Medical Statistics of the United States Army, Calendar Year 1953

CHAPTER II

Medical Care

A. Major Morbidity Indices

ADMISSIONS

During 1953, there were 482 admissions to hospitals and quarters per 1,000 average strength. Thus, fewer than half the men in the Army were admitted to hospitals and quarters at any time during the year, one of the lowest levels of morbidity ever recorded in the Army. Battle wounds and injuries constituted about 1 percent of all admissions.

Of the admissions for nonbattle causes during 1953, 88 percent were due to disease and 12 percent to nonbattle injuries.  There were, therefore, between 7 and 8 admissions due to disease for every one for nonbattle injury. The rate for disease, 421 per 1,000 average strength, was virtually the same as the 1952 rate of 419 per 1,000. Nonbattle injuries decreased from 61 per 1,000 in 1952 to 55 per 1,000 during 1953. The combined annual rate for all nonbattle causes (disease and nonbattle injury) was 476 admissions per 1,000 average strength?an indication of a highly favorable state of health prevailing in the Army during 1953.

Nearly one-third of the disease admissions were for acute respiratory infections (common cold, acute tonsillitis, pneumonia, etc.). Three other groups of diseases?the group labeled infective and parasitic diseases; diseases of the digestive system; and diseases of the skin and cellular tissue?together accounted for an additional one-third of the admissions for all disease conditions during the year.

Except for the increases that took place during periods of mobilization, e.g., World War II and the Korean Conflict, the general trend of admissions from nonbattle causes has been downward during the last century (see frontispiece). This decline is present for both components of the nonbattle causes rate, disease and nonbattle injury. Important factors responsible for this trend, especially since World War II, have undoubtedly been improvements in preventive medicine techniques, development of the antibiotics, expanded use of outpatient care, and the general improvement in the health of the population in the United States.

Approximately one percent of the nonbattle admissions were readmitted for treatment during the year. This proportion of readmissions, however,

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varied markedly according to disease and disease class (e. g., for diseases of the nervous system it was about 4.5 percent; for the infectious and parasitic diseases, it was only 0.7 percent).

A certain proportion of the individuals admitted to hospitals and quarters for the diagnoses indicated in this report had conditions that developed subsequent to admission, or that existed concurrently with the admission diagnosis. A count of these secondary diagnoses, together with the admission diagnoses, provides a better indication of the incidence of a specific condition. The incidence data shown in this report include these secondary diagnoses as well as the conditions that were admission diagnoses; they do not, however, include diagnoses treated among outpatients except where, as with venereal disease, the cases were carded for record only (see Appendix). During 1953, the incidence of all nonbattle conditions exceeded the admissions by 18 percent (16 percent for disease conditions and 33 percent for injuries). These proportions also varied considerably by disease or disease class.

All rates, with the exception of malaria, shown in summary table 1 under the heading ?incidence? consist of counts of the aforesaid primary and secondary diagnoses. Since it is often difficult to distinguish between a new case and a readmission for malaria, the incidence rate cited for this disease includes readmissions, as well as new admissions and secondary diagnoses. Thus, for malaria the rate can be described as an ?attack rate.?

Although the admission rates during 1953 were higher overseas than they were in the United States (527 per 1,000 and 427 per 1,000, respectively), the admission rate overseas declined between 1952 and 1953, whereas, in the United States, it increased slightly between the two years. This was due, to a large extent, to a combination of two factors. During the first part of 1953, the incidence of acute respiratory infections in continental United States declined more slowly than usual from its rather high seasonal peak, resulting in a higher overall rate for the year for this class of diseases in this area. (See Acute Respiratory Infections.) Exerting force in the opposite direction was the cessation of combat in Korea on 27 July 1953. This resulted in declines overseas not only in admissions for battle causes, but also in the morbidity from nonbattle injuries, from the psychiatric conditions associated with the stress of combat, and from certain diseases endemic to that peninsula.

Of the separate oversea areas, Japan had the highest level of morbidity, as reflected in admission rates. Admissions in Japan, however, as well as those in Korea, were inflated artificially by the two prisoner of war exchanges that took place during the year, ?Operation Little Switch? during April and May, and ?Operation Big Switch? during August and September. The repatriated prisoners of war found to be ill on their return had, in most instances, been ill for some time. The entry of these men to Army medical treatment facilities, however, was recorded as new admissions for the period, temporarily inflating the rates. (See, for example, Tuberculosis.)

During the year, the nonbattle admission rate among enlisted personnel was one and a half times the rate for officers. This disparity is due, largely,

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to a preponderance of morbidity among enlisted personnel from the infectious and parasitic diseases (especially venereal disease), and to nonbattle injury, diseases of the skin and cellular tissue, diseases of the urinary system and male genital system, and psychiatric disorders. For other disease groups, the disparity was not marked, however. For some classes, officers experienced the higher morbidity (e.g., diseases of the digestive system, the circulatory system, and neoplasms).

Age plays the most prominent role in the disparity in the admission rates by rank. Enlisted personnel are, as a group, younger than officers. As such, they are more susceptible to certain infective and parasitic diseases and to the acute respiratory diseases. Because of such factors as greater physical activity,

CHART A.?ADMISSIONS FOR NONBATTLE CAUSES, BY AGE, U. S. ARMY, 1953

less experience, etc., the younger enlisted personnel are likewise more prone to accidental injury. Conversely, officers are more likely to contract the diseases that occur with advancing age, such as diseases of the circulatory system and diseases of bones and organs of movement.

Generally, admission rates were highest under 20 years of age, decreased to a minimum in the 35-39 year age group, and increased steadily thereafter, with the rate among personnel over 50 being about equal to those between 20-24. The relationship between age and the rate of admission for several disease classes is depicted in chart B.

The nonbattle causes admission rate among Negroes exceeded the rate among whites by about 45 percent. This difference is attributable, mainly, to the higher Negro morbidity from venereal disease and from nonvenereal and

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CHART B.?ADMISSIONS FOR SELECTED DIAGNOSTIC CLASSES, BY AGE, U. S. ARMY, 1953

nongonococcic urethritis. The admission rate for venereal disease among Negroes (227 per 1,000) was almost 6 times the rate of 40 per 1,000 among whites; the Negro rate of 18 per 1,000 for nonvenereal and nongonococcic urethritis was more than double the white rate (8.29 per 1,000). Excluding these conditions, the nonbattle admission rate among Negroes (404 per 1,000) was about equal to the rate of 401 per 1,000 among whites.¹

The high nonbattle admission rate (710 per 1,000) among females (the rate for males was 473 per 1,000) is not produced solely by inclusion in female morbidity of certain conditions which occur only in this sex. The disease admission rate among females?excluding admissions for diseases of the breast and female genital system; deliveries and complications of pregnancy; and pregnancy, uterine, not delivered?is 609 per 1,000 compared with an admission rate of 462 for males from all diseases, excluding diseases of the male genital system.

Additional factors that may have a bearing on the sex differentials in the admission rates are rank, age, length of service, place and type of assignment, etc. A male-female comparison was made taking officer-enlisted ratios into consideration. More than 40 percent of the females in the Army during 1953 were officers as compared with approximately 10 percent of the males. Other things being equal, if in 1953 women in the Army had had the same strength

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¹These rates include cases carded for record only. (See Venereal Disease.)

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distribution between officers and enlisted personnel as did males, and if conditions peculiar to each of the sexes are excluded from consideration, then the nonbattle admission rate among females would have been nearly half again as great as for males. It appears likely that even after various factors such as age, length of service, rank, etc., are taken into account, the morbidity rate among females exceeded that among males.

Included in the ?admission? rates discussed thus far and included in the basic tables in Part Two of this report are those Army personnel treated on a duty status and carded for record only. If these cases?consisting largely of new venereal disease cases treated as outpatients?had been excluded, the effect would be to decrease the admission rate for all causes from 482 to 401 per 1,000 average strength and for nonbattle causes from 476 to 396 per 1,000 average strength. The admission rate for disease, of course, is most affected by the exclusion of CRO cases. The disease rate would be decreased from 421 to 343 per 1,000. The nonbattle injury admission rate is affected relatively little, declining from 55 to 53 per 1,000 average strength. Individual medical record tabulations of nonbattle morbidity for 1953 by such variables as area, rank, race, age, etc., include CRO cases. With respect to disease in the total Army, 18 percent of the ?admissions? were CRO cases. However, venereal disease CRO cases?80 percent of all disease CRO cases?comprised 95 percent of all venereal disease ?admissions.?

OUTPATIENT CARE

During recent years there has been an increased emphasis by the Army Medical Service on greater utilization of outpatient services. In an attempt to shift as much of the workload as possible from the inpatient services to the more economical outpatient services, commanders of Army medical treatment facilities have been instructed to treat patients on an outpatient (duty) status to the maximum extent feasible, without in any manner decreasing the high quality of medical care or depriving any individual of the treatment and hospitalization necessary to recovery.  Examples of the types of cases that are currently receiving outpatient care, unless hospitalization is required, are psychiatric patients, venereal disease patients, military personnel requiring medical board action, etc.

In 1953, Army medical treatment facilities worldwide performed slightly more than 21 million outpatient treatments. In addition, they performed 13.5 million immunizations, 1.3 million complete physical examinations (including flight physical examinations), 0.2 million specified periodic examinations or tests, and made 77,000 visits to home.

Compared with 1952, there was a slight decrease in 1953 in the overall outpatient activity. Nearly all of the decrease occurred in the number of outpatient treatments, which declined by 7 percent. Virtually all of the reduction in the number of outpatient treatments was due to the reduction in the enemy prisoner of war population. With the cessation of hostilities in

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TABLE I. ? OUTPATIENT CARE AT ARMY FACILITIES WORLDWIDE BY SELECTED CATEGORIES OF PERSONNEL AND TYPE OF CARE, 1953

Type of beneficiary	Outpatient work units				Specified periodic examinations or tests	Immunizations	Visits to home
	Total	Treatments	Physical examinations
			Flight	Other complete
All beneficiaries	22,375,528	21,053,641	5,654	1,316,233	207,153	13,511,091	77,115
Daily averagea	61,471	57,840	15	3,616	569	37,118	212
Active duty military personnel	14,003,551	12,904,059	5,581	1,093,911	88,927	11,584,418	3,153
Army	13,573,570	12,489,507	4,765	1,079,298	87,509	11,386,770	2,978
Navy and Marine Corps	76,829	74,698	2	2,129	478	7,025	27
Air Force	353,152	339,854	814	12,484	940	190,623	148
Dependents of military personnel	4,798,012	4,782,380	1	15,631	13,133	1,131,442	66,935
Army	4,057,639	4,043,315	-	14,324	12,528	980,487	55,665
Navy and Marine Corps	226,850	226,556	-	294	131	40,053	740
Air Force	513,523	512,509	1	1,013	474	110,902	10,530
Retired military personnel	91,632	91,487	-	145	121	1,544	144
Prisoners of war	1,528,910	1,528,859	-	51	679	270,480	-
All otherb	1.953,423	1,746,856	72	206,495	104,293	523,207	6,883

^aBased on 364 days in the report period.
^bPredominantly U.S. civil-service employees.
SOURCE: Outpatient Report (DD Form 444).

July 1953 and the subsequent prisoner exchange (?Operation Big Switch?) in August and September, enemy prisoners of war, except those already hospitalized or too sick to be repatriated, ceased to be a responsibility of the Army Medical Service. However, if outpatient care provided enemy prisoners of war during 1952 and 1953 is excluded, the overall outpatient activity was roughly the same in 1953 as in 1952.

Of the 21 million outpatient treatments administered by Army medical treatment facilities in 1953, approximately 61 percent were received by active duty military personnel (59 percent by Army personnel and 2 percent by Air Force, Navy, and Marine Corps personnel). Dependents of military personnel received 23 percent of the outpatient treatments. Almost half of the remaining 16 percent of the treatments were received by enemy prisoners of war. As might be expected, the distribution of outpatient treatments by type of treatment for active duty military personnel was quite different from that for dependents of military personnel. (See chart C.)

Although Army medical treatment facilities routinely administer large numbers of immunizations to active duty military personnel and their dependents, the immunization workload is of a much lesser order of significance than outpatient treatments from the standpoint of the amount of time and professional personnel required. About 86 percent of all immunizations administered by Army medical treatment facilities in 1953 were received by active duty military personnel. The bulk of the remainder were administered to dependents.

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CHART C. ?PERCENTAGE DISTRIBUTION OF OUTPATIENT TREATMENTS, BY TYPE OF TREATMENT, ALL U.S. ARMY MEDICAL TREATMENT FACILITIES, 1953

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TABLE II.?OUTPATIENT CARE AT ARMY FACILITIES WORLDWIDE BY SELECTED CATEGORIES OF PERSONNEL AND TYPE OF TREATMENT, 1953

[In thousands]

Type of treatment	Selected categories of personnel
	All beneficiaries	Active duty military personnel			Dependents of military personnel			Prisoners of war	All othera
		Army	Navy and Marine Corps	Air Force	Army	Navy and Marine Corps	Air Force
Total treatments	21,054	12,490	75	340	4,043	227	513	1,529	1,837
General medicine	11,315	7,384	31	149	1,414	55	129	1,149	1,004
Dermatology	913	571	7	29	124	8	18	97	59
General surgery	991	712	8	29	136	8	17	16	65
Surgical dressing room	1,903	1,193	5	28	132	7	16	173	349
Ophthalmology	1,152	888	6	28	122	5	14	26	63
Ear , nose, and throat	1,204	800	7	29	169	7	15	64	113
Neuropsychiatry	247	178	1	7	27	2	6	4	22
Psychological tests	54	32	(b)	1	4	1	1	-	15
Obstetrics	700	1	(b)	(b)	546	43	96	(b)	14
Gynecology	315	11	(b)	(b)	241	17	35	-	11
Pediatrics	1,224	-	-	-	989	66	143	-	26
Physiotherapy	1,007	706	9	38	132	8	21	-	93
X-ray and radium therapy	29	14	1	2	7	(b)	2	-	3

^aPredominantly U.S. civil-service employees. Of the 1,837,000 outpatient treatments received by the "all other" group, U.S. civil-service employees received 1,124,000. Also included in the total are 37,000 treatments administered to members of the civilian components of the U.S. Armed Forces on active duty for training.
^bLess than 500 treatments.

SOURCE: Outpatient Report (DD Form 444).

Unlike the admission and noneffective rates, the outpatient treatment rate for Army personnel for 1953 was at about the same level as that which prevailed just prior to World War II?roughly 8,500 treatments per 1,000 average strength per year. This does not mean that the rate has not been affected by the general long-term decline in morbidity that has taken place. It means rather that the balance between factors tending to reduce the outpatient rate (e.g., improved preventive medicine) and factors tending to increase the outpatient rate (e.g., increased emphasis on outpatient care) has produced a rate in 1953 that is at this particular level. Thus, the rate had declined (following a World War II rise) to about 5,800 per 1,000 in 1949. Its increase to the level of about 8,500 in 1952 and 1953 was in part related to the increased morbidity in the period of combat and in part to the increased emphasis on outpatient care. This is shown by the fact that the rate has not declined with the end of hostilities, but remains nearly 50 percent higher than in 1949, and, in fact, seems still to be increasing.

While it is evident that treating patients on an outpatient status reduces the amount of time lost from duty, it is not possible to measure precisely the amount of reduction in the admission rate or in noneffectiveness that results

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from this.  Part of the difficulty arises from the fact that data are not currently available on the numbers of individuals treated as outpatients for particular episodes of illness. However, in view of the growing importance of outpatient data in morbidity analysis, the current Outpatient Report (DD Form 444) is being revised to include additional relevant information in this matter.

AVERAGE DURATION

In evaluating the duration of stay data shown in this report, careful consideration should be given to the grossness of measures of this kind. As with all such overall or summary statistics, the results depend upon the various factors or components which enter into the total statistic. Examples of a few of these factors are presented below. The appendix should be consulted for a discussion of the concept of duration of stay, and for the methods of computing average durations.

Cases admitted for nonbattle causes remained in hospital and quarters an average of 14 days during 1953 (17 days in 1952, 16 days in 1951, and 18 days in 1950). In order to make use of an average of this sort, it is necessary to understand the different kinds of cases that make up the average and what kinds of differences there are in the average durations of the various components. Nonbattle injury cases in 1953 had an average duration of 25 days or almost double the average length of stay of disease cases (13 days). If the overall average for all nonbattle causes for a particular year includes relatively fewer injury cases than in other years, the all nonbattle causes average duration for this year will be lower simply by reason of this fact.

CHART D.?AVERAGE DURATION OF STAY IN HOSPITAL AND QUARTERS, BY TYPE OF DISPOSITION, U. S. ARMY, 1953

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The overall duration of 14 days is based on the time lost by both single diagnosis and multiple diagnoses cases. Approximately 13 percent of the cases included had more than one diagnosis. For the single diagnosis nonbattle cases alone, the average duration was 10 days (9 for disease cases and 17 for injuries). For making comparisons between individual diseases, the proportion having secondary diagnoses and the generally longer average duration of these multiple diagnoses cases need to be considered. For this reason, the data on average duration provided in summary table 16 are presented separately for single diagnosis cases and for single and multiple diagnoses cases combined.

CHART E.?AVERAGE DURATION OF STAY IN HOSPITAL AND QUARTERS, FOR SELECTED CONDITIONS, U. S. ARMY, 1953

The largest differences in length of stay are observed when the cases are distributed by type of final disposition. As indicated in chart D, the average duration of those nonbattle cases which terminated in separation from the Army for disability was almost 10 times the length of stay of all cases combined. There are many reasons why this is true, most of them having to do with the nature and severity of the cases from a medical viewpoint and the resultant kind and amount of treatment required, but also some concerned with the administrative processing required when persons are being separated for disability. The Army has long recognized that the disability separation cases comprise an important segment of the duration-of-stay pattern and has instituted a number of procedures designed to shorten their length of stay. The following duration-of-stay statistics for cases separated for disability due to nonbattle causes show that the 1953 durations are markedly lower than the

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1950 averages; for disease the duration is only about one-half as great, for nonbattle injury one-fourth less.

Year of separation	All nonbattle causes	Disease	Nonbattle injury
1950	248	240	392
1951	106	101	279
1952	143	131	326
1953	136	124	297

The Army policy in recent years of treating as outpatients as many as possible of the patients with milder diseases and injuries has undoubtedly resulted in savings in hospital beds and hospital costs but, as might not be readily apparent, it has probably tended to increase the overall duration of those patients who are treated on an excused-from-duty basis. This apparently paradoxical effect results from the exclusion from the average duration computation of cases which, had they been hospitalized, would have contributed only small numbers of days per case and would, therefore, have tended to reduce the overall average duration. This highlights the fact that average duration alone is not a reliable index to the effectiveness of medical service efforts to avoid any unnecessary days of hospitalization. For such purposes noneffective rates provide a more useful guide.

Another factor which must be considered in evaluating overall Army data on average duration is the effect of cases that are carded-for-record only. Inclusion of these cases, which are largely venereal diseases treated on a duty status, results in a lower overall average duration. The effect of these CRO cases is illustrated in the data presented in table III.

TABLE III.?AVERAGE DURATION OF STAY IN HOSPITALS AND QUARTERS FOR NONBATTLE CAUSES, U. S. ARMY, 1953

	Including CRO cases	Excluding CRO cases
	Days	Days
All nonbattle causes	14	17
Injuries	25	27
Disease	13	16
Venereal disease	1	16
Other disease	15	16

NONEFFECTIVENESS

As a measure of the time lost from duty by Army personnel because of sickness or injury, the noneffective rate is perhaps one of the best indices to the health of the Army. Loss of time for medical reasons is of considerable military importance because personnel sick in hospital and quarters are not available to perform their assigned duties and because Army Medical Service personnel must be available to care for them.

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The concept of noneffectiveness is usually expressed in terms of the noneffective rate. This rate represents the average daily number of patients in hospital and quarters per 1,000 average strength during the period under consideration. (The rate is computed by the formula indicated in the appendix.) Thus for the calendar year 1953 the noneffective rate of 19.8 means that on the average day during the year roughly 20 individuals out of each 1,000 troop strength were not available for duty because they had been admitted to hospital or infirmary or confined to quarters for medical reasons (disease, nonbattle injury, or battle injury or wound). This may also be expressed by stating that 2 percent of the Army?s strength was noneffective for medical reasons on the average day in 1953.

The amount of noneffectiveness experienced by the Army depends primarily on two factors: (1) the rate of admission to hospital and quarters on an excused-from-duty basis; (2) the average length of stay in hospital and quarters once a patient is admitted to medical treatment. As an example of the interplay of these two factors, the admission rate for disease in 1953 (420.6 admissions per 1,000) was almost 8 times that from nonbattle injury (55.0 per 1,000), while the total days lost (and thus noneffective rate) due to disease in 1953 was only 4 times the days lost from nonbattle injury. The difference involved is that the average duration of stay for disease cases once they were admitted (13 days) was only half that for nonbattle injury cases (25 days). Thus it is that some of the specific diagnoses, such as tuberculosis, while having a low admission rate, contribute heavily to the noneffective rate because of the lengthy hospitalization required for the average such case.

The Korean Conflict greatly affected the noneffectiveness experienced in the Army during calendar year 1953, although the truce was signed on 27 July 1953. Battle injuries and wounds accounted for 9 percent of the total days lost for medical reasons during the year, disease 73 percent, and nonbattle injury 18 percent (chart F). The respective 1953 noneffective rates were 1.8 per 1,000 average strength from battle injury and wound, 14.4 per 1,000 from disease, and 3.6 per 1,000 from nonbattle injury. The average daily noneffective rate from all causes was 19.8 per 1,000 average strength.

With the exception of the interruption caused by war, the general trend of the noneffective rate in the Army has been downward since the early 1930?s. This is the composite result of many factors operating over a period of time, such as improved methods in medical treatment, preventive medicine and sanitation, emphasis on reducing the length of hospital stay, and concerted efforts on the part of the Army to reduce the occurrence of accidents. The recent trend toward making increased use of outpatient facilities in the treatment of certain types of cases rather than handling them in an excused-from-duty status has also been a factor in the reduction of time lost from military duty.

As noted previously, the current relative contribution of disease and nonbattle injury to medical noneffectiveness in the Army is about 4 days lost from disease to 1 day lost from nonbattle injury. The five main groups that contribute most heavily to disease noneffectiveness are: (1) infective and

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CHART F.?PERCENTAGE DISTRIBUTION OF NONEFFECTIVENESS, BY CAUSE, TOTAL ARMY, 1953

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parasitic diseases; (2) acute respiratory infections; (3) neuropsychiatric conditions; (4) diseases of the digestive system and hernia; and (5) diseases of the bones and organs of movement (arthritis, osteomyelitis, etc.). (See chart F.)  Altogether these five groups accounted for roughly 60 percent of the noneffectiveness from disease. Infective and parasitic diseases and acute respiratory infections were important in the noneffective picture, for while having a relatively short average duration (days lost per case), their admission rates were high (91.3 and 130.2 admissions per 1,000 average strength respectively). For neuropsychiatric conditions, for diseases of the bones and organs of movement, and for diseases of the digestive system and hernia, their respective admission rates were much lower, but their average duration per case was higher than for the average disease case.

It is interesting to note that noneffectiveness from venereal disease has been so greatly reduced that it accounted for less than 1 in every 100 days lost from disease in 1953. The venereal disease noneffective rate was 0.1 per 1,000; i.e., on the average day in 1953, only 1 individual out of every 10,000 in the Army was not available for military duty because of being in hospital or quarters on an excused-from-duty basis while undergoing treatment for venereal disease. In the past 20 years, the noneffective rate for venereal disease has declined over 95 percent?4.0 per 1,000 in 1933 to 0.1 per 1,000 in 1953. Furthermore, venereal disease today accounts for a far smaller percentage of the total noneffectiveness from all nonbattle causes. In 1933, 14 percent of all nonbattle days lost were due to venereal disease as against less than 1 percent in 1953.

During 1953 the noneffective rates by month were influenced mostly by the events of the Korean Conflict and the usual seasonal incidence of disease during the year. From a peak in January, which was largely due to the unusually high level of incidence of the acute respiratory infections resulting from the 1952-53 influenza epidemic, the noneffective rate from all causes declined continuously through the month of July. The heavy fighting in Korea during the late spring and early summer prior to the signing of the armistice, coupled with the two prisoner of war exchanges, which also occurred around the time of the armistice, caused a short climb in the noneffective rate during August.  After this, the rate once again began to decline for the remainder of the year. For the monthly trend of the 1953 noneffective rates based on data from morbidity reports (DD Form 442), see chart G.

DEATHS

In examining data on deaths among Army personnel, one must consider separately deaths due to battle causes. In periods when combat is occurring, there are likely to be far more deaths from battle than from nonbattle causes, although prior to World War II the converse was the case. Even the nonbattle deaths may vary depending on whether or not active combat is occurring, nonbattle injury death rates in particular tending to rise in time of war. Aside from combat, however, there are features of this mortality experience which are

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CHART G.?NONEFFECTIVENESS RATES, BY MONTH, TOTAL ARMY, 1953

peculiar to the kind of population involved. Army nonbattle mortality is also affected by the fact that the Army population is a select one with regard to factors such as age and sex. Moreover it is screened at entrance, and persons who are rejected include many suffering from serious conditions. It is further affected by the separation from the Army for disability of many persons who are found to have serious chronic conditions. All of these factors have a bearing on the number of deaths (kind and amount of mortality) occurring among Army personnel, and their distribution by cause.

In 1953, there were 4,940 deaths among Army personnel, and although the fighting ended in July, almost half of the deaths were due to battle casualties. More than three-fourths of the nonbattle deaths were due to nonbattle injuries.² The death rate from all causes was 322 per 100,000 average strength, and the rates for the components were: battle casualties, 143; nonbattle injuries, 133; and diseases, 46. (Note that these and other death rates in this report are expressed in terms of numbers of deaths per 100,000, rather than per 1,000 as with other rates shown.) The death rate from battle causes was lower than it had been in the other years of the Korean Conflict; it has decreased each year since 1950. The battle casualty death rate during the first 7 months of 1953, however, was higher than that for (the entire year) 1952 but lower than for 1950 or 1951. Disease deaths stayed at about the same level as in 1951 and 1952 after the peak rate of 62 per 100,000 average strength in 1950. The nonbattle injury death rate for the continental United States was about the

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²The term "injury" is used to include all injuries resulting from accidents, violence, or poisonings.

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same in 1953 as in 1952, but overseas, the rate decreased from 154 to 119.  Korea and Alaska accounted for most of this decline, showing nonbattle injury death rates of 278 and 326 per 100,000, respectively, in 1952, compared with 183 and 119 in 1953.

Monthly variation in death rates was, of course, greatest for battle casualty deaths. The monthly variations which occurred in disease and in nonbattle injury death rates showed no clear seasonal pattern. 

The highest death rate from nonbattle causes occurred in Korea, and this was the only overseas area where the rate was higher than in the United States (see source table 13). Practically all of the variation among areas in nonbattle death rates reflects differences in rates for nonbattle injury deaths. The death rate from disease was lower in the United States than in any overseas area except the Caribbean, but the differences were not large; the extremes in Hawaii and the Caribbean should be discounted because of the small strengths in these areas. (See chart H.)

Approximately 70 percent of the disease deaths in each area except Hawaii were included in three broad causes of death: infective and parasitic diseases, neoplastic diseases, and diseases of the circulatory system. Korea had the highest death rate from infective and parasitic diseases, approximately five times the rate in Europe and in the United States. This excess was attributable almost solely to epidemic hemorrhagic fever.  For neoplastic diseases and diseases of the circulatory system, the rates in Korea were lower than in practically every other area, probably because of the presumably younger age composition of Army strength in Korea.

Death rates from neoplastic diseases and diseases of the circulatory. system show moderate increases with age up to 35 years. For older groups, the rates went up very sharply, until at 50 years and over, the rate for these two classes combined was 515 per 100,000 average strength. Diseases of the nervous system were the only other broad group which showed a clearly defined picture of increase with age, with a somewhat slower increase in the rates as age increased. The rate was 3.4 for all ages and it ranged from about 2 to 34.  Diseases of the digestive system had a rate of 2.8 per 100,000 average strength, with relatively little variation by geographic area. The rate for this class showed only a moderate tendency to increase in the older age groups.

Nonbattle injury deaths were almost as numerous as battle casualty deaths in 1953. The rates ranged from 126 to 166 per 100,000 average strength in the age groups under 35, but leveled off to about 115 in each older group with the exception of the 40-44 year interval.

In the United States, a large proportion of the deaths from nonbattle injuries had no connection with Army duty. That is, for every 100,000 Army personnel stationed in the United States, 56 died because of injuries sustained while they were on duty, while 91 died from injuries incurred while on leave or AWOL. Motor vehicle traffic accidents while off duty accounted for 71 of these 91 deaths. The highway death toll is the major factor in giving the United States a nonbattle injury death rate higher than for any other area

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CHART H.?DEATHS FROM NONBATTLE CAUSES, BY AREA, U.S. ARMY, 1953

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TABLE IV. ? DEATH RATES FROM DISEASE, U.S. ARMY, 1953

[Principal causes by age and area of admission]

Age and area of admission	Death rates per 100,000 average strength
	All diseases	Class I. Infective and parasitic diseases	Class II. Neoplastic diseases	Class VI. Diseases of the nervous system	Class XI. Diseases of the circulatory system	Class XIII. Diseases of the digestive system and hernia	All other diseases
Total deaths in 1953	46.2	6.8	11.9	3.4	14.2	3.0	6.9
Age at admission:
Under 20 years	34.0	15.1	4.5	1.8	6.3	-	6.3
20-24 years	26.6	6.6	6.7	2.6	3.8	1.3	5.6
25-29 years	40.1	7.1	11.4	3.3	7.0	2.2	9.1
30-34 years	57.4	3.9	15.5	3.9	17.4	11.7	5.0
35-39 years	105.2	1.4	25.3	8.4	44.9	8.4	16.8
40-44 years	271.8	2.9	74.3	5.7	160.1	17.2	11.6
45-49 years	322.9	12.9	90.4	19.4	154.9	25.8	19.5
50 years and over	572.3	-	183.2	34.3	332.0	11.4	11.4
Area of admission:
Continental U.S.	42.2	3.7	12.2	3.2	14.0	3.0	6.1
Overseas	50.4	10.2	11.8	3.6	14.5	3.0	7.3
Europe	48.5	3.3	13.0	4.7	18.0	3.6	5.9
Japan	69.0	8.4	17.8	6.3	21.9	4.2	10.4
Korea	49.1	17.3	9.1	2.0	9.1	2.8	8.8

except Korea. Overseas, relatively few deaths resulted from accidents while on leave; this, of course, reflects both the lessened availability of automobiles and the lessened amount of leave. The death rate from nonbattle injuries off duty off the post was only 14 in Japan and Korea, but was 36 per 100,000 in Europe, where traffic accidents were again the major cause. Excluding motor vehicle traffic accidents, the death rates from accidents while on leave or AWOL showed little variation between areas.

Korea?s rate of 183 nonbattle injury deaths per 100,000 average strength was about twice as high as the rate of 93 in Japan and in Europe, and considerably higher than the rate of 146 for continental United States.

Three-fourths of the deaths from nonbattle injuries were caused by three agents: motor vehicles (47 percent), instrumentalities of war (20 percent), and aviation accidents (9 percent). Motor-vehicle accidents (largely traffic accidents) produced most of the deaths in the United States, where the rate of 89.3 per 100,000 average strength was 61 percent of the total for nonbattle injury deaths; motor-vehicle accidents were among the leading causes in each area except Japan. Trucks and buses caused about half of these deaths in Korea; in Europe, more people died from accidents involving motorcycles, jeeps, command cars, and privately owned automobiles. Instrumentalities of war caused deaths at the rate of 10 to 25 per 100,000 average strength in the various areas

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CHART I. ? DEATHS FROM NONBATTLE INJURIES, BY CAUSATIVE AGENT, U.S. ARMY, 1953

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but in Korea, the rate was 84, representing 46 percent of the total for nonbattle injury deaths. Exposure to injury from weapons was greater in Korea, of course, not only during the period of combat, but also at the end of hostilities; some accidents occurred in the process of removing land mines and in other activities connected with the demilitarization of occupied zones. Aviation accidents were most important in Japan, where the rate of 39.7 per 100,000 average strength accounted for 43 percent of the total for nonbattle injury deaths, compared with a rate of 15 in continental United States and only 4 in Europe.

The remaining one-fourth of the nonbattle injury deaths were due to a wide variety of causative agents. Among these, poisoning, which accounted for a death rate of 5.6 per 100,000 average strength in the total Army, was a relatively important cause in one area, Japan, where the rate of 16.7 represented about one-sixth of the total deaths from nonbattle injury. Accidents involving transportation other than by motor vehicles (water transport, railroads, bicycle, etc.) accounted for a death rate of 4.9 per 100,000 average strength and showed little variation by area. The residual category of ?other specified agents? shows a rate of 9.2 per 100,000 average strength. Of this 9.2 rate, 6.2 were due to ?drowning not elsewhere classified.? Drownings which could be attributed to accidents involving water transport, motor vehicles, etc. raised the total rate for drownings to 11.7 per 100,000 average strength. The highest death rates from drownings appeared in Alaska and Korea.

Suicides and Homicides

There were 176 suicides and 110 homicides in the Army during 1953 producing rates of 11.5 and 7.2 per 100,000 average strength. Together, these two causes account for 14 percent of all nonbattle injury deaths and for more than one-fourth of the nonbattle injury deaths from causes other than motor-vehicle accidents. The death rate from suicides increased with age, while the homicide rate, beginning with the 25-29 year age group showed an inverse relation to age.  Oversea rates were only slightly higher than in the United States, the biggest differences showing up in Korea and in the Caribbean. In the United States, almost half of the suicides occurred among personnel on leave or otherwise away from the post and not on duty; the corresponding figure overseas was less than 10 percent.

The source tables show suicides and homicides as subtotal lines, but do not distribute them by nature of traumatism and causative agent. Injuries to the head, chest, and abdomen accounted for 91 percent of the homicide deaths and 63 percent of the suicides. Poisonings, asphyxiations, and strangulations caused 30 percent of the suicide deaths; these causes were not significant among the homicides. Instrumentalities of war accounted for almost one-half of the deaths from homicides as well as suicides.

Death by Rank and Race

Table V shows death rates separately for officers and for enlisted personnel and for white and Negro personnel. Some of the differences observed in totals

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TABLE V.?DEATH RATES, BY RANK AND RACE, U.S. ARMY, 1953

Cause of death and area of admission	Rate per 100,000 average strength
	Total Army	By rank		By race
		Officers	Enlisted	White	Negro
Total deaths, all causes	322	301	325	303	351
Continental U.S.	188	184	189	183	222
Overseas	465	468	464	431	484
Battle deaths, total	143	103	148	133	113
Killed in action	115	83	118	118	95
Died of wounds	15	11	16	15	18
Died in enemy prison or declared dead	13	9	14	-	-
Nonbattle deaths, total	179	198	177	170	238
Continental U.S.	188	184	189	183	222
Overseas	169	218	165	156	255
Disease deaths, total	46	99	40	44	63
Continental U.S.	42	98	35	40	53
Overseas	50	102	46	47	73
Nonbattle injury deaths, total	133	99	137	126	175
Continental U.S.	146	86	154	143	169
Overseas	119	116	119	109	182

are artifacts of the composition of the totals. Thus, the death rates for disease were higher among officers than among enlisted men, a result of the different age composition of the groups. The death rates for nonbattle injury were higher among enlisted men than among officers in the United States, although there was little difference overseas. The death rate overseas from battle injuries and wounds was higher for enlisted personnel than for officers. The relative proportions of officer and enlisted strength were not the same in the United States and overseas, and the proportions of deaths among disease, nonbattle injury, and battle injury and wounds, likewise differed between United States and overseas. The effect of this is that for all causes, officers and enlisted personnel had about the same death rate when United States or overseas is considered separately. However, for total Army, the net effect is that the death rate for enlisted men for all causes was higher than that for officers.

Nonbattle death rates were higher for Negroes than for whites for both disease and nonbattle injuries. These differences were greatest overseas, where the death rate for Negroes was 55 percent higher for disease, and 69 percent higher for nonbattle injuries.

Nature of Traumatisms Causing Death

Thirty-one percent of the nonbattle injury deaths resulted from fractures. Most of the fractures were incurred in automobile accidents. The United States had the highest death rate from automobile accidents and the highest death rate from fractures.

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Wounds (penetrating, perforated, and lacerated), which caused more than 19 percent of the nonbattle injury deaths, were the next most common traumatism. More than three-fourths of such wounds were inflicted by instrumentalities of war. Since these agents were largely responsible for the high death rate in Korea, it follows that the death rate from wounds was also higher in Korea than in any other area. Wounds of the head and wounds of the thorax each accounted for about 35 percent of the fatal nonbattle wounds; another 22 percent were wounds of the abdomen.

?Multiple injuries, extreme? caused 13 percent of the nonbattle injury deaths.  About half of these were due to aviation accidents, and the remainder were due principally to automobile accidents. Japan, with the highest death rate from aviation accidents, also showed the highest death rate from multiple injuries; the United States was second highest because of its traffic accidents.

Data relating to the length of time elapsing between admission to medical treatment facility and death from the nonbattle injury deaths in 1953 appear in table VI. These data indicate that a large proportion of those dying of nonbattle injuries are killed outright or die before receiving or reaching medical treatment. Of all the nonbattle injury deaths, 79 percent were carded for record (i. e., were not admitted alive to a medical treatment facility); 9 per-

TABLE VI.?NONBATTLE INJURY DEATHS BY LOCATION AND NATURE OF TRAUMATISM AND LENGTH OF MEDICAL TREATMENT RECEIVED, U.S. ARMY, 1953

Body location and nature of traumatism	Total deaths	Number of deaths by length of treatment
		Not treateda	1 day or less	2-9 day	10 days or more
Total nonbattle injury deaths	2,037	1,607	266	103	61
Head:
Fractures	509	377	81	34	17
Wounds	128	100	21	4	3
Other injuries	178	121	26	20	11
Thorax:
Wounds	125	109	14	-	2
Other injuries	135	103	23	6	3
Abdomen:
Wounds	84	35	28	13	8
Other injuries	35	26	3	4	2
Other body regions	251	204	28	9	10
Body generally:
Drowning	179	179	-	-	-
Poisoning; asphyxiation	121	105	9	6	1
Burns	50	32	10	4	4
Multiple injuries	228	216	10	2	-
All other injuries	14	-	13	1	-

^aCarded for record only (CRO).

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cent died before midnight of the day they were admitted, and 4 percent died on the day after admission.

SEPARATIONS FOR DISABILITY

During 1953, separations for disability continued to be accomplished under the provisions of Title IV of the Career Compensation Act of 1949. This act provides for uniform methods of determining appropriate disposition, and for uniform types of disposition, of all members of the Armed Forces, both officer and enlisted, found unfit to perform their duties by reason of physical disability.  The determination of physical fitness or unfitness of members is made in accordance with the physical standards for retention on active duty prescribed by the relevant regulations (SR 40-120-1).

A member of the Armed Forces found unfit for further duty because of disability may be retired (permanently retired or placed on the Temporary Disability Retired List), may be separated with severance pay, or may be separated without severance pay. Separation without severance pay occurs only if the disability resulted from intentional misconduct or willful neglect, if the disability was incurred during a period of unauthorized absence, or if the disability existed prior to the member?s term of active service and was not permanently aggravated by such service. In all of the other types of separation for disability listed, the member is entitled to benefits provided for by the Career Compensation Act of 1949, with the type of separation and the benefits depending upon a combination of factors?the degree of disability, stabilization  of the degree of disability, and the length of service.³ Members placed on the Temporary Disability Retired List are subject to physical examination for reevaluation of their disabilities not less frequently than every 18 months with final determination mandatory within 5 years.

General Findings

A total of 22,347 members of the Army were separated for disability during 1953, including those placed on the Temporary Disability Retired List. (For a complete distribution of these individuals by broad cause of separation and type of separation, classified by age, rank and race, length of service, and branch of service, see source table 18.) It should be noted that separations for pregnancy included by the Office of The Adjutant General among separation for ?physical disqualification? have been excluded from the disability data presented here. About 80 percent of the separations were for disabilities that resulted from disease; about 9 percent for disabilities due to nonbattle injuries; and 11 percent due to disabilities caused by battle injuries or wounds.

In terms of manpower losses, the 1953 separations for disability accounted for a yearly immediate loss of 14.6 individuals per 1,000 average strength: 11.7 due to disease; 1.3 due to nonbattle injuries; and 1.6 due to battle wounds and injuries.

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³See AR 600-450, ?Separation for Physical Disability,? 7 November 1949, and related regulations.

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Distribution by Type

As may be seen from table VII, the total separations were distributed as follows by type: Permanent retirements?22.2 percent; temporary retirements?10.6 percent; separations with severance pay?16.3 percent; separations without severance pay?50.9 percent. As might have been expected, permanent retirements were predominant among individuals separated for battle and nonbattle injuries, while separations without severance pay were most prominent among disabilities due to disease. The latter type of separations consisted almost exclusively of disabilities due to EPTS not service-aggravated conditions.

TABLE VII.?PERCENT DISTRIBUTION OF SEPARATIONS FOR DISABILITY BY BROAD CAUSE OF SEPARATION AND TYPE OF SEPARATION, U. S. ARMY, 1953

Type of separation	Percent distribution, by broad cause of separation
	Total	Disease	Nonbattle injuries	Battle injuries and wounds
Permanent retirement	22.2	11.3	45.9	82.5
Temporary retirement	10.6	10.9	8.6	10.0
With severance pay	16.3	17.9	12.5	7.5
Without severance pay	50.9	59.9	33.0	-
Total	100.0	100.0	100.0	100.0

Since temporary retirement is only a temporary status, it is important to consider the ultimate dispositions of cases on the TDRL. According to the available data, terminal actions were accomplished on 440 such individuals from the initiation of the Career Compensation Act through December 1953. About 29 percent of these individuals were permanently retired upon reevaluation; about 11 percent were separated with severance pay; and about 60 percent were found fit and returned to duty or discharged. (In addition to the 440 individuals mentioned above, 4 individuals were removed from the temporary disability retired list during this period because of death.) The high proportion of individuals on TDRL later found fit for duty results primarily from reevaluation of tuberculosis cases on the list, as indicated later. Whether the same proportionate distribution of final dispositions of the temporary retirements will hold in the future is a matter of conjecture, though later data (1954) seem to support such an assumption.⁴

Rates by Age and Rank

The total separation rates by age, as reflected in table VIII, follow a characteristic pattern. The total rates were relatively high in the age groups

⁴The separation data reported here relate to the original evaluation, without adjustment for the final disposition of the separatees on temporary disability retired list.

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TABLE VIII.?AGE SPECIFIC RATES OF DISABILITY SEPARATIONS, BY TYPE OF SEPARATION, U. S. ARMY, 1953

Age	Rates per 1,000 average strength per year
	Total	Retirement		Other
		Permanent	Temporary	With severance pay	Without severance pay
Under 20	20.8	3.0	0.9	1.7	15.2
20-24	14.7	2.8	1.4	2.2	8.3
25-29	14.0	3.0	1.8	3.4	5.8
30-34	8.7	2.9	1.8	3.1	0.9
35-39	8.3	3.5	2.1	2.1	0.6
40-44	11.2	5.8	2.7	2.0	0.7
45-49	16.7	10.6	4.1	1.7	0.3
50 and over	55.5	44.0	9.0	1.7	0.8
All ages	14.6	3.3	1.5	2.4	7.4

under 30, due primarily to separations for nonaggravated conditions that existed prior to service (separations without severance pay). There is a decrease in the total rates of the middle age groups of 30 through 39, and then a decisive increase in the older age group, especially among individuals in the 50 and over age group retired for disability.

As indicated in table IX, enlisted personnel had a total separation rate almost twice as high as officers. The higher separation rate among enlisted men is to be attributed to EPTS not service-aggravated conditions. Officers, however, had a higher permanent retirement rate (4.5 for officers versus 3.1 for enlisted personnel), which is entirely a function of age. (The age groups of 40 and above, which show high permanent retirement rates, include about 20 percent of the officers, and only about 2 percent of the enlisted personnel.)

TABLE IX.?RATES OF DISABILITY SEPARATIONS, BY RANK AND TYPE OF SEPARATION, U.S. ARMY, 1953

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Length of Service

Length of service refers to total service, including current and any previous tour(s) of duty. A distribution of the total separations and the various types of separations by length of service is presented in table X. The salient features of the table are as follows: of the individuals separated without severance pay, slightly over 47 percent had less than 3 months of service, or about 88 percent of them had less than 1 year of service, while 19 percent of individuals permanently retired and about 18 percent of the individuals separated with severance pay had less than one year of service.

TABLE X.?PERCENT DISTRIBUTION OF THE VARIOUS TYPES OF SEPARATIONS, BY LENGTH OF SERVICE OF SEPARATEES, U. S. ARMY, 1953

^aDenotes 1 to (but not including) 3 months, etc.

^bLess than 0.05 percent.

Primary Causes of Separation

Four detailed tables have been prepared showing the primary conditions causing separation. Three of these tables relate to separations for nonbattle disabilities, comprising disease and injuries (source tables 19-21), and one table deals with disabilities caused by battle injuries and wounds (source table 22). Only one condition is given in each case as the cause of separation; it is referred to as the primary cause of separation. Whenever several disabling conditions caused the separation, the condition with the highest ratable disability, according to the Veterans Administration disability standards, was chosen as the primary cause of separation.

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It may be observed that the numbers of separations distributed by diagnosis, as given in source tables 19-21, are somewhat less than those given in source table 18, specifically in the number of separations with or without severance pay. This is due to certain procedural difficulties encountered with respect to the latter separations. Such separations are frequently processed on an outpatient status and although it is required that they be carded for record only, i.e., that an individual medical record be prepared in each case at the time the separation is effected, it is known that for a certain proportion of these separations this was not done. It is problematical whether or not it can be assumed that these separations, for which no medical report cards were received, have the same distribution by diagnosis as the corresponding separations for which the diagnoses are known.

Nonbattle Disabilities, by Primary Cause of Separation

Source table 19, in which the various types of separations for nonbattle disabilities are distributed by primary cause of separation, indicates that, if temporary retirements are excluded, the three leading causes of separation were psychiatric disorders, impairments of the bones and organs of movement, and disabilities involving the circulatory system. Among the temporary retirements, the leading cause was tuberculosis as in the previous years. There was, however, an increase in 1953 in the number of tuberculosis cases among the temporary retirements. Because of this, the immediate yearly separation rate for tuberculosis has almost doubled in 1953 when compared with that of 1952, in spite of the fact that its yearly rate for permanent retirements was about one-half as large as that of 1952. However, current experience indicates that only about 1 out of 10 individuals on the temporary disability retired list because of tuberculosis is either permanently retired or separated with severance pay and that the remainder are found fit for service and are ordinarily discharged without severance pay. It may be thus expected that the ultimate disability separation rate for tuberculosis will be about the same as for previous years, fluctuating around 0.3 per 1,000 average strength per year.

It should be noted that individuals on the TDRL because of defects other than tuberculosis do not show as low a separation rate for disability upon final determination as the individuals placed on the TDRL because of tuberculosis. The available data seem to indicate that about one-half of individuals on the TDRL because of defects of the bones and organs of movement, about 90 percent of those so placed because of defects of the circulatory system or psychiatric conditions, and about two-thirds of all other individuals on the TDRL may be expected to be separated for disability (retired or separated with severance pay) upon final determination.

By age (source table 20), psychiatric disorders were the main cause of separation in the younger age groups, and disabilities of the circulatory system were the main cause in the older age groups. These age differentials are also reflected in the primary cause of separations by rank (source table 20). Enlisted personnel, being principally of younger ages, were separated primarily

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for psychiatric conditions, and officers, being largely of older age groups at the time of separation, were in a large proportion separated for disabilities of the circulatory system.

Closely connected with these differences by age are the differences by length of service, since younger age groups also have shorter periods of service. As may be observed from source table 21, the major cause of separation shifts from psychiatric disorders for separatees with short lengths of service to disabilities of the circulatory system for separatees with longer lengths of service.

Battle Disabilities, by Primary Cause of Separation

As may be observed from table XI, 7,057 individuals were separated during the period from 1950 through 1953 for disabilities caused by battle wounds and injuries. The highest number of these separations occurred in 1952. A distribution of these disabilities by primary cause of separation is presented in source table 22, relating to the 1953 separations. Contractures or shortening of the lower extremities, amputations of the lower extremities, and peripheral neuropathy were the main causes of the separations for battle disabilities. Explosive projectiles were the main causative agent responsible for the battle disabilities (source table 22). Except for 105 World War II cases, these disabilities relate to injuries and wounds incurred in the Korean Conflict.

TABLE XI.?SEPARATIONS FOR DISABILITIES DUE TO BATTLE INJURIES AND WOUNDS, BY TYPE OF SEPARATION, U. S. ARMY, 1950-53

At the end of 1953, there still remained in the hospitals 1,032 individuals admitted for treatment of battle disabilities.

B. Battle Casualty Experience⁵

With the truce negotiations at Panmunjom resulting in the cease-fire in Korea in July, battle injuries and wounds ceased to be a major cause of admission in the Army. The effect of this truce on the battle-casualty admission and death rates based on the complete 12-month period of 1953 was considerable. Of the battle injury or wound admissions during 1953, a large

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⁵These data, for the most part, are limited to the year 1953 due to the nature of this publication, and are also somewhat limited in detail. However, it is intended to publish a separate volume covering Army Medical Service experience during the complete period of the Korean Conflict (1950-53) which will include more definitive and more detailed statistics.

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number occurred during June and July, the last two months of action; the total Army annual admission rates for these two months were 18 and 27 per thousand average strength, respectively. During June, the Chinese and North Korean Communists had renewed heavy attacks on the central and eastern fronts. In July, after the Communists had launched a major attack to flatten out the United Nations line at the Kumsong River bulge, the U. N. began a counterattack on the east-central front. Despite these heavy engagements, battle injury and wound admissions during 1953, due largely to the cease-fire in Korea in July, were responsible for only 1.4 percent of all admissions during the year, and for only 9.2 percent of total noneffectiveness. The noneffective rate was 1.83 per thousand average strength per day.

The battle injury and wound admission rate (6.6 per thousand strength per year) as shown in the source tables is based on total Army strength and is a rate for the entire twelve months of 1953. Thus, it is an average which combines the experience of the earlier part of the year with the quite different experience of the last part of the year. A similar rate computed for only the 7-month period of active hostilities (January-July 1953) shows that in this portion of 1953, battle injury and wound admissions occurred at a rate of 11.4 per thousand average strength per year; this is slightly higher than the 1952 rate of 10.1 per thousand average strength. For purposes of comparison with the battle injury and wound admission rates experienced during each of the preceding years of the Korean Conflict, table XII presents these admission rates for total Army, both including and excluding slightly wounded or injured in action cases treated on an outpatient status and returned to duty the same calendar day (cases carded for record only). In either case (excluding or including CRO cases) the wounded or injured in action figures reported to the Office of The Surgeon General should not be expected to correspond to the numbers reported to The Adjutant General since they represent somewhat different coverages. Data collected by the Office of The Adjutant General generally include those cases wounded and requiring hospitalization; on the other hand, battle casualty data reported to OTSG refer generally to all cases admitted on an ?excused-from-duty? status to any medical treatment facilities (whether these facilities are hospitals or not). The OTSG data ?including CRO? further differ in that they include individuals who receive minor wounds or injuries in action and require only outpatient treatment at a medical treatment facility (usually an aid station), followed by immediate (i.e., on the same calendar day) return to duty. This category of individual, the outpatient battle casualty case, is not reportable to TAG under current regulations and, with some possible exception in the early part of the Korean action when there was ambiguity in the requirement, has never been reported to TAG.

From table XII, it may be seen that the battle injury and wound admission rate is reduced markedly when these slightly wounded cases who lost no time from duty (cases carded for record only) are excluded.

As previously noted, the battle injury and wound admission rate for 1953 was noticeably affected by the ending of hostilities in Korea (6.6 per thousand

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TABLE XII.?BATTLE INJURY AND WOUND ADMISSION RATES, TOTAL ARMY, INCLUDING AND EXCLUDING CRO^a CASES, 1950-53

[Rates expressed as admissions per 1,000 average strength per year]

Period	Total Army
	Including CRO cases	Excluding CRO cases
July-December 1950	60.4	55.6
January-December 1951	28.4	24.3
January-December 1952	10.1	7.5
January-July 1953	11.4	8.7

^aCases treated on an outpatient status and returned to duty on the same calendar day.  Such cases are recorded as cases carded for record only (CRO).

for the 12-month period compared with 11.4 per 1,000 for the 7-month period). For the same reason, deaths among battle casualties were affected to the same degree, although a few deaths did occur after active hostilities had ended. Although the cease-fire in Korea was responsible for limiting the final number of battle deaths, nevertheless, deaths among battle casualties were the leading cause of death in the Army during 1953. The death rate among battle casualties during the year was 143 per 100,000 average strength (based on the total Army strength for the complete 12-month period), compared to 246 per 100,000 average strength per year for the 7-month period. This latter rate (246), although somewhat higher than the battle casualty death rate of 197 per 100,000 experienced during 1952, is markedly lower than the battle casualty annual death rates of 2,508 and 639 per 100,000 average strength during the 6-month period July-December 1950 and the year 1951, respectively.

The deaths among battle casualties during 1953 comprised 44.4 percent of all deaths during the year. Four of every five battle deaths were classified as killed in action and 1 of every 10 as died of wounds. The remaining deaths among battle casualties occurred while in a captured status or were those officially declared dead from missing in action, etc. When related to age, the under-20-years-of-age group had the highest killed in action rate?174 per 100,000?based on total Army average strength for the complete 12-month period. The 20-24-year-old group was next highest with a killed-in-action rate of 135 per 100,000, and the lowest rate was 6 per 100,000 for the 40-44-year-old group. There were no killed in action among those 45 years of age or over during 1953.

Of the total deaths among battle casualties, 230 died of wounds during 1953, representing a case fatality rate of 3.0 percent among the total wounded or injured in action, excluding CRO cases. For the entire Korean Conflict (1950-53), the case fatality rate was 2.5 percent, based on OTSG data.

Forty percent of those dying of wounds during 1953 died from a head, face, or neck wound; 25 percent died from abdominal wounds. The fatal wound involved the thorax in 15 percent of the died-of-wound cases and the extremities

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in an additional 15 percent; one-third of the latter resulted from traumatic amputations. The balance died from wounds which involved the pelvis, spinal cord, and vertebrae or body generally. Of the 201 deaths among battle casualties other than the killed in action or died of wounds during 1953, 3 died while in enemy prisons and 198 were declared dead from missing in action.

In addition to these battle losses, there were 2,467 separations due to battle disability during 1953, four-fifths of which were permanent retirements. The disability resulted from a wound which was caused by explosive projectiles in 50 percent of the cases that resulted in disability separation; by grenades, mines, and other fragments in 18 percent of such cases; and by small arms in 15 percent of the cases. The balance, 17 percent, was caused by other agents, including those instances in which the agent was unknown. When these disability separations for battle causes are related to age and length of service of those separated, about 84 percent were 24 years of age or less, and 70 percent had less than 2 years of service.