History

Medical Statistics of the United States Army, Calendar Year 1954

CHAPTER III

Discussion of Specific Disease and Injury Conditions

ACUTE RESPIRATORY INFECTIONS

The acute respiratory infections (acute upper respiratory infection, acute bronchitis, influenza, and pneumonia) continue to be the leading cause of admission of U. S. Army troops to hospital and quarters. In the post?World War II period, 1946-1949, admission rates for acute respiratory infections ranged from 47.5 to 89.0 per 1,000 per year. During the Korean Conflict, the range was from 95.4 per 1,000 per year to 133.6. During 1954, however, the combined admission rate for these conditions?90.2 per 1,000 average strength per year?was the lowest in several years. The incidence rate (including secondary diagnoses) in 1954 was 94.5 per 1,000 among Army troops worldwide.

In general, admission rates for acute respiratory infections are appreciably higher among troops in the United States than among those stationed overseas. This is in part a reflection of the higher incidence of these conditions among basic trainees (recruits), nearly all of whom are stationed in continental United States. In 1954, the admission rate for acute respiratory infections among troops in continental United States was 99.8 per 1,000, as compared with 79.1 among those stationed overseas.

Although acute respiratory infections occur throughout the year, incidence rates for these conditions are ordinarily highest during the first and last three months of the year (January-March and October-December). Roughly 2 out of every 3 acute respiratory cases reported in any given year 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.

As may be seen from chart I, the incidence of acute respiratory infections was markedly lower, both in the United States and overseas, during most of 1954 than in 1953. It should be noted, however, that the incidence of these conditions was quite high during the early months of 1953 and that the rate of decline was slower than usual.

Of the 128,075 admissions for acute respiratory infections among U. S. Army troops worldwide during 1954, 77.1 percent were for acute upper respiratory infections. The balance of the respiratory disease admissions were distributed as follows: pneumonia (all forms), 10.5 percent; acute bronchitis, 10.0 percent; and influenza, 2.4 percent. About 4,900 of the 13,400 cases of

pneumonia were diagnosed as primary atypical pneumonia. In addition, 4,600 cases were diagnosed as lobar pneumonia, 2,500 as bronchopneumonia, and 1,400 as other or unspecified pneumonia. For each respiratory disease category, except influenza, admission rates for troops in the United States were higher than for troops overseas.

CHART I.?INCIDENCE RATES FOR ACUTE RESPIRATORY INFECTIONS, U.S. ARMY, OCTOBER 1952-SEPTEMBER 1954

Although of relatively short duration, acute respiratory infections were responsible for the loss of approximately 0.7 million man-days in 1954?about 12 percent of all days lost due to disease in 1954. This corresponds to a duration of stay in hospital and quarters of 5 days per case. Of the 13 deaths from acute respiratory infections during the year, the underlying cause was acute upper respiratory infections in 2 cases, and pneumonia in 11, with 2 of the latter being due to primary atypical pneumonia.

SELECTED RESPIRATORY AND RELATED INFECTIVE DISEASES

In addition to the acute respiratory infections discussed in the preceding section, there is a group of conditions, chiefly chronic and not necessarily of infective origin, classified as ?other diseases of the respiratory system? (class X); included in this group are such conditions as chronic bronchitis, pleurisy, pulmonary congestion, and bronchiectasis. There are also several infective diseases, chiefly acute, that are either predominantly localized in the respiratory tract and are transmissible by its discharges, or are predominantly localized outside the respiratory tract but are known to be or strongly suspected of being transmissible by its discharges; the specific diseases in this infective

group are listed in table XXI. Since these diseases and the class X conditions both involve the respiratory system, they are discussed together in this section. (Note that such infective diseases as respiratory tuberculosis, acute infectious encephalitis, and poliomyelitis are excluded from the discussion.)

From the standpoint of incidence, class X conditions and three of the "related infective diseases," rubella (German measles), streptococcal sore throat, and mumps (epidemic parotitis) were most important. (See table XXI.) In 1954 class X conditions accounted for 2,880 admissions among Army troops worldwide, and rubella, streptococcal sore throat, and mumps combined were responsible for 10,650. Corresponding secondary diagnoses among admissions for other causes accounted for 1,310 and 195 cases, respectively.

Based on cases completed in 1954, the average duration of stay in hospital and quarters was 33 days per case for class X diseases, and for the entire group of related infective diseases combined, 25 days per case, with the highest average duration (130 days per case) being for coccidioidomycosis. In 1954 class X conditions were responsible for 248 separations for disability, of which the largest proportion were due to bronchiectasis, and for 9 deaths, 6 of which were due to pulmonary congestion and hypostasis. Conditions in the related infective disease group were responsible for only 8 separations, all of which were due to coccidioidomycosis, and for 10 deaths, 5 of which also resulted from coccidioidomycosis.

TABLE XXI.?SELECTED RESPIRATORY AND RELATED INFECTIVE DISEASES:

INCIDENCE AND DEATHS, U. S. ARMY, 1954

Diagnostic category	Incidence	Deaths
Other diseases of the respiratory system (class X)	4,190	9
Related infective diseases^a	13,520	10
Chickenpox	1,040	-
Coccidioidomycosis	40	5
Diphtheria	-	-
Measles	580	-
Meningitis, meningococcal	155	4
Mumps	2,805	-
Pneumonic plague	-	-
Psittacosis	10	-
Rubella (German measles)	4,325	1
Scarlet fever	400	-
Smallpox	-	-
Streptococcal sore throat	3,715	-
Vincent's infection	445	-
Whooping cough	5	-

^aFor infective diseases excluded, see text.
NOTE: Incidence data (number of cases) are based on a 20 percent sample of individual medical records and exclude cases carded for record only. Data for deaths are based on complete files of individual medical records and include cases carded for record only.

It should be mentioned that much of the foregoing analysis is based on sample tabulations of individual medical records. Because of the problems often associated with the use of sample data for diseases of low incidence (see the appendix), incidence data from the Morbidity Report (DD Form 442) as well as from sample tabulations of individual medical records are shown in table XXII for the more important conditions. Although incidence data from the Morbidity Report, a recurring summary report, sometimes represent tentative or working diagnoses rather than the final diagnoses as shown on the individual medical record, differences between the two sets of data were not great for most of these diagnoses. However, for measles, streptococcal sore throat, and rubella, there were marked differences. With respect to measles, in many instances the diagnosis appearing on the Morbidity Report is doubtless a tentative or working diagnosis, with further study of the cases frequently resulting in a different diagnosis; some of these cases may later be diagnosed as rubella and the change of diagnosis reflected, or partially reflected, in reported cases of rubella, without downward adjustment in already reported cases of measles. With respect to streptococcal sore throat, some cases may be initially reported as ?diagnosis undetermined,? without reflection in the Morbidity Report of the subsequent diagnosis of streptococcal sore throat. These considerations should be kept in mind in evaluating Morbidity Report data for these diseases.

TABLE XXII.?INCIDENCE OF SELECTED RESPIRATORY AND RELATED INFECTIVE DISEASES, U. S. ARMY, 1954

Diagnostic category	Tabulations of individual medical records	Morbidity Report (DD Form 442)
Other diseases of the respiratory system (class X)	4,240	4,457
Related infective diseases	12,425	10,334
Diphtheria	-	3
Measles	580	1,156
Meningitis, meningococcal	155	144
Mumps	2,805	2,883
Rubella	4,325	3,939
Scarlet fever	400	378
Smallpox	-	-
Streptococcal sore throat	3,715	1,476
Vincent's infection	445	355

NOTE. All data include cases carded for record only.

TUBERCULOSIS

Morbidity due to tuberculosis was somewhat higher in 1954 than in 1953, whereas for the majority of all other diseases morbidity declined. The admission rate for tuberculosis rose from 1.0 per 1,000 average strength in 1953 to 1.1

in 1954, and the incidence rate from 1.1 to 1.2. Although tuberculosis was responsible for only 0.4 percent of total admissions for disease in 1954 and for 0.4 percent of total incidence, it accounted for 7 percent of total noneffectiveness (rate, 0.8), because of the long periods of hospitalization entailed, and for nearly 10 percent of of disability separations for disease and nonbattle injuries. Only 6 deaths occurred in 1954 in which a tuberculous condition was the underlying cause.

The total admission rate (1.1) for tuberculosis in 1954 was comprised of 0.8 per 1,000 average strength due to pulmonary tuberculosis and 0.3 due to other types of tuberculosis, the corresponding incidence rates for these subcategories being 0.8 and 0.4, respectively. It should be noted that the latter subcategory tentatively includes pulmonary infiltration of undetermined cause. Admission rates for tuberculosis were about the same in continental United States (1.09) as outside the United States (1.06), but were somewhat higher for enlisted personnel (1.09) than for officers (1.00). For sex and race noticeable differentials were found; the rate for women (3.85) was about four times as high as that for men (1.05), and the rate among Negroes (2.15) was slightly more than twice as high as that among whites (0.92).

As already indicated, tuberculosis was a major factor in disability separations. In 1954, 1,225 persons were separated for disability due to tuberculosis. The 1954 separation rate for tuberculosis (0.9 per 1,000 average strength) was about the same as that for 1953. However, in 1954 proportionately more separations for tuberculosis were temporary retirements (85.8 percent in 1954 compared to 76.1 percent in 1953; see table XXIII). Current experience indicate that about 10 percent of persons suffering from tuberculosis who are on the Temporary Disability Retired List may be expected to be permanently retired or separated with severance pay, and the remainder found fit for duty. On this basis, the 1954 ultimate separation rate for tuberculosis may be expected to be about 0.2 per 1,000 average strength per year. (For 1953 the corresponding expected rate was estimated as 0.3.)

TABLE XXIII.?PERCENT DISTRIBUTION OF DISABILITY SEPARATIONS, AND SEPARATION RATES DUE TO TUBERCULOSIS, BY TYPE OF SEPARATION, U. S. ARMY, 1953 AND 1954

Type of separation	Percent distribution		Separation rates per 1,000 average strength per year
Type of separation	1953	1954	1953	1954
Permanent retirement	12.8	3.5	0.11	0.03
Temporary retirement	76.0	85.8	0.66	0.74
With severance pay	0.3	0.2	0.00	0.00
Without severance pay	10.9	10.5	0.10	0.09
Total	100.0	100.0	0.87	0.86

MALARIA

Despite the fact that United States Army troops are now stationed in nearly all the known areas of the world, malaria has not been a major medical problem during the past two years. Most of the cases that have been encountered during this period have occurred among troops who had served, or were currently serving, in malarious areas, e. g., Korea and Panama. For areas outside the Caribbean and the Far East, the chief malarial problem has been the potential malaria cases transferred from those two areas, particularly from Korea. Since 1952, however, there has been a marked reduction in the reservoir of such cases. As a result, in most areas where troops are at present stationed, malaria is not considered the serious medical problem it was during World War II.

During 1954 there were 1,070 admissions due to malaria among Army troops worldwide. These correspond to a rate of 0.75 admissions per 1,000 average strength, as compared with 1.14 per 1,000 in 1953 and 8.05 in 1952 (See chart J.) The corresponding incidence rates for 1953 and 1954, included readmissions and secondary diagnoses, were 1.44. and 0.88, respectively.

The majority of all malaria cases reported among Army troops worldwide during 1954 occurred among troops stationed in the Far East. A large proportion of the remaining cases were among persons who had previously served in Korea.

In the Far East, admissions due to malaria during 1954 were at a rate of 1.78 per 1,000 average strength, as compared with 2.31 per 1,000 in 1953 and 8.09 in 1952. Although admission rates for Korea and for Japan during 1954 were about the same, 1.87 and 1.85 per 1,000, respectively, most of the cases diagnosed in Japan were among troops who had previously served in Korea.

In the Caribbean, admission rates for malaria averaged 1.39 per 1,000 in 1954 and 3.86 in 1953. For the most part, these cases occurred among troops stationed in the Canal Zone. However, as a result of the cooperative efforts of both U. S. Army and local health authorities, incidence in the Caribbean has been reduced markedly?from a level of 12.17 cases per 1,000 in 1952.

The amount of time lost per case for all cases disposed of in 1954 averaged 8 days per case, as compared with 11 days per case in 1953. As a result of the relatively short duration and decreased incidence of the disease, noneffectiveness due to malaria has been very low during each of the past two years?the average daily rate for all Army troops being 0.02 per 1,000 in 1954 and 0.03 per 1,000 in 1953.

There were no deaths or disability separations due to malaria in either 1953 or 1954.

CHART J.?ADMISSION RATES FOR MALARIA, SELECTED AREAS, U. S. ARMY, 1950-1954

INFECTIOUS HEPATITIS

The incidence of infectious hepatitis, Virus I. H. (Virus A) is worldwide, and the disease continues to be a medical problem of considerable importance to the Army. Contributing factors are: the lack of specific diagnostic tests, the epidemic potential of the disease, the high resistance of the causative virus to various antibiotic and chemotherapeutic agents effective against most infectious diseases, and the relatively long period of hospitalization.

From the standpoint of treatment one of the few regimens found to be of therapeutic value is bed rest during the early stages, ad lib activity during the later stages, and a high protein diet throughout the course of the disease. From the standpoint of prevention and control, the main obstacle is the absence of a proved satisfactory antigen. However, gamma globulin is thought to have prophylactic value against Virus I. H. (Virus A).

While cases of infectious hepatitis among Army troops have been reported both in the United States and in virtually every oversea command, the bulk of cases have occurred in two or three geographic areas. During 1954, as in the recent past, the highest incidence of infectious hepatitis was among troops in the Far East, particularly in Korea. During the last four months of the year, incidence among troops in Korea was almost three times that for the same period of 1953. Morbidity Reports (DD Form 442) from Korea indicate that incidence rates reached a level of 16.2 cases per 1,000 average strength per year in December 1954, the highest since May 1951. As a result, the incidence of infectious hepatitis was slightly higher among troops in the Far East during 1954 than in 1953.

Infectious hepatitis is endemic not only in the Far East but also in Europe and the Caribbean. In Europe, incidence rates decreased from 3.6 cases per 1,000 in 1953 to 2.9 in 1954. In the Caribbean, incidence increased slightly, from 3.0 cases per 1,000 in 1953 to 3.8 in 1954. For Army troops worldwide, the incidence rate decreased from 2.6 in 1953 to 2.5 in 1954.

Of the total new admissions for infectious hepatitis in 1954, the admission rate for those under 30 was 2.3 per 1,000, as compared with a rate of 1.6 for those 30 and over. The average length of stay in hospital and quarters for infectious hepatitis cases during 1954 was 63 days per case. In terms of non-effectiveness, this represents an average daily noneffective rate of 0.39 per 1,000 average strength, only slightly lower than the rate of 0.43 in 1953.

Among the 3,125 cases of infectious hepatitis reported in 1954, there were only 4 deaths. The rate of relapse, as measured by the relative number of readmissions, was also quite low in 1954?less than 0.5 percent of the total reported cases, and about half the corresponding rate for the prior two years.

Apart from these considerations, it should be noted that differential diagnosis of infectious hepatitis, Virus. I. H. (Virus A), and serum hepatitis, Virus S. H. (Virus B), is often difficult, due to the similarity of their clinical course after onset. Virus I. H., however, is transmitted naturally, whereas Virus S. H. is transmitted artificially by parenteral inoculation in such procedures as blood transfusion. In 1954, the reported incidence of serum hepatitis among all active duty Army personnel was only 0.07 case per 1,000 average strength. Incidence rates for this condition may not be entirely reliable, however, since some cases may have been diagnosed as the naturally occurring entity, and vice versa. (Serum hepatitis is not classified as a disease in the International Statistical Classification of Diseases, Injuries, and Causes of Death, but falls in the category of prophylactic or therapeutic mishaps.)

DYSENTERY AND RELATED CONDITIONS

This group of intestinal diseases, including typhoid, paratyphoid, dysentery, and food infection or poisoning, is shown in the source tables of this report under the infective and parasitic diseases as the subclass ?infections commonly rising in the digestive tract.? Many of these conditions are of such a nature that large and explosive outbreaks may occur in the military setting if certain environmental factors are not controlled by adequate sanitary and other preventive measures. (Not included in this subclass are cases of diarrhea of unknown cause, not elsewhere classified; or cases of colitis, gastroenteritis, enteritis, and enterocolitis, which are discussed under ?Diseases of the Digestive System.?)

Morbidity for this group of infections of the digestive tract continued its decline from the high wartime annual admission rate of 2.54 per 1,000 in 1951 to reach an annual rate of 1.16 per 1,000 average strength for 1954. This excludes a considerable number of milder cases treated on a duty basis.

No deaths in 1954 were attributed to these infections of the digestive tract, and admissions for such conditions accounted for only a small proportion (0.4 percent) of the noneffectiveness due to disease during 1954.

Since 1951, the admission rate for this group of diseases has declined for troops in continental United States as well as for troops outside continental United States, but with the oversea rate remaining on the higher level throughout this period. During 1954, admissions for these diseases occurred overseas at a rate which exceeded by two-fifths the rate among troops in continental United States (1.38 and 0.98, respectively).

The 1,650 admissions in 1954 due to infections commonly arising in the digestive tract were proportionally distributed as follows: food infection or poisoning (except due to salmonella), 40 percent; dysentery (except amebic), 26 percent; amebiasis, 25 percent; salmonella infections, 9 percent.

For the Army in continental United States and in Europe, the admission rates for food infection or poisoning (excluding that due to salmonella) decreased about one-third and one-half, respectively, during 1954. However, an outbreak of food poisoning due to staphylococcus infection (the organism was contained ice cream), involving 75 hospitalized cases in the Antilles Department, produced a disproportionally high rate for the Caribbean area.

Among 410 admissions for amebiasis in 1954 only 20 were characterized as nondysenteric, and 25 as amebic abscess of the liver. About 365 of the 410 amebiasis admissions might, therefore, be considered as amebic dysentery. Similarly, in 1953, about 350 of the 405 amebiasis admissions could be regarded as amebic dysentery. (The 1953 Annual Report erroneously referred to 25 admissions for amebic dysentery in that year.) On the whole, morbidity due to amebiasis in 1954 was about the same as in 1953, with the admission rate being highest in the Far East and Western Pacific area. An additional 95 cases amebiasis were diagnosed among patients admitted in 1954 for other conditions.

Of the 435 admissions for dysentery, other than amebic, included in this class, 230 were reported as bacillary dysentery and 70 as protozoal (except amebic) dysentery. For 135 the etiological agent was unspecified. An additional 45 cases of dysentery, all protozoal (exclusive of amebic), were diagnosed among 1954 admissions for other conditions.

Salmonella infections accounted for 140 admissions, twice as many as last year. An important outbreak of salmonellosis occurred among Army personnel in Alaska in October; 56 cases were diagnosed, of which 11 were hospitalized. Although in the 20 percent sample of individual medical records upon which these data are based no cases of typhoid fever appeared, the Morbidity Report (DD Form 442) provides the information that 8 cases of typhoid occurred among active Army personnel during 1954. All were admitted in continental United States, and 5 resulted from a localized outbreak among civilians near Fort Campbell, Kentucky, early in the year.

VENEREAL DISEASE

The venereal disease admission rate to hospital or quarters on an excused-from-duty basis has been steadily decreasing during the five-year period 1950-1954?from a rate of 5.56 per 1,000 troops per year in 1950 to 2.02 per 1,000 in 1954 (table XXIV). The admission rates for two of the component diseases, gonorrhea and syphilis, likewise exhibited regular decreases during this period, that for gonorrhea dropping from 2.24 to 0.80, and that for syphilis from 2.14 to 0.49. Chancroid and other venereal diseases produced more variable admission patterns during these five years, with the chancroid rate of 0.95 in 1950 reaching a peak of 1.70 for the following year, then falling off each year until in 1954 it stood at 0.50. A 45 percent decrease in the chancroid admission rate between 1953 and 1954 was accounted for largely by the decrease in the rate for the Far East, where chancroid, as an admission diagnosis, constituted the predominant type of venereal disease, and where a large proportion of the chancroid admissions in the Army occur.

The percentage of cases of chancroid among all venereal disease cases admitted to hospital and quarters on an excused-from-duty basis rose from 17 percent in 1950, to 29 percent in 1951, to 33 percent in 1952; it then declined to 29 percent and 25 percent in 1953 and 1954, respectively. Although in 1950 there were less than half as many admissions for chancroid as for syphilis, during the next three years admissions for chancroid exceeded those for syphilis; in 1954 admissions for chancroid and syphilis were about equal. The average duration per chancroid admission for this entire period was 13 days.

When admissions and CRO cases are taken together (table XXIV), it may be seen that between 1950 and 1952 there was a noticeable increase in the admissions plus CRO rate for all venereal disease, from 43 per 1,000 average strength to 73 per 1,000. (Since the venereal disease ?admission rates? published in the Annual Reports of previous years have included CRO cases, this is the comparison which must be made.) By 1954 the rate had declined

TABLE XXIV.?ADMISSIONS, AVERAGE DURATION, AND NONEFFECTIVE RATES FOR VENEREAL DISEASE, BY DIAGNOSIS AND YEAR, U. S. ARMY, 1950-1954

Year	Admissions^a			Admissions plus CRO cases			Incidence^c (rate)^b	Noneffective rate^d
	Rate^b	Average duration		Percent CRO	Rate^b	Average duration, all cases
	Rate^b	All cases	Single diagnosis cases	Percent CRO	Rate^b	Average duration, all cases
Venereal disease, total:
1950-1954	4.07	16	11	93	60.70	1	62.75	0.18
1950	5.56	16	13	87	43.39	2	46.16	0.25
1951	5.77	15	10	90	57.35	2	60.71	0.25
1952	4.56	18	11	94	73.37	1	75.69	0.21
1953	3.13	16	9	95	64.59	1	66.23	0.14
1954	2.02	16	10	96	54.35	1	54.86	0.08
Gonorrhea:
1950-1954	1.51	10	5	97	45.38	(^e)	46.30	0.04
1950	2.24	10	6	93	30.74	1	32.12	0.06
1951	2.05	10	5	95	38.05	1	39.59	0.05
1952	1.49	11	6	97	53.41	(^e)	54.36	0.05
1953	1.34	11	5	97	51.22	(^e)	51.91	0.04
1954	0.80	10	6	98	44.91	(^e)	45.19	0.02
Syphilis:
1950-1954	1.13	27	18	57	2.62	12	3.01	0.09
1950	2.14	25	19	55	4.78	11	5.44	0.15
1951	1.66	24	16	54	3.50	11	4.09	0.12
1952	1.23	30	19	52	2.64	14	3.08	0.09
1953	0.64	29	16	65	1.88	10	2.17	0.06
1954	0.49	27	15	65	1.41	10	1.53	0.03
Chancroid:
1950-1954	1.14	13	11	91	12.32	1	13.01	0.04
1950	0.95	11	10	87	7.58	1	8.25	0.03
1951	1.70	13	11	89	15.38	1	16.57	0.06
1952	1.48	13	10	91	16.89	1	17.76	0.05
1953	0.91	13	11	92	11.13	1	11.74	0.03
1954	0.50	14	12	93	7.66	1	7.76	0.02
Venereal disease, other and unspecified:
1950-1954	0.29	18	16	24	0.38	14	0.43	0.01
1950	0.23	13	16	20	0.29	10	0.35	0.01
1951	0.36	20	19	15	0.42	17	0.46	0.02
1952	0.36	18	18	15	0.43	15	0.49	0.02
1953	0.24	19	15	31	0.36	13	0.41	0.01
1954	0.23	14	10	38	0.37	17	0.38	0.01

^aCRO cases excluded.
^bNumber per 1,000 average strength per year.
^cAdmissions plus CRO cases plus cases secondary to another admission diagnosis.
^dDaily number per 1,000 average strength.
^eLess than one-half day.

to 54 per 1,000, but this was nonetheless higher than it had been in 1950. For gonorrhea, which constituted three-fourths of all venereal disease in the Army, the rate rose from 31 per 1,000 in 1950 to 53 in 1952, falling only to 45 per 1,000 by 1954. The rates for chancroid and syphilis were quite low in 1950; that for chancroid had doubled by 1952 but receded to the 1950 level by 1954, whereas that for syphilis declined steadily.

Table XXIV also shows the continuing increase over the past five years in the proportion of venereal disease cases treated on an outpatient basis and carded for record only; in 1954, 96 percent of all venereal disease cases were CRO, as compared with 87 percent in 1950. Nearly all cases of gonorrhea, about nine-tenths of cases of chancroid, and about two-thirds of cases of syphilis, were carded for record only in 1954; in each instance an increase from 1950 occurred in the proportion of CRO cases. The less numerous types of venereal disease, lymphogranuloma venereum and granuloma inguinale, are still for the most part treated on an excused-from-duty basis.

Among Army personnel worldwide in 1954, only 2,870 venereal disease cases were admitted to hospital or quarters on an excused-from-duty basis. An additional 715 cases, virtually all of which would otherwise have been treated on an outpatient basis, were found in patients admitted to medical treatment

CHART K.?NONEFFECTIVE RATES FOR VENEREAL DISEASE, U. S. ARMY, 1950-1954

facilities for other diseases or injury. The cases admitted to hospital or quarters on an excused-from-duty basis, are, of course, those not considered amenable to outpatient treatment.

Noneffectiveness due to venereal disease continued its downward trend, moving from a daily noneffective rate of 0.14 per 1,000 average strength in 1953 to 0.08 in 1954. Only 8 men out of each 100,000 in the Army were noneffective on the average day in 1954 because of venereal disease. The trend of total venereal disease and syphilis noneffectiveness during the past five years is depicted in chart K. Chart L delineates the trend in total venereal disease

CHART L.?ADMISSION AND INCIDENCE RATES FOR VENEREAL DISEASE, U. S. ARMY, 1950-1954

admission and incidence rates. It will be noted that the noneffective rate for total venereal disease did not change from 1950 to 1951, although there was a slight increase in the admission rate?the reason being that the increase in noneffectiveness due to chancroid was equal to the reduction in noneffectiveness due to syphilis (other venereal diseases exhibited neither an increase nor a decrease in noneffectiveness), whereas the upswing in chancroid admissions more than compensated for the falling off of gonorrhea and syphilis admissions. In subsequent years the decline in noneffectiveness for total venereal disease more or less reflected the reduction in the admission rate.

EPIDEMIC HEMORRHAGIC FEVER

Because of its comparatively high case fatality (deaths per 100 cases), epidemic hemorrhagic fever is considered one of the more serious of the infective and parasitic diseases. Since the time this disease was first diagnosed among Army troops in Korea (in the late spring of 1951) up to the end of 1954, nearly 2,500 Army cases have been reported, with an overall case fatality of 5.5 percent. Perhaps even more important is the fact that a sizable proportion of all disease deaths in the Army are attributable to epidemic hemorrhagic fever. In Korea, where this disease is endemic and where all cases are presumed to have been contracted, epidemic hemorrhagic fever accounted for approximately 13 percent of all disease deaths among Army troops during 1954. In 1953, the corresponding proportion was 25 percent. (Since all cases of epidemic hemorrhagic fever among Army troops are presumed to have been contracted in Korea, incidence and admission rates have been computed by relating all cases reported in the Army to the strength in Korea.)

Convalescence in the more serious cases may be prolonged, but recovery is generally complete. Nearly 95 percent of all cases reported since 1951 have been returned to duty. In 1954, the average length of stay in hospital and quarters was 68 days per case. For the period 1951-1954, less than 1

CHART M.?INCIDENCE RATES FOR EPIDEMIC HEMORRHAGIC FEVER, U. S. ARMY TROOPS IN KOREA, BY MONTH, JUNE 1951-DECEMBER 1954

percent of the surviving cases resulted in separation for disability. Of the 12 cases of epidemic hemorrhagic fever resulting in separation during this period, 9 separations were due to renal damage or disorders of the urinary system, 1 to a disorder of the circulatory system, 1 to myelopathy, and 1 to a schizophrenic reaction.

Although sporadic cases of epidemic hemorrhagic fever are reported throughout the year, there are two seasonal peaks, one during the spring?summer season (March-August) and one during the fall-winter season (September?February). As may be seen in chart M, the usual months of peak seasonal incidence are June or July, and November. Despite the higher incidence during the 1954 spring-summer season, the incidence rate for the year Army troops in Korea (1.7 cases per 1,000) was slightly lower than the corresponding rate for 1953 (1.9). In addition to the continuation during 1954 the downward trend in incidence, there was a sharp decrease in case fatality, 16.5 percent in 1953 to 3.2 percent in 1954.

SELECTED INFECTIVE AND PARASITIC DISEASES

Several of the more important infective and parasitic diseases are discussed as separate topics in other sections of this report. These include tuberculosis, venereal disease, malaria, infectious hepatitis, and epidemic hemorrhagic fever. Certain others, such as typhoid fever, amebiasis, dysentery, and food infection and food poisoning are included under ?Dysentery and Related Conditions;" while still others, such as mumps, streptococcal sore throat, rubella are discussed under ?Selected Respiratory and Related Infective Diseases.? Included in the group of conditions discussed in this section are all infective and parasitic diseases not discussed elsewhere. (See table XXV.)

Data for each of the foregoing diseases or disease groups, except the "selected respiratory diseases,? are shown in the source tables as ?infective and parasitic diseases.? This grouping corresponds to the group so labeled in the International Statistical Classification of Diseases, Injuries, and Causes of Death, and like that group excludes certain acute respiratory infections, enteritis, rheumatic fever, and certain localized infections, all of which are classified in other groups.

In 1954, excluding those cases carded for record only, the group of conditions shown in table XXV accounted for 29.7 percent of the total incidence of infective and parasitic diseases. If cases carded for record only are included, the corresponding proportion is 9.8 percent. In contrast, these same conditions accounted for almost half (31) of the 65 deaths due to infective and parasitic diseases in 1954.

Based on cases completed in 1954, the average length of stay in hospital or quarters for conditions in the residual group, ?selected infective and parasitic diseases,? ranged from 5 to 96 days per case. However, about 78 percent of these conditions had an average stay of 34 or fewer days per case. The principal disabling cause was sarcoidosis, which accounted for 57 of the 88 separa-

tions for disability. (Though of unknown etiology, this disease is included in the infective and parasitic disease group in accordance with the International Statistical Classification.) In 1954 there were 105 cases of sarcoidosis among U. S. Army troops worldwide, resulting in an incidence rate of 0.07 cases per 1,000 average strength. Again in 1954, admission rates for this condition were appreciably higher among Negro personnel than among other personnel?0.36 and 0.03 per 1,000, respectively.

In addition to the cases of sarcoidosis already mentioned, the category ?other? shown in table XXV includes a variety of infective and parasitic diseases. The principal ones are herpes simplex (295 cases), herpes zoster (270), erysipelas (65), pediculosis (115), epidemic pleurodynia (80), viral diseases not elsewhere classified (250), and fungus infections not elsewhere classified (135). Of the 9 deaths attributed to this ?other infective and parasitic disease? category, 5 were due to meningococcal bacteremia, 3 to bacteremia not elsewhere classified, and 1 to moniliasis.

As previously indicated (see section on ?Selected Respiratory and Related Infective Diseases?), neither sample tabulations of individual medical records nor Morbidity Report (DD Form 442) data are entirely satisfactory for analyzing morbidity experience for diseases of low incidence. However, a comparison of data from the two sources provides some indication of the direction and

TABLE XXV.?SELECTED INFECTIVE AND PARASITIC DISEASES: INCIDENCE AND DEATHS, U. S. ARMY, 1954

Diagnostic category	Incidence	Deaths
Selected infective and parasitic diseases^a	10,760	31
Relapsing fever	-	-
Encephalitis, infectious, acute^b	40	4
Dengue	-	-
Infectious mononucleosis	2,100	1
Typhus (tick-borne)^c	5	-
Schistosomiasis	295	1
Filariasis	5	-
Ankylostomiasis (hookworm)	1,010	-
Ascariasis	240	-
Worm infestation, n. e. c.	825	-
Dermatophytosis	3,965	-
Scabies	375	-
Poliomyelitis, acute	195	16
Other	1,705	9

^aFor diseases excluded, see text.
^bExcludes lymphocytic choriomeningitis. Thirty-five cases of this disease are included among the 75 cases shown in the source tables based on the tabulations of individual medical records.
^cAll reported cases of typhus were tick-borne.
Note: Incidence data (number of cases) are based on a 20 percent sample of individual medical records and exclude cases carded for record only. Data for deaths are based on complete files of individual medical records and include cases carded for record only.

of magnitude of error. For selected conditions for which comparable data are available, a comparison of the two sources with respect to incidence may be made from table XXVI.

TABLE XXVI.?INCIDENCE OF SELECTED INFECTIVE AND PARASITIC DISEASES, U. S. ARMY, 1954

Diagnostic category	Tabulations of individual medical records	Morbidity Report (DD Form 442)
Relapsing fever	-	-
Encephalitis, acute, infectious^a	40	24
Dengue	-	1
Tetanus	-	-
Gas bacillus infection	-	1
Spirochetal jaundice (Weil's disease)	-	5
Poliomyelitis, acute	195	174
Pappataci fever (sandfly fever)	-	1
Typhus, total	5	4
Rickettsial infection, n. e. c.^b	5	6
Filariasis	5	2
Scabies	380	402
Dermatophytosis	3,965	3,082

^aExcludes lymphocytic choriomeningitis. Thirty-five cases of this disease are included among the 75 cases shown in the source tables based on the tabulations of individual medical records.
^bQ fever, rickettsial pox, etc.
NOTE: All data include cases carded for record only.

NEOPLASTIC DISEASES

Again in 1954 neoplastic diseases caused more than one-fifth of all deaths and disease in the Army; the deaths in this class were due chiefly to malignant tumors and neoplastic conditions of the lymphatic and hematopotetic tissues. In other respects the neoplastic disease group was of less importance, contributing only 2 percent of the admissions, 4 percent of the noneffectiveness, and 2 percent of the disability separations for all disease conditions during 1954.

Malignant Neoplasms and Neoplastic Conditions of the Lymphatic and Hematopoietic Tissues

The admission rate for cancer (or malignant neoplasms and neoplastic conditions of the lymphatic and hematopoietic tissues) in the Army has varied but little in the past five years, ranging from 4 to 5 admissions for each 10,000 troops per year. The admission rate in 1954 (0.38 per 1,000 average strength) was the same as in 1953. In recent years neoplastic conditions of the lymphatic and hematopoietic tissues have constituted 15 to 20 percent of this group.

Of the 450 admissions for malignant neoplasms (here excluding neoplastic conditions of the lymphatic and hematopoietic tissues) during 1954, 285, or 63 percent, were for carcinoma (a little less than one-third of these being for

adenocarcinoma); another 22 percent were distributed about equally among sarcomas, tumors of the nerve tissue (all affecting the brain), dysgerminomas, teratomas, and melanomas; the remainder were admissions for other histological types.

The distribution of admissions and deaths from malignant neoplasms by anatomical site is presented in table XXVII. More than one-fifth of the cancer admissions were for cancer of the skin; among these admissions there were 2 deaths, both due to melanoma. Nine out of 10 admissions for skin cancer were returned to duty. Case fatality rates for cancer of the brain, of the lung and bronchi, and for leukemia were exceedingly high. It should be noted, however, that with respect to cancer, Army mortality figures are unquestionably lowered by the fact that many serious cases are separated for disability and die outside the Army. During 1954 there were more cases that were separated for disability because of cancer (156) than there were deaths due to cancer (112).

The 112 deaths due to cancer occurred at a rate of 8 per 100,000 troops per year. Of the 112 deaths, 82 were due to malignant neoplasms and 30 to

TABLE XXVII.?ADMISSIONS AND DEATHS DUE TO MALIGNANT NEOPLASMS AND NEOPLASTIC CONDITIONS OF THE LYMPHATIC AND HEMATOPOIETIC TISSUES, BY ANATOMICAL SITE, U. S. ARMY, 1954

Anatomical site	Admissions		Deaths
Anatomical site	Rate^a	Percent	Rate^a	Percent
Total	38	100.0	8.0	100.0
Malignant neoplasms	32	84.1	5.9	73.2
Buccal cavity and pharynx	3	7.5	0.1	0.9
Digestive organs and peritoneum	5	12.1	1.6	18.7
Stomach	-	-	0.4	4.5
Other	5	12.1	1.2	14.2
Respiratory system	2	6.5	1.3	17.0
Lung and bronchi	1	4.6	1.0	12.5
Other	1	1.9	0.3	4.5
Breast and genitourinary system	5	14.0	1.1	14.3
Testis	3	7.5	0.6	7.2
Other	2	6.5	0.5	7.1
Skin	9	21.6	0.1	1.8
Brain	2	6.5	1.1	13.4
Other	6	15.9	0.6	7.1
Neoplastic conditions of lymphatic and hematopoietic tissues	6	15.9	2.1	26.8
Hodgkin's disease	3	6.6	0.4	4.5
Leukemia	2	5.6	1.3	16.9
Other	1	3.7	0.4	5.4

^aExpressed as number per 100,000 average strength per year.

neoplastic conditions of the lymphatic and hematopoietic tissues. Historically, 45 of the deaths were due to carcinoma (about two-fifths of these being adenocarcinoma), 15 were due to tumors of the brain (5 glioblastoma multiforme; 2 astrocytoma; 1 medulloblastoma; 3 glioma, n. e. c.; 2 sarcoma; and 2 malignant tumors, n. e. c.), 8 additional deaths were due to sarcoma, 4 were due to dysgerminoma and teratoma, 2 were due to melanoma, and the remaining 8 were distributed among other histological types.

The average duration for admissions due to malignant neoplasms was 105 days; for neoplastic conditions of the lymphatic and hematopoietic tissues it was 124 days. Despite the high average duration of cancer admissions, its noneffectiveness is low (1 percent of the total days lost from all disease conditions) because of the low incidence of these diseases.

Benign Neoplasms

More than 90 percent of admissions for neoplastic conditions were characterized as benign cases. Furthermore, whereas less than 10 percent of the cases of malignant neoplasms were reported to have existed prior to entrance service (EPTS), nearly two-thirds of the cases of benign neoplasms were EPTS. This results for the most part from the inclusion in this group of the nearly 5,000 cases of pilonidal sinus or cyst, virtually all of which were reported as EPTS. Seventy-nine separations for disability and 3 deaths were attributed to benign neoplasms.

The most outstanding single diagnosis in this group, pilonidal sinus or cyst, contributed two-thirds of the admissions and noneffectiveness for the subclass and two-fifths of the disability separations. That most of the cases were EPTS is hardly surprising, since, although many individuals with pilonidal cyst may be asymptomatic in civilian life, symptoms are frequently activated by the conditions of military service.

In 1954 cases admitted for pilonidal sinus or cyst lost 108,000 days, producing a noneffective rate of 0.21 per 1,000 average strength. On the average, each of these admissions remained 22 days in hospital or quarters on an excused-from-duty basis; nonsurgical cases averaged 7 days per admission, whereas surgical cases averaged 30 days per admission. Of the new admissions in 1954 for pilonidal conditions, two-thirds were surgical cases. When the pilonidal condition was the sole diagnosis, surgical operations were performed less often in?57 percent of the admissions. The types of operations performed for all pilonidal cyst admissions are shown in table XXVIII. It will be observed that although excision continued to be the predominant type of operative procedure, in all oversea areas combined, incision and drainage was the procedure most frequently used. More than 99 percent of admissions for pilonidal cyst were returned to duty, with little difference in this respect between cases operated on and those not operated on.

TABLE XXVIII.?ADMISSIONS FOR PILONIDAL CYST OR SINUS, BY TYPE OF OPERATION AND AVERAGE DURATION OF STAY: BY BROAD GEOGRAPHIC AREA, U. S. ARMY, 1954

Type of operation	Admissions				Average duration (days)
	Number	Percent distribution			Total Army	Continental U.S.	Overseas
	Total Army	Total Army	Continental U.S.	Overseas	Total Army	Continental U.S.	Overseas
Total	4,805	100	^a100	^b100	22	26	18
With no operation	1,680	35	26	45	7	8	6
With operation	3,125	65	74	55	30	32	27
Excision	1,685	35	47	22	38	38	38
Incision and drainage	1,115	23	17	29	16	15	17
Marsupialization	280	6	9	3	35	31	49
Other	45	1	1	1	31	19	(^c)

^aRepresents 2,550 admissions.

^bRepresents 2,255 admissions.
^cToo few cases to yield a reliable average duration.

ALLERGIC, ENDOCRINE SYSTEM, METABOLIC, AND NUTRITIONAL DISEASES

Allergies

In terms of the history of American military medicine, the attention given to the diseases of allergy as a group represents a relatively recent development. In fact, the overall concept of ?allergies,? i. e., the clinical conditions denoted by the current term, is for the most part a biological discovery associated with the twentieth century, although some of the component diseases were recognized as clinical entities long before the present century. An allergy?a physiochemical reactivity to specific substances such as pollens, foods, or bacteria?can range from a mild, nondisabling condition not severe enough to interfere with a soldier?s normal duties, to a serious debilitating disease that can result in permanent loss of manpower in the Army. Undoubtedly the number of mild allergic cases among Army personnel has been large, with nearly all of the affected personnel continuing on duty without treatment, or being treated on an outpatient basis. Not all Army cases are as mild as this, however. Between 1950 and 1954, about 37,000 Army personnel were excused from duty and admitted to hospital or quarters because of allergic disorders and about 3,300 were separated from the Army for this cause. (See table XXIX.)

In addition to the 36,600 admissions during the past five years, 9,000 cases of allergy were diagnosed among Army personnel who had been admitted for other diseases or injuries, or who had multiple diagnoses of allergic disorders?bringing the total incidence count to about 45,600.

Physical standards for induction or enlistment have undergone some revision in the past ten years with respect to the allergic disorders. During World

War II, out of each 1,000 registrants examined, one had an allergy of a disqualifying nature.¹ The discovery and improvement of new pharmaceutical preparations as well as other preventive and therapeutic measures have permitted the induction of registrants who, ten years ago, might have been rejected by military service. Thus, current regulations provide that hay fever is now an acceptable (nondisqualifying) defect ?. . . if mild and controlled or controllable by antihistamines or by desensitization or by both.?² Nevertheless, certain allergies remain among the most important causes of disqualification among registrants who fail preinduction medical examinations, To illustrate: of all registrants disqualified for medical reasons during the recent period July 1950-December 1952, 6 percent were disqualified for asthma.

TABLE XXIX.?DISEASES OF ALLERGY:^a MORBIDITY INDICES, U. S. ARMY, 1950-1954

Year	Admissions^b		Average duration (days)	Noneffective rate^c	Disability separations
Year	Number	Rate	Average duration (days)	Noneffective rate^c	Disability separations
1950-1954	36,600	5.44	19	0.28	3,309
1950^d	4,185	5.85	22	0.35	221
1951^d	9,980	6.83	21	0.41	981
1952^d	9,385	5.86	21	0.31	948
1953	7,830	5.11	16	0.21	747
1954	5,220	3.68	13	0.14	412

^aHay fever, asthma, angioneurotic edema, urticaria, allergic eczema, and allergic disorders, n.e.c.
^bExcludes CRO cases. Rates show number of admissions per 1,000 average strength per year.
^cAverage daily number of excused-from-duty patients per 1,000 average strength.
^dData for 1950-1952 are preliminary.

In terms of total admissions, asthma and urticaria are the most prominent manifestations of allergic disorders among Army personnel.

There are few military duties that an asthmatic person can perform easily, since recurring paroxysms of dyspnea are a serious impediment to the routine responsibilities a soldier is expected to meet. For this reason, physical standards for Army service have been rigorous with regard to asthmatic defects and for the most part the presence of asthma has been sufficient cause for rejection of registrants. Current standards provide some latitude, but only for cases with ?. . . a history of childhood asthma with . . . freedom from symptoms since the twelfth birthday.?³

With standards as rigorous as these, and 6 out of every 100 medical rejections being for an asthmatic disorder, what has been the recent Army experience with this condition among active duty personnel? From 1950 through 1954, admission rates for asthma (perennial and pollinotic combined) have been about 2 admissions per 1,000 troops. This total Army experience

¹Average for the period November 1943-December 1944 was 0.8 per 1,000. (SOURCE: Unpublished data on file at the Office of The Surgeon General, Army.)

²?Physical Standards and Physical Profiling for Enlistment and Induction,? AR 40-115, 20 August 1948.
³A R 40-115.

is based on a total of 13,895 admissions for the 5-year period. Nevertheless, the trend in the admission rates (like that for most other diseases) has been downward in recent years, and noneffectiveness from asthma has been declining noticeably since 1951: the rate was 0.27 in 1951 and 0.09 in 1954 (average daily number of excused-from-duty patients noneffective from asthma per 1,000 average strength).

With most cases of asthma being of a disqualifying nature, however, the loss to the Army by reason of disability separation is large. Of the total disability separations for all allergic disorders between 1950 and 1954 (3,309), nearly 90 percent were separations for asthma (2,956). These severe cases of asthma?the cases that result in extensive temporary and permanent loss of manpower?are for the most part the perennial type, rather than pollinotic or seasonal asthma, as the following statistics for the total 5-year period (1950-1954) show:

	Admissions		Average duration (days)	Noneffective rate	Disability separations	Deaths
	Number	Rate	Average duration (days)	Noneffective rate	Disability separations	Deaths
Perennial asthma	12,015	1.78	35	0.18	2,848	5
Pollinotic asthma	1,880	0.28	16	0.01	108	-

Asthma has been particularly troublesome in Japan in recent years, as chart N indicates. Other geographic areas, for example, the Caribbean Command, have reported unusual incidence of asthmatic conditions, but only in Japan has the admission rate for this disease been consistently above average for the past five years. The reason for the high incidence of asthma in Japan

CHART N.?ADMISSIONS FOR ASTHMA, SELECTED AREAS, U. S. ARMY, 1950-1954

is still not clear, but the disease appears to be related to residence in industrial metropolitan areas with objectionable ?smog.? In general, patients who experience asthmatic attacks in Japan are greatly, if not completely, relieved within hours of their departure from the industrial areas.

Another allergy that affects the upper respiratory system is hay fever, i. e., rhinitis induced by pollen or some other allergen. The disease is not a leading cause of morbidity or of loss of time from duty in the Army, although undoubtedly many soldiers suffer the discomforts of the seasonal variety of the disease. In fact, only 1,400 admissions (rate, 0.21 per 1,000) have been reported as hay fever in the last five years (1950-1954), entailing a noneffective rate of 1 per 1,000, and a total of 95 disability separations. Whenever treatment is required for seasonal hay fever in the Army, the usual mode of treatment is on an outpatient or duty status, with only the serious cases requiring hospitalization.

Of the dermatological allergies, urticaria (nettle rash, or hives) has a relative important admission rate (2.08 per 1,000 for the period 1950-1954) among Army personnel. Nearly all cases are of short duration, however, and the rash has ordinarily disappeared within a few days, enabling the afflicted soldier to return to duty shortly after the onset. Accordingly, the noneffective rate for urticaria is likely to be low; in 1954 it was 0.03 per 1,000 average strength. Since chronic cases of urticaria are rare in a military population, the permanent loss to the Army is moderate, the total number of disability separations because of this disease in recent years (1950-1954) being less than 80. The contribution of other allergic diseases involving a skin reaction is slight, as the source tables in part II of this volume show. In 1954, 520 admissions for allergic eczema were reported. With this disease?as with all allergic dermatitides?the difficulty of diagnostic differentiation prevails, and thus the experience must be interpreted with cognizance of the diseases of the skin (class XVII) that resemble the allergic skin disorders. (See ?Diseases of the and Cellular Tissue.?)

Endocrine Disorders

Most of the endocrine disorders constitute sufficient cause for disqualification of registrants for military service, or for separation of active duty personnel from the Army. Some exceptions are made to the physical standards: thus, simple colloid goiter is acceptable, provided the enlargement of the thyroid not interfere with the wearing of a uniform or military equipment. If the goiter would so interfere, or if there are pressure symptoms, or if the goiter is toxic, the defect is considered disqualifying. Similarly, Fr?hlich?s syndrome, if mild or moderate in degree, is acceptable.

On the question of diabetes mellitus (table XXX), however, the standards are unequivocal; it is a disqualifying defect. Thus, every effort is made to recognize this disease among applicants for military service, and about one out every 100 medical disqualifications of registrants is for this disorder. Nevertheless, several hundred cases appear among Army personnel each year, with a

large percentage of these being separated from the Army soon after the diagnosis has been made and proper medical treatment provided. Each year, several deaths from the disease are reported. The relationship of diabetes mellitus admission rates to age is indicated in table XXXI.

TABLE XXX.?DIABETES MELLITUS: MORBIDITY AND MORTALITY, U. S. ARMY, 1950-1954

Year	Admissions^a		Average duration (days)	Noneffective rate^b	Disability separations	Deaths
Year	Number	Rate	Average duration (days)	Noneffective rate^b	Disability separations	Deaths
1950-1954	2,435	0.36	92	0.09	1,268	23
1950^c	295	0.41	112	0.12	126	2
1951^c	495	0.35	104	0.10	231	6
1952^c	590	0.37	103	0.11	325	4
1953	535	0.34	90	0.08	301	7
1954	520	0.37	68	0.08	285	4

^aExcludes CRO cases. Rates show number of admissions per 1,000 average strength per year.

^bAverage daily number of excused-from-duty patients per 1,000 average strength.
^cData for 1950-52 are preliminary.

TABLE XXXI.?ADMISSION RATES^a FOR DIABETES MELLITUS, BY AGE, U. S. ARMY, 1950-1954

Age	1950-1954	1950	1951	1952	1953	1954
Under 20	0.14	0.22	0.13	0.14	0.09	0.11
20-24	0.19	0.28	0.22	0.18	0.17	0.17
25-29	0.26	0.25	0.19	0.26	0.27	0.33
30-34	0.63	0.38	0.48	0.78	0.58	0.95
35-39	0.90	0.68	0.84	0.93	1.19	0.78
40-44	1.94	1.65	2.61	1.74	1.86	1.81
45-49	2.58	1.02	1.65	3.02	2.91	3.52
50 and over	5.96	4.94	3.60	8.60	6.29	5.87

^aRates expressed as number of admissions per 1,000 average strength per year.
NOTE: Data for 1954 exclude CRO cases. Data for other years include a small number of CRO cases.

Metabolic and Nutritional Disorders

Incidence of the nutritional diseases?beriberi, pellagra, scurvy, rickets, osteomalacia, etc.?is now rare among Army personnel, and seldom would be expected to occur except under circumstances imposing extreme dietary limitations. During the early history of the Army, vitamin deficiency resulting from faulty food supply was a critical problem. In World War I these diseases were more nearly under control; nevertheless, nearly 900 admissions were reported for rickets among white enlisted men in the Army, from 1 April 1917 through 31 December 1919.¹

¹SOURCE: The Medical Department of the United States Army in the World War, Vol. XV.

During World War II, with the strength of the Army much larger and Army personnel widely dispersed in many geographic areas of the world, amissions for beriberi totaled nearly 400, pellagra 145, rickets, 50, and scurvy 45.²

Since World War II, the frequency of these conditions has been minimal, even throughout the Korean Conflict. Incidence of ?vitamin deficiency, not here classified? (i. e., excluding beriberi, pellagra, scurvy, rickets, osteomalacia) totaled 1,459 cases for the past five years, yielding an incidence rate of 0.22 per 1,000 average strength per year (admissions plus secondary diagnoses). About 4,346 cases (incidence) of obesity, not specified as of endocrine origin, were reported among Army personnel between 1950 and 1954.

PSYCHIATRIC DISORDERS

Psychiatric disorders occurred in the Army at a lower rate in 1954 than in any other recent year; fewer than 11 admissions to excused-from-duty treatment occurred among the average 1,000 persons in the Army. This was less than half the rate (24) for 1950, and represented a decrease of about one-fifth in the relatively low rate (14) experienced in 1953. The decreases occurred largely among the psychoneurotic disorders, and, to a lesser extent, among the character and behavior disorders. The first of these two groups declined to one-third of its earlier size (from 12 in 1950 to 4 in 1954); the character and behavior disorders group declined to less than two-thirds of its earlier level (from 8 in 1950 to 5 in 1954).

All of the above statements concerning the decline in the rate of admission excused from duty treatment give essentially the same picture presented either the incidence rate or the admission plus CRO (cases carded for record only) rate. Table XXXII shows, for total psychiatric disorders, all of these rates, and a similar trend may be seen in each of them. By presenting admissions both with and without CRO cases, the table facilitates comparisons with reports for previous years.

As the rates of admission for psychoneurotic disorders and character and behavior disorders have declined, the admission rate for psychotic disorders, remaining relatively constant, has assumed a proportionately greater importance in the total rate for psychiatric disorders. Thus the psychotic disorders accounted for 8 percent of the total psychiatric admission rate in 1950, but this percentage had increased to 15 in 1954. About half of the reported cases of psychosis were characterized as having existed prior to service. The psychotic disorders, with an average duration several times as great as that for other psychiatric conditions, are particularly important as a cause of noneffectiveness. The noneffective rate (0.6) from these disorders in 1954 accounted for nearly half of all noneffectiveness from psychiatric causes. It is in disability separations, however, that the importance of the psychotic disorders as a cause of manpower loss is most apparent. There were 2,267 separations for disability

²1942-1945

due to psychotic disorders, constituting more than two-thirds of all the separations due to psychiatric causes and about one-sixth of disability separations from all causes. Most of the cases diagnosed as psychotic disorders terminated in separation from service, the 2,267 disability separations coming from among the fewer than 3,000 cases of psychosis disposed of in the year. This was in marked contrast to the experience for nonpsychotic disorders, since about four-fifths of such cases were disposed of by return to duty.

The marked decline in the admission rates for psychiatric disorders reflects many factors. Changes in environmental stress affect the rate; the years 1950 and 1951, for example, had rates of over 2 per 1,000 for transient personality reactions to acute or special stress (such as combat), while in the peacetime year 1954 the rate for this group of disorders was only one-seventh as large. One of the most important factors in the decline has been the continued increased emphasis on the use of outpatient care in both preventive and therapeutic psychiatry.

TABLE XXXII.?ADMISSION AND INCIDENCE RATES, NONEFFECTIVE RATES, AND AVERAGE DAYS PER CASE, THE TOTAL PSYCHIATRIC DISORDERS
AND FOR SELECTED SUBGROUPS, U. S. ARMY, 1950-1954

	1950	1951	1952	1953	1954
Total psychiatric disorders:^a
Admission rates^b	23.5	24.4	15.6	13.7	10.6
Admission rates^c	23.6	25.1	16.0	14.6	11.4
Incidence rates^c	29.1	30.4	19.3	17.8	13.4
Noneffective rates	2.8	3.0	2.2	1.8	1.3
Average days per case (excused from duty)	42	41	55	50	45
Psychotic disorders:
Admission rates^b	1.8	2.7	2.0	2.0	1.6
Noneffective rates	0.8	1.0	0.9	0.8	0.6
Average days per case (excused from duty)	185	127	165	146	128
Psychoneurotic disorders:
Admission rates^b	11.9	12.0	6.8	5.3	4.0
Noneffective rates	1.1	1.2	0.7	0.5	0.3
Average days per case (excused from duty)	31	36	41	35	29
Character and behavior disorders:
Admission rates^b	7.5	7.3	5.9	5.8	4.5
Noneffective rates	0.8	0.7	0.6	0.5	0.4
Average days per case (excused from duty)	40	34	36	30	30

^aIncludes disorders of intelligence and transient personality disorders, in addition to the three categories shown.
^bExcluding CRO cases.
^cIncluding CRO cases.
NOTE: Admission and incidence rates expressed as number per 1,000 average strength per year. Noneffective rates expressed as average number noneffective daily per 1,000 average strength.

Army policy is to treat mild psychoneurotic reactions, character and behavior disorders, and transient personality disorders on an outpatient basis whenever this is feasible, with the affected soldier continuing on full duty. Hospitalization is to be limited largely to psychotic cases and to the severe psychoneurotic reactions. There are sound therapeutic reasons for this policy, as well as obvious advantages in economy. Treatment on a duty basis tends knit the amount of ?secondary gain? derivable from an abnormal mental or emotional episode; hospitalization will in some instances automatically lessen the chances for rapid and complete recovery. Thus the trend has been toward more emphasis on outpatient psychiatric care and a corresponding deemphasis on inpatient or excused-from-duty care. To this end, mental hygiene consultation services have been established at all Army posts conducting basic training and at many other posts in the United States. In 1954 there were 19 such clinics, serving approximately a half million men, and over 23,000 persons were seen by these clinics in the year. At other posts and in oversea areas many more thousands of outpatients were seen for psychiatric conditions. The rate at which patients were seen on an outpatient basis for neuropsychiatric treatment increased from 102 treatments per 1,000 strength per year in 1952 (the first full year for which the data are available in this detail), to 123 in 1953, and to 131 in 1954.

It should be noted that there are practical limits to the extent to which inpatient psychiatric care can be restricted entirely to psychotic and severe psychoneurotic reactions. They arise chiefly from the difficulties in obtaining optimal numbers of adequately trained psychiatric personnel and from the difficulties in differential diagnosis of psychiatric disorders and the time required to identify properly the exact conditions involved. To cite two hypothetical examples, consider the case admitted to a hospital for what appears to be a psychosis; subsequently, perhaps 3 weeks later, this case is diagnosed as a psychoneurotic reaction and the patient is returned to duty. The ?cause of admission? on the individual medical record will reflect the corrected diagnosis, i.e., a psychoneurotic reaction. Further illustrative is the case first diagnosed as a psychoneurotic reaction, but later identified as a behavior disorder. This case is reported and recorded as an admission for a specific behavior disorder. Each of these cases, however, would have contributed to the overall duration and to the noneffectiveness from psychiatric conditions before being identified and returned to duty or separated from the service. The 1954 admission rates for psychoneurotic disorders and for character and behavior disorders reflect these considerations.

Thus, while one objective of the outpatient program is to confine hospitalization to psychotic and severe psychoneurotic cases, this limitation is feasible only to the point where such cases can be distinguished from other psychiatric conditions (e. g., character and behavior disorders). Since observation is often a prerequisite of such differential diagnosis, nonpsychotic cases will in some instances continue to be admitted and lose time from duty. The goal is to keep this number minimal.

DISEASES OF THE NERVOUS SYSTEM

At the preinduction medical examination, registrants for military service are carefully screened in order to detect the presence of neurological disorders, many of which are disqualifying defects. Thus, the active duty Army population is one that has been subjected to scrutiny, particularly with respect to such common neurological diseases as epilepsy, post-encephalitic and post-traumatic syndromes, multiple sclerosis, meningitis, and similar diseases.¹ Any serious neurological disorder is disqualifying?encephalomyelitis, cerebellar and Friedreich ?s ataxia, athetoses, Huntington?s chorea, cerebral arteriosclerosis, paralysis agitans, chronic or recurrent neuritis or neuralgia of an intensity which is periodically incapacitating, residuals of concussion or severe cerebral trauma that are incapacitating, paroxysmal convulsive disorders and disturbances of consciousness not controlled by medication, etc. To be enlisted or inducted into the Army, a registrant must present a healthy nervous system, as manifested by absence of signs of disease of the brain, spinal cord, and cranial and peripheral nerves. The only exceptions to these physical standards are minor tremors or paralyses not likely to interfere with training duties or those that have not interfered with locomotion and have not prevented the individual from successfully following a useful vocation in civil life.²

Nevertheless, incidence of neurological diseases among Army personnel has exceeded 33,000 cases within the past five years (1950-1954), producing a rate of 5 per 1,000 per year for the 5-year period.³ A large part of this total represented battle cases, with neural damage reported as a concomitant of a battle injury or wound. Other conditions?the subarachnoid and cerebral hemorrhages, for example?may be secondary to nonbattle injuries or to other types of diseases, such as vascular hypertension. This is part of the reason why the incidence rate (3.59 per 1,000) for neurological diseases in 1954 exceeds the admission rate (2.56 per 1,000) by 40 percent, another factor being the occurrence of multiple diseases of the nervous system in one patient.

The class, diseases of the nervous system, is subdivided into the following groups: (a) vascular lesions affecting the central nervous system; (b) inflammatory diseases of the central nervous system; (c) other diseases of the central nervous system; and (d) diseases of nerves and peripheral ganglia. Within these groups, the diagnoses that are the leading causes of morbidity or temporary manpower loss are epilepsy, migraine, sciatica, post-traumatic encephalopathy, facial paralysis, and the residual rubric, neuritis and neuropathy, not elsewhere classified.

Of these conditions, migraine (cause unknown) has resulted in admissions of 345, 840, 890, 570, and 655, respectively, for each year, 1950 through 1954. During the past few years the average duration of stay in cases admitted to hospital or quarters for migraine has been about 10 days, with a resultant small

¹About 2.7 percent of all medical disqualificaitons at preinduction examination during the period July 1950-December 1952 were for neurological disease. Source: Medical Statistics of the United States Army, 1953, p. 89.

²"Physical Standards and Physical Profiling for Enlistment and Induction," AR 40-115, 20 August 1948.

³Admissions plus secondary diagnoses.

effect on noneffectiveness. Less than 100 disability separations for migraine has been reported since 1950.

The disease title ?sciatica,? or neuralgia of the sciatic nerve, should properly exclude any radiculitis, neuritis, or sciatica due to displacement of intervertebral disc; such conditions are shown separately as ?herniation of nucleus pulposus? in the group of diseases of bones and organs of movement, which is how they were classified whenever they were so identified on the medical records. Nevertheless, and despite the fact that final (i. e., not ?admitting?) diagnoses are shown on the individual medical records, 220 admissions were reported in 1954 as due to sciatica. It may be assumed that many of those cases, treated at station hospitals for a time and then returned to duty, would have been found as either herniated discs or osteoarthritic syndromes if further study had been made by a neurological specialist.

By virtue of its nature, post-traumatic encephalopathy appears more frequently as a secondary than as an admission diagnosis. The average duration of cases admitted for encephalopathy due to trauma has been about 80 days in the past five years. A high proportion of such cases are separated from Army, since the conditions are serious. The incidence rate of 0.38 per 1,000 shown in table XXXIII includes about 600 admissions for battle injury or wound, in which post-traumatic encephalitis was reported as a secondary diagnosis. Facial paralysis likewise appears frequently as a secondary diagnosis. This condition includes neuralgia of the geniculate ganglion and facial nerve neuropathy (Bell?s palsy).

The rubric ?neuritis and neuropathy, not elsewhere classified? contains various diseases, some of which are chronic or seriously disabling. This is shown in the average duration for the group (66 days) and the noneffective rate of 0.14 per 1,000 (1950-1953). Again, however, these diseases are often concomitants of other diseases or injuries, as is demonstrated by the difference between the incidence rate and the admission rate. Further, of about 10,000 cases (admissions plus secondary diagnoses) of ?neuritis and neuropathy, n. e. c.,? during the period 1950-1953, about 3,500 (35 percent) were battle injury or wound cases. This only partially explains the noticeable decrease in the rate for this group that occurred during 1954. A considerable proportion of the admissions for ?neuritis and neuropathy, n. e. c.,? have been reported as peripheral neuropathy since 1950. In 1954, the distribution of the 680 admissions in the group was as follows: peripheral neuropathy, n. e. c. (290); neuralgia, n. e. c. (180); acute or unspecified neuritis (95); flaccid muscle paralysis (45); compression of brachial plexus due to displacement (30); compression of nerve, n.e.c. (30); and chronic neuritis (10). (Low-frequency diseases are, of course, subject to a greater degree of sampling error and thus the preceding data should be used with caution. See appendix.)

During 1954, as in the years of the Korean Conflict, most of the deaths from neurological disorders involved hemorrhages, subarachnoid or cerebral. Two deaths were recorded in 1954 as resulting from cerebral embolism and thrombosis, 2 from ?vascular lesions affecting the central nervous system,

TABLE XXXIII.?LEADING NEUROLOGICAL CAUSES OF MORBIDITY AND NONEFFECTIVENESS, U. S. ARMY, 1950-1953 AND 1954

Diagnosis and year	Admissions		Incidence		Noneffective rate^b
Diagnosis and year	Number	Rate^a	Number	Rate^a	Noneffective rate^b
Epilepsy:^c
1950-1953	4,300	0.81	4,960	0.93	0.14
1954	1,065	0.75	1,240	0.87	0.06
Migraine:
1950-1953	2,645	0.50	2,880	0.54	0.01
1954	655	0.46	730	0.51	0.01
Post-traumatic encephalopathy:
1950-1953	885	0.17	2,024	0.38	0.04
1954	130	0.09	240	0.17	0.03
Sciatica:^d
1950-1953	1,035	0.19	1,441	0.27	0.01
1954	220	0.15	255	0.18	0.01
Facial paralysis:
1950-1953	800	0.15	1,265	0.24	0.01
1954	220	0.15	285	0.20	0.01
Neuritis and neuropathy, n.e.c.:^e
1950-1953	3,810	0.72	9,903	1.86	0.14
1954	680	0.48	1,365	0.96	0.09

^aExpressed as number per 1,000 average strength per year.
^bExpressed as number daily noneffective per 1,000 average strength.
^cExcludes focal cortical seizure, alcoholic, epilepsy, and epilepsy with psychosis.
^dSee text for reservations regarding this diagnosis.
^eExcludes, in addition to specific conditions listed above, trigeminal neuralgia, brachial neuritis, polyneuritis and polyradiculitis, and erythredema polyneuritica.

n. e. c.,? 2 from intracranial and intraspinal abscess, 1 from a late effect of intracranial abscess or pyognic infection, 3 due to grand mal epilepsy, 2 to diseases of the brain, n. e. c., and 2 to polyneuritis or polyradiculitis. These represent the ?other neurological disorders? of table XXXIV. As a class, diseases of the nervous system usually rank among the leading nonbattle causes of death among Army personnel. Deaths from this class would be even higher were it not for the fact that, each year, a relatively large number of soldiers afflicted with severe neurological disorders are separated from the Army because of these disabling conditions.

Multiple sclerosis is a condition of prime interest because of its severity and its obscure etiology. In 1954 it accounted for only 40 admissions, and there were 29 separations for disability due to this cause. The year?s experience was not much different from that for other recent years. About 300 cases of this disease have been reported in the Army since 1945, most of which have resulted in separation for disability.

Among the most important diseases within the entire class is epilepsy. This disease is important from the viewpoint of admissions, incidence, and noneffectiveness (table XXXIII), as well as of disability separations (table

XXXV), although, since 1950, only 9 deaths from epilepsy have been reported. With the Army population as concentrated as it is, predominantly male, with about three-fifths between 20 and 24 years of age, almost 90 percent white, and 90 percent enlisted personnel, it is clear that only the most circumspect inferences can be drawn from Army data with respect to sex, age, race, and rank differentials. These limitations must be borne in mind in interpreting the data of tables XXXVI and XXXVII, which suggest higher rates of admission among enlisted and male, as compared with officer and female, personnel, and similar rates among Negroes and whites. The higher rate of admission for epilepsy among personnel under 20 years of age (table XXXVII) reflects in part the fact that, despite rigorous physical standards, some registrants are inducted with constitutional tendencies toward convulsive reactions, discovered soon after the induction of such personnel into the Army. Many such cases are soon separated from the military service for disability.

TABLE XXXIV.?DEATHS DUE TO DISEASES OF THE NERVOUS SYSTEM, U. S. ARMY, 1950-1953 AND 1954

Cause of death	1950-1953	1954
Total	190	56
Subarachnoid hemorrhage	59	20
Cerebral hemorrhage	52	12
Acute meningitis^a	14	6
Encephalitis, myelitis, and encephalomyelitis (except acute infectious), n.e.c.	21	4
Other neurological disorders	44	14

^aExcludes meningococcal meningitis.

TABLE XXXV.?SEPARATIONS AND DISABILITY DUE TO NEUROLOGICAL CONDITIONS, U. S. ARMY, 1950-1953 AND 1954

Cause of separation	1950-1953	1954
Total	5,262	866
Epilepsy, grand mal^a	1,183	173
Epilepsy, other^a	430	63
Post-traumatic encephalopathy	841	129
Motor neurone disease and muscular atrophy	159	39
Other diseases of the spinal cord	110	14
Multiple sclerosis	122	29
Sciatica	127	4
Facial paralysis	63	10
Other neuritis and neuropathy	1,675	298
Other neurological disorders	552	107

^aExcludes focal cortical seizure, alcoholic epilepsy, and epilepsy with psychosis.

TABLE XXXVI.?ADMISSIONS^a FOR EPILEPSY, BY RANK, SEX, AND RACE, U. S. ARMY, 1950-1954

Type of epilepsy	Rank		Sex		Race
Type of epilepsy	Officer	Enlisted	Male	Female	White	Negro
	Number
Total^b	205	5,375	5,550	30	4,840	740
Petit mal	30	390	420	-	345	75
Grand mal	115	3,765	3,855	25	3,420	460
Other	60	1,220	1,275	5	1,075	205
	Rate^c
Total^b	0.32	0.88	0.83	0.40	0.82	0.90
Petit mal	0.05	0.06	0.06	-	0.06	0.09
Grand mal	0.18	0.62	0.58	0.33	0.58	0.56
Other	0.09	0.20	0.19	0.07	0.18	0.25

^aIncludes 215 cases treated on an outpatient basis and carded for record only. This represents 4 percent of the total morbidity for epilepsy. The distributions of CRO cases by rank, sex, and race for 1950-1953 are not available, and therefore could not be excluded from these data.
^bExludes focal cortical seizure, alcoholic epilepsy, and epilepsy with psychosis.
^cExpressed as number per 1,000 average strength per year.

TABLE XXXVII.?ADMISSIONS^a FOR EPILEPSY,^b BY AGE, U. S. ARMY, 1950-1954

Age	Number				Rate^c
Age	Total	Petit mal	Grand mal	Other	Total	Petit mal	Grand mal	Other
All ages	5,545	420	3,855	1,270	0.82	0.06	0.57	0.19
Under 20	1,160	90	845	225	1.75	0.14	1.27	0.34
20-24	3,150	250	2,200	700	0.77	0.06	0.54	0.17
25-29	620	50	400	170	0.71	0.06	0.45	0.20
30-34	240	25	160	55	0.45	0.05	0.30	0.10
35-39	210	5	140	65	0.64	0.02	0.42	0.20
40-44	125	-	80	45	0.78	-	0.50	0.28
45-49	30	-	20	10	0.44	-	0.29	0.15
50 or over	5	-	5	-	0.12	-	0.12	-
Age unknown	5	-	5	-	...	...	...	...

^aIncludes 180 CRO cases for 1950-1953 because of the manner in which the data were tabulated.
^bExludes focal cortical seizure, alcoholic epilepsy, and epilepsy with psychosis.
^cExpressed as number per 1,000 average strength per year.

Although epilepsy is frequently a serious disease, the proportion of cases admitted that are returned to duty after treatment has shown a tendency to increase in recent years. Of cases disposed of during 1954 that had been admitted to hospital or quarters for epilepsy, 83 percent were returned to duty. An attempt has been made in recent years to salvage for active service as many of these cases of epilepsy as can be retained without detriment to the afflicted personnel or to the Army. Thus, in the latter part of 1952, a directive (DA Circular 98) clarified the policy with regard to paroxysmal convulsive disorders, emphasizing that individuals with these conditions should ordinarily be retained in service if the condition was controlled by medication. As seen in table XXXVIII, the proportion of cases returned to duty rose sharply thereafter, from around three-fifths in 1952 to more than four-fifths in 1954.

TABLE XXXVIII.?PERCENTAGE OF ADMISSIONS DUE TO EPILEPSY^a RETURNED TO DUTY, U. S. ARMY, 1950-1954^b

Year	Total	Petit mal^c	Grand mal	Other
1950-1954	64.3	64.3	63.2	67.8
1954	82.8	100.0	81.6	83.3
1953	73.8	72.7	74.7	71.4
1952	59.6	50.0	57.2	69.6
1951	50.2	56.7	46.6	58.0
1950	55.9	70.0	54.2	56.0

^aExcludes focal cortical seizure, alcoholic epilepsy, and epilepsy with psychosis.
^bBased on dispositions that occurred during the period 1950-1954.
^cData for petit mal dispositions, since they are based on relatively few cases and are thus subject to a greater degree of sampling error, should be used with caution.

This discussion of diseases of the nervous system has been limited largely to diseases classified in the group so labeled (class VI) in the International Statistical Classification of Diseases, Injuries, and Causes of Death and included in the corresponding section of the source tables in this report. Various other diseases which involve or affect the nervous system are classified in other system groups and are presented in other parts of the text and tables of this report. Thus, for example, the sections on infective and parasitic diseases include consideration of tuberculous meningitis, meningococcal meningitis, infectious encephalitis, and poliomyelitis. It is worth noting that the neurosyphilitic syndromes, such as dementia paralytica and tabes dorsalis, have ceased to be problems to the Army Medical Service. Twenty years ago these two conditions accounted for an annual admission rate of about 0.2 per 1,000, a rate which would have produced some 280 cases in 1954 had it still prevailed. Instead, however, there were only 5 admissions due to dementia paralytica and none due to tabes dorsalis.

The data on neoplasms, presented elsewhere, include a small number (35 admissions; rate, 2 per 100,000 per year) of malignant neoplasms involving the brain, and none involving the spinal cord. As a cause of death, malignant

neoplasms of this site were of some importance, accounting for 1 death per 100,000 average strength. These figures are not markedly different from those for 1953.

Various other disease entities of special interest to neurologists are included in the appropriate sections on the basis of the classification used.

A few diseases included in the group of diseases of the bones and organs of movement (class XVIII) deserve some mention here as well. One of these, herniation of nucleus pulposus, in 1954 accounted for about 1,000 admissions and for 168 disability separations. Others, much less frequent, but important because of their seriousness, were myasthenia gravis, progressive muscular dystrophy, and myotonia congenita. These conditions resulted in 5, 11, and 7 disability separations, respectively, in 1954. (These numbers of disability separations are based on tabulations of all medical records, and so are not subject to the sampling errors involved in the admission data in cases of such low frequency as these.)

DISEASES OF THE EYE

Diseases of the eye and adnexa are among the diagnostic categories generally considered of lesser importance as contributors to the total morbidity of the Army. In 1954 there were 5,505 admissions in which these diseases were the primary cause of admission, constituting 1.4 percent of all admissions for disease, The 1954 admission rate for these diseases was 3.9 per 1,000 average strength per year.

With respect to incidence, that is, including not only primary but secondary diagnoses, diseases of the eye and adnexa constituted 1.9 percent of total morbidity?a higher proportion than that for total admissions, obviously due to the fact that these diseases appeared relatively more frequently as secondary diagnoses. The 1954 incidence rate for diseases of the eye and adnexa was 6.2 per 1,000 average strength per year, and the noneffective rate was 0.19, contributing 1.7 percent to total noneffectiveness. No deaths from these diseases were recorded in 1954.

In comparison with 1953, the 1954 experience indicated a relatively greater decrease for diseases of the eye and adnexa than for total morbidity. In absolute numbers, the admissions for these diseases declined in 1954 by about 34 percent from those of 1953, against a decrease of about 26 percent during this period for all diseases. In terms of admission rates, these diseases showed a decrease of about 28 percent, against a decrease of about 20 percent for all diseases. Of the important diagnostic entities, only acute respiratory diseases revealed a somewhat greater decrease.

Inflammatory conditions of the eye accounted for about 61 percent of the 1954 admissions for these diseases, among which conjunctivitis and ophthalmia were the chief causes. The remaining 39 percent were distributed among other eye conditions, the leading causes being pterygium, strabismus, and chalazion, arranged in order of descending magnitude.

In terms of differentials of area, rank, sex, and race, admission rates for diseases of the eye and adnexa were considerably higher (about 81 percent) outside the United States than in continental United States; about 10 percent higher for enlisted personnel than for officers; about 19 percent higher for women than for men; and about 16 percent higher for Negro than for white personnel.

In 1954 a total of 603 individuals were separated for nonbattle disability in an eye condition was the primary cause of separation. About three?fourths (73 percent) of these separations were for conditions that existed prior to service and were not service-aggravated. It should be noted, however, that separations due to eye conditions could involve not only admissions for diseases of the eye and adnexa, but also eye conditions resulting from non?battle injuries (class XXIII). In 1954, for instance, a distribution of non?battle injuries by anatomical location indicates that 2,220 of these injuries affected the eye. Unilateral blindness and refractive errors were the main causes of separation for disability due to diseases and defects of the eye and adnexa, particularly among separations without severance pay.

DISEASES OF THE EAR, NOSE, AND THROAT

With advances in medical and allied sciences, and especially with the introduction of antibiotics, diseases of the ear, nose, and throat¹ have assumed less importance in the Army. Just prior to World War II, for example, the admission rate for this class was about 25 per 1,000 average strength per year; in 1954 the admission rate for the class was 9 per 1,000 average strength. On the average day in 1954 only 1 of every 3,000 Army personnel was in hospital or quarters for this group of diseases, contributing but 3 percent of noneffectiveness for all disease. Permanent manpower loss due to this class was negligible, since only 2 percent of all nonbattle disability separations and 1 death resulted from diseases of the ear, nose, and throat.

The admission rate for diseases in this class continued to decrease between 1953 and 1954, the rate of decline, nearly 20 percent, being about the same as for diseases of all classes. However, for the subclass ?diseases of the ear and mastoid process,? which was responsible for one-third of class VIII admissions, the admission rate was 33 percent lower; whereas for the larger subclass, "diseases of the nose and throat,? which contributed two-thirds of the admissions, the rate decreased by only 8 percent.

In 1954 diseases of the ear and mastoid process, although responsible for but one-third of class VIII admissions and for one-half of the noneffectiveness, contributed more than 9 of every 10 disability separations for this class. Otitis media was responsible for one-fifth of both the admissions and non?

¹In this report the diseases of the ear, nose, and throat (class VIII) are comprised of two subclasses. Subclass A, "diseases of ear and mastoid process,? corresponds to the grouping (International List numbers 390-398) having the same title in the International Statistical Classification of Diseases, Injuries, and Causes of Death. Subclass B, ?diseases of the nose and throat,? is limited to International List numbers 510-517, a part of the International List category ?other diseases of the respiratory system.?

effectiveness for class VIII. The greatest number of disability separations for class VIII resulted from deafness and impaired hearing, in 1954 involving 179 cases, or nearly 65 percent of all separations due to conditions in this class.

Among the diseases of the nose and throat, which accounted for the remaining two-thirds of the admissions and for one-half of the noneffectiveness for this class, hypertrophy of the tonsils and adenoids was responsible for more than one-third of the admissions but only one-fifth of the noneffectiveness for the class as a whole. An additional one-tenth of the admissions and non-effectiveness for this class were attributed to deflected nasal septum.

Diseases in this class occurred relatively frequently as secondary diagnoses; on the average, incidence exceeded admissions by 30 percent. The number of secondary diagnoses was exceptionally large for diseases of the ear and mastoid process, incidence exceeding admissions by 50 percent. The frequency of occurrence of deafness and impaired hearing as a secondary cause of admission was one and one-half times its frequency as a primary cause of admission. For diseases of the nose and throat, incidence exceeded admissions by about 20 percent.

The chronic nature of many of the conditions in class VIII is reflected by the relatively large number of cases, 17 percent of the total incidence, which were incurred prior to military service (EPTS cases). Cases of deflected nasal septum accounted for nearly two-fifths of all EPTS cases in this class, more than half of the cases of deflected nasal septum being EPTS cases.

With respect to age, sex, rank, and race differentials for diseases in this class, a more accurate picture may be obtained by analyzing the combined data for the past five years (1950-1954). During this period the average admission rate for diseases of the ear, nose, and throat was 12 per 1,000 average strength per year for the total Army. Admissions occurred relatively more frequently among younger personnel. The highest rate (14 per 1,000 average strength per year) was observed among those under 20 years of age, with declines in each age group to less than 8 per 1,000 per year for the 45-49 year age group, and then an increase to a rate of 10 per 1,000 for personnel 50 years of age or over. This pattern in large measure emanated from the combined effect of three important diagnostic categories: otitis media, hypertrophy of tonsils and adenoids, and deafness and impaired hearing, the first two categories of disease exhibiting a lower rate with higher age, and deafness and impaired hearing showing a reverse effect. (See O.) Although the overall admissions for deafness and impaired hearing were comparatively small, a proportionally greater number occurred among older personnel, accounting for the higher admission rates in higher age groups. Among personnel 50 years of age and over, nearly two-fifths of all class VIII admissions were due to deafness and impaired hearing.

As the above age comparison would indicate, the admission rate for enlisted personnel was higher than the rate for officers for the class as a whole during 1950-1954, the ratio being 3 to 2, but with the ratio reversed for deafness and impaired hearing.

For the class as a whole, female personnel were admitted one and one-half times as frequently (rate, 18.5) per 1,000 average strength per year as male personnel (rate, 12.0). Of the diagnoses listed in source table 4, the admission rate for men exceeded the admission rate for women only with respect to deafness and impaired hearing, peritonsillar abscess, and deflected nasal septum.

CHART O.?ADMISSIONS FOR SELECTED DISEASE CATEGORIES OF EAR, NOSE, AND THROAT, BY AGE, U. S. ARMY, 1950-1954

In terms of race, white personnel were admitted nearly one-third more frequently (rate, 12.4) than Negro personnel (9.5), for the class as a whole. For diseases of the ear and mastoid process, the rate for Negro personnel (2.4) was less than one-half the rate for white personnel (5.3). In the case of diseases of the nose and throat, the admission rate was the same for both races, although some of the component diagnoses?hypertrophy of tonsils and adenoids (white, 3.9; Negro, 5.2) and deflected nasal septum (white, 1.2; Negro, 0.2)?showed variation in opposite directions.

DISEASES OF THE CIRCULATORY SYSTEM

Diseases of the circulatory system continued to be the leading cause of death due to disease in the United States Army (13.7 per 100,000 average strength per year), constituting more than one-third of the total disease deaths

in 1954. Mortality due to diseases of the circulatory system in 1954 receded but little (3.5 percent) from the 1953 rate, whereas the decline in the total disease death rate was several times as great (14.5 percent). Although the mortality rate for circulatory diseases has been decreasing, the decline has not kept pace with that exhibited by all diseases. For example, between 1930-1934 and 1950-1954 the mortality rate for circulatory diseases decreased from 39 per 100,000 average strength per year to 14 per year, a 64 percent decrease; whereas deaths due to all diseases decreased by 79 percent during the same period, from a rate of 216 per year to 46 per year. Part of the reduction in the death rate, especially that for diseases of the circulatory system, is an artifact of the differential age composition in the two periods, there having been a greater proportion of troops in the higher age brackets during the earlier period. In the earlier period 18 percent of all disease deaths were ascribed to circulatory diseases; in the recent 5-year period the proportion was 30 percent. The increase in the relative importance of diseases of the circulatory system as a cause of death in the Army is a secondary result of the much greater reduction in deaths due to other diseases that are more directly affected by the newer drugs and therapeutic techniques.

Chart P depicts total disease and circulatory disease mortality from 1930 through 1954. The use of antibiotic therapy in the prevention of sequelae affecting the heart may have a long-term effect in reducing the level of the circulatory disease death rate. However, should there be a contraction in the size of the Army with its concomitant relative increase in the higher age groups, some rise in mortality due to circulatory diseases may be expected.

The heart diseases were responsible for 89 percent of all deaths due to diseases of the circulatory system, with an additional 5 percent of deaths resulting from rheumatic fever or hypertensive disease, both with heart involvement. Of the remaining 6 percent, two-thirds of the deaths were ascribed to diseases of the arteries,

As in the past, arteriosclerotic heart disease, including coronary disease, led all other heart diseases as a cause of death. Although this disease constituted about two-fifths of all admissions for heart disease, it was responsible for more than four-fifths of all deaths due to heart disease. The case fatality rate for this disease was about 19 percent, as compared with less than 2 percent for other heart diseases. Nearly 63 percent of these deaths occurred before admission to a medical treatment facility, and an additional 10 percent occurred on the day of arrival at a hospital. Thus, nearly three-fourths of the fatal cases received little or no treatment before death. It should be noted that the case fatality rates cited do not take into account deaths occurring among individuals separated from the service.

In 1954 the total Army mortality rate for arteriosclerotic heart disease, including coronary disease, was 10.2 per 100,000 average strength per year. A relatively high rate (16.5 per 100,000 per year) was observed in the Army in Europe, the rate being 1.6 times that in the total Army. On the other hand, in the Far East, including the Western Pacific islands, the rate (6.4 per 100,000

CHART P.?DEATHS DUE TO ALL DISEASE AND TO DISEASES OF THE CIRCULATORY SYSTEM, U. S. ARMY, 1930-1954

per year) was only three-fifths that of the Army as a whole. During four of the five years, 1950-1954, the rate for the Army in Europe exceeded that of the Army in continental United States; during four of the same five years, the rate in the Far East was lower than that in the United States. The most probable reason for the differential area rates is the higher proportion of younger personnel in a battle area.

In 1954 disability separations due to diseases of the circulatory system constituted about 8 percent of the total for all nonbattle causes, exhibiting a slight decrease from the 1953 proportion of nearly 9 percent. Chronic rheumatic heart disease, which was responsible for one-half of these separations in 1953, was again the leading cause in 1954, accounting for 45 percent of class XI disability separations.

The admission rate of 9.25 per 1,000 average strength per year for diseases of the circulatory system in the total Army represented only 3 percent of all disease. Nine of every 10 admissions in this class were for diseases of the circulatory system other than heart disease, with hemorrhoids accounting for 5 of the 9 cases.

In spite of the low admission rate for class XI as a whole, the time lost from duty was relatively high, constituting 6 percent of the total days lost from all disease. Hemorrhoids, because of the large number of admissions, and heart disease, with its long duration of hospitalization, together were responsible for one-half of all noneffectiveness due to diseases of the circulatory system.

DISEASES OF THE DIGESTIVE SYSTEM

The title of this section refers to such conditions as ulcer of the stomach or duodenum, gastritis, appendicitis, hernia, of the abdominal cavity, gastroenteritis, and diseases of the liver, which are shown as class XIII in the source tables of this report. Excluded from class XIII are diseases of the teeth and supporting structures (class XII); diseases of the pharynx and tonsils (included in classes VIII and IX); Vincent?s infection and thrush (included in class I); tuberculous and cancerous conditions of digestive organs (?Tuberculosis?; ?Neoplastic Diseases?); certain gastrointestinal disorders regarded as somatization reactions (?Psychiatric Disorders?); diarrhea of unknown cause, not elsewhere classified (included in class XXI); and similar conditions. Discussed in the section ?Dysentery and Related Conditions? are dysentery, food infection and food poisoning, etc.

Among the conditions included in class XIII, the following, which will be considered as a group for the purpose of this discussion, may be classified as ?diarrheal diseases?: acute gastroenteritis, acute enteritis, acute colitis, and acute enterocolitis.

The admission rate for diseases of the digestive system in the total Army during 1954 (31.81 per 1,000) remained at a level which it has maintained for the past five years. As it had been during the four previous years, in 1954 the oversea rate (34.73 per 1,000) was higher than the rate in continental United States (29.31 per 1,000).

This disease class comprised 12 percent of all admissions for disease in 1954, with admissions for the combined group of diarrheal diseases (12.38 per 1,000) accounting for almost two-fifths of the patients admitted for diseases of the digestive system. Considering admissions for diarrhea of unknown cause, not elsewhere classified, with this group of ?diarrheal diseases? increases the admission rate for this group to 15.40 per 1,000 average strength per year.

Due mainly to the morbidity pattern for ?diarrheal diseases,? the admission rate for diseases of the digestive system in the total Army during 1954 was somewhat higher among officers than among enlisted men, twice as high among women as among men, and slightly higher among white personnel than among Negro personnel. Admission rates for ?diarrheal diseases? among these groups in 1954 are as follows: officers?16.07; enlisted men?12.01; women?38.53; men?12.13; white personnel?13.00; Negro personnel?8. 19.

The effects of age on morbidity due to diseases of this class varied among certain categories. For appendicitis, morbidity was higher among younger

personnel; for the ?diarrheal diseases? and the diseases of the buccal cavity included in this class, admissions occurred at about the same rate for all age groups; for inguinal hernia, the admission rate was lowest for personnel between 30 and 39 years old and highest for those 40 years of age and over. However, for other diseases of this class combined, the admission rate increased with age from 7.27 per 1,000 for personnel under 25 years to 27.71 per 1,000 for personnel years of age and older.

In the total Army, 39 deaths due to diseases of the digestive system occurred during 1954, at a rate of 2.7 per 100,000 average strength per year. This represents a 10 percent decrease from the 1953 mortality rate. The 1954 mortality rate was lower for admissions overseas (2.5 per 100,000) than for admissions in continental United States (3.2 per 100,000). Of the 39 deaths, the largest number, 13, were ascribed to diseases of the liver, with 10 of the 13 deaths being due to cirrhosis of the liver. In addition to these 39 deaths, there were 6 deaths in 1954 for which the immediate causes, but not the underlying causes, were conditions of the digestive system.

There were 645 disability separations for diseases of the digestive system during 1954 (about 400 less than in 1953), two-thirds of which were due to ulcer of the stomach or duodenum. In more than one-half of these peptic ulcer separations the condition was designated as having originated prior to the patient?s entering the service.

Since the admission rate did not change from 1953 to 1954, and the average duration decreased from 18 days per admission in 1953 to 16 days in 1954, noneffectiveness for this disease class decreased one-sixth during 1954. The time loss attributed to this class during 1954 constituted 12 percent of the total loss of manpower due to disease admissions. About one-fourth of this noneffectiveness was caused by ulcer of the stomach or duodenum and one-fourth by inguinal hernia.

The annual admission rate for peptic ulcer in the total Army, which had risen during the period 1950-1953, decreased somewhat in 1954?2.85 per 1,000 for 1954, compared to 3.07 per 1,000 for 1953 (3.03 per 1,000 if the 50 CRO cases had been excluded). The largest decrease was observed in Europe (from 6.37 per 1,000 in 1953 to 4.59 per 1,000 in 1954). Contrary to the changes which occurred in most of the other areas, the rate in the Caribbean area increased from 2.28 per 1,000 in 1953 to 4.39 per 1,000 in 1954. The decline in peptic ulcer morbidity during 1954 was observed in each of the various age groups under 40 years. Compared to the admission rate for patients with 2 or more years of service (5.54 per 1,000), the admission rate for this condition during 1954 was relatively low among personnel with less than 2 years of service (1.54 per 1,000). In the total Army during 1954, the admission rate for peptic ulcer dropped 7 percent among enlisted men, but for officers the 1954 rate was about the same as that for 1953. The admission rate for peptic ulcer declined 9 percent among white personnel, but increased 11 percent among Negro personnel during 1954.

DISEASES OF THE URINARY AND MALE GENITAL SYSTEM

In 1954 diseases of the urinary and male genital system constituted less than 5 percent of the admissions, 4 percent of the noneffectiveness, and 3 percent of the deaths for all disease in the Army. Disability separations due to this group of diseases were negligible, comprising only 1 percent of all separations due to nonbattle causes. By comparison with the 1953 rates, only slight changes were noted in each of these indices.

Between 1953 and 1954 the rate for cases of this disease group admitted to hospital or quarters on an excused-from-duty basis decreased 9 percent, from 14.3 per 1,000 average strength per year to 13.0 per 1,000 per year. A large additional number of cases of diseases in this class were treated on an outpatient basis and were carded for record. The 1953 ?admission? figure, as published in the Annual Report, included CRO cases with the admissions, producing a rate of 23.6 per 1,000. Inclusion of the CRO cases with the admissions in 1954 would have given a rate of 22.0 per 1,000 per year, resulting in nearly the same relative decrease (7 percent) from the preceding year. Almost all (98.1 percent) of the CRO cases in this disease class were cases of nonvenereal or nongonococcal urethritis. Consequently the exclusion of CRO cases from the 1954 admissions had little or no effect upon rates for other diseases in this class.

Diseases of the urinary system were responsible for only one-fourth of all admissions in class XIV, but contributed most of the permanent manpower losses?all of the 17 deaths and 93 percent of the disability separations. As expected, nephritis and nephrosis accounted for the majority of these cases. Although these two diseases constituted less than 2 percent of all admissions for this class, they were the cause of three-fifths of the disability separations and all but 1 death.

As stated previously, almost all of the urethritides were treated on an outpatient basis. The exclusion of these cases thus produced the 1954 urethritis admission rate of only 0.41 per 1,000 average strength per year, as against a rate of 9.22 had the CRO cases been included. The effect of the exclusion of CRO cases was to be found in a modification of a number of relationships. Diseases of the urinary system, including CRO cases, occurred in oversea areas at a rate 5 times that for the continental United States; excluding CRO cases furnished but a 4 to 3 ratio for the rates. Again, including the CRO cases, the rates among enlisted personnel and among Negro personnel were more than twice those for officers and white personnel, respectively; but limiting the data to admissions, the rate for enlisted personnel was two-thirds that for officers, and the rate for Negro personnel was but three-fifths higher than for white personnel.

The diseases most frequently observed among diseases of the male genital system were redundant prepuce and phimosis, which were responsible for one-third of class XIV admissions, followed by orchitis and epididymitis (both nonvenereal), which accounted for more than one-fifth of class XIV admis?

sions. These diseases, as well as most of the other diseases in this group, occurred relatively more frequently in areas outside continental United States than in the continental United States, more frequently among Negro personnnel than among white personnel, and more frequently among enlisted personnel than among officers; the ratios in each instance were of the order of 2 to 1.

As in 1952 and 1953, the admission rate for redundant prepuce and phimosis in the Far East (8.89 per 1,000 average strength per year) was very high compared to the rates for continental United States (2.83) and Europe (3.70). The principal reason may perhaps be the high venereal disease rate in the Far East. A relatively greater number of patients with venereal disease visited outpatient clinics in this area, and it is likely that these visits resulted in discovery of cases of redundant prepuce and phimosis requiring admission that would otherwise have escaped detection.

DISEASES OF THE SKIN AND CELLULAR TISSUE

Diseases of the skin and cellular tissue rank high among the various disease classes as a cause of admission to medical facilities, with a rate of 22 per 1,000 in 1954. This rate represents an 11 percent decrease from 1953, decreases having occurred in most of the disease categories in the class. The highest rates for this disease group were for cases admitted outside continental United States (United States, 19.7; overseas, 25.4); this was true not only of the group as a whole but also of most of the subgroups, although dermatitis (occupational and other) continued to be an exception to this geographical

differential (United States, 3.7; overseas, 1.9).

Cellulitis and abscess headed the list among the various skin diseases in each of the principal geographic areas. Boils and carbuncles were second highest in all areas except continental United States and the Caribbean. In the United States, dermatitis, occupational and other, was second, with boils and carbuncles third; in the Caribbean, diseases of the nail ranked second, and boils and carbuncles third.

The decrease in the admission rate was reflected in each of the age groups. Again, morbidity decreased with age?those under 20 years of age having a rate of 28.2; those 50 years of age and over having a rate of 11.1. The inverse relationship of morbidity and age in general held true for the various skin disease categories, with a few exceptions, such as psoriasis and similar disorders, and pruritus and related conditions, in which age did not seem to be a relevant factor.

Athough there were a large number of admissions for skin and cellular tissue diseases, there were no deaths from these diseases, and, in comparison with noneffectiveness for the other disease classes, loss of time from duty was relatively low. Diseases of the skin contributed 8 percent of all disease admissions, but were responsible for only 5 percent of all noneffectiveness due to disease. While such skin diseases as cellulitis, abscess, and boils were

numerous, they required relatively short periods of time in medical treatment facilities; this in part accounts for the lower proportion of noneffectiveness.

Included among the diseases of the skin and cellular tissue, however, were several categories of diseases requiring relatively long periods of hospitalization. Examples are psoriasis and similar disorders, with an average of 34 days; pruritus and related conditions, averaging 37 days; and eczema, 28 days. These conditions required extended hospital care and accounted for nearly half of the separations from the service due to this class of diseases.

Only 2 percent of all separations for disability due to nonbattle causes were ascribed to diseases of the skin and cellular tissue. It is apparent that most of these were EPTS cases not aggravated by service, since 77 percent were separated without severance pay. Of those separated for EPTS conditions, 46 percent had been in service for less than 6 months, and 80 percent for less than 1 year.

DISEASES OF THE BONES AND ORGANS OF MOVEMENT

The 1954 admission rate for diseases of the bones and organs of movement was 11.6 per 1,000 average strength per year. The total number of admissions during the year in which these diseases were the primary cause was 16,450:

Although admissions for these diseases accounted for 4.2 percent of all admissions for disease, they were responsible for 9.4 percent of total noneffectiveness due to disease, since diseases of the bones and organs of movement required relatively long periods of hospitalization. The 1954 noneffective rate for these diseases was 1.1. The 1954 incidence rate (including both primary and secondary diagnoses) for diseases of the bones and organs of movement was 15.3 per 1,000 average strength per year. There was only 1 death in which this diagnostic category was the underlying cause.

Compared with 1953, the year 1954 showed decreases in both the absolute -number of admissions for diseases of the bones and organs of movement and the rate of admission. In terms of absolute numbers, the decrease was about 15 percent, as compared with a decrease of about 8 percent in the rate of admission. As in the case of all diseases, the fact that there was a greater proportional decrease in the absolute number of these diseases than in their admission rate was due to a decrease in the strength of the Army, as well as to factors responsible for a general decline in morbidity, such as cessation of hostilities and comparatively fewer new accessions in relation to strength.

In terms of age, the admission rate for diseases of the bones and organs of movement was definitely greater in the higher age groups. From an admission rate of 8.7 for the under-20 age group, it gradually increased to a rate of 25.8 for ages 40-44. There was some decrease in the age group 45-49 (the admission rate for this group was 21.1), but it rose sharply to a rate of 51.5 for the 50-and-over age group. The effect of age on the admission rates for this diagnostic category as a whole was also evident in various degrees for

most of the individual diagnoses, with the exception of internal derangement of the knee, which showed a downward trend in relation to age.

By rank, the admission rate for diseases of the bones and organs of movement was about 41 percent higher for officers (15.8) than for enlisted men (11.2), with arthritis (including rheumatism) and herniation of nucleus pulposus being the predominant factors in the higher rates. These differentials are attributable mainly to the higher average age of officers.

By race, the total admission rates for diseases of the bones and organs of movement were generally not markedly different (11.5 and 12.2 for white and Negro, respectively). Racial differentials were found, however, within this diagnostic category. For instance, the admission rates for herniation of nucleus pulposus and for affection of the sacroiliac joint were much higher for white than for Negro personnel.

By sex, the admission rates for the diseases of bones and organs of movement was about twice as high for female as for male personnel (11.5 and 22.4, for male and female, respectively). By specific diagnoses, the admission rates among women were especially high for arthritis, herniation of nucleus pulposus, synovitis, bursitis, and tenosynovitis.

In 1954 disability separations for diseases of the bones and organs of movement constituted about 21 percent of all nonbattle disability separations, a total of 2,730 individuals being separated in 1954 for disabilities due to these diseases. By type, these separations were distributed as follows: permanent retirements, 24.0 percent; temporary retirements, 10.8 percent; with severance pay, 8.2 percent; and without severance pay, 57.0 percent. The last group of separations was for conditions that existed prior to service, not service-aggravated. (Note that the disability separations relate not only to admissions for conditions in class XVIII, but also to similar conditions resulting from nonbattle injuries in class XXIII.)

ACCIDENTS, VIOLENCE, AND POISONINGS

There were 69,740 admissions due to accidents, violence, and poisonings (also termed ?nonbattle injury? in the text and source tables of this report) in 1954, the rate of admission being 49 per 1,000 average strength per year. These ?external causes? accounted for 15 percent of all admissions, 20 percent of total time lost, 15 percent of disability separations, and 73 percent of all deaths.

In table XXXIX nonbattle injury rates for 1953 and 1954 are presented for comparison, together with the rates for all nonbattle causes and for all diseases in each of the two years. It may be seen from the table that the admission rate for nonbattle injury did not decrease as much as did the admission rate for disease. With respect to noneffectiveness and deaths, the trend for nonbattle injuries was parallel to the trend for disease. The disability separation rate for nonbattle injuries was 1.49 per 1,000 in 1954; the breakdown between disease and injury was not on a completely comparable basis

in 1953, and so the comparison with that year cannot be made (It should be noted that these disability separation rates reflect the year of separation, which is not necessarily the year in which the disability was incurred.)

As in past years, in 1954 the admission rate for nonbattle injury was higher among troops overseas than in the United States. However, the 1953-1954 decrease in the rate for the Army worldwide was attributable to a sharp decline in nonbattle injury admissions overseas, particularly in the Far East. The important factor in lowering the nonbattle injury admission rate in that area, of course, was the cessation of combat operations in 1953.

Among the many variables considered in the source tables in this report, officer-enlisted status appeared to be quite closely correlated with the admission rate for nonbattle injuries, the nonbattle injury admission rate for enlisted personnel being roughly twice as high as that for officers. (For disease, the rate of admission for enlisted personnel was about 1.2 times as high as the rate for officers.) The nonbattle injury admission rate for women was approximately equal to that for men. Race also appeared to be a factor of little importance; both in the United States and overseas, rates for white and Negro personnel were substantially identical.

TABLE XXXIX.?SELECTED RATES FOR ALL NONBATTLE CAUSES, DISEASE, AND NONBATTLE INJURY, U. S. ARMY, 1953 AND 1954

Rate	All nonbattle causes		Disease		Nonbattle injury
Rate	1953	1954	1953	1954	1953	1954
Admissions^a	^b396.39	324.71	^b343.65	275.58	^b52.74	49.13
Noneffectiveness^c	17.97	13.91	14.39	11.12	3.58	2.79
Disability separations^a	12.97	9.31	(^d)	7.82	(^d)	1.49
Deaths^a	1.79	1.48	0.46	0.39	1.33	1.09

^aRates for admissions, separations, and deaths expressed as number per 1,000 average strength per year.

^bExcludes CRO cases. (Admission rates given in the 1953 Annual Report, however, include such cases.)
^cRates expressed as average number noneffective daily per 1,000 average strength.

^dBreakdown between disease and nonbattle injury for 1953 not completely comparable. See section on ?Disability Separations.?

Many studies of accidents have indicated that high rates are observed in the lower age brackets. In the 1953-1954 Army experience, the nonbattic injury admission rate for those under 20 was about 1.3 times the rate for all Army personnel. For succeeding age groups, the admission rate declined until at age 50 and over it was about 60 percent of that for all Army personnel. This relationship between age and nonbattle injury admission rates is one of the factors accounting for the difference, noted above, between admission rates for officers and enlisted personnel.

It has been suggested that high rates of injury among Army personnel in the younger age groups are due to the fact that these age groups include recently

ruited personnel undergoing basic and advanced training. However, analysis of nonbattle injury rates in 1954 by length of military service reveals cat personnel who had completed less than 6 months of service were admitted for nonbattle injuries at a rate of about 40 per 1,000, in contrast to the rate of 49 per 1,000 for all Army personnel.

Accidents involving motor vehicles were the most frequent cause of admission for treatment of nonbattle injury, as they were the most frequent cause of fatal injuries, causing 16 percent of the admissions for injury and half the fatalities. Falls or jumps together with athletics or sports accounted for 28 percent of the injury admissions but only 2 percent of the deaths. On the other hand, instrumentalities of war and accidents associated with aviation produced only 6 percent of the admissions, but 22 percent of the fatal injuries.

Admissions for nonbattle injury occurred at quite different rates among personnel of the various arms and services. Such rates in five military branches for selected groups of causative agents are shown in table XL.

TABLE XL.?NONBATTLE INJURY ADMISSION RATES FOR SELECTED MILITARY BRANCHES, BY CAUSATIVE AGENT, U. S. ARMY, 1954

(Rates expressed as number of admissions per 1,000 average strength per year)

Selected causative agents	All branches	Armor	Artillery	Infantry	Engineers	Medical
All agents	49.13	117.15	94.76	78.97	69.42	58.10
Aviation	0.99	0.96	1.20	4.29	0.46	0.66
Parachuting	0.94	0.96	1.12	4.17	0.41	0.66
Others	0.05	-	0.08	0.12	0.05	-
Land transport	7.96	25.18	14.60	11.79	11.19	8.84
Motor vehicles	7.77	24.50	14.19	11.49	10.99	8.57
Others	0.19	0.68	0.41	0.30	0.20	0.27
Machinery, tools, and related agents	7.46	16.83	13.44	10.89	14.61	7.18
Instrumentalities of war	1.86	5.88	6.01	3.44	1.74	0.40
Environmental?heat, sun, light, and cold	1.98	3.83	3.00	5.51	1.79	0.86
Falls or jumps	7.39	19.02	13.67	13.33	9.30	9.97
Sports and calisthenics	6.50	13.69	14.23	8.95	8.22	9.31
Other agents	14.99	31.76	28.61	20.77	22.11	20.88

It may be seen in source table 8 that the largest proportion (57 percent) of nonbattle injuries were incurred in activities related to scheduled training or assigned duties. About 6 percent were due to assault, and-less than 1 percent were self-inflicted. Of all nonbattle injuries, some 9 percent were incurred by personnel absent from their stations on leave, etc. Of injuries incurred in motor vehicle traffic accidents?the leading cause of admission and of accidental deaths?about 27 percent were sustained by personnel on leave or otherwise absent.

While this discussion has emphasized epidemiological variables, some of the source tables dealing with nonbattle injuries in this report are designed to bring out certain surgical and other therapeutic aspects of providing medical care for injury cases. Nonbattle injury cases are classified in these tables according to general surgical nature of the traumatism in terms of such variables as geographic area, sex, and age at admission. Injury admissions in broad groupings by nature of traumatism are classified in source table 9 according to the anatomical regions and parts affected.