SECTION I
I. MEDICAL SERVICE IN WAR
An efficient medical service is essential to the military success ofan army, not only in protecting the health of the troops by initiatingproper sanitary measures, but also by insuring the return of sick and woundedmen from the hospitals to their organizations as promptly as possible.
An adequate medical service is also of importance in maintaining themorale of any fighting force. One can easily visualize the difference inthe mental attitude of two men going into battle, the one realizing thathe will receive medical attention when required, while the other one knowsthat he may lie wounded on the battle field for many hours before he receivestreatment.
In addition to the military necessity for an efficient medical service,the people in all modern, civilized, and well organized countries expectand demand that proper medical attention and adequate hospitalization shallbe provided for the men in the military service. This is especially truein time of war, when armies must be composed of young men drawn from practicallyevery family in the country.
Although the public is willing to pay for any amount of medical servicewhich is essential for military success, and to properly care for the individual,yet it must be only so large as the necessity requires. To divert too muchmaterial and too many men from the other branches of the army for the medicalservice may jeopardize the military success of an expedition.
The answer to the question of "What is an adequate medical service?"differs necessarily with each war plan, and its solution requires carefulconsideration and study. A number of factors must be considered, of whichthe following are especially important.
a. The size of the military force to be used and the number of recruitsincluded. There is always more sickness among men when assembled in largenumbers, and still more among recruits than among seasoned men.
b. The epidemiological condition of the population and of the territoryto be occupied. More sickness will inevitably occur among troops operatingunder war conditions in a country with unfavorable health conditions, orin one with an unhealthy and overcrowded civil population than in the UnitedStates.
c. The military forces of the enemy, the character of his military weapons,and the possibilities as to the military defenses of his country are important.A careful study of these latter factors should assist
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one in making an approximate estimate of the relative number of wounded.Such an estimate is most important since a wounded man requires much greaterand more prolonged care than a sick one.
If available statistics are systematically and carefully arranged andstudied, the data may be helpful in solving the problem involved. The followingstudy is an attempt in that direction. Before beginning the discussionof such data as may be presented, it is necessary to consider several generalterms which will be used throughout.
B. TERMS USED AND CONSTANTS EMPLOYED.
1. Strength. - The strength of a command is the numberof soldiers in that command. Since it varies materially from day to day,and especially so during periods of mobilization and demobilization, whilethe sick occur only among those present, it is necessary that we have anaverage daily strength for any period in question. The average daily strengthis computed by adding together the strength of each day in a period, andthen dividing the aggregate thus obtained by the number of days in theperiod, which obviously may vary from 2 to 365 or more days. Ordinarily,since military reports are furnished monthly, the strengths for the variousdays of the month are added, and the total is then divided by the numberof days in the mouth to obtain an average daily strength for the month.The 12 such average strengths in the year are added and divided by 12 tofind the average daily strength for the year. It is important to rememberthat the strength used in this study, is always an average daily one althoughit may be averaged for one day, for a week, a month, a year or more.
2. Causes of sickness and injury. - The causes of sickness andphysical disabilities resulting therefrom and deaths are either diseasesor injuries.
Injuries are subdivided into non-battle injuries and battle injuries.
a. Non-battle injuries occur either in peace or in war, from external causesother than the hostile act of a military enemy.
b. A battle injury or wound is one that is caused by a primary or secondarymissile or by a deleterious gas set in motion by the hostile act of a militaryenemy. Wounds or injuries from projectiles dropped by airplanes many milesback of the front lines, or as a result of the sinking of a ship by a torpedofrom a submarine, are properly included as battle injuries. Accidentalinjuries received while in action are not included under, the head of battleinjuries.
3. Place of treatment. - Cases of sickness and injury are furtherclassified according to the place of treatment, as follows:
a. Hospital cases include the more seriously ill or injured, who are retainedin hospital for treatment and consequently require hospital beds.
b. Quarters cases include the less seriously sick or injured, who requiremedical attention and are excused from the performance of all
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or part of their military duty, but remain in their quarters and hencedo not require hospital beds.
c. Dispensary cases include the less serious cases of sickness or injury.They require medical attention, but their condition is not of sufficientgravity to necessitate their excuse from the performance of their militaryduties. Although such cases materially increase the work of the MedicalDepartment as well as the amount of medical supplies required, they willnot be included in the subsequent discussion. If, however, the total numberof sick for whom medical supplies and attention must be provided shouldbe desired, such data as are presented hereafter should be increased 50%1.
4. Percentage of cases treated in hospitals and in quarters.- The percentage of cases which are treated in hospital or in quartersvaries materially from time to time, and especially so during war as comparedwith peace. This is quite an important item, since it determines in partthe number of hospital beds required. Fig. 1 shows the
Fig. 1. -Percentage of cases of diseases and nonbattle injuries treated in hospital.
Sources of information:
a. United States:
(1) 1904 - 1915.2
(2) 1917 - 1919. Total cases as published.3 Quarter'scases estimated from:
(a) Average days lost by each quarter's case during 1904- 19152 (7.24); and
(b) the days lost in quarters in 1917.2
(3) 1925 - 1927. Total cases as published.2 Quarter'scases estimated from:
(a) Average days lost by each quarter's case during 1904- 19152 (7.24);
and (b) days lost in quarters during 1925 - 1927.2
b. Europe in 1917 - 1919:
Estimated from: (a) Total cases in Europe as determined bythe number of deaths there from diseases and nonbattle injuries,3and the fatality rate in the U. S. from the same causes during the sameperiod3 (Deaths ÷ Fatality Rate = Cases) ; and (b) thehospital cases in Europe during the last six months of 1918.2
percentage of cases treated in hospital among troops in the United Statesbefore, during and since the World War; and also in hospital in Europeduring that period.
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During the World War, although there were base hospitals in nearly allof the large camps, in the United States, they were usually under differentadministrative control and were located some distance from the troop areas,hence probably the smaller percentage of cases treated in hospitals duringthat period, as compared with the prewar and postwar periods. In the Theatreof Operations in the American Expeditionary Forces, where the permanenthospital beds were still further removed from the troop area, the percentageof total sick sent to hospital was still smaller.
5. Admission rates. - Cases treated in hospital or quarters areofficially reported to the War Department, but only local records are keptof dispensary cases. Each case treated in hospital or quarters is "Admittedto Sick Report", and hence is termed "Admission". Throughoutthe following discussion, the term "case" will be used as synonymouswith "admission" and with "patient".
Before any comparisons can be made of the amount of sickness in thedifferent commands, it is necessary to reduce the number of sick in eachone to a common ratio of its strength. The unit of strength used mightbe the individual. The rates then would be so many cases per man, but thiswould necessitate the extensive use of decimals, which it is always desirableto avoid. Ordinarily in the United States Army, the unit of strength usedis 1000 men. Consequently, we speak of so many cases per 1000 strength.Thus, 1200 cases, or admissions, in a command of 2000 gives a rate of
1200 ÷ (2000 ÷ 1000) = 600 per 1000.
The admission rates must also show how many cases occur in each 1000men during any specified time. The time period may be a day, a month, ora year. A day's rate is 1/365 as large as one for a year, and a month'srate is 1/12 as great as that for a year, and also 30 times as large asthe one for a day.
It is important to note that the strength used is always an averagedaily one for the period, but that the admission rate increases in proportionto the length of the period just as the cases do. The following formulaeshow the method of computing admission rates per 1000 men:
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Daily rate per 1000=
Day's cases ÷ (Average daily strength/1000)= (Days cases ×1000)/Avg. daily strength
Monthly rate per 1000=
Month's cases ÷ (Average daily strength/1000)= (Month'scases × 1000)/Avg. daily strength
Annual rate per 1000=
Year's cases ÷(Average daily strength/1000)= (Year's cases× 1000)/Avg. daily strength
Annual rates are used ordinarily in the discussion of military and publichealth statistics. If the period during which the cases have occurred isless than one year, they must be increased correspondingly. Thus, if wewish to calculate an annual admission rate for the cases which occurredduring one week they must be multiplied by 52 before the final computingis done, or if an exact figure is desired, by 365 ÷ 7.
Annual admission rate per 1000 from one week's cases =
(Week's cases × 52 × 1000)/Average daily strength
Conversely, if one wishes to calculate an average daily admission ratefrom the aggregate cases of one month or of one year, they must be dividedby 30 or 365 as required. Thus the average daily admission rate per 1000from cases of one year is
(Year's cases/365) ÷ (Average daily strength/1000) = (Year'scases × 1000)/(Avg. daily-strength × 365)
Throughout this study, daily admission rates will be used.
6. Average days lost per case. - Since each day of sickness inhospital means that a man is absent from his duty and is using a hospitalbed for that time, the duration of treatment is quite an important item.The method of calculating this factor is quite simple. The formula is:
Average days per patient = Aggregate no. of days lost by all cases/Aggregatenumber of cases.
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As with the admission rate per day, the average days per case may befor those of one day, one ninth, one year or more. If for one year theformula is:
Days lost by all patients in year/ Number of patients during year = Days lost per patient averaged for one year.
Figs. 2 and 3 show the average days lost per patient (case) in differentcountries, at different times, and from different causes. In Fig. 2 theaverage is for the cases treated in hospital and quarters combined;
Fig. 2. -Average days of treatment per case of disease and nonbattle injury treatedin hospital and quarters combined among white and colored American troopsin different countries at different periods.
Sources of information: 1904 - 1908.2
1920 - 1927.2 The averages for the troops in theP. I., Hawaii, and Panama include only time lost while under the treatmentthere, and do not include the time lost after departure by cases sent backto the U. S.
NOTE: The average days per case of white soldiers in the U.S., 1925 - 1927,was 16.35.
but in Fig. 3, the data shows in addition, the average for each caseof disease and nonbattle, injury in hospital only, in the United Statesand Europe during the World War, and also that for each gas case and gunshotcase in hospital in the American Expeditionary Forces.
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One sees from Fig. 3 that the duration of treatment for a gunshot casewas more than twice as great as it was for a gas one, which in turn wasmuch more than that for a disease and non-battle injury case; and furtherthat the average treatment time for each hospital case of disease or non-battleinjury was longer in the American Expeditionary Forces than in the UnitedStates. The last mentioned fact was apparently the result of at least threefactors:
Fig. 3. -Average days of treatment per case in the United States and Europe duringthe World War (April 1917 - December 1919).
Sources of information:
a. Diseases and nonbattle injuries:
(1) In hospital and quarters combined:
(a) United States. 3 (b) Europe: Total cases asestimated for Fig. 1, (b). Hospital cases as published,3 slightlyreduced to exclude quarter cases during 1917 2 and the firstsix months of 1918,2 as indicated by the experience during thelast six months of 1918.2 The difference between the total casesand hospital cases when multiplied by 7.24 (See Fig. 1. (a) (2)) givesthe estimated days for quarter's cases. These latter added to the numberof days as published 3 give the estimated total days to be dividedby the estimated total cases.
(2) In hospital only:
(a) United States. Estimated quarter cases multiplied by7.24 (See Fig. 1, (a) (2)) to find estimated quarter's days. This numbersubtracted from the total days3 gives the estimated days inhospital only, which is then divided by the hospital cases (Total cases3 - estimated quarter cases) equals average days per case.
(b) Europe.1
b. Battle injuries in Europe.3
a. A smaller percentage of cases, and only those of a more serious natureand consequently of longer duration, were sent to the hospital in the AmericanExpeditionary Forces.
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b. The hospitals in the American Expeditionary Forces were a greaterdistance from the troop areas, and consequently patients were apparentlyless promptly returned to their organizations or to replacement depots.
c. To expedite the demobilization after the armistice many patientswho had recovered were returned to the United States as sick. This resultedin an unnecessary loss of time in hospital for these cases and increasedthe average time lost by each one.
The longer treatment since the World War, as compared with that before,is due apparently to the more intensive hospital treatment which patientsnow receive.
7. Noneffective rates. - The noneffective rate shows the numberof patients that, after several months accumulation of them, will be sickeach day in a period, or as usually expressed "Constantly sick."It is always expressed as a daily rate for which the formula is:
Daily noneffective rate per 1000 strength =
(Patient days/Days in period) ÷ (Average daily strength/1000)= (Patient days × 1000)/(Average daily strength × daysin period.)
Like the daily admission rate, it may be the average for one day, oneweek, one year, or more. If it is an average for one year, the formulais:
Daily noneffective rate per 1000 strength =
(Patient days during year/365 )÷ (Average daily strength/1000)= (Patient days during year × 1000)/(Average daily strength ×365.)
Fig. 4 shows the relationship that exists between the average dailyadmission rate, the average days lost per patient, and the noneffectiverate. This relationship is very important, for by its use we can determinethe ultimate number of sick for any given admission rate, if the averageduration of each case (which is more nearly constant than the admissionrate) is known.
As an illustration of the use of this formula, let us take our experiencewith enlisted men in the United States during the World War, when the noneffectiverate was 50.40.3
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Fig. 4. -The relation of the noneffective rate to the average daily admission rateand the average days lost per patient.
Enlisted men, U. S., April, 1917-December, 1919.
Admissions
2,577,261
Average daily strength per year
766,726
Days lost during period
38,835,016
Days in period
1,605
Daily admission rate = (2,577,261 × 1000)/(766,726 ×1005)= 3.34466
Days lost per patient = 38,835,016/2,577,261 = 15.0683
Noneffective rate = 3.3447 × 15.0683 = 50.3989
Note: All rates are per 1000 of strength.
Since the average duration of treatment includes days lost by casesof long duration as well as by those of short duration, the ultimate non-effectiverate is obviously not reached until the cases with the longest treatmenthave left hospital. As will be shown later, the duration of treatment forcases of disease and nonbattle injuries varies from one day to approximatelyone year; for men wounded by war gases, from one day to approximately oneyear and for gunshot battle injuries, from one day to 2.5 years. Consequently,the ultimate noneffective rate is not reached in cases of disease and nonbattleinjuries until the end of one
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year after M day, and of gas and gunshot injuries not until one andtwo and one-half years, respectively, from the beginning of hostilities.
Since the noneffective rate is equal to the product of the average daysper patient multiplied by the daily admission rate, it necessarily followsthat with a theoretical daily admission rate of 1.00 per 1000 the noneffectiverate would be equal to the average days per patient. Thus, if the dailyadmission rate in the United States during the World War had been 1.00when the average days per sick case treated in hospital and quarters were15.07, the corresponding noneffective rate would have been 15.07 (15.07× 1); while in the American Expeditionary Forces with an averageof 18.93 days per case, it would have been 18.93 (Fig. 3).
For cases treated in hospital only, for which the average daysper case were 20.36 in the United States and 27.29 in the A.E.F., the correspondingnoneffective rates with a daily admission rate of 1.00 per 1000 to hospitalonly, would have been 20.36 and 27.29 respectively (Fig. 3.)
These and other related facts are summarized in the following table.
Table 1. Percentage of casestreated in hospital with the average days per case and the correspondingnoneffective rates when the admission rates are as assumed.
| Country | Percentage of cases treated in hospital | Hospital & Quarter Cases | Hospital Cases | ||||
| Admission Rate | Average days per case | Noneffectives (Patients) | Admission rate | Average days per case | Noneffectives (Patients) | ||
| (1) | (2) | (3) | (4)a | (5)b | (6) | (7)c | |
U.S. | 61.38 | 1.00 | 15.07 | 15.07 | .6138 | 20.36 | 12.50 |
Europe | 56.00 | 1.00 | 18.93 | 18.93 | .5600 | 27.29 | 15.28 |
U.S. | 61.38 | 1.63 | 15.07 | 24.56 | 1.00 | 20.36 | 20.36 |
Europe | 56.00 | 1.78 | 18.93 | 83.70 | 1.00 | 27.29 | 27.29 |
C. ADMISSION RATES FOR TROOPS IN THE UNITEDSTATES.
Can any information be obtained from the vital statistical experienceof the United States Army which will be helpful in determining approximatefuture admission rates under specified conditions? The answer is believedto be in the affirmative.
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8. Decline since 1819. - To find what changes have occurred inthe army admission rates in the United States since the beginning of ourmedico-military records, let us examine such data as are available. Fig.5 shows the daily admission rates to hospital and quarters from non-
Fig. 5. -Daily admission rates to hospital and quarters combined from nonbattleinjuries, diseases, and the two combined per 1000 strength, American troops,serving in the U.S., by periods from 1819 to 1927 inclusive. 1 2 34 5 6 7
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battle injuries from diseases, and from both combined by periods from1819 through 1927, a period of 108 years. It is apparent from this graphthat, with the exceptions as noted below, there has been a very markedand steady decline in the admission rates from all causes during the periodsof peace, the one in 1920-1927 being only one-fourth as great as that in1839-1846. The first exception is that the one for each of the first twoperiods was lower than that for the third, which is probably to be accountedfor by the incompleteness of the reports during the early years; the secondis that a slight increase occurred in the rate for the period followingthe Spanish-American War over that for the one preceding it, due to conditionsresulting from the war.
9. Increase during war. - Another important fact is that duringwar periods the general admission rate has always been much greater thanthe one for the preceding and succeeding periods, due to the marked increasein the number of cases of disease- at the same time an actual decline inthe admission rate from non-battle injuries is noted.
10. Decline in succeeding war rates. - Although the reportingof cases during the Civil War was not nearly so complete as during theWorld War, the admission rate during the former was more than twice asgreat as that during the latter. The Spanish-American War rate was alsomuch greater than that of the World War, notwithstanding the pandemic ofinfluenza which occurred during the latter conflict.
11. Estimation of future admission rates for unseasoned troops.- Since there has been such a marked decline in the admission rates underboth peace and war conditions, it is obvious that it would be unwise togo back farther than the World War period for experience to use as an indicationof future medical requirements. If, then, the World War experience is used,what rate should be selected for a war army in the United States? The averagedaily admission rate to hospital and quarters of 3.34 per 1000 strengthin the United States for the statistical period of the World War (April,1917 - December, 1919), is not a satisfactory one to use,3 becauseit included the year 1919 when the troops who had been well seasoned byservice in Europe were returned to the United States for demobilization.What is desired are the probable rates among unseasoned troops as theyare mobilized in large numbers for war training. Probably the best experienceis that of 1918, for during that year there was a constant inflow and outgoof a large number of men at the various training camps in the United States.If the epidemic influenza months of September and October are excluded,the average daily admission rate to hospital and quarters for the yearwas 3.50 per 1000.3
An average daily admission rate for the year, however, is probably nota satisfactory one upon which to base an estimate of the probable requirementsof medical service, since many factors will cause variations above or belowthe average. Certainly no engineer would plan a bridge
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to carry only the average load. Similarly, in planning medical service,it would be unwise to base the expectancy upon an average rate. Unusuallyhigh rates which continue for only a few days, or those which occur fromexceptional outbreaks of infectious disease, can hardly be provided for,but provision should be made for at least a reasonable variation abovethe average.
12. Causes of variations in admission rates in United States.- a. Season.-Fig. 6 shows that, after excluding Septemberand October, the average daily admission rate of 3.50 to hospital and quartersin 1918 was exceeded in January, March, and April. If the average for theyear
Fig. 6. -Daily admission rates to hospital and quarters from diseases and nonbattleinjuries by months per 1000 enlisted men serving in the United States.2
had been used as an estimation basis, there would have been a shortageof hospital beds for the United States as a whole during the entire periodof those three months; furthermore, these seasonal variations above theaverage for the entire United States do not show those which occurred inmany camps, from factors other than seasonal. Figure 6 shows also
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the excess of the rates for unseasoned troops in 1918 over those forthe peace time Army from 1920 to 1927.
b. Race. - Race is another material factor in causing variationsin admission rates. Figure 7 shows that during peace there is more sicknessamong the white than among the colored troops, due apparently in part tothe larger percentage of new enlistments among the white soldiers. Thusfrom 1923-1927, inclusive, 60 per cent of the white men enlisting had no
Fig. 7. -Daily admission rates to hospital and quarters from diseases and nonbattleinjuries per 1000 strength of white and colored troops by color, servingin the United States at different periods. 2 3
previous service, while only 31 per cent of the colored enlistmentswere without it. The graph points out, however, that during the World War,when practically all recruits, both white and colored, were without previousservice, the latter had 1.5 times as much sickness as the white ones.
c. Nativity. - The region from which the recruits are drawnis also a very material factor in determining the amount of sickness. Fig.8 shows, the relative amount which occurred among the soldiers fromvarious States, as compared with the average for the United States at 100.The
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Fig. 8. -Relative Magnitude of admission rates to hopital and quarters from diseasesand nonbattle injuries among white men by nativity (native state) servingin the United States and Europe from April 1, 1917 through December 1919.1
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white recruits from the Southern States had 56% more than the average,while those from the other States had 11 % less.
These same data arranged by corps areas are shown by Fig. 9 which givesnot only the variation in the combined rates for white and colored troops,but also that for the white men alone. The latter from the area of thepresent Fourth Corps (Southern states) had 59% more than the average amountof sickness, while those from that of the present Ninth
Fig. 9. -Relative magnitude of admission rates to hospital and quarters from diseasesand nonbattle injuries by nativity (native state), arranged by Corps Areas,among white troops, and also among white and colored troops combined, whowere serving in the United States and Europe from April 1, 1917 throughDecember 1919.1
Corps (Pacific coast and Rocky Mountains) had 39 % less.
d. Camps. - The combined results of the various factors of race, nativity,season, overcrowding, etc., all of which affected the admission rates tohospital and quarters in the various training camps, are shown by Fig.10. This graph shows not only the average daily admission rate
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Fig. 10. -Daily admission rates to hospital and quarters from diseases and nonbattleinjuries per 1000 strength, American troops in thirty large camps during1918, excluding September and October. Also the maximum rate averages forany one month in each camp, again excluding September and October.3
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for one year in each of 30 concentration camps, but also the averagedaily rate for the worst calendar month. The average daily admission ratein the United States of 3.50 to hospital and quarters (excluding Septemberand October) was exceeded by the camp average in 14 of the 30 camps, andby the rate for the worst month in all of them except one. Clearly then,the average rate in the United States for the year would have been an unsatisfactoryone upon which to base the expectancy of hospital requirements. A dailyadmission rate of 4.80, or an increase of 37 per cent over the averageof 3.50, was exceeded by the maximum daily rate for the worst month in21 of the 30 camps, and was almost equaled in one other. Apparently then,an increase of 37 % to cover expected variations above the average ratewould not be excessive for the United States as a whole, higher or lowerrates being used locally depending upon the nativity and color of the troops(infra).
13. Admission rates in United States camps, 1918. - All of the30 camps were in operation during the entire year of 1918. The minimumaverage daily strength in any one of them for any one month was approximately8,000, and the maximum slightly over 50,000.3 There was thensufficient population in each camp during every month to furnish reliableadmission rates.
a. To hospital and quarters combined. - Fig. 11 shows how oftenthe various daily admission rates to hospital and quarters combinedaveraged by months (excluding September and October) occurred in the 300camp-months (30 camps × 10 months each). Thus there was a daily admissionrate of 1.50 per 1000 in 7 per cent of the camp-months; 2.00 per 1000 in14 per cent, and 4.00 per 1000 in 11 per cent, or in 33 camp-months. Theaverage rate of 3.50 occurred in 12 per cent of the camp months, ratesless than 3.50 in 50 per cent, and greater in 38 per cent of them.
One sees then that, if the average rate of 3.50 had been selected asa basis for estimating medical requirements, it would have been exceededin 38 per cent (see right hand margin of Fig. 11) of the camp-months; thatis, in 114 of the 300 camp-months there would have been more hospital sickthan available hospital beds. Also, if an admission rate of 4.50 per 1000had been so selected, there would have been a higher rate of sickness in19% of the months, or 57 camp-months.
It is suggested that the admission rate of 4.80, or one 37% above theaverage 3.50 (see Fig. 10), be adopted as the basis for estimating therequirements for medical service and hospital beds for mobilization inthe United States under similar circumstances. This rate occurred in 7%of the camp-months and a greater one in approximately 15% of them. Consequently,if we use 4.80 we will have provided for 85% of the probable monthly rates.
If the hospital beds required for such an admission rate (4.80' X 12.50*- 60.00 per 1000) are provided, and properly distributed to corps
*See Table 1, p. 10.
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areas, there will usually be a bed for every sick or injured man inthe training camps in the United States; the excess can be provided forby emergency beds. This estimate will also be sufficient to provide fordispersion of beds. It does not, however, include any provisions for thesick returning to the United States from any expeditionary area. For suchan estimate see page 68.
Fig. 11. -Relative frequency of daily admission rates from diseases and nonbattleinjuries to hospital and quarters combined per 1000 strength in 30 largecamps in the United States during 1918, exclusive of September and October.3
NOTE: For method of graduation see Fig. 77, p. 144.
b. To hospital only. - Fig. 12 shows how often the various admissionrates to hospital only (each one of which is 61.38 % of the admission rateto hospital and quarters combined) occurred. If the requirements for
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hospital beds had been based upon an expected daily admission rate of3.00 to hospital only, there would have been a deficiency of hospital bedsin only 14 % of the camp-months. We have suggested 2.95 to hospital,, orthe equivalent of 4.80 to hospital and quarters combined.
Fig. 12. -Relative frequency of daily admission rates from diseases and nonbattleinjuries to hospital only per 1000 strength in 30 large camps in the UnitedStates during 1918, exclusive of September and October.
NOTE: For method of graduation see Fig. 78, p. 145. Hospital cases calculatedfrom basic distribution Table 3 as 61.38% (Fig. 77, p. 144) of total cases.
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c. Interrelation of admission and noneffective rates. - Fig.13 shows for each admission rate to hospital and quarters, the equivalentone to hospital only, and the two corresponding noneffective rates. Thuswhen
Fig. 13. -To show for each daily admission rate to hospital and quarters combinedfrom, diseases and nonbattle injuries in the Zone of the Interior (SeeFig. 11), the corresponding rate to hospital only; and also the ultimatenumber of sick accumulating from each daily admission rate.
NOTE: Column A is from Fig. 11. The rates in B, C, and D are calculatedfrom the corresponding ones in A by multiplying by 61.38%, (see Fig.1), 15.07, (see Fig. 3), and 12.50 (see Table 1), respectively.
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the admission rate to hospital and quarters is 4.00, the correspondingone to hospital only is 2.46, and the number ultimately sick is 60.28,of which 50.00 are in hospital, with 10.28 in quarters.
Example:
If the admission rate to hospital and quarters combined = 4.00
Then the admission rate to hospital only = 4.00 × 61.38 % *= 2.46
Also the sick in hospital and quarters = 4.00 × 15.07 ? = 60.28
And the sick in hospital only = 2.46 × 20.36 ? = 50.00
Or also the sick in hospital only = 4.00 × 12.50 § = 50.00
Then the sick in quarters only = 60.28 ? 50.00 = 10.28.* Figure 1. ? Figure 3. § Table 1.
D. ADMISSION RATES FOR OVERSEAS TROOPS.
14. Admission rates for seasoned and unseasoned troops. - Thereis not only more sickness among unseasoned than among seasoned troops,but also more sickness among seasoned troops living under war condi-
Fig. 14. -A. Comparative daily admission rates to hospital and quarters, from diseasesand nonbattle injuries per 1000 strength, seasoned and unseasoned AmericanTroops, under peace and war conditions. 2
B. Also their approximate relative magnitude, as shown by the scaleabove, where the rate for seasoned troops in the United States under peaceconditions is used as a standard at 100.
tions, than among such troops during peace. Fig. 14 shows the relativedaily admission rates per 1000 men under three sets of conditions. Therate in the United States during the years 1920 to 1926, inclusive, (raisedfrom 1.96 to 2.00 simply for convenience in calculating) is taken as abasis for the seasoned troops; the one for the army in Europe during 1918(excluding September and October) for seasoned troops under war conditions;and that for the troops in the United States during the same period (excludingSeptember and October) for unseasoned men.
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The comparison here is really between partially seasoned troops andraw, green ones. Troops such as followed General Pershing on the PunitiveExpedition into Mexico could more properly be called "seasoned."
15. Comparison of overseas and United States admission rates. - What experience can be used as a basis for estimating the probable requirementsfor overseas expeditions? The experience in the Philippine Islands duringthe Insurrection, in China during the Boxer Rebellion, and in Cuba duringthe first and second interventions, might conceivably be used for sucha purpose. Clearly though, it would not be logical to revert to the Spanish-AmericanWar or to the Civil War for experience upon which to base the present medicalexpectancy in the United States. With modern information in regard to thecauses and methods for the prevention of many infectious diseases, thereis little probability that we will have such rates as then occurred. Similarly,it is not reasonable to expect that there would be as much sickness amongoverseas troops as there was a number of years ago.
Can then the admission rates for troops in the United States be usedas a basis for estimating those among American troops of the same character,who may be serving in other countries? If this can be done, the expectedoverseas rates can be lowered as improved sanitation and better knowledgeof the causes and prevention of disease make it possible to reduce themin the United States. Let us then examine some comparative rates for UnitedStates troops serving in varied climates.
Fig. 15 shows the daily admission rates among American troops in theUnited States and certain overseas countries during three periods. It isapparent that there has been a very marked reduction in the admission ratesin each of the countries in question. But, as the rate has declined inthe United States, has there been a corresponding decline in the othercountries? Or, in other words, is there any stability in their relativestanding?
16. Relative standing of overseas and United States admission rates.- In answer to the question raised in the preceding paragraph, Fig. 16shows the relative standing of the admission rates in Fig. 15. For eachperiod, the rate in the United States is taken as a basis of comparisonat 100, and the relative standing of the others computed therefrom. Onesees that during the Philippine Insurrection there was almost 38 percentmore sickness in the Philippine Islands than among the troops in the UnitedStates at that time; from 1904-1908, approximately 30 per cent more; andfrom 1920-1926, an excess of almost 48 per cent. It is apparent that, althoughthe relationship varies, there is always more sickness among American troopsin the Philippine Islands than in the United States.
During the Boxer Rebellion in China there was 79 per cent more sickness,in our expeditionary force than among the troops in the United
24
States at the same time; and in 1920 to 1926, over 34 per cent more.From this one might reasonably infer that considerably more sickness wouldoccur among troops in China than in the United States.
Fig. 15. -Daily admission rates to hospital and quarters from diseases and non-battleinjuries per 1000 strength American troops in different countries at differentperiods.2
Using Fig. 16 as a basis, an approximate average of the comparativestanding of those rates is given in Fig. 17. Thus the approximate standingof the Philippine Islands is shown as 140, as compared with that of theUnited States at 100; whereas that of Europe is placed at 100 because itis assumed from the World War experience that among the same characterof troops there would be no more sickness in Europe than in the UnitedStates.
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Fig. 16. -Relative magnitude of, admission rates to hospital and quarters from diseasesand nonbattle injuries among American troops in different countries atdifferent periods, compared with that in the United States during eachperiod set as a standard at 100.
NOTE: Calculated from Fig. 15.
17. Influence of climate on admission rates. - Using the countries namedas a basis for estimating climatic influences, the lower part of Fig. 17shows the relative amount of sickness which will probably occur in temperateand tropical countries, under favorable and unfavorable conditions, ascompared with that in the United States. Thus it is assumed that in theconduct of warfare in the tropical zone, under the most favorable conditions,there will be 10 per cent more sickness than among the same kind of troopsin the United States, and under unfavorable conditions, 40 per cent more.It is also assumed that in temperate zones under favorable conditions therewould be no more sickness than in the United States; but, if the conditionsare unfavorable, as they would be in a densely populated country with anunhealthy civil population, or where it is difficult or impossible to sanitatethe area properly, the relative amount of sickness would be increased 30per cent.
26
Fig. 17. -A. Approximate Average relative magnitude of admission rates to hospitaland quarters from diseases and nonbattle injuries among American troopsin different countries under peace conditions, compared with that in theUnited States as a standard at 100.
B. Also the estimated relative magnitude of such rates in war in differentclimates under favorable and unfavorable conditions.
NOTE: Estimated from Fig. 16.
27
18. Combined effect of seasoning of troops and of climate. -We can then consider four major factors in estimating the probable amountof sickness, and consequently the requirements for medical service in anyoverseas country. First, the peace or war conditions; second the amountof seasoning of the troops; third, the character of the climate; and fourth,the general possibilities of efficient sanitation. The combination of thesefactors (the first two as given by Fig. 14 and the other two by the lowersection of Fig. 17), gives the result shown by the first section of Fig.18.
Three rates are given for the United States in Fig. 18: (a) the firstfor seasoned troops under peace conditions; (b) the second for seasonedtroops under war conditions; (c) the third for unseasoned troops underwar conditions. These rates when varied according to climatic conditions(Fig. 17 A) give those shown in the next four bars.
But average rates cannot be used as a satisfactory basis upon whichto estimate the requirements of a medical service. Consequently the averagerates are increased 37% (Figs. 10 and 11). The results are shown in thesecond section (B). From the second section it is only a step to the thirdone, which is computed from the second by multiplying each of the dailyadmission rates to hospital and quarters combined by 12.50,or the average days in hospital for each such daily admission.
The average of 12.50 days in hospital for each case admitted to hospitaland quarters combined is, however, less than our experience in the AmericanExpeditionary Forces (15.28. See Table 1) and also less than can be expectedin expeditionary forces. The actual increase in the admission rate to coverexpected variations in terms of the American Expeditionary Forces experienceis only 12% and not 37%; and is no more than is sufficient to provide forthe dispersion of patients when all of the fixed hospitalization is inthe rear areas.
Example:
Expected admission rate to hospital and quarters combined during a warin a foreign country in a temperate climate and under unfavorable conditions= 2.50
If 2.50 is increased 37% (or to 137%) it = 3.42
3.42 × 12.50 (see Table 1, Col. (7)) = 42.75
But the average duration of treatment for expeditionary forces is no longerthan in the United States (see Fig. 3). Reversing then the process
42.75 ÷ 15.28 (see Table 1, Col. (7)) = 2.80
2.80 ÷ 2.50 = 112%
The third section (C.) of this graph emphasizes the undesirability ofrushing unseasoned, troops into a war area, and especially so if such areais sanitarily unfavorable. If military necessity demands it, the sacrificemust be made, but the probable cost, should be recognized.
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Fig. 18. -Daily admission rates to hospital and quarters and noneffective rates inhospital from diseases and nonbattle injuries per 1000 strength Americantroops serving in different countries under different conditions.
NOTE: A. Calculated from Figs. 14 and 17. C. Calculated from B bymultiplying each rate thereon by 12.50 (see Table 1, p. 10).
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E. ADMISSION RATES FROM BATTLE CASUALTIES.
Many more days were lost from each case which was gassed in the AmericanExpeditionary Forces than from each one of disease and non-battle injury(Fig. 3); and more than twice as many days from each gunshot wound as fromeach gas casualty. Consequently, it is necessary to know what our experienceshows in regard to the number of men wounded under various conditions,and as the result of various degrees of military resistance.
Fig. 19. -Daily admission rates from battle injuries per 1000 men in the Union Armyduring the Civil War; and also in the U. S. Army in the Philippine Islandsduring the Philippine Insurrection.
Source of information: (a) Civil War.8 (b) Philippine Insurrection.29
19. Civil War and Philippine Insurrection. - Fig. 19 shows thedaily admission rates per 1000 of the total strength during the variousyears and the entire period of the Civil War, and in like manner of thePhilippine Insurrection. Since the character of future combat will probablybe quite different from that which occurred during the Civil War, the datafor that period are probably only of historical interest; but the averagedaily number of wounded during the Philippine Insurrection can be usedas a basis to estimate the number of casualties to be expected under likeconditions of warfare at the present time.
30
20. World War. - Fig. 20 shows the daily average number of woundedin the American Expeditionary Force: (a) by gas, (b) by gunshot missiles,and (c) by the two combined, arranged by months and by periods. The rates,which are based upon the total strength of the American Expeditionary Forces,probably furnish a very good basis upon which to estimate those for offensiveand defensive military operations against a first-class military enemy,when there is the same ratio of
Fig. 20. -Daily admission rates from gas and gunshot missiles separately and combined,per 1000 men in the total American Expeditionary Forces by months and alsoby periods.2
NOTE: The above admission rates are to hospital only.
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combat troops to those in the total forces. For similar data for combatDivisions, Corps, and the First American Army, see pp. 106 to 123.
The period from January 1 to April 30, was one of training in trenchwarfare. From May 1 to July 14 the training in trench warfare continuedwith some major active operations, including the Cantigny offensive andthe Chateau Thierry defensive. From July 15 to September 25 there werethe important offensives of the Marne, the Aisne-Marne and the St. Mihiel;also the first phases of the Somme, the Oise-Aisne, and the Ypres-Lys operations.From September 26 to November 11 the major offensive of the Meuse-Argonneoccurred, in addition to the later phases of the Somme, the Oise-Aisne,the Ypres-Lys, and the Puvenelle attacks.10 The greatest resistancewas encountered during the first 15 days of the Meuse-Argonne drive, whenthe average number of wounded per 1000 of the total American ExpeditionaryForces strength was 2.33 per day.
F. METHOD OF ESTIMATING THE CONSTANT INCREASEIN THE TOTAL SICK AND THE HOSPITAL POPULATIONS.
21. Basis of the method. - As shown by Fig. 4, the ultimate noneffectiverate is the product of the daily admission rate multiplied by the averagenumber of days lost by each ease. Since the average days lost include thoselost by cases remaining in hospital many days, as well as only a few days,it follows that for recently mobilized commands the ultimate noneffectiverate is not reached until the completion of the treatment of the long durationcases, or approximately one year after M day.
It is necessary then to find how the noneffective rate increases, especiallythat part in hospital, before an estimate can be made of the probable requirementsfor medical service and of the number of hospital beds which will be neededfor any command from time to time.
Those who are interested in the technical details of the process arereferred to pages 133 to 167. Briefly stated, the noneffectives increaseeach day by the addition of the incoming sick to those remaining from previousdays, and this increase continues until the number
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leaving equals the number coming on sick report. Fig. 21 shows how manyof any day's admissions (as for example, those of M day) continue sickfrom day to day. The basic material for this graph is from the experiencewith the white enlisted men in the United States during the years 1925-1927,inclusive,2 when the daily admission rate to hospital and quarterscombined was 1.8954 per 1000 men. One sees from the graph that the greaterpart of the cases leave the sick report in a very short time, and lessthan half of them are remaining at the end of the seventh day. At the endof 30 days, only .237 (1 in 8) of the original 1.8954 are remaining sick.Thereafter the cases leave more slowly, and a few remain at the end ofone year's time.
Fig. 21. -Daily reduction during one half day and the entire day in the number ofpatients in a group admitted on any one day.
NOTE: For basic formulae see Fig. 80, (1), p. 147.
Fig. 22 shows how a sick population builds up. The admissions of eachday are added to the number remaining from the preceding ones. Thus onthe first day after M day, the total sick consist of the day's admissionsplus the number remaining from M (A) day. On the tenth
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day after M (A) day, the total sick is the sum of the number of menadmitted that day plus those remaining from each of the preceding ninedays and the M day.
The net increase, in the total number of patients from day to day equalsthe remnant still remaining at that time from the original group admittedon M day. Consequently, the ultimate noneffective rate will not be reacheduntil the last of M day's cases have been eliminated from the sick report,either by return to duty, by death, or by discharge for disability. Afterthat time the number coming on sick report each day will be equalled bythe number leaving it.
Fig. 22. -Showing how the total number of patients from diseases and nonbattle in-juriesin the Zone of the Interior increase on each of ten days after mobilizationbegins (M day) when the daily admission rate is 1.895 per 1000. The lettersA to K are used to designate each days group of admissions (1.895) andthe continually decreasing num-ber of each individual group that remainsick from day to day.
NOTE: For basic data see Fig, 21.
FOOT NOTE: A hospital, or sick, population continues to increase untilthe stab-ilization point (see p. 31) is reached because new cases are admittedeach day. After a command is demobilized, no additional cases of diseasesor nonbattle injuries will occur; and after military combat ceases no morebattle casualties will be admitted. Thereafter then the hospital populationwill consist of cases remaining from the previous admissions until theyall leave hospital.
Thus in Figure 22, if there were no admissions after the fifth day, thecases would be:
On the sixth day 7.96 (9.86 - 1.895):
On the seventh day 7.12 (10.78 - 1.895 - 1.76).
In connection with Figure 28 (p. 41), let us assume that up to the ninetiethday, there is 1.00 admission per day from war gases, and that after thattime there is: (a) No more admissions, and (b) that 0.50 cases are admittedeach day. Then on the 120th day and thereafter the patients will be:
(a) With no admissions after 90 days | (b)With .50 admissions per day | ||||
Day | A. Day Specified | B. 90 days earlier (Fig. 28) | C. Patients remaining (A-B) | D. 90 Days | E. Patients |
120 | 39.63 | 22.24 | 17.39 | 11.12 | 28.61 |
150 | 40.74 | 32.41 | 8.33 | 16.20 | 24.53 |
180 | 41.28 | 37.30 | 3.98 | 18.65 | 22.63 |
210 | 41.53 | 39.63 | 1.90 | 19.81 | 21.71 |
240 | 41.66 | 40.74 | .92 | 20.37 | 21.29 |
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22. Total sick in United States. - a. Daily admission rateto hospital and quarters of 1.8954 per 1000, during 1925-1927. - Continuingthe study of the experience with the white enlisted men in the United Statesduring the years 1925 to 1927, Fig. 23 shows graphically how the noneffectiverate increases from day to day. The results are from the same basic processas illustrated by Figs. 21 and 22. Thus we start on M day with 1.8954 admissionsto hospital and quarters and on the fifth day after M day (see also Fig.22), the number of noneffectives in hospital and quarters is 8.85; on thetenth day, 13.16. The ultimate noneffective rate in hospital and quartersas shown by this graph is 30.69, and the one as calculated in the usualway by the formula on page 8 is 30.45.
Fig. 23. -Daily increase in the number of disease andnonbattle injury patients inhospitals and quarters in the United States, 1925 to 1927.
NOTE: For basic formula see Fig. 80 (1) p. 147.
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b. Daily admission rate to hospital and quarters of 1.00 per 1000,during the World War. - Fig. 23 can be used as a basis in calculatingthe number of sick at any time with any given admission rate, but to doso would require the division of the noneffectives as calculated for anyday by the basic admission rate of 1.8954. This can be done once for all,and the results be given on a unit basis. Then the ultimate noneffectiverate is 16.35, which was the average days for each such case among whitesoldiers during 1925-1927. The upper line on Fig. 24 shows this reducedto 15.07 to conform to the 1918 experience in the United States, when theaverage days for each ease in hospital and quarters was 15.07 (see Fig.3). It shows the total sick on any day from M to 360, when the daily admissionrate to hospital and quarters combined is 1.00 per 1000.
Fig. 24. -Daily increase in the number of disease and nonbattle injury patients inhospital and quarters, in hospital, and in quarters in the United Statesin 1918.
NOTE: For basic formula see Fig. 80, (3) p. 147.
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Since 61.38 % of the sick in the United States daring the World Warwere treated in hospital, for 1.00 admission to hospital and quarters combined,0.6138 was admitted to hospital only. The lower curve (Fig. 24) based uponthat admission rate therefore shows the noneffectives in hospital only.
The graph can be used in calculating the number of sick and also ofhospital patients to be expected in any command with any estimated basicadmission rate to hospital and quarters combined, provided the averageduration of treatment remains approximately the same. The difference betweenthe noneffectives shown on the upper line as total sick, and those on thelower line as sick in hospital, represents the sick in quarters.
Example: In a command of 10,000 men with an average daily admissionrate to hospital and quarters of 3.50 per 1000, the sick on the 90th daywould be
Sick in hospital and quarters =
13.78 (upper curve) × 3.50 × (10,000 ÷ 1000) = 482.3
Sick in hospital only =
11.35 (lower curve) × 3.50 × (10,000 ÷ 1000) = 397.3
Sick in quarters = 482.3 - 397.3 = 85It is assumed here that 61.38%of the admissions to sick reports are treated in hospital. Consequently,the 85 patients in quarters represent the accumulation from 38.62 % (100.00%- 61.38%) of 1.00 case each day.
It may be decided that 70% of all cases will be treated in hospital,and only 30% in quarters. Then the accumulation of patients in quarterscan be determined as follows:
85 : 38.62 :: X : 30.00
X= 66 patients in quarters under the conditions as above are treated there.
The hospital patients under the conditions as above are:
482.3 - 66= 416.3
c. Noneffectives in hospital in an increasing command. - To illustratethe use of Fig. 24, when there is an increasing command, let us assumethat it is necessary to find the number of hospital beds required at 15day intervals for a command, which after starting with 10,000 men on Mday in-creases by 10,000 every 15 days. Let us also assume that the dailyadmission rate to hospital and quarters combined is 3.50 per 1000, as itwas in the United States during 1918 (Sept. and Oct. excluded).
The detail work is shown by Fig. 25. The data (third line) from thelower curve, Fig. 24, when multiplied by the assumed rate of 3.50, givethe patients in hospital (fourth line) under the conditions as stated.The
37
most rapid increase in the number sick in hospital occurs during theearly weeks because the patients coming in during that period greatly exceedthose going out of hospital. Each 15 day group of men must then establishits own flow of patients in and out of hospital as has been done by thepreceding group; and each succeeding group has 15 days less to establishits hospital population. Then after 180 days, the first 10,000 will havea hospital population of 431 (Fig. 25, last column, fifth line) accumulatedduring 180 days, whereas the 10,000 that report on the 180th day have onlythe one day's hospital sick, or 21.
Fig. 25. -A method of computing the number of hospital patients in a Zone of theinterior command which is increasing 10,000 each 15 days, when the dailyadmission rate to hospital and quarters combined is 3.50 per 1000, as itwas in the U. S. in 1918 (excluding September and October).
The total beds, required at the end of each 15 day period, by all menthen in camp, are shown on the bottom line.
The total patients, including those treated in quarters, can be calculatedin like manner by using the data on the top curve of Fig. 24.
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23. Sick in hospital only in United States during the World War.As shown by Fig. 3, the average number of days spent in hospital in theUnited States by each case admitted thereto in 1918 was 20.36. One seesfrom Fig. 26 how the number of patients in hospital increases from 1.00to 20.36, when the daily admission rate to hospital only is 1.00 per 1000.
For method of estimating the number of patients with a diminishing admissionrate see page 33.
The noneffectives in hospital at any time can be calculated from eitherFig. 24 or Fig. 26; (a) by multiplying in the first instance by the admissionrate to hospital and quarters combined, and (b) in the second by the oneto hospital only.
Fig. 26. -Daily increase in the number of disease and nonbattle injury patients inhospital only in the United States, 1918.
NOTE: for basic formula see Fig. 82, (2) p. 149. When using this graph,the admission rate to hospital equals 16.38% of the admission rate to hospitaland quarters.
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Example: When Fig. 24 is used, the data on the bottom curve,show-ing the patients in hospital at any time, when the daily admissionrate to hospital and quarters combined is 1.00 per 1000, is multipliedby the assumed daily admission rate to hospital and quarters combined.It answers the question; How many patients will there be in hospital onthe 90th day after M day, when the daily admission rate to hospital andquarters com-bined is 3.50 per 1000 and the strength is 10,000?
Then 11.35 (bottom curve, Fig. 24) × 3.50 × (10,000 ÷1000) =397.3
Fig. 26 answers the question: How many patients will there be in hospitalon the 90th day after M day, when the daily admission rate to hospitalis 2.15 (61.38% of 3.50) per 1000, and the strength is 10,000?
Then, 18.49 (Fig. 26) × 2.15 × (10,000 ÷ 1000)=397.5
24. Hospital patients in the American Expeditionary Forces. -
a. Disease and nonbattle injury patients. - As shown by Fig. 3,page 7 the average days lost by each hospital patient sick from diseaseor non-battle injury in the American Expeditionary Force was 27.29. Fig.27 shows how the number of patients in hospital increases from 1.00 patienton M day to 27.29 on M plus 360 days.
A curve to show the total sick from disease and nonbattle injury inthe American Expeditionary Force, similar to the one for the United States(top curve, Fig. 24), can not be constructed because there are no experiencedata available.
When Fig. 27 is used, an admission rate to hospital only similar tothe one that occurred in the American Expeditionary Force must be computed;i. e., any admission rate to hospital and quarters combined must be reducedto 56 % of the total instead of to 61.38% as in the United States. Thuswith a daily admission rate of 3.50 per 1000 to hospital and quarters combinedin a command of 10,000, the hospital sick on the 90th day would be
25.08 (Fig. 27) × 1.96 (56% of 3.50) × (10,000 ÷1000) = 491.6
This number in hospital is much greater than the 397.5 in the UnitedStates under similar conditions (supra). Some of the probable reasonsare given on pages 7 and 8.
If it is assumed that the duration of treatment in the American ExpeditionaryForce was too great and that the average time lost by such cases couldbe reduced by better administration, the curve can be lowered proportionately.Thus, if we feel that the averaged duration of such cases can be reducedto 24 days and we require the data for the 90th day, then,
27.9 : 24 ::25.08 :X
X= 22.06
Then the hospital sick on the 90th day under the conditions as statedabove would be:
22.06 × 1.96 (56 % of 3.50) × (10,000 ÷ 1000)= 432.4
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This excess, over the figures for the United States, is probably nogreater than would be necessary, due to the greater distance of the hospitalsfor any expeditionary force from the troop area, battle front, etc.
Fig. 27. -Daily increase in hte number of Theater of Operations hospital patientsadmitted from diseases and nonbattle injuries.
NOTE: For basic formula see Fig. 84, (1), p.151. When using this graphthe admission rate to hospital equals 56% of the admission rate to hospitaland quarters.
b. Gas patients. - One sees from Fig. 3, that the average dayslost by each gas patient was 41.77. With a theoretical daily admissionrate of 1.00 per 1000 from gas injuries there would be 22.24 patients inhospital on the 30th day; 40.74 on the 150th day, etc. (Fig. 28). The methodof application is similar to that for the preceding graph. Thus the, numbersshown for the patients in hospital are multiplied by the anticipated admissionrate, and then by the number of men in thousands in the command. Admissionrates for gas patients, and also for gunshot patients (Fig. 20), are tohospital. For method of estimating the number of patients with a diminishingadmission rate see p. 33.
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Example: In a command with an average daily strength of 100,000and with an average daily admission rate from war gases of .35 per 1000,how many patients would be in hospital after 90 days of fighting.
Then, 37.30 (Fig. 28) × .35 × (100,000 ÷1000)= 1306.
Fig. 28. -Daily increase in the number of Theater of Operations hospital patientsadmitted for wounds by war (poisonous) gases.
NOTE: For basic formula see Fig. 87, (a), p. 154.
c. Gunshot cases. - Again referring to Fig. 3, it is noted thatthe average days per case for each gunshot injury in the American Expedition-aryForces was 94.84. With a theoretical admission rate of 1.00 per 1000 perday, we would then expect the ultimate noneffective rate to be 94.84 ×1.00= 94.84. From Fig. 29, it is apparent that the ultimate noneffective
42
rate is not reached until the 920th day, because of the long durationof cases of compound fractures of the long bones and other serious wounds.
The daily admission rate from gunshot wounds during the Meuse-Argonneoffensive was 1.10 per 1000 men in the total American Expeditionary Forces.With such a rate in a command of 150,000 men, the number of gunshot woundedpatients in hospital on the 150th day would be.
75.89 (Fig. 29) × 1.10 × (150,000 ÷ 1000)= 12,533 patients.
Fig. 29. -Daily increase in the number of Theater of Operations hospital patientsadmitted for woulds by gunshot missiles.
NOTE: For basic formula see Fig. 88, (a), (1), p. 155.
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d. Gas and gunshot cases. - Although separate graphs for gasand gunshot wounds are much more useful as a basis for estimating medicalrequirements (since there is but a slight possibility that they will occuragain in the same proportions as in the American Expeditionary Forces),one based on the experience there may be of interest. This is exhibitedin Fig. 30, which indicates how the number of patients wounded by gas andgunshot, when admitted in the same proportions as they occurred in theAmerican Expeditionary Forces, increases from day to day.
Fig. 30. -Daily increase in the number of battle injury cases in hospital in theAmerican Expeditionary Forces in 1918.
NOTE: For basic data see Figs. 28 and 29.
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Example: In a command with an average daily strength of 100,000and with an average daily admission rate of 1.25 per 1000 from war gasesand gunshot wounds combined in the same proportions as in the AmericanExpeditionary Forces, how many patients would there be in hospital from,these causes on the 120th day?
Gas patients =
12.48 (lower curve) ×1.25 × (100,000 ÷ 1000) = 1560
Gunshot patients =
47.11 (middle curve) ×1.25 × (100,000 ÷ 1000) = 5889
Gas & Gunshot patients =
59.59 (upper curve) ×1.25 × (100.000 ÷ 1000) = 7449
The percentage of the command in hospital would be,
7449 ÷ 100,000 = 7.45%.
c. Hospital cases from all causes in the American Expeditionary Forces.- Fig. 31 demonstrates how hospital patients accumulate under such conditionsas existed in the American Expeditionary Forces from July 1 to November11, 1918. One sees again the importance of battle injuries when convertedinto requirements for hospital beds. Starting out with a theoretical admissionrate of 1.65 per 1000 from diseases and nonbattle injuries, and with only1.00 per 1000 per day from gas and gunshot wounds combined in approximatelythe same proportions as they occurred in the American Expeditionary Forces,the number of patients of the last named group exceeded those of the firstnamed one in less than 45 days. At the end of one year there would havebeen only 45.03 per 1000 from diseases and nonbattle injuries as comparedwith 76.75 from battle wounds.
The curve shows approximately 105.00 per 1000, or 10.50%, in hospitalat the end of 130 days after July 1, or about November 11. At that timethere were between 9.0 and 10.0 per cent of the command in hospital inthe American Expeditionary Forces, in addition to a number who had beentransferred to the United States and then occupied hospital beds eitherin the United States or on ships enroute thereto.
After one year of such experience, as the American Expeditionary Forceshad in the Meuse-Argonne offensive, the number of hospital patients ineach 1000 men would be as follows:
Disease and nonbattle injury patients =
27.29 (Fig. 27) × 1.65 × (1000 ÷ 1000) = 45.03
Gas patients =
41.77 (Fig. 28) × .45 (Fig. 20) × (1000 ÷ 1000) =18.80
Gunshot patients =
92.82 (Fig. 29) × 1.10 (Fig. 20) × (1000 ÷ 1000)= 102.10
Total patients =
165.93
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The 165.93 per 1000 strength would be the actual number of patientsin hospital; and if only 10% is added for the dispersion of patients, thenumber of beds required would be 182.52 per 1000, or 18.25%, of the totalstrength of a force organized with the same proportion of combat and communicationszone troops as the American Expeditionary Forces.
Fig. 31. -Daily increase in the total number of American Expeditionary Forces patientsin hospital in 1918.
NOTE: For basic data see Figs. 27 and 30.
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25. Disposition of Zone of Interior cases in the United States.- After mobilization day in the Zone of the Interior, and the beginningof operations or of military combat in the Theatre of Operations, the numberof patients in hospital in either area gradually increases until the outflowof men from the hospital equals the inflow (Figs. 23 - 31).
A large proportion of the patients who enter the hospital from day today will recover and will be available again for military duty. A muchsmaller percentage of cases, who also recover after a more prolonged stayin hospital, will be incapacitated for further military duty on accountof a physical disability or chronic disease; still others will die in hospital.
Fig. 32 shows the constant changes among patients admitted to hospitalin the United States in 1918. Thus, 30 days after any group was admitted,19.69% were in hospital. 76.25% had returned to duty, 2.41% had died, and1.65% had been discharged as disabled. At the end of one year, only 0.02%were in hospital, 93.72% had returned to duty, 2.63% had died, and 3.63%had been discharged as disabled. Most of the deaths occurred during thefirst few weeks of treatment, but the majority of the disability dischargeswere later. The deaths and discharges referred to here include only thosewhich occurred among patients in hospital.
26. Disposition of Theater of Operations cases in the American ExpeditionaryForces. - Figs. 33 - 37 show the continuous change in the AmericanExpeditionary Forces. Thus, transfer to the United States was an AmericanExpeditionary Force disposition, even though such patients remained undertreatment after leaving there.
Table 2. -- Disposition ofany one group of American Expeditionary Forces patients in the AmericanExpeditionary Forces during one year following admission.
| Group | Died | Sent to U.S. including disability cases | Total losses c=a+b | In hospital at the end of one year. | Returned to duty. 100-(c+d) | From Fig. No. |
Disease & non-battle injuries | 3.70 | 7.52 | 11.22 | .00 | 88.78 | 33 |
Gas wounds | 1.73 | 9.08 | 10.81 | .01 | 89.18 | 34 |
Gunshot wounds | 8.12 | 29.58 | 37.70 | .42 | 61.88 | 35 |
Gas & gunshot wounds | 6.10 | 23.12 | 29.22 | .29 | 70.49 | 36 |
Total American Expeditionary Forces cases | 4.60 | 13.42 | 18.02 | .11 | 81.87 | 37 |
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Fig. 32. -Continuous change in the status of disease and nonbattle injury patientsin the United States.
NOTE: For basic formulae see:
Remaining in hospital, Fig. 82, (3), p. 149.
Deaths in hospital, Fig. 93, (1), p. 160.
Discharges for disability in hospital, Fig. 94, (1), p. 161.
Patients returned to duty equals difference between 100% and the sum ofthe three above.
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Fig. 33. -Continuous change in the status of disease and nonbattle injury hospitalpatients while in the American Expeditionary Forces.
NOTE: For basic formulae see:
Remaining in hospital, Fig. 86, (3), p. 153.
Return to duty, Fig. 90, (1), p. 157.
Deaths in hospital, Fig. 96, (3), p. 163.
Patients sent to the Zone of the Interior equals difference between 100%and the sum of the the three above.
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Fig. 34. -Continuous change in the status of gas patients while in the American ExpeditionaryForces.
NOTE: For basic formulae see:
Remaining in hospital, Fig. 87, (b), (2), p. 154.
Return to duty, Fig. 91, (1), p. 158.
Deaths in hospital, Fig. 97, (3), p. 164.
Patients sent to the Zone of the Interior equals difference between 100%and the sum of the the three above.
50
Fig. 35. -Continuous change in the status of gunshot patients while in the AmericanExpeditionary Forces.
NOTE: For basic formulae see:
Remaining in hospital, Fig. 88, (b), (2), p. 155
Return to duty, Fig. 92, (1), p. 159
Deaths in hospital, Fig. 98, (3), p. 165.
Patients sent to the Zone of the Interior equals difference between 100%and the sum of the the three above.
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Fig. 36. -Continuous change in the status of gas and gunshot patients while in theAmerican Expeditionary Forces combined in the same proportion as they occurredthere.
NOTE: For basic data see Figs. 34 and 35.
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Fig. 37. -Continuous change in the status of hospital patients while in theAmerican Expeditionary Forces, admitted for all causes and in the sameproportions as in the American Expeditionary Forces.
NOTE: For basic data see Figs. 33, 34, and 35.
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27. Total duration of treatment of Theater of Operations cases.- Figs. 33 - 37 show, among other items, the percentage of Theater of Operationscases remaining under treatment in the American Expeditionary Forces aftervarious periods of treatment. But the treatment of some of, the cases whichwere sent to the Zone of the Interior (United States) continued after transferfrom the American Expeditionary Forces. Consequently the total durationof treatment was greater than that shown by Figs. 33 - 37, which includeonly time spent in the American Expeditionary Forces. The total durationof treatment of American Expeditionary Forces cases is shown by Figs. 38- 40. These graphs are so closely associated with the question of the treatmentof Theater of Operations cases, both there and in the Zone of the Interior,that they are discussed in connection with that subject.
H. HOSPITAL CARE OF THEATER OF OPERATIONS PATIENTSIN THEATER OF OPERATIONS AND IN THE ZONE OF THE INTERIOR.
28. Character of patients to be sent to the Zone of Interior. - Hospitalpatients in the Theater of Operations who are permanently incapacitatedshould be returned to the Zone of the Interior as promptly as the interestsof the patients and the military situation will permit. Thus patients withpulmonary tuberculosis, those who are mentally unsound, and those who havesuch definite surgical disabilities as deformed or amputated limbs, oftencan be classified as disability cases very soon after entering hospital;while in other cases a more extended period of observation will be necessarybefore the ultimate result of treatment can be determined.
The return of patients to the Zone of the Interior reduces the hospitalizationrequirements in the Theater of Operations but correspondingly increasesthem in the Zone of the Interior. Inadequate hospital facilities, the scarcityof material from which they can be provided, proximity to the Zone of theInterior, or other reasons may make it necessary or desirable to send tothe Zone of the Interior patients who may be returned to duty eventually.Usually this will be undesirable from a military viewpoint because patientsreturning to duty from hospital are trained replacements, and a temporaryor permanent replacement must be supplied for every man who is sent awayfrom the Theater of Operations. Even when the lines of communication areopen and the distance between the Zone of the Interior and Theater of Operationsis not great, unnecessary time is lost when potential duty cases are sentto the Zone of the Interior, and then returned to the Theater of Operations.The nearer the hospitals are to the troop area, the less will be the averagetime lost by each hospital case. In addition to the unnecessary loss oftime in transit to and from the Zone of the Interior, there is also
54
always a probability that many patients who completely recover afterreturn to the Zone of the Interior will never return to the Theater ofOperations, or that their return will be greatly delayed.
To insure then that all Theater of Operations patients who recover willreturn to organizations there as promptly as possible, hospital facilitiesshould be provided for as large a percentage of cases as practicable, andthese hospitals should be as near to the active troop areas as the militarysituation will permit.
The unnecessarily high percentage of cases returned to the Zone of theInterior from the American Expeditionary Forces was due largely to thereturn of many recovered patients after the Armistice, who would ordinarilyhave been retained for duty in the Theater of Operations. If it is desiredto conserve the man power in the Theater of Operations our experience indicatesthat it will not be necessary to return to the Zone of the Interior, morethan 3% of the cases of diseases and nonbattle injuries, 6% of those woundedby war gases, and 20% of those wounded by gunshot missiles. These percentageswould be sufficient to cover the physically disabled and also the recoverycases requiring prolonged treatment, provided that the men sent to theTheater of Operations are selected physically. Obviously all physicallyunfit men who are sent to the Theater of Operations will have to be returnedto the Zone of the Interior. Thus during the years 1923-1927, when themen for overseas duty were not selected so carefully as during the WorldWar, 3.5% of all overseas disease and nonbattle injury hospital patientswere eventually discharged as physically disabled, as compared with 2%of the American Expeditionary Forces hospital cases. The percentage ofsuch cases from the American Expeditionary Forces who were eventually dischargedin the United States were: Diseases and nonbattle injury, 2%; gas wounded,4 %; and gunshot wounded, 15%.
29. Duration of hospital treatment of Theater of Operations patients.- a. Disease and nonbattle injury patients. (1) Percentage remainingin hospital. - As shown by Fig. 38, of the American Expeditionary Forcescases admitted for diseases and nonbattle injury, 47.39%, remained in hospitalmore than 15 days either there or in the United States; 28.26% more than30 days; and 12.39% more than 60 days.
(2) Relation to hospital beds required in Theater of Operations andin Zone of the Interior. - This graph answers the questions: (a) Whatpercentage of patients remain beyond a certain time, and (b) at what timeis there a certain percentage of patients remaining in hospital? Thus onthe 90th day of treatment 5.70% of the patients are remaining; similarly9% of all patients are remaining on the 72nd day of treatment.
The number of hospital beds required in the Theater of Operations andin the Zone of the Interior, when a certain percentage of the Theater ofOperations admissions are returned to the Zone of the Interior, can bedetermined from Figs. 27 and 38. Thus if 3% of the admissions from dis-
55
eases and nonbattle injuries are so returned, all cases averaging morethan 115 days will be included (Fig 38). This means then that the hospitalcurve in the Theater of Operations (Fig. 27) will become stabilized atthat time, for all cases averaging longer will be sent to the Zone of theInterior. Fig. 27 shows that on the 115th day the hospital curve has reached26.13 patients per 1000 men. This then is the number of patients to betreated in the Theater of Operations and the difference between 26.13 andthe total hospital cases under these assumed conditions (27.29) must beprovided for in the Zone of the Interior (1.16).
Similarly if 6% of admissions for diseases and nonbattle injuries areto be returned to the Zone of the Interior, all cases averaging more than88 days will be transferred, (Fig.. 38) on which day the hospital curvehas reached about 24.95 patients (Fig. 27). The difference between 27.29and 24.95, or 2.34, must be provided for in the Zone of the Interior.
Fig. 38. -Duration of treatment both in the Theater of Operations and Zone of theInterior of Theater of Operations disease and nonbattle injury patients.
NOTE: For basic formula see Fig. 84, (2), p. 151.
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b. Gas patients. - Fig. 39 shows what percentage of one day's groupof gas patients are remaining in hospital at different periods of time.The average duration of each case of disease and nonbattle injury in theAmerican Expeditionary Forces was 27.29, and of each gas case 41.77 (Fig.3). Consequently during the first few months a larger percentage of eachday's gas cases, than of disease and nonbattle injury ones, remain in hospital.Thus at the end of 30 days there is 46.50 % (Fig. 39) of gas cases remaining,as compared with 28.26% (Fig. 38) of those of disease and nonbattle injury;and at the end of 60 days, 21.96%, of the former and 12.39% of the latter.
If 6% of gas admissions are sent to the Zone of the Interior, all casesaveraging more than 115 days will be included (Fig. 39). Turning to
Fig. 39. -Duration of treatment both in the Theater of Operations and Zone of theInterior of Theater of Operations gassed patients.
NOTE: For basic formula see Fig. 87, (a), (2), p. 154.
Graduated points for the first 90 days altered very slightlyto agree with results on Fig. 34.
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Fig. 28, one sees that on that day the hospital curve reaches 39.35gas patients. This then is the number to be provided for in the Theaterof Operations under the assumed conditions, and 2.42, or the differencebetween 41.77 and 39.35, in the Zone of the Interior.
c. Gunshot patients. - The percentage of one day's group of gunshotcases remaining in hospital at different time intervals is shown by Fig.40. It appears from Fig. 3 that the average duration of each gunshot casein the American Expeditionary Forces was 94.84 days, as compared with 41.77for each gas case. Consequently a larger percentage of any one group ofgunshot cases are remaining at each time interval. Thus at the end of 30days, 66.00% (Fig. 40) of the gunshot admissions are remaining, as comparedwith 46.50% (Fig. 39) of the gas cases, and 28.26%
Fig. 40. -Duration of treatment both in the Theater of Operations and Zone of theInterior of Theater of Operations gunshot patients.
NOTE: For basic formula see Fig. 88, (a), (2), p. 155.
Graduated points for the first 105 days altered slightlyto agree with results on Fig. 35.
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(Fig. 38) of the disease and nonbattle injury ones. Similarly at theend of 60 days, 45.05% of the gunshot cases, 21.96% of the gas cases, and12.39% of the disease and nonbattle injury admissions are remaining.
If, as previously suggested, 20% of all gunshot admissions are sentto the Zone of the Interior, all cases averaging more than 151 days willbe so transferred. Turning to Fig. 29 it appears that on that day the hospitalcurve reaches approximately 76.07 patients. This then is the number tobe provided for in the Theater of Operations and the difference between94.84 and 76.07, or 18.77, must be cared for in the Zone of the Interior.
30. Percentage of Theater of Operations patients sent to the Zoneof the Interior in relation to hospital beds required in each area.- It obviously would be impracticable to adhere rigidly to a program ofsending any definite percentage of Theater of Operations cases of variouskinds to the Zone of the Interior, but if the effort is made to conservethe strength of the military forces in the Theater of Operations by providinga sufficient number of hospital beds there and by returning to the Zoneof the Interior only such cases as will be physically unfit for furthermilitary duty, or whose treatment will be unduly prolonged, the percentagesuggested can be approximated. To repeat, this means the return to theZone of the Interior of 3% of all. admissions for diseases and nonbattleinjuries, 6% of all those wounded by gases, and 20% of all wounded by gunshotmissiles.
Of the cases transferred to the Zone of the Interior, some will remainin hospital, while others will be disposed of by return to duty in theZone of the Interior, discharge for disability, or death.
a. Disease and nonbattle injury patients. - Fig. 41 shows (uppercurve) the total number of Theater of Operations patients sick from diseaseand nonbattle injuries in hospital at different intervals of time, when1.00 per 1000 strength is admitted each day. It also shows how many ofsuch patients are in hospital in the Theater of Operations and also inthe Zone of the Interior when 9%, 6%, or 3% are returned to the Zone ofthe Interior for treatment. For the purpose of this study all cases arecounted as in the Zone of the Interior as soon as they leave the Theaterof Operations, and the number of beds required in the Zone of the Interiorfor Theater of Operations cases includes those occupied on troop ships.
Under each set of conditions, the number of patients in the Zone ofthe Interior is necessarily the difference between the total number andthose remaining in the Theater of Operations. From these data it is easyto calculate like data for any similar set of conditions. Thus, supposeit is decided to return to the Zone of the Interior 411 cases of diseasesand non-battle injuries averaging more than 60 days in hospital. Turningto Fig. 38 we find that this will include 12.39% of all such admissions,which is the percentage remaining on that day. From Fig. 27 we see thaton the 60th day the hospital curve has reached 22.49 patients, Which isthe number to be treated in the Theater of Operations under the assumedset of
59
conditions, and the difference between 27.29 and 22.49, or 4.80, isthe number to be cared for in the Zone of the Interior.
Fig. 41.* -Number of Theater of Operations patients from diseases and nonbattle injuriesin hospital in the Theater of Operations and Zone of the Interior, whencertain percentages of the Theater of Operations admissions are sent tothe Zone of the Interior.
*NOTE: For basic formula see:- (a) Total patients in hospital, Fig.84, (1) p. 151. (b) Patients in hospital in American Expeditionary Forces(Theater of Operations) only, when 9% are sent to the Zone of the Interior,calculated from (a) and (b). (d) Patients in hospital in Zone of the Interioronly are the differences between total patients (a) and those in Theaterof Operations (b) and (c).
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To calculate the number of beds required at different periods in eacharea, find the number of times that 3% is contained in 12.39%; i.e., thepercentage remaining in hospital on the 60th day, and multiply the datafor the 3% assumption (Fig. 41) by the quotient (12.39 ÷ 3 = 4.13).The following table shows the calculation in detail:
Table 3. - Disease and nonbattleinjury Theater of Operations patients in hospital at the end of each month,when the daily admission rate is 1.00 per 1000 total American ExpeditionaryForces strength; the number of those in hospital in the Zone of Interior,when either 3% or 12.39 % of all admissions are sent there; and the numberin the Theater of Operation hospitals when the latter percentage has beentransferred.
A. | B. | C. | D. | E. |
0 | 1.00 | 0. | 0. | 1.00 |
The differences between the ultimate numbers calculated as in the Theaterof Operations (22.42) and in the Zone of the Interior (4.87), and thoseshown on p. 59 (22.49 and 4.80) are small and are the result of using the.decimals to only the second place.
b. Gas patients. - Fig. 42 shows the number of patients for whomhospital beds must be provided in the Theater of Operations and the Zoneof the Interior when 1.00 patient wounded by war gases per 1000 strengthis admitted each day, and 9%, 6%, or 3% of such admissions are returnedto the Zone of the Interior for further. treatment. The method of calculatingdata for different percentages is the same as that shown by Table 3.
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Fig. 42.* -Number of Theater of Operations patients from gas injuries in hospitalin the Theater of Operations and Zone of the Interior, when certain percentagesof the Theater of Operations admissions are sent to the Zone of the Interior.
*NOTE: For basic formula see (a) Total patients in hospital, Fig. 87, (a),(1) p. 154. (b) Patients in hospital in the American Expeditionary Forces(T. of O.) only, when 9% are sent to the Zone of the the Interior, Fig.87, (b), (1), p. 154. (c) Patients in hospital in the American ExpeditionaryForces (T. of O.) only, when 3% or 6% are sent to the Zone of the Interior,calculated from (a) and (b). (d) Patients in hospital in Zone of the Interioronly are the differences between total patients (a) and those in Theaterof Operations (b) and (c).
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Fig. 43.* -Number of Theater of Operations patients from gunshot injuries in hospitalin the Theater of Operations and Zone of the Interior, when certain percentagesof the admissions are sent to the Zone of the Interior.
*NOTE: For basic formula see:
(a) Total patients in hospital, Fig. 88, (a), (1), p.155
(b) Patients in hospital in A. E. F. (T. of O.) only when 30% are sentto Z. of I., Fig. 88, (b), (1), p. 155
(c) Patients in hospital in A. E. F. (T. of O.) only when 10% or 20% aresent to Z. of I., calculated from (a) and (b).
(d) Patients in hospital in Z. of I., only are the differences betweentotal patients (a) and those in T. of O., (b) and (c).
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c. Gunshot patients. - In like manner Fig. 43 shows the numberof gunshot patients for whom hospital beds must be provided in the Theaterof Operations and Zone of the Interior, when 1.00 patient per 1000 strengthis admitted each day, and when 30%, 20%, or 10% of all such admis-sionsare sent to the Zone of the Interior. The data for other percentages tobe sent to the Zone of the Interior can be calculated as shown by Table3.
d. Total of Theater of Operations patients. - (1) With constantrates and constant strength. - The following table shows: (1) the patientsin hospital in the Theater of Operations and Zone of the Interior whenthe admissions from diseases and, nonbattle injuries, gas, and gunshotinjuries are each 1.00 per 1000 strength per day, and when 3%, 6%, and20% respectively of each class of cases are sent to the Zone of the Interior;and (2) the same as above but with approximately the same admission ratesas there were in the American Expeditionary Forces from July 1 to November11, 1918.
Table 4. - (1) Patients per1000 Theater of Operations strength in hospital in the Theater of Operationsand Zone of Interior when 1.00 per 1000 Theater of Operations strengthis admitted each day from each cause, and the specified percentages aresent to the Zone of Interior.
A Days of Operation in | B Disease and non-battle injury patients when 3%are sent to Z. of I. | C Gas Patients when 6% are sent to Z. of I. | D Gunshot patients when 20% are sent to Z. of I. | |||
In | In | In | In | In | In | |
0 | 1.00 | 0. | 1.00 | 0. | 1.00 | 0. |
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Table 4. - (2) Patients per 1000 Theater of Operationsstrength in hospital in the Theater of Operations and Zone of the Interiorwhen 1.65 from diseases and nonbattle injuries, .3148 from gas wounds and.6852 from gunshot wounds per 1000 Theater of Operations strength are admittedeach day, (or approximately the same rates as occurred in the AmericanExpeditionary Forces from July 1 - November 11, 1918) and the specifiedpercentages are sent to the Zone of the Interior.
E | F | G | H | I F + G + H | ||||
In | In | In | In | In | In | In | In | |
0 | 1.65 | 0. | .3148 | 0. | .6852 | 0. | 2.65 | 0. |
Under the conditions as assumed, at the end of 360 days there wouldbe 107.00 patients per 1000 strength in hospital in the Theater of Operations,and 14.77 in the Zone of the Interior, a total of 121.77. If 10% increaseis allowed for dispersion of patients, the bed requirements would be 117.70in Theater of Operations and 16.25 in the Zone of the Interior, a totalof 133.95 per 1000, or 13.40%.
With a force of 1,900,000 men as there was in the American Expedi-tionaryForces, and under approximately such conditions as existed there from July1 to November 11, 1918, the bed requirements at the end of a year, witha 10% dispersion factor for safety, would be 254,499, with 223,630 in theTheater of Operations and 30,869 in the Zone of the Interior.
If these same conditions had continued there would have been a slightthough continued increase in the bed requirements after 360 days and untilthe 920th day, due to the prolonged treatment required for gunshot cases.On the 920th day, the total beds required would have been 107.59 in theTheater of Operations and 15.57 in the Zone of the Interior, or a totalof 123.16 per 1000 Theater of Operations strength. With 10% increase fordispersion of patients these figures would have been 118.35 in the Theater
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of Operations and 17.13 in the Zone of the Interior, or a total of 135.48beds per 1000 strength.
With military combat of the same intensity as there was during the Meuse-Argonneoffensive from September 26 - November 11, 1918, when
Fig. 44. -Method of computing the total hospital patients to be expected in a Theaterof Operations command under approximately the same conditions as therewas in the American Expeditionary Forces in 1918, with a material increasein the strength each month, and where the daily admission rate to hospitalonly from disease and nonbattle injuries was 1.65; from war gases, 0.24; and from gunshot missiles, 0.53 per 1000 strength.
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the admission rate (see Fig. 20) from gas .45, from gunshot missiles1.10, and from diseases and nonbattle injuries 1.65 per 1000 Theater ofOperations strength, the number of beds required for Theater of Operationspatients in the Theater of Operations and Zone of Interior at the end of360 and 920 days when 3% of diseases and nonbattle injuries, 6% of
Fig. 45. -Method of computing for a command in the Theater of Operations the hospitalpatients to be treated in the Theater of Operations when: (a) Thereis an increasing strength; (b) admissions from both battle and nonbattlecauses; (c) and certain percentages are sent to the Zone of the Interiorfor further treatment.
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Fig. 46. -Method of computing the Theater of Operations hospital patients to be treatedin the Zone of the Interior when certain percentages of patients are senttherefrom a command in the Theater of Operations, where there is an increasingstrength, and where there are admissions from both battle and nonbattlecauses with the same rates as there were in the American ExpeditionaryForces in 1918.
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gassed cases, and 20% of gunshot cases are sent to the Zone of Interiorwould be as follows:
Table 5. - Beds required forTheater of Operations patients as per preceding paragraph.
Kind of cases | At the end of 360 days | At the end of 920 days | ||||
T. of O. | Z. of I. | Total | T. of O. | Z. of I. | Total | |
Diseases and nonbattle injuries | 43.08 | 1.95 | 45.03 | 43.08 | 1.95 | 45.03 |
Gas wounds | 17.69 | 1.10 | 18.79 | 17.69 | 1.10 | 18.79 |
Gunshot | 82.76 | 19.34 | 102.10 | 83.70 | 20.62 | 104.32 |
Total | 143.53 | 22.39 | 165.92 | 144.47 | 23.67 | 168.14 |
10% increase | 157.88 | 24.63 | 182.51 | 158.92 | 26.04 | 184.96 |
(2) With constant rates but an increasing strength. - It willbe necessary quite often to estimate the number of quite often to estimatethe number of Theater of Operations patients to be hospitalized eitherthere or in the Zone of the Interior when there is an increasing strength.The details of the method of computing the data, are shown by Figures 44,45, and 46.
The method is the same as that outlined (supra) for Figure 25,the principal difference being that in Figures 44-46, there are three causesof admissions considered, whereas in Fig. 25 there is only one.
I. TOTAL HOSPITAL BEDS REQUIRED IN THE ZONEOF THE INTERIOR
It has been estimated on page 18, that 6% of hospital beds should beprovided in mobilization camps such as existed in the United States during1918. The 30,869 Theater of Operations patients (see page 64) to be caredfor on transports and in the Zone of the Interior beds means 1.9% in termsof the strength in the United States in October, 1918. If we can assumethat .4% are in transit, 1.5% remain to occupy Zone of Interior hospitalbeds, which raises the total required there to 7.5%.
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