwounded with wounds of the thorax and abdomen, compared to one operationfor each wounded of either the head, face or neck area, or of the upperor lower extremities combined. When the number of surgical operations arerestricted to those who received the operations, the distribution is slightlydifferent. Surgical specialties associated with wounded of the head, faceand neck area for whom operations were performed, averaged 2.2 operations,those with thoracoabdominal wounds and operations were almost identicalwith an average 2.1 operations, and those with extremity wounds and surgicaloperations averaged 1.8 operations. Although plastic surgery was undoubtedlyperformed on such body regions as the head, face, neck, and the extremities,this specialty was not separately identified in this connotation, and onlythose surgical procedures classified as plastic surgery, "not elsewhereclassified (n.e.c.)" were identified. Attesting to its magnitude,however, even this restricted classification shows an average of 1.7 operationsper wounded for which plastic surgery "n.e.c." was recorded.

Table 76 shows the surgical specialties by type of operation performedseparately for wounded division and non-division troops. Of the 46,024wounded with one or more surgical operations, 43,803 (95.2 percent) weredivision troops and only 2,221 (4.8 percent) were non-division troops.This, of course, is added testimony to the constant, and immediate needfor surgical hospital support of frontline divisions. Other than orderof magnitude, there appear to be no marked differences between the distributionsby type of specialty. However, there were slightly larger proportions ofthoracic surgery,

Table 75.-Admissions for wounded in actionand surgical operations, anatomical location and type of surgery, U.S.Army, Korea, July 1950-July 1953

Anatomical location and type of surgery	Wounds			Number of Operations	Average number of operations
	Number	With surgery			For admissions	For cases with operations
	Number	Number	Percent		For admissions	For cases with operations
Body region and type of surgery	77,788	46,024	59.2	89,974	1.2	2.0
Head, face, and neck	14,349	6,603	46.0	14,294	1.0	2.2
Neurosurgery	⁽¹⁾	1,659	11.6	3,984	⁽¹⁾	2.4
Eye, ear, nose, and throat	⁽¹⁾	1,668	11.6	3,341	⁽¹⁾	2.0
Oral surgery	⁽¹⁾	408	2.8	1,237	⁽¹⁾	3.0
General surgery, head and neck, not elsewhere classified	⁽¹⁾	2,868	20.0	5,732	⁽¹⁾	2.0
Thorax-abdomen	12,541	8,179	65.2	17,118	1.4	2.1
Thoracic surgery	⁽¹⁾	2,106	16.8	3,140	⁽¹⁾	1.5
Gastrointestinal and abdominal	⁽¹⁾	1,827	14.6	4,148	⁽¹⁾	2.3
Genitourinary surgery	⁽¹⁾	356	2.8	1,614	⁽¹⁾	4.5
General surgery, trunk, not elsewhere classified	⁽¹⁾	3,890	31.0	8,216	⁽¹⁾	2.1
Upper and lower extremities	50,489	26,668	52.8	48,787	1.0	1.8
Orthopedic surgery	⁽¹⁾	10,624	21.0	16,041	⁽¹⁾	1.5
General surgery, extremities, not elsewhere classified	⁽¹⁾	16,044	31.8	32,746	⁽¹⁾	2.0
Body generally	114	⁽¹⁾	⁽¹⁾	⁽¹⁾	⁽¹⁾	⁽¹⁾
Anatomical location unknown	295	⁽¹⁾	⁽¹⁾	⁽¹⁾	⁽¹⁾	⁽¹⁾
Plastic surgery, not elsewhere classified	⁽¹⁾	3,118	⁽¹⁾	5,327	⁽¹⁾	1.7
All other surgery	⁽¹⁾	1,456	⁽¹⁾	4,448	⁽¹⁾	3.1

¹Not applicable or data not available.

Table 76.- Admission for wounded in actionwith surgical operations, annual rates, and percent distribution, by typeof surgery and type of unit, U.S. Army, Korea, July 1950-July 1953
[Rates stated as cases per year per 1,000 average strength]

Type of surgery	U.S. Army, Korea			Type of unit
	U.S. Army, Korea			Division			Non-division
	Number	Rate	Percent	Number	Rate	Percent	Number	Rate	Percent
Total with surgery	46,024	71.81	100.0	43,803	132.20	100.00	2,221	7.18	100.0
Neurosurgery	1,659	2.58	3.6	1,559	4.71	3.6	100	0.32	4.5
Brain and meninges	1,067	1.66	2.3	996	3.01	2.3	71	0.23	3.2
Other neurosurgery	592	0.92	1.3	563	1.70	1.3	29	0.09	1.3
Eye, ear, nose, and throat	1,668	2.60	3.6	1,587	4.79	3.6	81	0.26	3.6
Oral surgery	408	0.64	0.9	374	1.13	0.9	34	0.11	1.5
General surgery, head and neck, not elsewhere classified	2,868	4.48	6.2	2,689	8.12	6.2	179	0.58	8.1
Thoracic surgery	2,106	3.28	4.6	2,030	6.13	4.6	76	0.25	3.4
Heart, paricardium, and great vessels	27	0.04	0.1	27	0.08	0.1	0	--	--
Other thoracic surgery	2,079	3.24	4.5	2,003	6.05	4.5	76	0.25	3.4
Gastrointestinal and abdominal	1,827	2.85	4.0	1,759	5.30	4.0	68	0.22	3.1
Esophagus and stomach	52	0.08	0.1	48	0.14	0.1	4	0.01	0.2
Other gastro-abdominal	1,775	2.77	3.9	1,711	5.16	3.9	64	0.21	2.9
Genitourinary surgery	356	0.56	0.8	344	1.04	0.8	12	0.04	0.5
Kidney	93	0.15	0.2	93	0.28	0.2	0	--	--
Other genitourinary	263	0.41	0.6	251	0.76	0.6	12	0.04	0.5
General surgery of trunk, not elsewhere classified	3,890	6.07	8.4	3,695	11.15	8.4	195	0.63	8.8
Orthopedic surgery	10,624	16.58	23.1	10,261	30.97	23.4	363	1.17	16.3
General surgery, extremities, not elsewhere classified	16,044	25.03	34.8	15,190	45.84	34.7	854	2.76	38.5
Plastic surgery, not elsewhere classified	3,118	4.87	6.8	2,893	9.00	6.8	135	0.44	6.1
All other surgery	1,456	2.27	3.2	1,332	4.02	3.0	124	0.40	5.6

Table 77.- Comparison of admissions excludedto total nonbattle admissions processed, by type of admission with surgicaloperation, U.S. Army, Korea, July 1950-December 1953

Type of admission	Admissions processed
Type of admission	All nonbattle causes	Disease	Nonbattle injury
U.S. Army, Korea, admissions	409,490	328,395	81,095
Number processed in surgery count	404,540	323,940	80,600
Number not included	4,950	4,455	495
Percent of admissions excluded	1.2	1.4	0.6
Non-division admissions	215,170	178,235	36,935
Number processed in surgery count	210,220	173,780	36,440
Number not included	4,950	4,455	495
Percent of admissions excluded	2.3	2.5	1.3

gastrointestinal and abdominal surgery, and orthopedic surgery amongdivision troops, whereas non-division troops showed a slightly higher relativeproportion of neurosurgery (brain and meninges) than did the division wounded.This latter situation may result from the chance of non-division seriouslywounded receiving medical treatment in contrast to division seriously woundedsurviving to reach medical care.

SURGERY AND NONBATTLE ADMISSIONS

Unfortunately, nonbattle admissions were not processed to the same degreeof detail as were the battle admissions and, therefore, only the numberof admissions in Korea with surgical operation recorded by type of operationis available. The number of procedures and the specialties required, identifiedby specific area or origin, as Japan-Korea, are not at hand. Another difficultyarose in processing the nonbattle admissions for total U.S. Amy, Korea,by type of unit. Some of the cases which would ordinarily fall into thenon-division category (after all division cases were properly identified)were inadvertently omitted at the time of processing. The number involvedwas small, however, and amounted to about 1 percent of the total countsfor nonbattle admissions in Korea during the period July 1950-Deceber 1953.Table 77 provides a comparison of the differences related to total U.S.Army, Korea, and to the non-division group to which they apply. Even whencompared with the overall counts for non-division admissions in Korea,the excluded cases amount to about 2 percent of the total, a not too significantproportion for the introduction of bias.

Unlike the wounded where almost all of those requiring surgery originatedin division units, the surgical requirements for nonbattle admissions wereabout even by type of unit (table 78). There were, however, slightly higherproportions of nonbattle injury admissions with surgery originating fromdivisions (57.5 percent,) and slightly, lower proportions of disease admissionswith surgery from divisions (46.0 percent). The relative proportions werereversed for nonbattle admissions with, surgery from non-division units,being 42.5 percent of all nonbattle injury admissions with surgery in Koreaand 54.0 percent of all disease admissions in Korea with surgery.

When the comparison is made within each type of unit rather than betweenunits, the divisions showed 53.5 percent of their nonbattle admissionswith surgery were due to disease and 46.5 percent were due to nonbattleinjury. With the nonbattle admissions with surgery restricted to thoseoriginating in non-division units, 64.7 percent were due to disease and35.3 percent were due to nonbattle injury. For total U.S. Army, Korea,the overall proportions with surgery were 59.0 percent, due to diseaseand 41.0 percent due to nonbattle injury.

Tables 79 slid 80 present information by type of unit, and type of surgicalspecialty for disease admissions with surgical operations and for nonbattleinjury admissions with surgical operations, separately. Excluding the relativelyhigher proportions for oral surgery among division troops and relativelylower proportions for genitourinary surgery, there are no major differencesbetween these two types of units for disease admissions with surgical operations.The two surgical specialties with the highest proportionate shares of diseaseoperations were (1) gastrointestinal and abdominal, and (2) genitourinarysurgery. Nonbattle injury, admissions with surgical operations show onlyvery

Table 78.-Number and Percent of nonbattleadmissions processed, by type of admission with surgical operation, U.S.Army, Korea, July 1950-December 1953

Type of admission	Admissions processed
Type of admission	All nonbattle causes	Disease	Nonbattle injury
U.S. Army, Korea	404,540	323,940	80,600
Admissions with surgery	56,400	33,325	23,165
Percent with surgery	14.0	10.3	28.7
Percent with surgery by type of admission	100.0	59.0	41.0
Division	194,320	150,160	44,160
Admissions with surgery	28,645	15,315	13,330
Percent with surgery	14.7	10.2	30.2
Percent with surgery by type of admission	100.0	53.5	46.5
Percent with surgery by type of unit	50.7	46.0	57.5
Non-division	210,220	173,780	36,440
Admissions with surgery	27,845	18,010	9,835
Percent with surgery	13.2	10.4	27.0
Percent with surgery by type of admission	100.0	64.7	35.3
Percent with surgery by type of unit	49.3	54.0	42.5

slight variations between division and non-division troops for oralsurgery, thoracic surgery, genitourinary surgery, and plastic surgery.The highest proportions are concentrated in orthopedic surgery and generalsurgery of the extremities. In terms of nonbattle admissions, with operationsper 1,000 average strength per year, disease admissions with an operationrate of 52 per 1,000 exceed those for nonbattle injury of 36 per 1,000per year. For disease, the non-division troops are highest with a rate,of 58 per 1,000 per year compared to 46 per 1,000 for divisions. On theother hand, the nonbattle injury admissions with operations show the highestannual rate (40 per 1,000) among the

Table 79.- Admissions for disease withsurgical operations, annual rates, and percent distribution, by type ofsurgery and type of unit, U.S. Army, Korea, July 1950-December 1953
[Rates stated as cases per year per 1,000 average strength]

Type of surgery	U.S. Army Korea			Type of unit
	U.S. Army Korea			Division			Non-division
	Number	Rate	Percent	Number	Rate	Percent	Number	Rate	Percent
Total with surgery	33,325	52.00	100.0	15,315	46.22	100.0	18,010	58.19	100.0
Neurosurgery	605	0.94	1.8	220	0.66	1.4	385	1.24	2.1
Brain and meninges	85	0.13	0.2	25	0.07	0.1	60	0.19	0.3
Other neurosurgery	520	0.81	1.6	195	0.59	1.3	325	1.05	1.8
Eye, ear, nose, and throat	2,330	3.64	7.0	980	2.96	6.4	1,350	4.36	7.5
Oral surgery	2,035	3.18	6.1	1,145	3.46	7.5	890	2.88	4.9
General surgery, head and neck, not elsewhere classified	1,130	1.76	3.4	505	1.52	3.3	625	2.02	3.5
Thoracic surgery	435	0.68	1.3	195	0.59	1.2	240	0.78	1.3
Heart, paricardium, and great vessels	5	0.01	0.0	5	0.02	0.0	0	0	0
Other thoracic surgery	430	0.67	1.3	190	0.57	1.2	240	0.78	1.3
Gastrointestinal and abdominal	10,475	16.34	31.4	4,925	14.86	32.2	5,550	17.93	30.8
Esophagus and stomach	85	0.13	0.2	55	0.16	0.4	30	0.10	0.2
Other gastro-abdominal	10,390	16.21	31.2	4,870	14.70	31.8	5,520	17.93	30.6
Genitourinary surgery	5,970	9.32	17.9	2,210	6.67	14.4	3,760	12.15	20.9
Kidney	105	0.16	0.3	65	0.20	0.4	40	0.13	0.2
Other genitourinary	5,865	9.16	17.6	2,145	6.47	14.0	3,720	12.02	20.7
General surgery of trunk, not elsewhere classified	1,500	2.34	4.5	655	1.98	4.3	845	2.73	4.7
Orthopedic surgery	1,435	2.24	4.3	665	2.01	4.3	770	2.49	4.3
General surgery, extremities, not elsewhere classified	3,320	5.18	10.0	1,635	4.93	10.7	1,685	5.44	9.4
Plastic surgery, not elsewhere classified	140	0.22	0.4	40	0.12	0.3	100	0.32	0.6
All other surgery	3,950	6.16	11.9	2,140	6.46	14.0	1,810	5.85	10.0

Table 80.- Admissions for nonbattle injurywith surgical operations, annual rates, and percent distribution, by typeof surgery and type of unit, U.S. Army, Korea, July 1950-December 1953
[Rates stated as cases per year per 1,000 average strength]

Type of surgery	U.S. Army, Korea			Type of unit
	U.S. Army, Korea			Division			Non-division,
	Number	Rate	Percent	Number	Rate	Percent	Number	Rate	Percent
Total with surgery	23,165	36.15	100.0	13,330	40.23	100.0	9,835	31.77	100.0
Neurosurgery	270	0.42	1.1	170	0.51	1.3	100	0.32	1.0
Brain and meninges	166	0.26	0.7	80	0.24	0.6	85	0.27	0.9
Other neurosurgery	105	0.16	0.4	90	0.27	0.7	15	0.05	0.1
Eye, ear, nose, and throat	1,210	1.89	5.2	635	1.92	4.8	575	1.86	5.8
Oral surgery	495	0.77	2.1	210	0.63	1.6	285	0.92	2.9
General surgery, head and neck, not elsewhere classified	1,660	2.59	7.2	805	2.43	6.0	855	2.76	8.7
Thoracic surgery	210	0.33	0.9	85	0.26	0.6	125	0.41	1.3
Heart, pericardium, and great vessels	5	0.01	0.0	0	--	0	5	0.02	0.1
Other thoracic surgery	205	0.32	0.9	85	0.26	0.6	120	0.39	1.2
Gastrointestinal and abdominal	345	0.54	1.5	200	0.60	1.5	145	0.47	1.5
Esophagus and stomach	20	0.03	0.1	10	0.03	0.1	10	0.03	0.1
Other gastro-abdominal	325	0.51	1.4	190	0.57	1.4	135	0.44	1.4
Genitourinary surgery	115	0.18	0.5	45	0.14	0.3	70	0.22	0.7
Kidney	20	0.03	0.1	10	0.03	0.1	10	0.03	0.1
Other genitourinary	95	0.15	0.4	35	0.11	0.3	60	0.19	0.6
General surgery of trunk, not elsewhere classified	370	0.58	1.6	205	0.62	1.5	165	0.53	1.7
Orthopedic surgery	10,630	16.58	45.9	6,210	18.74	46.6	4,420	14.28	44.9
General surgery, extremities, not elsewhere classified	6,220	9.71	26.9	3,740	11.29	28.1	2,480	8.01	25.2
Plastic surgery, not elsewhere classified	1,160	1.81	5.0	790	2.38	5.9	370	1.20	3.8
All other surgery	480	0.75	2.1	235	0.71	1.8	245	0.79	2.5

division troops with non-divisions amounting to only 32 per 1,000.

MEDICAL SURVEYS OF REPATRIATED PRISONERS OF WAR

Two POW exchanges were arranged by the armistice negotiators in Korea,for which medical surveys were performed. The first exchange involved 149U.S. military personnel in need of immediate medical treatment who wereprisoners of the enemy: 127 Army, 19 Navy-Marine, and three Air Force personnel.This exchange took place over a 2-week period between 21, April and 3 May1953 and was referred to as "Little Switch." The second exchangeof prisoners occurred after the armistice agreement was signed and included3,596 U.S. military personnel desiring repatriation: 3,195 Army, 184 Navy-Marine,and 217 Air Force personnel. This latter exchange of prisoners took placebetween 4 August and 6 September 1953 and was designated "Big Switch."Two U.S. Army personnel were included in Little Switch for whom medicalrecords were not received and 11 names (10 Army and one Air Force) werelisted in Big Switch, for which most of the medical records were not received.The available data, therefore, cover medical surveys of 147 individualsfrom Little Switch and, for the most part, 3,585 individuals from Big Switch.Where data are available, information is given for 3,596 individuals.

The ages of these former prisoners of the enemy at the time of physicalexamination are shown in table 81. The majority (93 percent) were between20 and 34 years of age, an additional 157 were between 35 and 39 years,and 68 were 40-54 years of age. Forty-two were 19 years of age or less,and the age was not stated for the remaining five.

When the amount of weight lost is related to the nature of their bodybuild at the time of capture (table 82), those with the heavier body buildapparently lost more weight on the average. The prisoners exchanged duringOperation Little Switch show greater average weight loss, reflecting theirpoorer physical condition. This is also true when weight loss is relatedto weeks of captivity with one exception: the 50-99 weeks' interval. Noreason is apparent for this difference other than the chance

Table 81.- U.S. military repatriatedprisoners of war, Korea, by age group

Age	Little Switch	Big switch	Total
19 Years or less	7	35	42
20-24 years	97	1,971	2,068
25-29 years	24	955	979
30-34 years	10	403	413
35-39years	5	152	157
40-44 years	3	46	49
46-49 years	1	15	16
50-54 years.	0	3	3
Not stated	0	5	5
Total	147	3,585	3,732

variation resulting in part from the extremely small numbers of casesincluded in the first five intervals for Operation Little Switch.

Table 83 shows that almost all (145) of those included in Little Switchand slightly less than two-thirds (61.5 percent) of those included in BigSwitch were identified as ever having been wounded. When the distributionby anatomical location of wound is compared with all nonfatal wounded forU.S. Army, Korea (table 45), and with wounded evacuees received in continentalUnited States from Japan-Korea, (table 71.), there were slightly higherproportions of head wounds and chest, abdomen, and back wounds among theexchanged prisoners and a slightly lower proportion of extremity wounds.These ratios were 18.2 percent and 16.0 percent, for head, face and neckamong the total wounded and the evacuee wounded, respectively, comparedto 21.8 percent for head wounds among repatriated prisoners of war. Thethoracoabdominal region showed 15.4 percent and 15.7 percent, respectively,for the two former distributions compared to 16.7 percent for the chest,abdomen, and back combined among the repatriated prisoners. Extremity woundswere 66.3 percent and 68.1 percent, respectively, for the first two distributionsand only 61.5 percent for the repatriated prisoners of war who had beenwounded.

There were 618 cases (17 percent) of those repatriated for whom surveymedical records were received which recorded a surgical operation while,in captivity (table 84). Only 11 (2 percent) had a major amputation, althoughthe majority of amputees were exchanged in Operation Little Switch where11 percent with surgical operation involved a major amputation, of oneor both extremities. Minor amputations of fingers or toes were involvedin 9 percent of the surgical operations and 1.8 percent of the operationsinvolved the removal of foreign bodies. The majority of cases with surgicaloperation in both POW exchanges involved "other types not stated."

The results of intensive physical examinations of the U.S. militaryrepatriated prisoners of war are shown in tables 85-89. Four-fifths ofall repatriated prisoners were in good mental health and morale, and only18 percent suffered from psychiatric conditions upon examination (table,85). The largest proportion (7 percent) were diagnosed as psychoneurotic,with character and behavior disorders second at 6 percent. Only 1 percentof all returned prisoners were classified as being psychotic.

Results of physical examinations of the eyes, lips, and mouth are presentedin table 86. Almost 90 percent of all the repatriated prisoners showedno abnormalities involving these anatomical areas, although the proportionwas less for those exchanged during Operation Little Switch. Of those witheye

Table 82.- Average weight lost by bodybuild at capture and by weeks in captivity, U.S. military repatriated prisonersof war, Korea

Prisoners of war with weight loss	Operation Little Switch		Operation Big Switch
Prisoners of war with weight loss	Cases with weight loss	Average pounds lost	Cases with weight loss	Average pounds lost
Body build at capture	136	24.16	3,404	21.89
Slender	36	20.61	561	17.92
Medium	78	23.76	2,314	21.03
Heavy	22	31.41	514	29.40
Obese	--	--	15	45.53
Weeks in captivity	136	24.16	3,404	21.89
0-9	11	22.36	121	20.21
10-19	3	33.67	40	17.35
20-29	12	22.00	40	19.95
30-49	6	29.50	115	24.46
50-99	17	20.88	282	23.39
100-199	87	24.63	2,803	21.98
Not reported	--	--	--	14.67

Table 83.- Number and percent of woundedin action by anatomical location of wound, U.S. military repatriated prisonersof war, Korea

Anatomical location	Total		Operation Little Switch		Operation Big Switch
Anatomical location	Number	Percent	Number	Percent	Number	Percent
All body regions	2,351	100.0	145	100.0	2,206	100.0
Head	512	21.8	29	20.0	483	21.9
Chest	95	4.0	13	8.9	82	3.7
Abdomen	42	1.8	3	2.1	39	1.8
Back	257	10.9	11	7.6	246	11.1
Extremities	1,445	61.5	89	61.4	1,356	61.5

conditions noted, conjunctival changes showed the highest relative proportions.Gingivitis, bleeding, had the highest, proportional ratio for lip and mouthconditions, with no other diagnosis showing any appreciable amount in total.During Operation Little Switch, however, atrophy-papilla of tongue wasthe leading mouth condition diagnosed, amounting to one-third of the conditionsfound and representing a ratio of 8 percent of all the prisoners exchangedduring Operation Little Switch.

Only 12 prisoners had malaria, all of whom were exchanged during OperationBig Switch. Six were diagnosed as falciparum, five as vivax, and one asmalariae. The results of chest X-ray examinations (table 87) show morethan 90 percent of the exchanged prisoners with no pathology. This proportionwas smaller during Operation Little Switch, of course, because the verynature of the prisoners' condition qualified them for inclusion in thefirst exchange. In total, however, fewer than 2 percent of all prisonershad active tuberculosis and about equal proportions, or less, showed anyother form of lung pathology.

Examination of the skin and body surface (table 88) showed 78 percentof all of the prisoners had no skin abnormality; in Operation Little Switch,however, only 48 percent were, free of any skin conditions. Of all prisonerswith skin conditions, 56 percent had dermatophytosis, 8 percent had acne,and 6 percent had follicular hyperkeratosis. Of those with skin conditionswho were exchanged during Operation Little Switch, 41 percent had follicularhyperkeratosis, 11 percent had dermatophytosis, and 10 percent had acne.

Stool cultures among prisoners exchanged during Little Switch showedshigella in seven cases and no pathogens in 127 cases; no reports werefurnished for the remaining 13 who were exchanged. For Operation Big Switch,stool cultures produced shigella in 14 cases, salmonella in three cases,and no pathogens in 1,995 cases. No report was received for 1,120 cases,and 454 were stated as "other" unspecified. Table 89 presentsthe associated data on the results of stool examinations among repatriatedprisoners of war. Two-fifths of all prisoners were found to harbor parasites.This figure was almost two-thirds for those exchanged during OperationLittle Switch compared to 38 percent for Big Switch. The following variousparasites were found: 59 percent ascaris, 8 percent amebae, and 7 percenthookworms. Twenty-five percent were not specified as to type. The onlylarge proportional differences between the two prisoner exchanges werethe higher ratios during Operation Little Switch for amebae (16 percent)and hookworms (11 percent) compared to 7 percent each for Opera-

Table 84.- Number and percent with surgicaloperations, U.S. military U.S. military repatriated prisoners of war, Korea

Surgical operation	Total			Operation Little Switch		Operation Big Switch
	Number	Percent	Number		Percent		Number	Percent
Total with surgery	618	100.0	83		100.0		535	100.0
Amputation, major	11	1.8	9		10.8		2	0.4
One lower extremity	5	0.8	3		3.6		2	0.4
Both lower extremities	3	0.5	3		3.6		--	--
One extremity, not stated	3	0.5	3		3.6		--	--
Amputation, fingers or toes	54	8.7	11		13.3		43	8.0
Removal of foreign body	109	17.6	16		19.3		93	17.4
All other operations	444	71.9	47		56.6		397	74.2

Table 85.- Number and percent of resultsof psychiatric examinations, medical survey of U.S. military repatriatedprisoners of war, Korea

Results of examinations	Total		Operating Little Switch		Operation Big Switch
Results of examinations	Number	Percent	Number	Percent	Number	Percent
Total diagnoses	3,743	100.0	147	100.0	3,596	100.0
Good mental health and morale	3,073	82.1	120	81.7	2,953	82.1
Psychoses	37	1.0	3	2.0	34	0.9
Psychoneuroses	267	7.1	8	5.4	259	7.2
Character and behavior disorders	219	5.8	7	4.8	212	5.9
Mental deficiency	33	0.9	4	2.7	29	0.8
Transient personality disorders	112	3.0	5	3.4	107	3.0
Other or not reported	2	0.1	--	--	2	0.1

Table 86.- Number and percent of resultsof eye, lip, and mouth medical survey of U.S. military repatriated prisonersof war, Korea

Results of examinations	Total		Operation Little Switch		Operation Big Switch
Results of examinations	Number	Percent	Number	Percent	Number	Percent
Eye conditions
Total diagnoses	3,745	100.0	148	100.0	3,597	100.0
No abnormality found	3,298	88.0	114	77.0	3,184	88.5
Scleral changes	26	0.7	2	1.4	24	0.7
Corneal changes	19	0.5	1	0.7	18	0.5
Conjunctival changes	55	1.5	5	3.4	50	1.4
Other or not reported	347	9.3	26	17.5	321	8.9
Lip and mouth conditions
Total diagnoses	3,764	100.0	154	100.0	3,610	100.0
No abnormality found	3,315	88.0	Ill.	7510	3,204	$817
Cyanosis	5	0.1	1	0.7	4	0.1
Pallor	11	0.3	1	0.7	10	0.3
Cheilosis	27	0.7	2	1.3	25	0.7
Angular features	18	0.5	5	3.2	13	0.4
Pellagrous glossitis	3	0.1	2	1.3	1	0.0
Atrophy, papilla of tongue	37	1.0	12	7.8	25	0.7
Gingivitis, bleeding	89	2.4	8	5.2	81	2.2
Tonsillar exudate or membrane	14	0.4	1	0.7	13	0.4
Other or not reported	245	6.5	11	7.1	234	6.5

Table 87.- Number and percent of resultsof chest X-ray examinations, U.S. military repatriated prisoners of war,Korea

Results of examinations	Total		Operation Little Switch		Operation Big switch
Results of examinations	Number	Percent	Number	Percent	Number	Percent
Total diagnoses	3,743	100.0	147	100.0	3,596	100.0
Negative results	3,454	92.2	115	78.2	3,339	92.9
Active tuberculosis	58	1.5	7	4.8	51	1.4
Arrested tuberculosis	7	0.2	1	0.7	6	0.2
Other lung pathology	70	1.9	9	6.1	61	1.7
Retained foreign body	25	0.7	6	4.1	19	0.5
Other pathology	93	2.5	9	6.1	84	2.3
Not reported	36	1.0	--	--	36	1.0

Table 88.- Number and percent of resultsof skin examinations, medical survey of U.S. military repatriated prisonersof war, Korea

Results of examination	Total		Operation Little Switch		Operation Big Switch
Results of examination	Number	Percent	Number	Percent	Number	Percent
No abnormality found	2,903	77.7	71	48.3	2,832	79.0
Individuals with skin conditions	827	22.2	76	51.7	751	20.9
Not reported	2	0.1	--	--	2	0.1
Skin conditions found	892	100.0	91	100.0	801	100.0
Follicular hyperkeratosis	56	6.3	37	40.6	19	2.4
Petechia	1	0.1	1	1.1	--	--
Purpura	1	0.1	--	--	1	0.1
Pellagrous dermatitis	1	0.1	--	--	1	0.1
Ulcers, extensive	6	0.7	--	--	6	0.7
Dermatophytosis	502	56.3	10	11.0	492	61.5
Acne, any form	74	8.3	9	9.9	65	8.1
Other skin disorders, not specified	251	28.1	34	37.4	217	27.1

tion Big Switch, and the lower proportion for ascaris (43 percent) comparedto 61 percent among prisoners exchanged in Operation Big Switch.

ESTIMATING BED REQUIREMENTS OVERSEAS

It is possible to estimate bed requirements on the basis of a seriesof probability values for patients remaining in hospital, by type of patient,or to estimate various types of disposition from hospital, as a functionof time after the day of admission to hospital. These patient remainingand disposition distributions are commonly referred to as "curves"although, in the mathematical sense, they are but collections of discreteprobabilities. Although the general properties of remaining and dispositioncurves, in this connotation, are well documented beginning with Love'sstudy (13) on World War I casualties and later by Beebe and DeBakey(14) on World War II data, full potential of this knowledge wasnever applied to the complete interplay of requirements for fixed versusnonfixed facilities overseas. Beebe and DeBakey recognized the importanceof considering the characteristics of the entire system and emphasizedits benefits when applied to estimating bed requirements in forward orcombat areas occupied by held armies. Their approach essentially involvedthe summation of the daily values comprising the remaining curve to determinethe total accumulation of patients through a stated number of days (usuallythe number of the days in the theater evacuation policy) reduced by thatproportion evacuated from the army area or theater. This adjustment wasdetermined by assuming a fixed number of hospital days in the army areafor evacuees and the length of time in days for the latter adjustment wasnecessarily arbitrary. Although Beebe and DeBakey recognized that patientsare evacuated over time in keeping with various probability distributions,nevertheless, to further simplify computational procedures, they assumedall patients were hospitalized for the same number of days before evacuation;that is, if the last day hospitalized in

Table 89.- Number and percent of resultsof stool examinations, medical survey of U.S. military repatriated prisonersof war, Korea

Results of examinations	Total		Operation Little Switch		Operation Big Switch
Results of examinations	Number	Percent	Number	Percent	Number	Percent
No parasite or not reported	2,285	61.2	55	37.4	2,230	62.2
Individuals with parasites	1,447	38.8	92	62.6	1,355	37.8
Parasites found	1,733	100.0	137	100.0	1,596	100.0
Amebae	141	8.1	22	16.1	119	7.5
Ascaris	1,026	59.2	59	43.1	967	60.6
Hookworm	124	7.2	15	10.9	109	6.8
Pinworm	2	0.1	1	0.7	1	0.1
Tapeworm	4	0.2	--	--	4	0.2
Other, not specified	436	25.2	40	29.2	396	24.8

the army area was 6 days, then no patient was evacuated before or after6 days of hospitalization. This approach was similar to that used at thetime by the Army Medical Department for estimating fixed bed requirements,the assumption being that a constant time to evacuation for all patientswas valid for all evacuation policies. Thus, estimates for fixed beds werebased on patient accumulations through the number of days in the statedevacuation policy, with no differences occurring in either overseas theateror CONUS (continental United States) patient accumulation between evacuationpolicies, until the length of days in a stated evacuation policy was reached.One result of this method was to develop an accumulation factor, or accumulationof patients remaining, after any number of days which was identical forthe same number of days, regardless of the length of the theater evacuationpolicy. For example, the theater accumulation factor was the same at 5,10, or 20 days for a 30-day evacuation policy as it was for a 60-, 90-,or 120-day evacuation policy. Similarly, the theater factors at 30 or 60days were, identical whether the evacuation policy was 60, 90, or 120 days(15). Beebe and DeBakey recognized this limitation and advancedtheir theory for evacuating all patients (who would eventually requireevacuation) after a fixed number of hospital days. This latter period oftime was referred to as the "evacuation schedule" and was tobe restricted to an estimate of the number of days before patients becametransportable. The selection of any number of days as a fixed period ofhospitalization, however, produces the same effect through that numberof days, regardless of how short the period of time considered.

This deficiency was later overcome by the present author as appliedto fixed bed accumulation factors, with the introduction of a distinctiveset of evacuation probabilities for certain specified evacuation policies.These evacuee "curves" were derived by relating the number ofdays spent in overseas theater hospitals before evacuation to the eventualtotal days hospitalized for patients, by type, ultimately discharged incontinental United States. Using this methodology, it was also possibleto subdivide the remaining curve based upon the theoretical limitationsestablished by the criteria for each respective evacuation policy, as itrelated to those patients whose eventual final disposition exceeded theselimitations. Using the same methodology, it was also possible to developsimilar curves for each separate type of final disposition. By summationof various portions of the remaining, evacuation, and disposition curvesand through appropriate computation of these sums, it is possible to deriveaccumulation-decumulation factors. These factors permit time-phased estimationsof dispositions among a group of patients arising from constant daily,admissions up to a point in time, after which no further admissions occur.The accumulation-decumulation factors derived from World War II and KoreanWar experience are current doctrine (16) for estimating fixed bed requirementsand patient dispositions, but, despite Beebe and DeBakey's foresight, nofurther effort had been made to apply similar techniques to the estimationof mobile bed nonfixed requirements. One reason, of course, was officialpolicy which dictated requirements for nonfixed beds be based on a basisof allocation; that is, one 60-bed surgical and two 200-bed evacuationhospitals per each division supported.

ESTIMATING PATIENT ACCUMULATIONS AND DISPOSITIONS

The probability data for patients remaining, included in appendix C,are based on the disposition of 1950-53 wounded admissions in Korea, (tableC-1) and on the dispositions of 1950-53 disease and nonbattle injury admissionsin all overseas areas (table C-2). These remaining figures are estimatesof the probabilities that any one patient will require a hospital bed anywhere(mobile, fixed, theater, or CONUS) through the indicated number of day'safter initial admission. These probabilities are called remaining factorsand are, as a matter of convenience, referred to as a remaining "curve."From the properties of probability, it may be seen that summation of theremaining curve from day
one through day n yieldsthe average duration of hospitalization to date (day n) for patients admittedon day one. These sums are also called accumulation factors for the expectednumbers of patients (based on an admission of one per day) remaining inhospital anywhere at the end of specified number of days. To adjust thesetotal accumulations to account for evacuations, evacuee factors must beutilized. The basic data for those factors are included in appendix tableC-3 for wounded patients and in table C-4 , for disease and nonbattle injurypatients, for specified evacuation policies.

Figure 13.- Accumulation and accumulation-decumulationof wounded hospital admissions, U.S. Army, Korea, 1950-53, converted toone patient per day.

These daily evacuation rates are based on the average number of daysoverseas before evacuation as reported on the individual evacuee reportcard (12) related to the total days of hospitalization to final dispositionas reported on the individual medical record (4) for the same patient.These ratios have been fitted to the respective remaining probability curvebased on the theoretical limitations which define the parameters for eachseparate evacuation policy. The evacuee factors developed from these data,therefore, are applicable only to those patients admitted overseas andto whom the eventual final disposition is either a disability separation,or, which exceeds a specified number of hospital days as stated by therespective evacuation policy.

Estimates of patient accumulations are usually made to coincide withcertain specified periods of time. The intervals between these time-periodsare referred to as periods of estimate and usually are of equal lengthsof time. For planning purposes, the typical periods of estimate are statedin intervals of 30 days. For any period of estimate, however, and for anylength of evacuation policy, it is possible to develop factors for estimatingpatient accumulation and disposition, based on the overall duration ofstay anywhere and the duration of stay before evacuation. When a groupof patients are accumulated from constant daily admissions up to a statedpoint in time and then decumulated through estimated dispositions overintervals of time, the resultant figures are referred to as accumulation-decumulationfactors. Figure 13 provides a graphical description of both the accumulationand accumulation-decumulation process. A more complete description, however,is provided in appendix A.

SUBDIVIDING THE REMAINING CURVE

The remaining curve essentially presents the probability of patients'remaining in hospital anywhere, as a function of time after the day ofadmission to hospital. Patients remaining, therefore, are but one of aset of distribution functions. Besides patients remaining, the varioustypes of disposition overseas are duty, death, and evacuation. These variousdistributions apply to both field army and to COMMZ (Communications Zone)of overseas theaters. Theater evacuation to CONUS converts into a patientremaining category for overseas admissions hospitalized in CONUS, in additionto disability separations which are considered only at that echelon.

The shifting of patients remaining by echelon, as the remaining curveis subdivided, may be visualized from figure 14. That segment of the remainingcurve (R) through point (fN ) indicates patientsremaining anywhere through the number of days of the field army evacuation,policy (f). The curve Rf indicates the proportion who are remaining infield army nonfixed beds through the number of days of the field army evacuationpolicy (f). And the curve OA represents the proportion remaining in theaterfixed beds, while the curve OB represents the proportion remaining in CONUSfixed beds through the same number of days (f). The segment of the remainingcurve fN pN representspatients remaining anywhere, between the number of days of the field armyevacuation policy (f) and the length of days of the theater evacuationpolicy (p). The curve Ap indicates the proportion who are remaining intheater fixed beds during this period while the curve BpNindicates the proportion in CONUS fixed beds. The balance of the remainingcurve (pN R_i), following the numberof days of the theater evacuation policy (p), represents only evacuee patientsremaining in CONUS fixed beds. The respective proportions represented bycurves OA and OpN are developed from patientevacuation curves for varying lengths of evacuation policy (see figure15 for wounded patients) and can be applied either to the field army orto overseas. theaters, or to both.

NONFIXED VERSUS FIXED BEDS OVERSEAS

Although accumulation-decumulation factors for the field army area canbe derived for any number of days included in a field army evacuation policy(see appendix A), those selected for inclusion in table 90 are limitedto policies ranging from 5 to 10 days. Since the same methodology appliesto any overseas area, however, factors for the theater evacuation policiesof 15, 20, and 30 days could apply equally as well to the field army area,if evacuation policies of these respective lengths were assigned to fieldarmies in relatively fixed situations. However, for all mobile situationswhere the field army evacuation policy exceeds 9 days, the standardizedfactors for 10 days and over should apply. The reason is that, althoughpatients may be transportable for evacuation within the theater, they

Figure 14.- Subdivisions of the remainingcurve, by echelon of hospitalization.

Figure 15.- Percentage of wounded hospitaladmissions evacuated, by length of evacuation policy, U.S. Army, Korea,1950-53.

Table 90.-Field Army accumulation-decumulationfactors, by type of case, and specified evacuation policies
[Based on hospital admission of one per day for 30 days, then decumulation]

Evacuation policy and period of estimate	Admissions to hospital
	Wounded in action				Disease and nonbattle injury
	Evacuees	Duty	Death	Remaining	Evacuees	Duty	Death	Remaining
5-day:
1-30	25.25	0.98	0.32	3.45	22.17	5.72	0.03	2.08
31-60	3.33	0.10	0.02	0	1.49	0.58	0.01	0
Total	28.58	1.08	0.34	0	23.66	6.30	0.04	0
6-day:
1-30	24.13	1.30	0.34	4.23	19.86	7.28	0.04	2.82
31-60	4.04	0.17	0.02	0	1.93	0.89	0	0
Total	28.17	1.47	0.36	0	21.79	8.17	0.04	0
7-day:
1-30	22.97	1.64	0.36	5.13	17.78	8.63	0.04	3.55
31-60	4.86	0.25	0.02	0	2.31	1.24	0	0
Total	27.73	1.89	0.38	0	20.09	9.86	0.04	0
8-day
1-30	21.90	1.91	0.37	5.82	15.80	10.02	0.04	3.55
31-60	5.45	0.34	0.03	0	2.48	1.66	0	0
Total	27.35	2.25	0.40	0	18.28	11.68	0.04	0
9-day
1-30	21.00	2.18	0.38	6.44	14.06	11.13	0.05	4.76
31-60	5.98	0.43	0.03	0	2.70	2.06	0	0
Total	26.98	2.61	0.41	0	16.76	13.19	0.05	0
10-day and over:
1-30	20.14	2.42	0.38	7.06	12.65	11.99	0.05	5.31
31-60	6.48	0.54	0.04	0	2.88	2.43	0	0
Total	26.62	2.96	0.42	0	15.53	14.42	0.05	0
5- to 10-day:
1-30	25.25	0.98	0.32	3.45	22.17	5.72	0.03	2.08
31-60	3.10	0.32	0.03	0	0.98	1.09	0.01	0
Total	28.35	1.30	0.35	0	23.15	6.81	0.04	0

are not necessarily transportable for evacuation out of theater withinthe same number of days for the respective longer evacuation policies.Usually, one might expect the field army area to operate under a 5- or6-day evacuation policy and the overseas theater to operate under the 15-,20-, 30-day, or longer, theater evacuation policies. Tables 90 and 91 presentthe various remaining and disposition factors for wounded and disease andnonbattle injury, respectively, based on an accumulation of one admissionper day for 30 days (period of estimate) and subsequent decumulation, bytype of disposition, to zero. Since patients are accumulated through 30days, there are patients accumulated and remaining in hospital at day 30for each of the short evacuation policies. However, patients are decumulatedto zero through some form of disposition by day (d+p-1) which would beday 34 where the evacuation policy (p) was 5 days and the period of estimate(d) was 30 days. For evacuation, policies longer than the number of daysin the period of estimate (p>d), patients accumulated through 30 dayscould theoretically remain up to 59 days for duty under a 30-day evacuationpolicy, approaching zero at 60 days; remain up to 89 days for duty undera 60-day evacuation, policy, approaching zero at 90 days; remain up to119 days for duty under a 90-day evacuation policy, approaching zero at120 days; and so forth. Since these factors are based on patients remainingand

Table 91.- Theater accumulation-decumulationfactors, by type of case, and specified evacuation policies
[Based on hospital admission of one per day for 30 days, then decumulation]

Evacuation policy and period of estimate	Admissions to hospital
	Wounded in action				Disease and nonbattle injury
	Evacuees	Duty	Death	Remaining	Evacuees	Duty	Death	Remaining
15-day:
1-30	16.71	3.36	0.40	9.53	7.94	14.53	0.05	7.48
31-60	8.32	1.16	0.05	0	3.41	4.07	0	0
Total	25.03	4.52	0.45	0	11.35	18.60	0.05	0
20-day:
1-30	13.83	4.08	0.41	11.68	5.38	15.65	0.05	8.92
31-60	9.51	2.11	0.06	0	3.43	5.49	0	0
Total	23.34	6.19	0.47	0	8.81	21.14	0.05	0
30-day:
1-30	9.87	4.66	0.41	15.06	2.91	16.19	0.05	10.85
31-60	10.40	4.59	0.07	0	3.22	7.62	0.01	0
Total	20.27	9.25	0.48	0	6.13	23.81	0.06	0
60-day:
1-30	4.42	4.66	0.41	20.51	0.76	16.19	0.05	13.00
31-60	7.44	8.56	0.08	4.43	1.73	9.59	0.01	1.67
61-90	1.34	3.09	0	0	0.42	1.25	0	0
Total	13.20	16.31	0.49	0	2.91	27.03	0.06	0
90-day:
1-30	2.73	4.66	0.41	22.20	0.34	16.19	0.05	13.42
31-60	5.03	8.56	0.08	8.53	0.86	9.59	0.01	2.96
61-90	1.59	5.09	0.02	1.83	0.41	1.97	0	0.58
91-120	0.32	1.50	0.01	0	0.08	0.50	0	0
Total	9.67	19.81	0.52	0	1.70	28.25	0.06	0
120-day
1-30	2.06	4.66	0.41	22.87	0.23	16.19	0.05	13.53
31-60	3.90	8.56	0.08	10.33	0.56	9.59	0.01	3.37
61-90	1.33	5.09	0.02	3.89	0.26	1.97	0	1.14
91-120	0.43	2.56	0.01	0.89	0.08	0.81	0	0.25
121-150	0.10	0.79	0	0	0.02	0.23	0	0
Total	7.82	21.66	0.52	0	1.15	28.79	0.06	0
15- to 30-day
1-30	16.71	3.36	0.40	9.53	7.94	14.53	0.05	7.48
31-60	6.74	2.73	0.06	0	1.84	5.64	0	0
Total	23.45	6.09	0.46	0	9.78	20.17	0.05	0
20- to 60-day
1-30	13.83	4.08	0.41	11.68	5.38	15.65	0.05	8.92
31-60	4.56	4.90	0.07	2.15	0.92	7.25	0	0.75
61-90	0.82	1.33	0	0	0.22	0.53	0	0
Total	19.21	10.31	0.48	0	6.52	23.43	0.05	0
30- to 60-day:
1-30	9.87	4.66	0.41	15.06	2.91	16.19	0.05	10.85
31-60	5.74	6.63	0.08	2.61	1.23	8.65	0.01	0.96
61-90	1.03	1.58	0	0	0.30	0.66	0	0
Total	16.64	12.87	0.49	0	4.44	25.50	0.06	0

Table 92.- Accumulation-decumulationfactors for wounded patients by echelon, for a 5-day Army and 30-day theaterevacuation policy
[Based on hospital admission of one per day for 30 days, then decumulation]

Echelon	Evacuation policy	Evacuees	Duty	Death	Remaining accumulation- decumulation	Total
1-30 days of estimate:
Theater	30-day	9.87	4.66	0.41	15.06	30.00
Army	5-day	(25.25)	0.98	0.32	3.45	30.00
COMMZ	--	9.87	3.68	0.09	11.61	25.25
30-60 days of estimate:
Theater	30-day	10.40	4.59	0.07	0	15.06
Army	5-day	(3.33)	0.10	0.02	0	3.45
COMMZ	--	10.40	4.49	0.05	0	11.61

patient dispositions at all U.S. Army hospitals worldwide for an admissionoriginating overseas, and the theater evacuation policy includes all hospitaldays lost in theater, it is possible to obtain factors for COMMZ fixedbed requirements for those patients admitted in and evacuated from thefield army area, by subtraction from the respective overseas theater factors.For example, under a 5-day field army evacuation policy (f=5) and a 30-daytheater evacuation policy (p=30), based on one admission per day throughday 30-then none, the COMMZ factors for patients wounded in tire fieldarmy area taken from tables (90 and 91 are shown in table 92.

It will be noted that the total dispositions for COMMZ equal the numberof evacuees received from the field army. Assuming constant daily admissions,these factors for wounded patients indicate the field army would require3.45 times the number of daily wounded admissions plus dispersion in nonfixedbeds for wounded patients; COMMZ would require 11.61 times the number ofdaily wounded admissions in the field army, plus dispersion, in fixed bedsfor field army wounded evacuees, plus 15.06 times the daily number of woundedpatients initially admitted to COMMZ hospitals, plus dispersion. The sameprocess can be repeated for DNBI patients to obtain total nonfixed as wellas fixed bed requirements in an overseas theater of operations. To convertthese factors into percentages per month, it is only necessary to multiplyby 100 and to divide by 30. For example, the total wounded evacuated of28.58 under a 5-day evacuation policy, converts to 95.27 percent, whichmay be read directly from the patients remaining column as shown in appendixtable C-1 at day 5.

SKIPPING ECHELONS OF HOSPITALIZATION IN EVACUATION

It is also possible to skip intermediate echelons of hospitalizationby direct evacuation of any desired proportion of those patients who areidentified as eventual evacuees from the skipped echelons. For example,if 60 percent of those patients scheduled for transfer to COMMZ (and whowould later require evacuation to CONUS from COMMZ) were evacuated directlyto CONUS from the Field Army, the figures shown in table 92 for COMMZ evacueeswould be changed from 9.87 and 10.40 to 3.95 and 4.16, respectively, thelatter two figures being 40 percent of the former two. The patients remainingfigure of 11.61, as shown, changes to 6.79 and is derived by subtractingthe respective smaller proportion requiring evacuation and the respectiveCOMMZ duty and death dispositions (which are unchanged), by days of estimate,from the smaller proportions of evacuees received in COMMZ from the FieldArmy. These latter figures are computed by applying the desired percentagefor direct evacuation (60 percent) to that proportion requiring eventualevacuation from COMMZ under a 30-day evacuation policy in this example.Table 91 indicates a total of 20.27 wounded require eventual evacuationunder a 30-day evacuation policy; 60 percent of this figure shows a productof 12.16 for direct evacuation to CONUS. Since the Field Army is undera 5-day evacuation policy, the, figure of 12.16 direct evacuation mustbe scheduled out of theater at the rate of evacuation for the 5-day policy(see appendix A for evacuation where p<d) and, in this example, is 10.74during the first period of estimate (1-30 days) and 1.42 during the secondcarryover (31-60 days). Under

100

Table 93.- CONUS accumulation-decumulationfactors, by type of case, and specified evacuation policies
[Based on hospital admission of one per day for 30 days, then decumulation]

Evacuation policy and period of estimate	Admissions to hospital
	Wounded in action				Disease and nonbattle injury
	Duty	Death	Disability separation	Remaining accumulation- decumulation	Duty	Death	Disability separation	Remaining accumulation- decumulation
15-day:
1-30	1.30	0.01	0	15.40	1.66	0	0	6.28
31-60	7.40	0.03	0	16.29	5.52	0.01	0	4.16
61-90	5.09	0.01	0.01	11.18	1.97	0	0.02	2.17
20-day:
1-30	0.57	0.01	0	13.25	0.54	0	0	4.84
31-60	6.45	0.02	0	16.29	4.10	0.01	0	4.16
61-90	5.09	0.01	0.01	11.18	1.97	0	0.02	2.17
30-day:
1-30	0	0	0	9.87	0	0	0	2.91
31-60	3.97	0.01	0	16.29	1.97	0	0	4.16
61-90	5.09	0.01	0.01	11.18	1.97	0	0.02	2.17
60-day:
1-30	0	0	0	4.42	0	0	0	0.76
31-60	0	0	0	11.86	0	0	0	2.49
61-90	2.01	0	0.01	11.18	0.72	0	0.02	2.17
91-120	2.57	0	0.04	8.57	0.81	0	0.03	1.33
90-day:
1-30	0	0	0	2.73	0	0	0	0.34
31-60	0	0	0	7.76	0	0	0	1.20
61-90	0	0	0.01	9.35	0	0	0.02	1.03
91-120	1.06	0	0.04	8.57	0.31	0	0.03	1.33
121-150	1.48	0	0.08	7.01	0.39	0.01	0.04	0.89
120-day:
1-30	0	0	0	2.06	0	0	0	0.23
31-60	0	0	0	5.96	0	0	0	0.79
61-90	0	0	0.01	7.28	0	0	0.02	1.03
91-120	0	0	0.04	7.67	0	0	0.03	1.08
121-150	0.68	0	0.08	7.01	0.16	0.01	0.04	0.89
All policies:
180	1.08	0	0.10	5.83	0.22	0	0.04	0.63
210	0.76	0	0.13	4.94	0.13	0.01	0.04	0.45
240	0.57	0	0.16	4.21	0.08	0	0.04	0.33
270	0.43	0	0.20	3.58	0.05	0.01	0.04	0.23
300	0.33	0	0.21	3.04	0.04	0	0.03	0.16
330	0.25	0	0.23	2.56	0.02	0	0.02	0.12
360	0.19	0	0.22	2.15	0.01	0	0.02	0.09
390	0.15	0	0.21	1.79	0.01	0	0.01	0.07
420	0.11	0	0.19	1.49	0.01	0	0.01	0.05
450	0.09	0	0.17	1.23	0	0	0.01	0.04
480	0.07	0	0.14	1.02	0	0	0.01	0.03
510 and over	0.25	0	0.77	0	0	0	0.03	0
15- to 30-day:
31-60	5.83	0.02	0	16.29	3.95	0.01	0	4.16
61-90	5.09	0.01	0.01	11.18	1.97	0	0.02	2.17
20- to 60-day:
31-60	3.66	0.01	0	14.14	2.34	0.01	0	3.41
61-90	3.76	0.01	0.01	11.18	1.44	0	0.02	2.17
91-120	2.57	0	0.04	8.57	0.81	0	0.03	1.33
30- to 60-day:
31-60	1.93	0	0	13.68	0.94	0	0	3.20
61-90	3.51	0.01	0.01	11.18	1.31	0	0.02	2.17
91-120	2.57	0	0.04	8.57	0.81	0	0.03	1.33

this skip policy of 60 percent for wounded patients, COMMZ would receive14.51 evacuees during the first period of estimate (25.25 as shown in table92 less 10.74 direct evacuees to CONUS) and 1.91 during the second period(3.33 less 1.42). When the respective dispositions are subtracted (3.95evacuees, 3.68 duty, and 0.09 death) from 14.51, the COMMZ remaining figureof 6.79 is derived. The subtraction of the second-period COMMZ dispositions(4.16 evacuees, 4.49 duty, and 0.05 death) from 1.91 second-period evacueesfrom Field Army added to the 6.79 COMMZ remaining figure, equals zero (0)remaining in COMM at the end of the second period.

101

Skipping routines may be applied in different proportions for differenttypes of patients and also may be changed from one period of estimate toanother. It is necessary to apply the desired proportion only to thosepatients on hand who will require eventual evacuation from the echelonof hospitalization to be skipped.

ESTIMATING BEDS FOR OVERSEAS EVACUEES

Patients, who are admitted overseas and whose estimated period of hospitalizationto eventual final disposition exceeds the permissible length of time establishedby the respective theater evacuation policy, are evacuated to CONUS hospitalsas soon as their condition permits and the means of transportation becomesavailable. Since the accumulation factors for CONUS simply represent thefurther extension of overseas theater evacuee factors, they are, therefore,applicable only to the respective daily number of overseas admissions whichoriginate the requirements for fixed beds at the CONUS level of hospitalization.Table 93 presents these factors for wounded patients and DNBI patients,respectively, by length of theater evacuation policy for 30-day periodsof estimate. It will be noted that patients accumulate in CONUS at differentrates based on the respective length of the theater evacuation policy.Patient accumulations in CONUS reach a higher level under the shorter evacuationpolicies until the day of operations equals the length of a respectivepolicy; thereafter, accumulations in CONUS are the same for any evacuationpolicy.