Medical Statistics of the United States Army, Calendar Year 1953
CHAPTER III
Discussion of Specific Disease and Injury Conditions
ACUTE RESPIRATORY INFECTIONS
During 1953 the acute respiratory infections (acute upper respiratory infection, acute bronchitis, influenza, and pneumonia) were the leading cause of admission of U. S. Army troops to medical treatment facilities. The admission rate for all acute respiratory infections was 130 per 1,000 average strength. The chief contributor was the acute upper respiratory infections (common cold, acute pharyngitis, acute tonsillitis, etc.), with an admission rate of 96 per 1,000. Influenza and pneumonia each accounted for 12 admissions per 1,000 strength, while acute bronchitis accounted for 10 per 1,000. The incidence rate for all acute respiratory infections was 136 cases per 1,000, of which 100 cases per 1,000 were due to acute upper respiratory infection, 11 per 1,000 to acute bronchitis, 12 per 1,000 to influenza, and 13 per 1,000 to pneumonia.
As a group, these conditions accounted for almost 200,000 admissions to hospital and quarters, or 1 out of every 3 admissions from disease in 1953.
Although acute respiratory infections occur throughout any given calendar year, the incidence of these conditions is ordinarily the highest during the first 3 months of the year (January-March) and during the last 3 months (October-December). In any given year, roughly 2 out of every 3 acute respiratory cases reported occur during this 6-month period. For this reason the period from October of one year through March of the following year is arbitrarily referred to as the respiratory disease season.
The first sizable outbreak of acute respiratory infections among Army troops during the 1952-53 respiratory disease season occurred in November 1952. By January 1953 (the peak month for 1953), the incidence of common respiratory diseases (acute upper respiratory infection and acute bronchitis) and influenza among Army troops world-wide had exceeded 400 cases per 1,000 strength per year. This is the highest annual incidence rate for common respiratory diseases and influenza among U. S. Army troops during any month in nearly a decade. (The monthly incidence data used in this discussion of acute respiratory infections are from morbidity reports (DD Form 442).)
The reported incidence of clinically diagnosed influenza worldwide during January 1953 was 68 cases per 1,000 per year, which was also the highest such rate in the Army for any month in recent years. As a result of this and other recent experience with influenza and influenza-like diseases, the three military services in the fall of 1953 broadened their program designed to control the spread of influenza and influenza-like diseases. The program was made ap-
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plicable to oversea areas with climates favorable to increasing the risk of contracting these diseases. By 15 November 1953 all military personnel in these areas had been immunized against influenza. Replacements to such areas during the period November 1953 through March 1954 were also required to be immunized against influenza. In addition, during the same period, specified installations of each military service collected a minimum of two blood serum specimens each week from respiratory disease cases and forwarded these to designated laboratories for influenza detection studies.
While the peak levels of the acute respiratory infections for Army troops stationed in the continental United States and for Army troops overseas were not markedly different, there was a marked difference in the level of incidence during the succeeding months (after January, the peak month). (See chart J, which is based on morbidity report data.)
Peak pneumonia incidence rates were higher among Army troops in the United States than among those overseas. In January, when pneumonia incidence was at its highest, the rate for troops in the United States was nearly twice that for troops overseas. In the total Army in 1953 there were approximately 20,000 reported cases of all forms of pneumonia. Of these, 8,000 were diagnosed as primary atypical pneumonia, 5,000 as lobar pneumonia, 5,000 as bronchopneumonia, and 2,000 as other or unspecified pneumonia. The incidence of primary atypical pneumonia remained relatively high among Army troops in the United States throughout 1953.
In 1953 there were 18 deaths due to pneumonia other than primary atypical pneumonia. There were no deaths due to primary atypical pneumonia or to other acute respiratory infections.
SELECTED RESPIRATORY AND RELATED CONDITIONS
In addition to the acute respiratory infections, there are several other disease conditions of particular interest that are spread by way of the respiratory system. Among these are the following: measles, rubella (German measles), epidemic parotitis (mumps), streptococcal sore throat, scarlet fever, and ?other diseases of the respiratory system? (class X). (Respiratory tuberculosis is excluded.)
During 1953 these six disease conditions accounted for 22,325 admissions and were responsible for the loss of more than a quarter of a million man-days. Half of these days lost were due to ?other diseases of the respiratory system? (class X). There were, however, very few deaths in 1953 due to any of these conditions. In fact, only 11 deaths were reported, all of which were due to diseases in class X (pleurisy, pulmonary congestion, etc.).
Of these six conditions, rubella was?from the standpoint of numbers of admissions?by far the most important. In 1953 rubella was responsible for 9,535 admissions, or 43 percent of the total number of admissions for the group. A large number of admissions (over 1,500) was reported during each of the 3 months, February, March, and April. The admission rate for all Army troops
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for the calendar year was 6.2 admissions per 1,000; the incidence rate was 6.3 cases per 1,000.
By far, the largest proportion of cases of rubella reported during 1953 occurred among troops in the continental United States. Over half of the cases overseas occurred among troops in the Caribbean. A large part of the difference in the rubella incidence rate for the United States and that for overseas is due to the greater number of recruits among troops in the United States. Various studies of respiratory disease incidence among military populations have indicated that the incidence of these conditions is usually much higher among recruits than among seasoned troops.
TUBERCULOSIS
Although tuberculosis has a low incidence, it is a prime cause of manpower loss?both temporary and permanent and, with its long average duration of hospital stay, can impose a heavy workload upon the medical service. Tuberculosis (all forms) contributed less than 0.3 percent of the total disease admissions in 1953, but accounted for nearly 6 percent of the noneffectiveness from disease, and more than 7 percent of the disability separations due to all diseases during the year.
Tuberculosis incidence in 1953, as in 1951 and 1952, was one case per 1,000 average strength per year. Incidence exceeded admissions by 20 percent in 1953. For pulmonary tuberculosis the admission rate increased 10 percent over the average rates for 1951 and 1952; however, a 30 percent decrease in the rate for all other tuberculosis resulted in a 3 percent decrease in the total tuberculosis admission rate. For every 100 new tuberculosis admissions, in both the pulmonary and nonpulmonary forms, 7 patients were readmitted for treatment.
Pending resolution of its disease classification, pulmonary infiltration of undetermined cause has been included among tuberculosis admissions. This diagnosis accounts for about 10 percent of the total admissions for tuberculosis and had an average duration of 69 days. This is less than one-fourth the duration for tuberculosis, all forms. All dispositions for pulmonary infiltration, cause undetermined, were to duty. The inclusion of this diagnosis, therefore, tends to lower the average duration for tuberculosis admissions and to increase the percentage of cases recorded as duty dispositions.
The admission rate in continental United States (1.10 per 1,000) was higher than the rate overseas (0.83 per 1,000). Generally, tuberculosis admission rates were highest during the first four months of the year. In the Far East, the August rate of 1.60 per 1,000 average strength per year was more than twice the rate of 0.77 for the entire year. This was due to the discovery of the disease among repatriated American prisoners of war during ?Operation Big Switch.?
Tuberculosis mortality in 1953 declined substantially to reach a level two ?thirds of the low levels experienced in 1951 and 1952?0.8 per 100,000 compared
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with a 1951-52 average of 1.2 per 100,000 average strength per year. This low mortality rate is influenced by the fact that deaths among tuberculosis cases separated from the Army are not included in the mortality count.
The length of hospital stay for tuberculosis was the longest among all disease admissions. The average duration for tuberculosis, 299 days per admission, was 23 times the total disease average of 13 days.
Almost three-fifths of all tuberculosis dispositions during 1953 were disability separations and over 90 percent of the 1,333 disability separations were for respiratory tuberculosis. The disability separation rate for 1953 (0.87 per 1,000) was 90 percent greater than the corresponding 1952 rate (0.46 per 1,000). This difference, accounted for by an increase in temporary disability retirements, was probably in large measure the outgrowth of a regulation directing that patients requiring prolonged hospitalization, whose return to duty is contraindicated, be separated from the Army and transferred to Veterans? Administrations hospitals.1
One-eighth of the disability separations due to tuberculosis, all forms, were cases who had presumably incurred the disease prior to entry into the Army (EPTS cases). Most EPTS cases were released relatively soon after the disease was discovered; 65 percent had had less than six months of service and 80 percent less than one year at time of admission. Only 17 percent of the disability separations among non-EPTS cases were for personnel in service under one year at time of admission.
MALARIA
With the end of the Korean Conflict in 1953, the incidence of malaria in the U. S. Army declined considerably, falling almost to the low level prevailing at about the beginning of hostilities in 1950. In 1953 Korea was still one of the focal centers of malaria among Army troops, but to a lesser degree than earlier in the Korean Conflict.
The admission rate in 1953 for malaria among U. S. Army troops was 1.1 admissions per 1,000 average strength. Of the 1,755 admissions, over 80 percent were admitted during the 6-month period, May through October, with peak monthly admission rates of 2.3 per 1,000 average strength per year in May and in June, and 2.4 in July. Counting admissions, readmissions, and cases admitted for other diagnoses but in which malaria existed concurrently or was diagnosed subsequent to admission, the incidence rate for malaria was 1.4 cases per 1,000 in 1953.
Troops in the Far East and in the continental United States furnished the majority of the Army cases. In the Far East the admission rate in 1953 was 2.3 admissions per 1,000 average strength, the highest monthly admission rates being 5.1, 4.8, and 4.3 per 1,000 per year in May, July, and August, respectively. The cases among troops in the United States represented returnees from the Far East.
__________
1AR 40-680, ?Length of Hospitalization and Disposition of Patients,? 7 April 1952.
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In Korea, malaria was a problem for military medicine among U. S. Army occupation troops in 1946-49, and then again during the Korean Conflict. The transmission of the disease to American troops was due to the presence of a highly parasitized civilian population in Korea coupled with abundant anopheline mosquito vectors. The cessation of hostilities, the use of the drugs chloroquine and primaquine, and the continuing removal of troops with latent malaria from Korea on rotation to other areas or as evacuee patients dropped the admission rate in Korea to 1.8 per 1,000 in 1953, less than a fifth of what it had been earlier.
The long latent interval characteristic of Korean vivax malaria and the discontinuance of chloroquine suppression among Army personnel upon their departure from Korea created a potential reservoir of infection, which was reflected in delayed primary attacks of malaria among Army troops transferred from Korea to Japan, or returned to the United States, Hawaii, or the Caribbean. The admission rate in 1953 was 3.8 admissions per 1,000 in Japan, 0.9 in the United States, and 3.9 in Hawaii and in the Caribbean. As the program of true causal prophylaxis with primaquine became increasingly effective, these rates began to decline.
The average duration for all admissions from malaria was 11 days per case (see source table 16). This figure, computed by the method described in the appendix, would be decreased to 9 days if, as is sometimes done, the duration figure were expressed as days lost per admission or readmission; i.e., days per episode of treatment for the condition.
INFECTIOUS HEPATITIS
Infectious hepatitis continues to be a disease of military importance, chiefly from the viewpoint of the size of its admission rate and the amount of time lost from military duty by U. S. Army personnel acquiring the disease. Although infectious hepatitis was reported in large numbers among Army troops in World War II, the incidence of this disease has declined markedly, and in 1953 was the lowest since the end of World War II.
During 1953 the rate of admission of Army personnel to medical treatment facilities for infectious hepatitis was 2.4 admissions per 1,000 average strength. The incidence rate was only slightly higher: 2.5 cases per 1,000. In all, there were 3,675 admissions to hospital and quarters on an excused-from-duty status due to infectious hepatitis. There were an additional 138 cases diagnosed among Army personnel admitted for other diagnoses, making a total of 3,813 cases of the disease. As in the past, there were considerably more cases of infectious hepatitis reported in 1953 among Army troops stationed overseas than among Army personnel in the continental United States, the admission rate overseas also being much the higher: 3.6 admissions per 1,000 overseas as against 1.2 admissions per 1,000 in the United States.
The three areas in which the incidence of infectious hepatitis was particularly high in 1953 were Europe, the Far East (particularly Japan), and the
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Caribbean. The incidence of the disease in Alaska was low, as it has usually been. The rate of admission for infectious hepatitis in Europe in 1953 was 3.6 admissions per 1,000, 4.1 in the Far East as a whole, 4.9 in Japan, 3.6 in Korea, and 3.7 in the Caribbean. The rate in Korea was the lowest there since the beginning of the Korean Conflict; the incidence of the disease in Korea had been exceptionally high in 1950 and 1951. Because of the importance of the disease, the Army continued to operate two hepatitis centers overseas, one in Germany and one in Japan.
There were only five deaths from infectious hepatitis in the Army in 1953. The case fatality was thus extremely low.
Almost a quarter of a million man-days were lost to the Army in 1953 from infectious hepatitis, the average case losing 64 days. The time lost by patients with infectious hepatitis constituted a fifth of all the time lost due to all of the infective and parasitic diseases, being exceeded in this category only by the days lost due to tuberculosis.
The number of cases of serum hepatitis, which is clinically similar to infectious hepatitis and sometimes difficult to distinguish, was very small. The numbers and rates quoted above for infectious hepatitis exclude cases diagnosed as serum hepatitis, which is included under the category ?accidents, violence, and poisonings,? where it is so classified by the International Statistical Classification of Diseases, Injuries, and Causes of Death.
DYSENTERY AND RELATED CONDITIONS
This group of intestinal diseases, including dysentery, amebiasis, food infection, food poisoning, salmonella infections, and brucellosis, is of great potential importance to the military forces. Formerly these diseases were a serious health problem in the Army, as in the civilian population. Today, however, they are rarely fatal and are of relatively low incidence, becoming somewhat more prevalent whenever troops are engaged in wartime field operations. The current low incidence of these intestinal diseases in the Army is largely a direct result of the constant application of effective measures of sanitation control and preventive medicine.
In the Army in 1953 there were 2,005 admissions from this group of infections commonly arising in the digestive tract, yielding an admission rate of 1.3 admissions per 1,000 average strength. The rate of admission from these diseases was higher among Army troops overseas (rate of 1.5 per 1,000 strength) than for those stationed in the continental United States (1.2 per 1,000), as might be expected.
During 1953 almost 1 in every 3 admissions due to these infections commonly arising in the digestive tract was a case of dysentery. Of these, bacillary dysentery was the most commonly diagnosed type, for there were 265 admissions from bacillary dysentery, 25 from amebic dysentery, 175 from other protozoal dysentery, and 185 unspecified as to type of etiological agent. Altogether these accounted
for a total of 650 dysentery admissions (rate of 0.4 per 1,000 strength).
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Approximately half of the admissions from infections commonly arising in the digestive tract were cases of food infection and food poisoning (excluding cases of food infection due to salmonella). Of the two, the cases of food poisoning were far more common in 1953, accounting for 860 of the 905 food infection and food poisoning admissions. Staphylococcus toxin was the chief offender among these food poisoning cases.
Amebiasis accounted for roughly one-fifth of the admissions from infections commonly arising in the digestive tract. As previously noted in the discussion of dysentery, there were 25 admissions for amebic dysentery in 1953. In addition to this one type of amebiasis, there were many other cases of infection, ulcer, colitis, or hepatitis caused by amebae. Altogether there were 405 amebiasis admissions in 1953 (0.3 per 1,000 average strength).
Salmonella infections of the digestive tract were rare (only 70 cases) in the Army in 1953, with typhoid and paratyphoid cases comprising less than one-fifth of the salmonella infections.
Diarrhea of unknown cause, as well as diseases of the digestive system (class XIII, which includes such diseases as gastritis, colitis, gastroenteritis, enteritis, and enterocolitis), are discussed at another point in this report.
VENEREAL DISEASE
Venereal disease is no longer the military problem it was 10 or 15 years ago. Advancements in medical science and education, augmented by the character guidance program of the Army, have greatly reduced noneffectiveness resulting from venereal disease. The antibiotics have made it possible to treat most venereal disease patients in the Army today on an outpatient basis, that is, on a duty status rather than on an excused-from-duty status. The total number of days lost to the Army because of venereal disease during 1953 was less than 1 percent of the total days lost because of all disease. In the years just prior to World War II, the corresponding proportion averaged 18 percent.
Venereal disease rates in the source tables of this report, like the rates for other disease conditions, include cases carded for record only. For most disease conditions, however, such cases represent only a small fraction of the total number of reported cases. On the other hand, all new cases of venereal disease treated on a duty (outpatient) status are required by regulation to be carded for record and reported. Since the close of World War II, the bulk of all venereal disease patients have been carded for record only; i.e., treated on a duty status. In 1953, venereal disease cases carded for record accounted for 95 percent of all venereal disease cases in the Army.
For the Army, worldwide, there were only 4,805 venereal disease cases admitted to hospital or quarters for treatment on an excused-from-duty status in 1953. There were an additional 2,484 cases of venereal disease diagnosed among patients admitted for other disease or injury conditions. The number of carded-for-record-only venereal disease cases was 94,215. The incidence rate for all venereal disease (including carded-for-record-only cases) in the
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Army in 1953 was 66.2 cases per 1,000 strength, about 10 percent lower than the corresponding rate in 1952. In general, the incidence rate was considerably higher overseas than in the continental United States.
The greatest proportion of patients treated for venereal disease were treated for gonorrhea, which accounted for almost 80 percent of all venereal disease cases reported in the Army. Chancroid was the second largest cause for illness from venereal disease, accounting for almost 20 percent of all venereal disease cases. This disease had not been of any great importance in the Army until large numbers of troops were stationed in the Far East, where the disease is endemic. The incidence of syphilis in the Army has declined almost steadily since World War II.
EPIDEMIC HEMORRHAGIC FEVER
The year 1953 represents the third year in which epidemic hemorrhagic fever has been reported among United States Army troops in Korea. The first case of the disease was reported by the Far East Command in June 1951, although subsequent reports indicated that the first case had actually occurred in April 1951. Prior to 1951 the disease was relatively unknown to western military medicine, although it had been described earlier in Japanese and Russian medical literature. Many of the symptoms of epidemic hemorrhagic fever have characteristics previously identifiable with other diseases endemic or prevalent in Korea, such as louse-borne (epidemic) typhus, leptospirosis, malaria, scarlet fever, influenza, etc. (A more detailed description of what is currently known about this disease entity is presented in a technical bulletin published by the Army Medical Service?TB MED 240, ?Epidemic Hemorrhagic Fever,? 5 May 1953.)
In 1953 there were several hundred cases of epidemic hemorrhagic fever reported among United States Army personnel. Practically all of these cases were admitted to medical treatment in Korea, there having been only a small number of cases first diagnosed in Japan or discovered among Army troops aboard transports returning them to the United States from the Far East.
Since it is presumed that all of the recorded cases of epidemic hemorrhagic fever noted to date among Army troops were acquired in Korea, the incidence of this condition is best measured by relating the total number of cases to the Army strength in Korea rather than to the worldwide Army strength. Thus the 1953 incidence rate for epidemic hemorrhagic fever among Army troops in Korea was 1.9 cases per 1,000 average strength, about half the rate in 1951 and 1952.
From the time the disease was first reported among Army troops in Korea in the late spring of 1951 to the end of 1953, a total of over 2,000 Army cases had been reported, with an overall case fatality of about 6 percent; that is, out of every 100 American soldiers contracting epidemic hemorrhagic fever in Korea, 6 have died. Epidemic hemorrhagic fever therefore ranks high among the more serious of the infective and parasitic diseases because of its relatively
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high case fatality rate. Possibly more important is the fact that the number of deaths due to epidemic hemorrhagic fever represented a substantial fraction of all deaths due to all infective and parasitic diseases in the total Army in 1953.
As was the case in 1951 and 1952, the incidence of epidemic hemorrhagic fever continued to exhibit two distinct seasonal peaks, one during the early summer months (the so-called spring-summer phase) and one during the fall months (the fall-winter phase). The etiological agent, vector, reservoir, and mode of transmission of epidemic hemorrhagic fever are not known at the present time. Available evidence tends to implicate chiggers (trombiculid mites) as the vector, whose prevalence in spring and fall corresponds approximately to the two seasonal peaks in incidence of the disease that have been regularly observed among Army troops in Korea.
Most of the statistical data concerning epidemic hemorrhagic fever presented in the tables of this report are subject to some sampling error due to the relatively small number of cases involved in the sample, and therefore such data should be used with caution.
SELECTED INFECTIVE AND PARASITIC DISEASES
The group of diseases shown in the source tables as ?Infective and Parasitic Diseases? corresponds to the group so labeled in the International Statistical Classification of Diseases, Injuries, and Causes of Death. Like that group, it includes all infective and parasitic diseases except certain acute respiratory infections, enteritis, rheumatic fever, and certain localized infections, all of which are classified in other groups.
The more important infective and parasitic diseases are discussed under specific topics in other sections in this report. These include tuberculosis, venereal disease, malaria, infectious hepatitis, and epidemic hemorrhagic fever. Certain other diseases, such as typhoid fever, dysentery, and food infection and poisoning, are covered under ?Dysentery and related conditions?; while others, such as scarlet fever, measles, rubella, mumps, and streptococcal sore throat, are dealt with in ?Selected respiratory and related conditions.?
The incidence of the specific infective and parasitic diseases referred to above (130,631 cases) comprised 88.4 percent of the incidence of all infective and parasitic diseases in 1953 (147,730 cases). Data for the remainder are presented in table XIII.
Because of certain problems associated with the use of sample data for low incidence diseases, discussed in the appendix of this report, these data on morbidity due to the subject conditions may be better evaluated by making some comparisons with incidence data separately compiled from another source, the Morbidity Report (DD Form 442). Incidence data from individual medical records are based almost entirely on a 20 percent sample; therefore, such data for disease categories of low frequency are especially affected by sampling error. On the other hand, incidence data based on the Morbidity Report, a recurrent summary report, in some instances represent tentative or working diagnoses, rather than the final diagnoses as shown on the individual medical record sub-
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Diagnostic category | Incidence | Deaths | Separations for disability |
Selected infective and parasitic diseasesb | 17,099 | 55 | 107 |
Meningitis, meningococcal | 196 | 12 | - |
Vincent's infection | 566 | - | - |
Relapsing fever | - | - | - |
Spirochetal jaundice (Weil's disease) | 1 | - | - |
Poliomyelitis, acute | 90 | 16 | 1 |
Encephalitis, infectious, acutec | 55 | 7 | - |
Smallpox | 5 | 1 | - |
Chickenpox | 1,356 | - | - |
Dengue | - | - | - |
Infectious mononucleosis | 1,922 | 1 | - |
Typhus (tick and mite-borne)d | 5 | - | - |
Schistosomiasis | 245 | 2 | 2 |
Filariasis | 5 | - | - |
Ankylostomiasis (Hookworm) | 1,621 | - | - |
Ascariasis | 1,016 | - | - |
Worm infestation, n.e.c. | 1,152 | - | - |
Dermatophytosis | 5,384 | - | 12 |
Coccidioidomycosis | 112 | 5 | 6 |
Scabies | 827 | - | - |
Other | 2,541 | e11 | f86 |
aExcept for a small number of cases which were secondary diagnoses in battle casualty admission, which are based on a complete count, the incidence data are based on a 20 percent sample of individual medical records. Deaths and separations are based on complete files of individual medical records.
bExcludes tuberculosis, venereal disease, malaria, infectious hepatitis, epidemic hemorrhagic fever, dysentery and related conditions, measles, rubella, mumps, scarlet fever, and streptococcal sore throat.
cExcludes lymphocytic choriomeningitis. Twenty of this disease are included among the 75 cases shown in the source tables based on the tabulations of individual medical records.
dThere were no cases of louse-borne or flea-borne typhus.
eDistributed by cause as follows: meningococcal infection, n.e.c., 6; bacterial infection, n.e.c., 2; fungus infection, n.e.c., 1; infective and parasitic disease, n.e.c.,2.
fSarcoidosis was the cause of separation in 67 of these cases.
mitted upon disposition of the patient. For disease categories in table XIII showing less than 100 cases and for certain other diseases appearing in residual categories, this is how the two sources compare with respect to incidence:
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| Diagnostic category | Tabulations of individual medical records | Morbidity Report (DD Form 442) |
Diphtheria | 5 | 5 |
Tetanus | - | 1 |
Gas bacillus infection | 17 | 3 |
Relapsing fever | - | - |
Spirochetal jaundice (Weil?s disease) | 1 | 4 |
Poliomyelitis, acute | 90 | 150 |
Encephalitis, infectious, acutea | 55 | 57 |
Smallpox | 5 | 4 |
Dengue | - | 1 |
Pappataci fever (sandfly fever) | - | 3 |
Typhus (tick and mite-borne)b | 5 | 4 |
Rickettsial infection, n.e.c.c | - | 15 |
Filariasis | 5 | 5 |
aExcludes lymphocytic choriomeningitis. Twenty cases of this disease are included among the 75 cases shown in the source tables based on the tabulations of individual medical records.
bThere were no cases of louse-borne or flea-borne typhus.
cQ Fever, rickettsialpox, etc.
Leprosy, anthrax, psittacosis, and plague are some of the other important low incidence diseases in which there may be special interest. These did not appear as separate, specific categories for regular reporting on the Morbidity Report. In the tabulations of individual medical records, including deaths, no cases of these diseases were shown for 1953. Unlike cases of many other diseases, almost all cases of discovered leprosy in Army experience have terminated in disability separation of the patient. Among disability separations during 1953, four were reported as due to leprosy. Three of these separations were admitted for leprosy in 1953 and one in 1952, but none appeared in the 20 percent sample.
Based on individual medical records, the incidence of the selected infective and parasitic diseases exceeded admissions by 29 percent. This excess was 9 percent for meningococcal meningitis; 23 percent for Vincent?s infection; 20 percent for dermatophytosis; 10 percent for scabies; and for worm infestations the incidence was more than twice the number of admissions.
Mortality from the selected group of diseases was disproportionately higher than that from the other infective and parasitic diseases. Although the incidence for the selected group was only 11.6 percent of the incidence of all infective and parasitic diseases in 1953, the 55 deaths due to the selected conditions represent 52.4 percent of the mortality from all infective and parasitic diseases, or 7.8 percent of the mortality from all disease, in 1953.
Sarcoidosis, included above in the residual category ?Other,?2 was the chief single disabling cause (67 disability separations in 1953), accounting for
__________
2Though of unknown etiology, this disease is included In the Infective and Parasitic Disease group in accordance with the International Statistical Classification.
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62 6 percent of the total disability separations for these selected infective and parasitic diseases in 1953. The incidence of sarcoidosis in the total Army during 1953 was 180 cases, or 0.12 per 1,000 average strength per year; but the rate among Negro personnel was 0.59 per 1,000, as compared to 0.05 per 1,000 for other personnel.
The selected conditions accounted for 23 percent of the noneffectiveness from all infective and parasitic diseases, with dermatophytosis causing almost one-fourth of the noneffectiveness.
Based on dispositions made during 1953, the average length of stay in medical facilities for admissions due to these diseases (22 days per admission) was significantly longer than that for the other infective and parasitic diseases (9 days per admission), with acute poliomyelitis (4 months per admission) and meningococcal meningitis and acute infectious encephalitis (2 months per admission each) showing the longer average durations.
NEOPLASTIC DISEASES
The neoplastic diseases were not of great importance in the Army in 1953 when considered in terms of temporary manpower loss through noneffectiveness or permanent loss by reason of disability separation. This group of diseases accounted for only about 2 percent of the admissions to medical treatment facilities for disease, 3 percent of the days lost, and 2 percent of the disability separations for all disease conditions during 1953. The neoplasms, however, constituted one of the most important causes of mortality. More than one-quarter of all deaths from disease in the Army in 1953 was due to tumors, largely malignant tumors, and neoplastic conditions of the lymphatic and hematopoietic tissues.
Malignant Neoplasms and Neoplastic Conditions of the Lymphatic and Hematopoietic Tissues
With improvements in the control of the communicable and other diseases, malignancies have come to account for an increasing proportion of deaths among Army personnel. In 1920, only 3.0 percent of all disease deaths in the Army were from malignant conditions. In 1930, the proportion was 11.6 percent, and in 1940 it had risen to 14.2 percent. During 1950-52, cancer caused 21.3 percent of the deaths from disease in the Army and by 1953, the proportion had reached 25.8 percent.
The increase in the relative importance of the malignant neoplastic conditions as a cause of death in the Army is not an indication of any increase in the mortality rate from this group of diseases. In 1920, for example, the crude death rate from cancer, 13.8 per 100,000 average strength per year, was slightly higher than the probability of dying from this disease group in 1953 (11.2 per 100,000 per year). The increased relative importance of this group results from reductions in. the mortality rates achieved with other diseases.
Since physical screening prior to induction in the Army results in the re-
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jection of some Selective Service registrants already suffering from cancer, the Army incidence rate of 0.41 per 1,000 average strength in 1953 may be considered to reflect the approximate rate at which new cases of cancer occur in a population composed principally of young men. It is only approximate (and is probably, in this sense, somewhat overstated) because some of the cases included in the recorded incidence were, in fact, cases which existed prior to entry into service and were presumably not detected at time of entrance examination. The Army mortality rate from the malignancies, however, considerably understates the fatality for such population inasmuch as the more serious cases ordinarily are separated for disability and die elsewhere. During 1953, for example, there were almost as many disability separations due to malignant neoplasms and neoplastic conditions of the lymphatic and hematopoietic tissue (169) as there were deaths from these conditions (172).
Histologically, 260, or 54 percent of the malignant neoplasms, were carcinomas (about a fifth of these adenocarcinomas); an additional 30 percent were distributed about equally among sarcomas, tumors of the nerve tissues, dysgerminomas and teratomas, and melanomas; the remaining 16 percent consisted of other miscellaneous histological types.
The Joint Armed Forces Statistical Classification and Basic Diagnostic Nomenclature established a histological classification for the reporting of neoplasms. The anatomical site (taken as the site of primary origin of the tumor, where known, and otherwise the site involved) is coded as supplementary information. Inasmuch as statistics on cancer morbidity and mortality by anatomical site are of considerable interest, a distribution of the admissions and deaths from malignant neoplasms by anatomical site is presented in table XIV, separately by rank and race.
Almost one-half (45 percent) of the cancer admissions involved a relatively accessible site, i.e., a site for which the diagnosis can be made either visually or through other routine physical examination. The probability of survival for personnel with cancer of these sites, i.e., buccal cavity, skin, eye, breast, testis, and rectum is, generally, much greater than for cases with cancer of the relatively inaccessible sites (i.e., stomach, lung, etc.) and for cases with neoplastic conditions of the lymphatic and hematopoietic tissues. This observation is substantiated from an examination of the ultimate dispositions of the admissions for cancer during 1953. Among the admissions for a malignancy of an accessible site (the aforesaid 45 percent), 74 percent were returned to duty. Only 33 percent of the admissions for cancer of inaccessible sites were so disposed of. Further, of the former group, only 2 percent died, whereas 20 percent of the admissions for cancer of inaccessible sites resulted in death while in the Army.
Of the 117 deaths from malignant neoplasms during the year, 73 were from carcinomas (about two-fifths of these being adenocarcinomas), 12 due to sarcomas, 8 from melanomas, 7 due to tumors of the nerve tissue or related structures, 5 deaths ascribed to dysgerminoma and teratoma, and the remainder (12) were distributed among other histological types.
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Anatomical site | Percent of total | Total | Rank | Male enlisted | ||
Officers | Enlisted | White | Negro | |||
Admissions | ||||||
Total | 100.0 | 0.38 | 0.78 | 0.34 | 0.36 | 0.28 |
| Malignant neoplasms | 78.8 | .30 | .71 | .26 | .28 | .18 |
| Buccal cavity and pharynx | 17.8 | .07 | .10 | .06 | .07 | .05 |
| Digestive organs and peritoneum | 5.9 | .02 | .07 | .02 | .02 | - |
| Stomach | .8 | .00 | - | .00 | .00 | - |
| Other | 5.1 | .02 | .07 | .02 | .01 | - |
| Respiratory system | 7.6 | .03 | .17 | .02 | .01 | .03 |
| Lung and bronchi | 1.7 | .01 | .03 | .00 | .00 | - |
| Other | 5.9 | .02 | .14 | .02 | .01 | .03 |
| Genito-urinary system | 16.1 | .06 | .17 | .05 | .06 | - |
| Testis | 8.5 | .03 | .03 | .03 | .04 | - |
| Other | 7.6 | .03 | .14 | .02 | .02 | - |
| Skin | 13.6 | .05 | .14 | .04 | .05 | .02 |
| Brain | 6.8 | .03 | - | .03 | .03 | .03 |
| Other | 11.0 | .04 | .06 | .04 | .04 | .05 |
| Neoplastic conditions of lymphatic and hematopoietic tissues | 21.2 | .08 | .07 | .08 | .08 | .10 |
| Hodgkin's disease | 11.0 | .04 | .04 | .04 | .05 | .03 |
| Leukemia | 6.8 | .03 | .03 | .03 | .02 | .05 |
| Other | 3.4 | .01 | - | .01 | .01 | .02 |
| Deaths | |||||
Total | 100.0 | 11.2 | 33.1 | 8.9 | 9.2 | 6.6 |
| Malignant neoplasms | 68.0 | 7.6 | 25.7 | 5.7 | 5.8 | 4.6 |
| Buccal cavity and pharynx | 1.2 | .1 | 1.4 | - | - | - |
| Digestive organs and peritoneum | 23.1 | 2.6 | 7.4 | 2.1 | 2.2 | 1.6 |
| Stomach | 6.4 | .7 | 2.0 | .6 | .7 | - |
| Other | 16.7 | 1.9 | 5.4 | 1.5 | 1.5 | 1.6 |
| Respiratory system | 16.9 | 1.9 | 5.4 | 1.5 | 1.7 | .5 |
| Lung and bronchi | 14.0 | 1.6 | 4.7 | 1.2 | 1.4 | .5 |
| Other | 2.9 | .3 | .7 | .3 | .3 | - |
| Genito-urinary system | 8.1 | .9 | 4.7 | .5 | .4 | 1.0 |
| Testis | 5.8 | .7 | 3.4 | .4 | .3 | .5 |
| Other | 2.3 | .2 | 1.3 | .1 | .1 | .5 |
| Skin | 4.7 | .5 | 2.0 | .4 | .3 | - |
| Brain | 5.8 | .7 | 2.7 | .4 | .3 | 1.0 |
| Other | 8.2 | .9 | 2.1 | .8 | .9 | .5 |
| Neoplastic conditions of lymphatic and hematopoietic tissues | 32.0 | 3.6 | 7.4 | 3.2 | 3.4 | 2.0 |
| Hodgkin's disease | 5.8 | .7 | 4.7 | .2 | .3 | - |
| Leukemia | 18.6 | 2.1 | 2.0 | 2.1 | 2.2 | 1.5 |
| Other | 7.6 | .8 | .7 | .9 | .9 | .5 |
51
Although cancer was responsible for less than 1 percent of the total days lost from disease conditions, this relatively small amount of noneffectiveness was due solely to the low incidence of the disease, for the average duration per case was considerable. Thus, an admission for a malignant neoplasm required, on the average, 110 days of treatment, while the neoplastic conditions of the lymphatic and hematopoietic tissues remained in a medical treatment facility for 157 days. The average durations of such cases eventually separated for disability were even greater: 206 days for malignant neoplasms and 214 days for neoplastic conditions of the lymphatic and hematopoietic tissues.
Benign Neoplasms
More than half (55 percent) of the total incidence of nonmalignant tumors in the Army in 1953 was accounted for by cases of pilonidal cyst. These cases, which occurred primarily among white enlisted personnel under 29 years of age, were admitted for inpatient treatment at a rate of 3.23 per 1,000 average strength per year and contributed 122,000 days lost during 1953. This is almost half the noneffectiveness due to all neoplastic diseases combined, and approximately twice the time lost from duty due to cancer.
The therapeutic approach with respect to pilonidal cyst cases during the year was largely in the direction of operative repair as evidenced from the statistics presented in table XV.
Type of operation | Total admissions | Type of disposition (percent of total admissions) | Average days lost per admission | ||
Duty | Disability separation | Other dispositions a | |||
Total | 4,995 | 97.4 | 1.8 | 0.8 | 25 |
With no operation | 1,660 | 94.9 | 5.1 | - | 8 |
With operation | 3,295 | 98.6 | .2 | 1.2 | 30 |
Excision | 1,705 | 97.7 | .2 | 2.1 | 38 |
Incision and drainage | 1,310 | 99.6 | - | .4 | 18 |
Marsupialization | 245 | 100.0 | - | - | 46 |
Other | 35 | 100.0 | - | - | 36 |
a No deaths due to pilonidal cyst were reported.
As indicated in the table, two-thirds of the new admissions for pilonidal cyst were surgical cases during 1953, more than half of these operations consisting of an excision of the cyst. Although cases that underwent surgery spent about four times as long in the hospital as did those who received conservative treatment, less than two in every 100 of the former cases were permanently lost to the Army as compared with five of every 100 cases treated conservatively. This disparity, however, may largely be the result of case
52
selectivity; that is, for cases with a long history of noneffectiveness due to pilonidal cyst, and whose condition existed prior to entering the service, a decision might have been made to separate these individuals directly rather than perform an operation when the possibility of a return to duty was remote. Of supplementary interest is the fact that among the 150 cases readmitted during the year, 95?or 63 percent?required an operation (largely an excision of the cyst).
Excluding pilonidal cyst, about 30 percent of the admissions for benign neoplasms were for tumors located in the upper extremities or the abdomen. The following is a percentage distribution of the admissions for benign neoplasms (excluding pilonidal cyst) by anatomical location:
Percent | Percent | ||
Total | 100.0 | Upper extremities | 14.3 |
Head | 3.4 | Thorax | 4.7 |
Ear | 2.5 | Abdomen | 15.5 |
Eye | 2.0 | External genitalia | 3.2 |
Face | 10.8 | Other | 25.7 |
Neck | 5.4 | Unknown | 12.5 |
When considered alongside the other major disease groups, the neoplastic diseases were a relatively minor problem in the Army during 1953. Further, as long as the Army remains at its present level and composition (e. g., a relatively young population constantly replenished by new inductees), neoplasms should continue to have only a minor effect upon Army health.
PSYCHIATRIC DISORDERS
With the end of the Korean Conflict in 1953, it was evident that the rates of admission for mental, psychoneurotic, and personality disorders for the entire Korean period were well below the levels that might have been anticipated on the basis of the experience of World War II. Worldwide, an average of less than 15 psychiatric admissions was reported for every 1,000 Army personnel during 1953. This represents a 9 percent reduction of the 1952 rate (approximately 16 per 1,000); a 42-percent reduction of the 1951 rate (25 per 1,000). These total psychiatric rates include the psychoses, for which the admission rates remain relatively constant through the years. Preventive psychiatry, increased emphasis on outpatient treatment, the influence of mental hygiene clinics, intensified application of the principles of combat psychiatry based on World War II experience?each of these and other factors have helped to reduce the inpatient medical workload of nonpsychotic psychiatric disorders.3
Nevertheless, the scope of the psychiatric problem in the Army continues to be large. Despite the reduction of admission rates for psychiatric dis-
__________
3Neuropsychiatric disorders are among the conditions whose mode of treatment in recent years has undergone a noticeable shift in emphasis from inpatient to outpatient treatment. This has occurred to such a degree that any analysis limited to inpatient cases (plus the relatively few outpatient cases that are carded for record) is necessarily incomplete. Evidence of the recent increase in neuropsychiatric outpatient treatments is the rate per 1,000 total Army strength for 1953 (123 per 1,000), as contrasted with the corresponding 1952 rate (102 per 1,000) (Army personnel in Army facilities).
53
CHART K.?RECENT TRENDS IN PSYCHIATRIC DISORDERS, U. S. ARMY, 1951, 1952, AND 1953
orders, this class of diagnoses (including psychotic disorders) was in 1953: the eighth leading cause of admissions among all classes of disease and nonbattle injury; third among all classes with respect to the average duration of stay reported for its cases; the fourth leading cause of noneffectiveness in the Army; first among causes of disability separations.
That this class of mental disorders will require continuous attention is demonstrated by the following: Were the psychotic and psychoneurotic disorders to be reduced to minimal incidence, along with the disorders of intelligence and the transient personality disorders, there would still remain the formidable number of ?character and behavior? disorders that always represent a challenge to ingenuity of military medicine. In 1953, a year during which less than 7 months were months of active hostilities, nearly 10,000 admissions were reported for the character and behavior disorders (rate: 6.4 per 1,000). This total included 3,260 admissions for pathological personality (2.1 per 1,000); 2,175 admissions for emotional instability (1.4 per 1,000); 1,835 admissions for aggressiveness (1.2 per 1,000); and 1,010 admissions for chronic alcoholism (0.7 per 1,000). These figures are limited to admissions; if secondary diagnoses are included in the count, the number of character and behavior cases is seen to have exceeded 12,000.
Admissions
By diagnostic groups, the most prominent causes of admission among the mental, psychoneurotic, and personality disorders in 1953 are shown in
54
chart L. Among the various commands, the rates for individual diagnoses varied. In the continental United States, for example, psychotic disorders occurred at a rate of 2.7 per 1,000?more than twice the oversea admission rate (1.26 per 1,000). Alcoholism, 0.27 in continental United States, was reported at a rate of 1.07 per 1,000 abroad. The common personality disorders, the psychoneuroses, and schizophrenic reactions repeatedly figure in the disorders reported from most areas. In contrast to these diagnoses, the paranoid and other psychoses, transient personality disorders, and drug addiction occur less often.
CHART L.?ADMISSIONS FOR PSYCHIATRIC DISORDERS, U. S. ARMY, 1953
Inferences with regard to rank, sex, race, or age differentials within this class of disorders must be circumspect because of the differences in size of the respective population groups. During 1953 about 65 percent of the total Army strength was in the 20-24 age interval, in contrast to 7 percent under 20 years of age, 12 percent between 25 and 29 years, 7 percent 30-34 years, 5 percent 35-39 years, etc. Accordingly, any generalization based on experience in the under-20 age group?where psychiatric admissions totaled 2,595?would be less reliable than a corresponding inference based on the 12,680 admissions reported for the 20-24 age group.
With these qualifications in mind, one can, nevertheless, note certain contrasts in the experience of the different groups. Among officers, for example, 26 percent of the psychiatric admissions were for character and behavior disorders (rate: 2.03 per 1,000), whereas 45 percent of the psychiatric admissions among enlisted personnel were for character and behavior disorders (rate: 6.83). Psychoneurotic disorders comprised 55 percent of the psychiatric ad-
55
missions for officers (rate: 4.29) in contradistinction to 37 percent for enlisted personnel (rate: 5.63).
Although only 500 admissions among women were reported for the mental, psychoneurotic, and personality disorders during 1953, this figure represents a rate of 33.8 per 1,000, as compared with a rate of 14.4 per 1,000 (21,910 cases) for male personnel. Of the 500 admissions among females, 290 were for psychoneurotic disorders, predominantly anxiety reaction without mention of somatic symptoms.
For Negroes, the total class rate was somewhat higher than for white personnel (18.5 per 1,000; 14.0 per 1,000), although racial differences for the various diagnoses were not substantial.
Even with the allowance made that the under-20 age component comprises only 7 percent of the total Army strength, the class V rate for this component is relatively high (23.2 per 1,000). With a strength of about 112,000, this age group had 2,595 admissions for psychiatric disorders?including 1,465 character and behavior disorders. Secondly, with respect to age differentials, the rate for alcoholism shows a well-defined pattern of increase with age: 0.15 (20-24 years); 0.65 (25-29); 1.90 (30-34); 2.74 (35-39); 5.30 (40-44); 8.07 (45-49). There were no admissions of alcoholism among personnel under 20 years of age, and the ?50 and over? age group reflected only 25 admissions (rate: 2.9 per 1,000).
Disposition and Duration of Stay4
Approximately 70 percent of the dispositions of mental, psychoneurotic, and personality disorder admissions are return-to-duty dispositions.5 Few deaths occur from these conditions; about 17 percent are separated from service because of disability; 12 percent receive other types of separations. The average duration for psychiatric admissions during 1953 was 47 days.
As one would expect, the psychotic disorders exhibit the longest length of stay: schizophrenic disorders (149 days, on the average); other psychotic disorders (74 days). Psychoneurotic disorders averaged a 34-day duration; transient personality disorders, 29 days; disorders of intelligence, 28 days; character and behavior disorders, 27 days. Thus, the character and behavior disorders, foremost among the psychiatric diagnoses in terms of admissions, tend to have a shorter duration of stay than any of the remaining subclasses (psychotic disorders, psychoneurotic disorders, transient personality disorders, disorders of intelligence). Pathological personality, a diagnosis prominent among the causes of admission, showed in 1953 an average duration of 30 days per case.
When the different types of disposition of psychiatric cases are considered separately, it is seen that the cases that eventuate in disability separation
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4Data on disposition or duration reflect only those cases disposed of during 1953 for which the cause of admission was a psychiatric disorder.
5Of total dispositions among psychotic disorders, 22 percent were return-to-duty dispositions; of nonpsychotic psychiatric dispositions, 78 percent were returned to duty.
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represent the most conspicuous problem with respect to any attempt to reduce length of stay. Duty (and AWOL) dispositions average 23 days per disposition; disability separations average 144 days per case.6
Noneffectiveness
Noneffective rates reflect two factors: the number of cases; the average duration of cases. Accordingly, psychiatric disorders, eighth among classes in terms of admissions and third among classes in terms of duration of stay, ranked fourth among the leading causes of noneffectiveness?or time lost from duty?in the Army during 1953. Were not a continual effort being made to treat psychiatric cases on an outpatient basis wherever feasible, the contribution of class V to total noneffectiveness would have been even greater during the year than the average daily noneffective rate registered? 1.77 per 1,000 strength. An important component of the total psychiatric noneffective rate?and one that contributes significantly to loss of time by psychiatric disorders?is the psychotic component. (See chart K.)
Disability Separations
No more dramatic morbidity index can be found among the measures of the psychiatric problem in the Army than the rate of disability separations reported for the mental, psychoneurotic, and personality disorders.
A total of 4,134 disability separations for psychiatric disorders occurred during 1953?23.2 percent of the total separations for all nonbattle causes (17,748). Thus psychiatric disorders constituted the leading cause of disability separations. Most of the 4,134 separations were without severance pay (2,495), indicating a large percentage of cases in whom the psychiatric disorder existed prior to entry into service (EPTS conditions) Over 67 percent of the disability separations for psychiatric conditions in 1953 (4,134) were caused by psychotic disorders (2,786). Approximately 53 percent of the total class V disability separations was comprised of individuals separated with less than 1 year of service.
DISEASES OF THE CIRCULATORY SYSTEM
Diseases of the circulatory system have for some time been the leading cause of death due to disease in the United States Army, constituting nearly one-third of the total disease deaths in 1953. In the civilian population of the United States during this year about 45 percent of all disease deaths were due to this group of diseases. The lower proportion in the Army reflects a younger adult age group, the selection of personnel through physical examinations at time of induction, and the separation from service for disability of some of the more serious cases.
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6The duration data cited cover single and multiple diagnostic cases. If the data are confined to 1953 dispositions in which the sole diagnosis was a psychiatric disorder, the resultant durations are less, e. g., 40 days for psychiatric disorders, instead of 47 days. (See table 16, column 7.)
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The heart diseases were the leading cause of mortality among diseases of the circulatory system, contributing 84 percent of all deaths due to this group of diseases. With the inclusion of deaths from rheumatic fever and hypertensive disease, both with heart involvement, nine of every ten deaths due to diseases of the circulatory system involved the heart.
Seven of these nine deaths were attributed to arteriosclerotic heart disease, including coronary disease. For this disease the case fatality rate, expressed in terms of the number of deaths per 100 cases of this disease during 1953, was 19 percent. (This percentage is here taken as the percentage of deaths occurring among all cases finally disposed of during the year; it should not differ materially from the percentage of deaths occurring among all cases admitted with this condition.) For all other heart diseases the corresponding case fatality rate was only 2 percent. It should be noted, however, that these case fatality rates may be considerably understated by the exclusion of those deaths which occur among individuals separated from the service.
Among the diseases of the circulatory system other than heart disease, diseases of the arteries constituted the principal cause of death, accounting for over one-third of the deaths in this group.
As expected, the death rates for diseases of the circulatory system were highest among the older age groups. One-half of the deaths due to diseases of the circulatory system, including more than 60 percent of the deaths attributed to arteriosclerotic heart disease (with coronary disease included), occurred among personnel 40 years of age and older?a group which made up less than 4 percent of the total Army strength.
Disability separations for diseases of the circulatory system comprised 9 percent of the total disability separations due to disease (source table 19). Nearly 90 percent of the dispositions in 1953 of cases admitted for diseases of the circulatory system were returned to duty. This high proportion of cases returned to duty was due, however, to the relatively large number of cases of circulatory disease other than heart disease; these circulatory disease cases (other than heart disease) comprised 86 percent of all admissions for diseases of the circulatory system. When only those cases with heart disease are considered, the ratio for those returned to duty drops to 55 percent.
The largest proportion of circulatory disease cases lost to the Army through disability separation were those admitted for chronic rheumatic heart disease: 65 percent of the total dispositions for this condition were cases separated for disability; these constituted one-half of the disability separations due to diseases of the circulatory system, although they were responsible for only 4 percent of the admissions for this class of diseases. More than three-fifths of the disability separations for chronic rheumatic heart disease consisted of EPTS cases, of which 10 percent were considered to have been aggravated by service. In comparison, for all other diseases of the circulatory system, 23 percent were EPTS cases, of which only 3 percent were aggravated by service.
Diseases of the circulatory system contributed relatively little to the admission rate or to the noneffective rate in the Army. Admissions for this
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group of diseases constituted only 2 percent of disease admissions and only 6 percent of the days lost from all diseases. About one-half of the admissions in this disease group were for hemorrhoids, which occurred 1? times as frequently in oversea areas as in the continental United States. Slightly over 2 percent of new admissions for diseases of the circulatory system were later readmitted for the same disease during 1953, this ratio being highest for arteriosclerotic heart disease: one in every 10 admissions for this diagnosis was readmitted for this condition during the year.
The average length of stay in hospital and quarters for circulatory diseases was about 1 month; the longest duration, more than 3 months, was for rheumatic fever and arteriosclerotic heart disease (including coronary diseases).
Thus, the importance of the diseases of the circulatory system arises from the relative seriousness of these conditions. As seen from the source tables in Part II of this report, in 1953 the admission rate for this entire group was only 10.32 per 1,000 per year, while the death rate was 0.14 per 1,000 (14.2 per 100,000) per year, and the average daily noneffective rate was 0.83 per 1,000. In terms of numbers, while there were only 15,825 admissions in the total Army due to this group of causes, they accounted for 217 deaths and 1,541 (source table 19) separations for disability.
DISEASES OF THE DIGESTIVE SYSTEM
With the exception of diseases of the teeth and supporting structures, for which statistics have been reported in class XII, this diagnostic category is comprised of those conditions classified as diseases of the digestive system by the ?International Statistical Classification of Diseases, Injuries, and Causes of Death.? In accordance with this classification, hernia of the abdominal cavity is included among diseases of the digestive system. The revision of the International list, adopted in 1948, excludes diseases of the pharynx and tonsils and streptococcal sore throat which, under the previous list, had been included with this group. This group?diseases of the digestive system?does not include many conditions directly affecting the digestive system which have been classified elsewhere; for example, Vincent?s infection, tuberculous and cancerous conditions of the digestive system, diarrhea of unknown cause?not elsewhere classified, and certain gastrointestinal disorders regarded as somatization reactions. Included in class XIII are some conditions which may be classified as ?diarrheal diseases? for purposes of this discussion. The ?diarrheal diseases? considered as a group below are acute gastroenteritis, acute enteritis, acute colitis, and acute enterocolitis.
The admission rate of 32.03 per 1,000 average strength for diseases of the digestive system in the total Army during 1953 showed no significant change from the 1952 level. This is true for admissions outside continental United States as well as for continental United States admissions, with the oversea rate for 1953 (35.48 per 1,000) being 24 percent higher than the rate for Army personnel in the United States (28.78 per 1,000).
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This disease group comprised 8 percent of all admissions for disease, with acute gastroenteritis accounting for one-third of the admissions for diseases of the digestive system. The combined group of diarrheal diseases were reported as causes for admission in 36 percent of the patients admitted for diseases of the digestive system in 1953. The addition of admissions for diarrhea, cause unknown, which were not elsewhere classified (in the class XXI disease group), to this group of ?diarrheal diseases? would increase the admission rate from 11.59 to 14.32 per 1,000 average strength per year.
Seven percent of the digestive system disease cases were designated as involving conditions which originated in the patients prior to entering the service. Among the class XIII diseases, the proportion of cases originating prior to entering the service was highest for hernia, namely, 27 percent.
The mortality rate for diseases of the digestive system, 3.0 per 100,000 average strength in the total Army in 1953, showed an increase of 14 percent over the 1952 rate. Thirty percent of the deaths were due to diseases of the liver, mainly, cirrhosis of the liver. Case fatality from diseases of the digestive system was approximately 1 percent in 1953, with the highest rate, 5 percent, for diseases of the pancreas.
The length of stay for diseases of the digestive system (18 days per admission) was greater than the average for all disease admissions (13 days per admission). However, the average duration of those admissions in which more than one diagnosis was reported (45 days per admission) was three times the duration of the single diagnosis cases (15 days per admission).
Disability separations due to diseases of the digestive system comprised 6 percent of the total disability separations due to disease in 1953. Ulcer of the stomach and the duodenum was by far the leading cause of separation for disability in 1953 among this group, representing 80 percent of all disability separations due to diseases of the digestive system.
Of the total number of man-days lost in 1953 due to disease admissions, 11 percent were attributed to diseases of the digestive system. Admissions due to ulcer of the stomach and the duodenum contributed slightly over one-fourth of these noneffective days, and inguinal hernia another one-fourth.
During the past 4 years the admission rate for peptic ulcer in the total Army has steadily increased, primarily due to large increases in the high admission rate for this condition among personnel stationed in Europe. In that area, during 1953, the year of the largest increase, the admission rate (6.41 per 1,000) increased 67 percent over the preceding year (3.85 per 1,000). The rate in Europe was 13 percent higher among enlisted men than it was among officers, a reversal of the usual distribution of peptic ulcer admissions by rank. The admission rate among officers in Europe was 75 percent greater than the rate among officers in continental United States; and the rate among enlisted men in Europe was more than twice the rate for enlisted men in continental United States.
The increase was seen both for stomach and duodenal ulcer. It occurred primarily among Europe-stationed enlisted personnel in the 20 to 24 years
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age group, for whom the admission rate was twice as high as the corresponding rate for continental United States. This situation is not explained by the relative numbers of cases existing prior to service, because only 1 percent of the new admissions for peptic ulcer in Europe during 1953 were so reported, while 31 percent of the new admissions were in this category in continental United States. Limiting the comparison to cases originating while the patients were on active duty, the morbidity rate for enlisted men 20 to 24 years old in Europe during 1953 is observed to be five times the comparable rate for continental United States. Of perhaps supplementary interest is the 14 percent increase in the psychiatric disease rate in Europe between 1952 and 1953, during which time the psychiatric disease rate for the rest of the Army decreased 13 percent; and the fact that Europe exhibited the highest psychiatric admission rate of any major geographic area.
DISEASES OF THE URINARY AND MALE GENITAL SYSTEM
The 1953 admission rate of 23.59 per 1,000 average strength per year for this class represents a 47 percent increase over the 1952 admission rate. The increase, spurious in nature, was due to a change in morbidity reporting instructions7 which: (1) introduced to this class new terms?urethritis, nongonococcic, acute; urethritis, nongonococcic, chronic?to be applied to urethritides that could not definitely be ascertained as of nonvenereal origin; and (2) directed that all new cases of acute or chronic nongonococcic urethritis and nonvenereal urethritis treated or observed on a ?not excused from duty? status be carded for record only (CRO cases). These new requirements, initiated following evidence of increasing numbers of cases of nongonococcic urethritis among military personnel, were designed to obtain accurate statistical information; thus, the magnitude and relative importance of the disease would be delineated, aiding in the establishment of its cause and mode of transmission. This resulted in the recording of cases for which, in many instances, records were not previously required.
The effect of the reporting change is apparent: CRO cases accounted for 40 percent of the class admissions in 1953 compared to 0.2 percent in 1952. Excluding all the CRO cases, the 1953 admission rate for diseases in this class (14.28 per 1,000) decreased 11 percent over the corresponding rate for 1952.
Only about 4 percent of the noneffectiveness, less than 2 percent of the disability separations, and slightly over 3 percent of the deaths due to all diseases during the year resulted from diseases in this class.
The urethritides accounted for over 40 percent of the total class admissions, but almost 95 out of every 100 were CRO cases; consequently, they caused only 3 percent of the noneffectiveness due to this class. No permanent manpower loss resulted from these conditions. On the other hand, nephritis and nephrosis together contributed only about one percent of the class admissions, but were responsible for over half of the disability separations, 21 of the 24 deaths, and more than a tenth of the total noneffectiveness due to this class.
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7DA Circular 87, 9 October 1952.
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The average duration of stay for nephritis and nephrosis, 77 days per admission, was the highest among diseases in class XIV.
Diseases of the male genital organs accounted for 46 percent of the admissions and 60 percent of the noneffectiveness, but only 10 percent of the disability separations and one death from diseases in this class. Two groups of diseases among diseases of the male genital organs, orchitis and epididymitis, and redundant prepuce and phimosis, were responsible for 32 percent (12 and 20 percent, respectively) of the admissions and 38 percent of the noneffectiveness due to class XIV.
Diseases in this diagnostic class occurred relatively frequently as secondary diagnoses; total incidence exceeded admissions by more than 20 percent. Readmissions for treatment of diseases in this class as a whole occurred at the rate of 7 cases for every 1,000 new admissions. For nephritis and nephrosis, however, readmissions occurred more frequently?24 per 1,000 new admissions.
Most of the diseases in this class continue to occur among personnel in areas outside continental United States; the total oversea rate was more than three times the rate for continental United States. Higher admission rates were observed among younger than older personnel, among enlisted personnel than officers, and among Negro personnel than white personnel. Female personnel were admitted for total diseases of the urinary system at about the same rate as male personnel (12.86 and 12.74, respectively). Excluding the urethritides, for which there were few admissions observed among female personnel, females were admitted for diseases of the urinary system at more than four times the rate of admission for male personnel.
DISEASES OF THE SKIN AND CELLULAR TISSUE
Diseases of the skin and cellular tissue constituted 6 percent of all disease admissions and were responsible for about 5 percent of the noneffectiveness from all diseases in the Army. More than one-third of the admissions and one-fourth of the days lost for skin and cellular tissue diseases were attributed to cellulitis and abscess. Admissions were also relatively frequent for dermatitis, furuncles, and carbuncles. A marked difference was noted between the daily noneffectiveness of male officers and male enlisted personnel (0.35 per 1,000 and 0.77 per 1,000, respectively), a difference due to the disparity in the admission rates of the two classes.
In general, diseases of the skin and cellular tissue were not as serious as many of the other diseases. Nearly all of the admissions for these diseases were returned to duty. Only one percent was separated for disability, and no deaths due to these diseases were reported during this year. The average length of stay in hospital and quarters for all diseases in this group was 11 days; the shortest duration being for furuncle and carbuncle with 5 days, and the longest?about a month?for eczema, pruritus and related conditions, and psoriasis and similar disorders.
The admission rate for diseases of the skin and cellular tissue declined between the 1950-52 period and 1953 (30.6 and 25.5, respectively). This
62
decline occurred in both the continental United States as well as outside the continental United States. Although the greater decrease took place overseas, the oversea admission rate was still one-third higher than the rate in the United States. The exception to this geographical difference was dermatitis (occupational and other), for which admissions occurred at a higher rate in the continental United States?about 60 percent higher than in all oversea areas combined.
Morbidity decreased with age. The rate was highest for those under 20 years of age and decreased steadily as the age level increased beginning with a rate of 34.3 for those under 20 years of age to a rate of 13.2 for those 50 years of age or over. This variation by age was confined principally to admissions for infections of the skin and subcutaneous tissue. For other diseases of the skin and cellular tissue, the variations in age specific rates were less prominent; and, for certain individual diagnoses, for example pruritus and related conditions, the rate for the youngest age group was less than one-third that of the 50-and-over age group.
Although a difference was observed in the admission rate between males and females for diseases of the skin and cellular tissue (the rate for males being nearly 45 percent higher than the rate for females), the disparity was not as marked between male enlisted and female enlisted personnel (27.00 and 21.84, respectively), nor was any difference observed between the rate for male and female officers (11.72 and 11.90, respectively). The relatively large difference in the rate between males and females was due to variation in the strength distribution by rank (less than 10 percent of the males were officers compared to more than 40 percent for females). By diagnosis, the disparity by sex among the enlisted varied; thus for erythematous conditions, the admission rate among female enlisted was seven times the rate in male enlisted.
The influence of race on the admission rate was negligible for diseases of the skin and cellular tissue. The most notable difference was for occupational and certain other forms of dermatitis, for which the admission rate among whites was 2.3 times the rate among Negroes.
The number of recurrent cases in diseases of the skin and cellular tissue was relatively low. Only one of every 100 new admissions was readmitted to hospital or quarters for treatment. This low percentage of readmissions was due primarily to the fact that cases with carbuncles, furuncles, and cellulitis or abscess, which constituted one-half of all admissions for the diseases in the class, had a ratio of 1 readmission for every 200 new admissions. It is of interest to note, however, the frequency with which skin and cellular tissue diseases were reported as secondary diagnoses. During the year, incidence exceeded admissions by more than 30 percent. The disease reported most frequently as a secondary diagnosis was acne, with an incidence nearly three times the admission rate.
Cases incurred prior to military service (EPTS cases) constituted less than 5 percent of the incidence of these diseases. This low percentage is due to the acute nature of most of the conditions. For certain of the diagnoses
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which are generally considered to be of a chronic nature, the proportion of EPTS cases was relatively high. Thus, 40 percent of the incidence of acne was EPTS. Psoriasis (and similar disorders) and pruritus (and related conditions) were other diseases for which the proportion of EPTS cases was relatively high.
The number of separations for disability due to diseases of the skin and cellular tissues was negligible, constituting only 2 percent of the total disability separations from all disease. More than three-fourths of these were separated without severance pay indicating that they were EPTS cases not aggravated by service. The majority of cases separated for disability were among men with relatively short service in the Army. More than two-thirds of the disability separations consisted of those with less than one year of service at the time of admission for treatment.
DISEASES OF THE BONES AND ORGANS OF MOVEMENT
With an admission rate of 13.7 per 1,000 average strength per year, and an average duration per case of 37 days in hospital and quarters, diseases of the bones and organs of movement were responsible for almost three-quarters of a million days lost from duty during 1953. This noneffectiveness was close to 10 percent of the days lost from all disease conditions during the year. Moreover, for diagnoses such as arthritis and osteomyelitis a little over 2 out of every 10 cases admitted were permanently lost to the Army through disability separation. Thus, the class XVIII disease group was one of considerable importance in the Army in 1953, as in previous years.
It is of significance to note, in view of the considerable manpower loss, that more than 25 percent of the morbidity from diseases of the bones and organs of movement resulted from cases whose hospitalization was the result of a condition which existed prior to entry in service. This was particularly true for some of the more important contributors to the overall incidence of 18.7 per 1,000 per year. For example, 45 percent of the cases with internal derangement of the knee were considered to have existed prior to entering the Army.
The age-specific admission rates for diseases of the bones and organs of movement were unusual in that the rates were similar for each age group through age 44. Among personnel 45 years of age and over, however, the admission rates were about double the rate in the total Army. For individual diagnoses the distributions by age varied from the aforesaid pattern.
Diseases of the bones and organs of movement, when considered by race, presented a major difference with respect to only one diagnosis?herniation of the nucleus pulposus. For this condition, the admission rate among whites was 3 times the rate among Negroes. This diagnosis, incidentally, occurred twice as often among officers as it did among enlisted personnel. Although herniated nucleus pulposus admissions made up only 4 percent of the incidence of diseases of the bones and organs of movement, these cases contributed more
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than 10 percent of the noneffective days due to the disease group. Length of stay averaged about 87 days per case. In addition to this long duration (the longest duration of any diagnosis in class XVIII), the disease was of further concern in that more than 1 out of every 10 admissions was readmitted for this condition.
Although females constituted only a relatively small proportion of Army strength, they were admitted to hospital and quarters at a higher rate than males for each diagnosis in class XVIII. This was particularly true for diseases of the musculoskeletal system such as synovitis, bursitis, and tenosynovitis, wherein the rate among females was more than double the admission rate among males.
As indicated above, noneffectiveness was the major problem with diseases of the bones and organs of movement. The principal contributor to this noneffectiveness was arthritis, which accounted for 169,000 days lost during the year or almost one-quarter of the noneffectiveness due to diseases of the bones and organs of movement.
Coupled with the time lost from duty was the considerable number of cases in this class which were permanently lost to the Army through disability separation. During the year, 3,920, or 22 percent of the disability separations from all causes were due to a diagnosis in this disease group. It is significant that almost 60 percent of these cases separated for disability due to a class XVIII disease had a condition which was considered to have existed prior to entering the service. Very few of these EPTS cases, however, were indicated to have been service aggravated.
Although much of the noneffectiveness of the diseases in class XVIII is contributed by EPTS cases, there is little the Army can do to alleviate the situation inasmuch as most of these conditions are not discernible at induction.
ACCIDENTS, VIOLENCE, AND POISONINGS
There were 84,290 new nonbattle admissions of Army personnel to medical treatment facilities due to accidents, violence, and poisonings (all nonbattle injuries) during 1953, resulting in an admission rate of 55 per 1,000 average strength. In relation to all causes (disease, nonbattle injuries, and battle injuries and wounds), nonbattle injuries were responsible for 11 percent of all admissions, 41 percent of all deaths, 10 percent of all disability separations, and 18 percent of all noneffectiveness. The noneffective rate from nonbattle injuries was 3.6 per 1,000 average strength per day.
The admission rate of 55 per 1,000 was somewhat less than the rate of 62 per 1,000 experienced during 1952. Much of this reduction was due to the cease-fire in Korea in July. Although the nonbattle injury admission rate for the entire year among U. S. Army troops in Korea (73) was higher than that for any other area, this rate in Korea had nevertheless declined precipitously during the year. It dropped from 88 per 1,000 in July 1953 to 51 per 1,000 in December. For the continental United States and total oversea areas, the admission rates per 1,000 average strength during 1953 were 47 and 64, respectively.
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Chart M presents the percentage distribution of total Army nonbattle injury admissions by diagnosis. Sprains, strains, and dislocations combined?with an admission rate of 14.4 per 1,000 average strength? comprised the leading group of diagnoses among nonbattle injury admissions. Fractures were second with an admission rate of 12.1 per 1,000. The extremities were involved in 7 of each 10 fracture cases, and the skull, face, or neck in 2 of each 10. Wounds of all types, with an admission rate of 8.1 per 1,000 average strength, were next in magnitude. About three-quarters of the wounds were lacerated and incised; one-fifth were penetrating, perforating, or punctured; and the balance were unqualified as to type. Contusions (6.1 per 1,000), burns (2.6), abrasions and blisters (2.0), and concussions (1.7) were the next most important causes of admission, in that order.
Cold injury, amounting to only one percent of the total nonbattle injury admissions during 1953, was not nearly the problem it had been earlier. The admission rate for cold injury during 1953 was 0.5 per 1,000 average strength for the total Army, compared with 1.1 per 1,000 in 1952 and 4.0 in 1951. The rate continued to be higher in Korea than in other areas but the principal reduction occurred in the rate there. For that area the rate had been 23 per 1,000 average strength in 1951 and for 1953 was only 0.9.
There were only 740 cases of poisonings (1 percent of all nonbattle injury admissions) in the total Army, the admission rate being 0.5 per 1,000 average strength during 1953. It should be noted that the number of cases of poisonings (740) shown in the source tables as having this admission diagnosis includes all such cases regardless of the cause. In other tables, classified by causative agents, the number shown (580) for poisons as the primary causative agent excludes those cases where poisoning was caused by certain other specific agents such as venomous reptiles, chemical warfare agents, etc. Following poisonings were the traumatic amputations (about one percent of the total nonbattle injury admissions). Of 585 traumatic amputations, the upper extremities were involved in 90 percent of the cases.
The various causative agents responsible for the nonbattle injury admissions are indicated by chart N. The various modes of transportation (aviation, land, and water) combined?with an admission rate of 10.5 per 1,000 average strength?were responsible for 19 percent of all nonbattle injury admissions among the U. S. Army during 1953. Motor vehicle accidents accounted for most of these admissions, with an admission rate of 9.3 admissions per 1,000 average strength. They were responsible for about 17 percent of the total nonbattle injury admissions during the year. Less than one-half (41 percent) of these motor vehicle accidents were related to scheduled training or to assigned duties; about one-third of the reported motor vehicle accidents occurred while on leave or otherwise off the post in a nonduty status. Falls or jumps were second (after transportation) with an admission rate of 8.7 per 1,000; fractures resulted in about a third of these cases. Athletics or sports with an admission rate of 6.2 per 1,000 average strength were next in magnitude as a causative agent; about one-fourth of these cases resulted in fractures. Instrumentalities
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CHART M. ? NONBATTLE INJURY ADMISSIONS, BY DIAGNOSIS, U.S. ARMY, 1953
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CHART N. ? NONBATTLE INJURY ADMISSIONS, BY CAUSATIVE AGENT, U.S. ARMY, 1953
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of war were next and were the causative agent for an additional 3.2 nonbattle injury admissions per 1,000 average strength, nine-tenths of which occurred while on duty status or on post. Almost three-quarters of the admissions due to instrumentalities of war were related to scheduled training or to assigned duties; an additional 5 percent were intentionally self-inflicted. Free falling or propelled objects accounted for 2.6 admissions per 1,000 average strength and fights or brawls for another 2.5 per 1,000, ranking next in that order. Cutting or piercing objects or instruments (2.3 per 1,000); twisting, turning, slipping, running (2.3); fire, explosion, hot or corrosive substances (2.2); prophylactic reactions and therapeutic misadventures (1.8); and effects of heat, sun, light, and cold (1.5) were the next most important causative agents in that order.
There were 2,037 deaths due to accidents, violence, and poisonings during 1953, resulting in a mortality rate of 133 per 100,000 average strength. This represents an appreciable reduction from the nonbattle injury death rate of 149 per 100,000 experienced during 1952. The leading cause of accidental deaths in the U. S. Army during this year was motor vehicle accidents with a death rate of 62 per 100,000. Some 955, or 47 percent of all the nonbattle injury deaths were due to this causative agent. An additional 26.7 deaths per 100,000 average strength occurred as the result of accidents involving instruments of war. This latter causative agent accounted for 20 percent of all the nonbattle injury deaths, a large percentage of which occurred in Korea.
Almost 95 percent of the total nonbattle injury deaths were associated with specific injuries, one-third of which involved fractures and one-fifth of which involved various types of wounds. Burns caused death in 3 percent of the total injuries, and drownings an additional 9 percent. (For additional detail on nonbattle injury mortality, see ?Deaths.?)
The loss of time due to admission for treatment of nonbattle injury was, in the average case, almost double that of a disease admission. Based on all cases (including cases with multiple diagnoses), the average days lost per disease admission was 13, while the average days lost per nonbattle injury admission was 25.
The relative importance of fractures as a cause of time lost is readily apparent when one considers their frequency (almost one-fourth of all nonbattle injuries) along with their long duration. The average time lost per case for all types of fractures was 63 days; compound, comminuted fractures averaged 167 days, other types of compound fractures 66, and simple fractures averaged 51 days lost per case.
Traumatic amputations, although few in number, were responsible for an average of 72 days lost per case, while both burns and wounds (all types combined) averaged 19 days lost per case, respectively.
In addition to the losses from noneffectiveness and death, nonbattle injuries were responsible for 1,983 disability separations, almost one-half of which resulted in permanent retirements. These nonbattle injury cases separated for disability during 1953 lost, on the average, 297 days per case prior to separation.
