CHAPTER XI
Diabetes Mellitus
Alexander Marble, M.D.
Although the incidence of diabetes mellitus in the U.S. Armyduring World War II was relatively low, those diabetic patients who wereencountered presented problems in diagnosis, treatment, and disposition, whichin individual cases were often of considerable moment. The small number ofdiabetics seen in Army hospitals during the war was chiefly due to two factors:(1) By far the greater part of military personnel was drawn from age groups (18to 37 years) in which the incidence of diabetes is relatively low in the generalpopulation, and (2) routine examination of the urine was made at inductionstations, with rejection for military service of all found to have diabetes byanalyses of urine and blood.
OBSERVATIONS AT INDUCTIONSTATIONS
General.-Several sources of data1relatingto the prevalence of diabetes mellitus among registrants examined for militaryservice in World War II are presented in table 51. As may be seen from thetable, the reported prevalence rates are quite different. They range from ashigh as 11.0 (Blotner) to as low as 0.3 (Spellberg and Leff), per 1,000examinees.
The initial study by Blotner and Hyde2was based on registrants examined at an induction stationin Boston, Mass. These authors found that of the 45,650 examined selectees andvolunteers, aged from 18 to 45 years, 367 examinees (approximately 8 per 1,000)had glycosuria. These examinees were diagnosed as follows: Transient glycosuria,126 cases; renal glycosuria, 33 cases; and diabetes mellitus, 208 cases. Inother words, 4.6 per 1,000 men examined were diagnosed as having diabetes.
1(1) Causes of Rejection and Incidence of Defects: Local BoardExaminations of Selective Service Registrants in Peacetime. Medical StatisticsBulletin No. 2, National Headquarters, Selective Service System, Washington, D.C., 1 Aug. 1943, table 7. (2) Physical Examinations of Selective Service Registrants During Wartime. Medical Statistics Bulletin No. 3, National Headquarters, Selective Service System, Washington, D.C., 1 Nov. 1944, app. C, table 6. (3) Blotner, H., and Hyde, R. W.: Studies in Diabetes Mellitus and Transient Glycosuria in Selectees and Volunteers. New EnglandJ. Med. 229: 885-892, 9 Dec. 1943. (4) Spellberg,M. A., and Leff, W. A.: The Incidence of Diabetes Mellitus and Glycosuria inInductees. J.A.M.A. 129: 246-250, 22 Sept.1945. (5) Blotner, H.: Studies in Glycosuria and Diabetes Mellitus in Selectees. J.A.M.A. 131: 1109-1114, 3 Aug. 1946. (6) Karpinos, B. D.: Defects Among Registrants Examined for Military Service, World War II (in manuscript form). MedicalStatistics Division, Office of The Surgeon General, Department of the Army.
2See footnote 1 (3).
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[Rate expressed as number per 1,000 examined registrants]
Source and period |
| White | Negro |
Selective Service: |
|
|
|
| November 1940 through September 19411 | 2.9 | 3.0 | 1.9 |
| April 1942 through December 19432 | 2.6 | 2.9 | .8 |
Blotner and Hyde3 | 4.6 | --- | --- |
Spellberg and Leff4 | .3 | --- | --- |
Blotner5 | 11.0 | --- | --- |
Karpinos:6 |
|
|
|
| Principal disqualifying defect | 1.2 | 1.3 | .4 |
| Prevalence of disqualifying defect | 1.3 | 1.4 | .5 |
1Causes of Rejection and Incidence of Defects: Local BoardExaminations of Selective Service Registrants in Peacetime. MedicalStatistics Bulletin No. 2, National Headquarters, Selective Service System,Washington, D.C., 1 Aug. 1943 (table 7).
2Physical Examinations of Selective Service Registrants DuringWartime. Medical Statistics Bulletin No. 3, National Headquarters, SelectiveService System, Washington, D.C., 1 Nov. 1944 (app. C, table 6).
3Blotner, H., and Hyde, R. W.: Studies in Diabetes Mellitusand Transient Glycosuria in Selectees and Volunteers. New England J. Med. 229:885-892, 9 Dec. 1943.
4Spellberg, M. A., and Leff, W. A.: The Incidence of DiabetesMellitus and Glycosuria in Inductees. J.A.M.A. 129: 246-250, 22 Sept. 1945.
5Blotner, H.: Studies in Glycosuria and Diabetes Mellitus inSelectees. J.A.M.A. 131: 1109-1114, 3 Aug. 1946.
6Karpinos, B. D.: Defects Among Registrants Examined forMilitary Service, World War II (in manuscript form). Medical StatisticsDivision, Office of The Surgeon General, Department of the Army.
Of the diabetics, 107 were classified as mild, 58 asmoderate, and 43 as severe. Only 42 of the diabetics were aware of theirdisease.
Spellberg and Leff3 in a later study, based on examinationsof some 32,000 registrants at an induction station in New Orleans, La., found afar lower prevalence of glycosuria and diabetes. They found only 37 cases ofglycosuria among those examinees, and only 9 of these were diagnosed as havingdiabetes. The prevalence rates were thus 1.2 for glycosuria and 0.3 fordiabetes, per 1,000 examinees.
These wide discrepancies in rates led Blotner4to continue his studies which gave him more surprisingresults than those observed in the first study. Among the 69,088 registrants,aged from 18 to 37 years, examined in this study, Blotner found glycosuria in1,383 cases; that is, 20 per 1,000 men examined. About 57 percent of these (11per 1,000 examinees) had diabetes mellitus as judged either by clinicalmanifestations or, more often, by well-marked glycosuria or by the results of aglucose-tolerance test.
Blotner has explained these discrepancies to be due, in part,to age differentials-the selectees at New Orleans being somewhat younger; inpart, to race differentials-one-third of these examinees being Negroes
3See footnote 1 (4), p 293.
4See footnote 1 (5), p. 293.
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who had lower prevalence rates; and, in part, to differencesin the applied diagnostic methods and criteria.
The studies just cited are regional in character. The otherstudies to be cited were derived from nationwide data.
The first study by the National Headquarters, SelectiveService System, deals with the emergency period preceding World War II (November1940 through September 1941); their second study deals with the period fromApril 1942 through December 1943. Both were sample studies.5 Thefirst study comprised some 122,000 medical examination reports; the second wasbased on an approximate 20 percent sample of over 9 million men examined duringthis period. Both studies indicate about identical prevalence rates of diabetesmellitus for the total (white and Negro) groups: 2.9 and 2.6 per 1,000 examinedregistrants, during the first and second periods, respectively. Thecorresponding rates, by period and race, were: 3.0 and 2.9, per 1,000 white; and1.9 and 0.8, per 1,000 Negro examinees.
The quoted Selective Service data are from tables showingprevalence rates of all defects, without distinguishing between defects of adisqualifying and of a nondisqualifying nature. Though MR (MobilizationRegulations) 1-9, War Department, 1940, 1942, 1943, and 1944, provide thatdiabetes mellitus, if so diagnosed is disqualifying, it is possible that theserates include some borderline cases of diabetes which would not have beenconsidered disqualifying.
The study by Karpinos6 is limited to cases in which diabetesmellitus was either the principal or, at least, the secondary cause ofdisqualification. (It excludes defects of a nondisqualifying nature.)
This study covers a 14-month period from November 1943through December 1944. It was a sample study, containing some 384,000 physicalexamination forms. According to this study, the disqualification rate fordiabetes mellitus was 1.2 per 1,000 total (white and Negro); 1.3 per 1,000 white and 0.4 per 1,000 Negro examinees.
The total prevalence of disqualifying diabetes mellitus,which includes both principal and secondary cases of disqualification, wassomewhat higher; namely, 1.3-per 1,000 total (white and Negro); 1.4-per 1,000 white, and 0.5-per 1,000 Negroexaminees.
Race and age differentials-Thecited studies clearly indicate race and age differences. The disqualificationrates for diabetes mellitus were by far lower among Negroes than among whites.The prevalence increases with age (table 52). For example, in the total group(white and Negro), the prevalence increased from 0.8 in the youngest (18-19)age group to 2.7 in the oldest (35-37) age group. The same holds by race.
5See footnote l (1) and (2), p.293.
6See footnote 1 (6), p. 293.
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[Rate expressed as number disqualified per 1,000 registrantsexamined]
Age |
| Prevalence of disqualifying defect | ||||
| White | Negro | Total | White | Negro | |
18 to 19 | 0.74 | 0.81 | 0.19 | 0.79 | 0.87 | 0.19 |
20 to 24 | .71 | .74 | .52 | .75 | .79 | .53 |
25 to 29 | 1.19 | 1.34 | .35 | 1.24 | 1.39 | .36 |
30 to 34 | 1.61 | 1.84 | .34 | 1.73 | 1.95 | .48 |
35 to 37 | 2.44 | 2.63 | 1.30 | 2.68 | 2.85 | 1.70 |
|
| 1.20 | 1.32 | 0.45 | 1.28 | 1.40 | 0.53 |
Source: Karpinos, B. D.: Defects Among Registrants Examinedfor Military Service, World War II (in manuscript form). Medical StatisticsDivision, Office of The Surgeon General, Department of the Army. (This studycovers the period from November 1943 through December 1944.)
Number disqualified for diabetes mellitus-The NationalHeadquartersSelective Service System,7 estimated that, of the total number ofregistants (4,828,000) in class IV-F and in classes with "F"designation, 45,300 registrants were so classified because of endocrinediseases. It has been found from the 1943-44 Selective Service experience8that some 42.7 percent of the endocrine diseases are casesof diabetes mellitus. Accordingly, some 19,300 registrants were seeminglyclassified as IV-F, as of 1 August 1945, because of diabetes mellitus. Thisconstitutes a disqualification rate of about 1.2 per 1,000 examinees, asindicated by the rate limited to disqualifying diabetes mellitus (Karpinos,table 51).
The IV-F figures exclude examinees disqualified by thelocal boards, given in the IV-F table9 as "Manifestly DisqualifyingDefects," without a diagnostic breakdown. It has been estimated that, ifthe cases disqualified by the local boards for diabetes mellitus were added tothe number of registrants classified as IV-F because of this disease as aresult of the induction station examinations, the adjusted number would be23,500.10
The overall disqualification for diabetes mellitus in WorldWar II was thus apparently 1.5 per 1,000 examinees.
7Physical Examinations of Selective Service Registrants in theFinal Months of the War. Medical Statistics Bulletin No. 4, NationalHeadquarters, Selective Service System, Washington, D.C., June 1946, app. B,table 4.
8Physical Examination of SelectiveService Registrants During Wartime. Medical Statistics Bulletin No. 3, NationalHeadquarters, Selective Service System, Washington, D.C., 1 Nov. 1944. app. C,table 5.
9See footnote 7.
10The estimate of cases ofdiabetes mellitus among the "Manifestly Disqualifying Defects" wasmade by the Medical Statistics Division, Office of The Surgeon General,Department of the Army, from diagnostic data of local board disqualifications.
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INCIDENCE, DISPOSITION, AND MORTALITY
World War I
Experience with diabetes mellitus in World War I, in thetotal Army with an average strength of 1,500,000 for the war period,11is summarized in the tabulation which is to follow. During this period, from 1April 1917 to 31 December 1919, which was before the discovery of insulin, themortality was 14.5 percent, or one death for each seven admissions.
Summary of data: | Absolute numbers |
|
Admissions2 | 718 | 0.17 |
Days lost3 | 39,062 | .03 |
Deaths4 | 104 | .03 |
Discharges for disability | 330 | .08 |
1Number per annum, except that "Days lost" represents the number noneffective daily.
2By original cause ofadmission.
3Average days lost per case: 54.
4Percent of admissions: 14.5.
In the First World War, General Hospital No. 9, Lakewood,N.J., was designated to receive all diabetic patients from the eastern part ofthe United States and those evacuated from overseas. Actually, from July 1918 toMay 1919, only 37 cases were treated.12
World War II
Essential data.-It is not the purpose of the presentaccount to give detailed statistics on the incidence of diabetes in the SecondWorld War, since these are to be found in complete tables elsewhere. However,enough data13 willbe presented to give some idea of the number of soldiers affected. In table 53,the most significant figures are shown.
It will be noted that the annual rates of admission tomedical treatment facilities per 1,000 strength were 0.28 in 1941, 0.34 in 1942,0.28 in 1943, and 0.23 in 1945, with the latter year having an average strengthof approximately 7? million men.The rate for 1944 was only 0.19 for approximately 8 million soldiers. The lastfigure is close to that of 0.17 for the Army with its strength averaging 1?million men in World War I. Considering primary and secondary diagnoses, theincidence rate for 1944 was 0.23 per 1,000 and for 1945 it was 0.28 per 1,000,compared to admission rates of 0.19 and 0.23 per 1,000, respectively.
11The Medical Department of theUnited States Army in the World War. Washington: Government Printing Office,1925, vol. XV, pt. 2.
12Allen, F. M., and Mitchell, J. W.:Report of Diabetic Serviceat U.S. Army General Hospital No. 9, Lakewood, New Jersey. Am. J.M. Sc. 159:25, January 1920.
13All data from World War II (except those onpages 300-302 regarding diabetic coma) were furnished by the MedicalStatistics Division, Office of The Surgeon General, Department of the Army.
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TABLE 53.-Summary of data on diabetes1 (primary diagnosis2), in World War II, 1941-45
[Preliminary data based on sample tabulations of individual medical records]
Year |
| Military disposition3 | Deaths3 | |||
Number | Annual rate per 1,000 men | Separated for disability (percent) | Returned to duty (percent) | Number | Percent of admissions | |
1941 | 379 | 0.28 | --- | --- | 2 | 0.5 |
1942 | 1,110 | .34 | 74.2 | 24.8 | 8 | .7 |
1943 | 1,915 | .28 | 75.0 | 22.5 | 21 | 1.1 |
1944 | 1,463 | .19 | 76.4 | 22.3 | 15 | 1.0 |
1945 | 1,770 | .23 | 77.7 | 410.2 | 15 | .9 |
1Includes diabetic coma and diabetic gangrene.
2Includes only cases admitted tomedical treatment facilities with a primary diagnosis of diabetes. For a summary of cases admitted with a primary diagnosis other thandiabetes, see page 297.
3Figures are those of eventual death or disposition, notnecessarily in the calendar year of admission.
4Approximately 11 percent of the 1945admissions were separated for nonmedical reasons. This, for the most part,accounts for the difference between the percent of duty dispositions in 1945 andthat of preceding years.
As may be seen in table 53, approximately three-fourths ofthe soldiers with diabetes were separated for disability.14 Most ofthe remaining soldiers were retained in the service, presumably because theyeither had mild diabetes or were key personnel.
Of especial interest is the mortality, as shown in table 53.Of patients admitted with the primary diagnosis of diabetes from 1941 through1945, death occurred in a minimum of 0.5 percent to a maximum of 1.1 percent, ascontrasted with 14.5 percent in World War I (p. 297). Actually, however, therewere more deaths due to diabetes in World War II than table 53 would suggest,since some were the underlying cause of death in cases originally admitted withanother primary diagnosis. (Conversely, in the deaths summarized in table 53,diabetes mellitus need not necessarily have been the underlying cause ofdeaths.) Deaths (1942-45) attributable to diabetes according to the calendaryear of death without regard to the year of admission, or the original cause ofadmission to the hospital, were as follows: 1942, 8; in 1943, 20; in 1944, 23;and in 1945, 15. Adding the 2 deaths in 1941 (table 53) brings the total to 68deaths. Although the number was small, it would appear overly large for the agegroup concerned.
Race.-In view of the frequently expressed opinion thatdiabetes is less common in Negroes than in white people, the data in table 54are of interest. It is evident that diabetes was at least as common among Negroas among white enlisted men, taking into account the much smaller numbers ofNegro soldiers.
14The percentages, shown in table53, for those separated for disability are somewhat understated, and converselythe percentages of duty dispositions somewhat overstated, as the result ofcoding as duty disposition cases which were returned to duty pending separationfor disability.
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Rank.-The admission rate for officers was consistently higher than that forenlisted personnel (table 55). It should be kept in mind that among commissionedofficers there was a higher percentage of older men, in whom diabetes is morecommon.
Age.-The influence of age upon incidence is shown intable 56. The rate per 1,000 rises from 0.09 at ages under 20 years to 1.60 forages 45 and over.
[Rate expressed as number of admissions perannum per 1,000average strength]
[Preliminary data based on sample tabulations of individualmedical records]
Year |
| White2 | Negro | |||
| Rate | Number | Rate | Number | Rate | |
1941 | 337 | 0.27 | 321 | 0.27 | 16 | 0.25 |
1942 | 997 | .33 | 896 | .32 | 101 | .49 |
1943 | 1,726 | .28 | 1,504 | .26 | 222 | .42 |
1944 | 1,188 | .17 | 1,037 | .16 | 151 | .23 |
1945 | 1,417 | .21 | 1,246 | .21 | 171 | .27 |
1Includes diabetic coma and diabetic gangrene.
2Includes all non-Negroid personnel.
TABLE 55.-Admissions for diabetes mellitus,1 U.S. Army, by rank and year, 1941-45
[Rate expressed as number of admissions per annum per 1,000average strength]
[Preliminary data based on sample tabulations of individualmedical records]
Year |
| Officers | Enlisted personnel | |||
| Rate | Number | Rate | Number | Rate | |
1941 | 379 | 0.28 | 42 | 0.49 | 337 | 0.27 |
1942 | 1,110 | .34 | 113 | .50 | 997 | .33 |
1943 | 1,915 | .28 | 184 | .32 | 1,731 | .27 |
1944 | 1,463 | .19 | 241 | .32 | 1,222 | .17 |
1945 | 1,770 | .23 | 343 | .40 | 1,427 | .21 |
1Includes diabetic coma and diabetic gangrene.
Sex.-The number of admissions for diabetes among femalepersonnel amounted to only 2 in 1941, none in 1942, 12 in 1943, 44 in 1944, and 30 in 1945. The annual admission rate for women per 1,000persons in 1943 was 0.15; in 1944, 0.44; and in 1945, 0.21.
Theater.-Throughout the war, the admission rate fordiabetes reported from oversea theaters was appreciably less than that reportedfrom the continental United States. Illustrative are the data for 1944
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TABLE 56.-Admissions for diabetes mellitus,1U.S. Army, by age, 1944
[Rate expressed as number of admissions per annum per 1,000average strength]
[Preliminary data based on sample tabulations of individualmedical records]
Age |
| |
| Rate | |
Under 20 | 62 | 0.09 |
20-24 | 386 | .13 |
25-29 | 364 | .17 |
30-34 | 241 | .21 |
35-39 | 246 | .41 |
40-44 | 57 | .56 |
45 and over | 107 | 1.60 |
|
| 1,463 | .19 |
1Includesdiabetic coma and diabetic gangrene.
shown in table 57. Undoubtedly, an important factor in thedifference was the screening out of those unable to meet medical standards foroversea service. Another factor may have been that personnel overseas usuallywere more active physically and often had a lower caloric intake. Again,probably fewer of the older men were included among them.
Average duration.-The average length of stay in medicalfacilities for patients with diabetes was slightly under 2 months. The actualfigures were: In 1941, 59 days; in 1942,58 days; in 1943, 58 days; in 1944, 55 days;and in 1945, 72 days (table 59, p. 305). In evaluating the duration of hospitalcare in terms of time lost, it must be kept in mind that approximatelythree-fourths of the diabetics were separated from service. The time in hospitalwas spent not only in regulation of the diabetic condition with diet andinsulin, if indicated, and in instruction to prepare the patients for return tocivilian life, but also in effecting the separation itself.
DIABETIC COMA
In December 1945, the files of the ArmyInstitute of Pathology, Washington, D.C., were examined to ascertain the numberof deaths from diabetic coma reported since September 1940. Although not all ofthe autopsy reports for 1945 had been received, study of the available materialproved to be instructive.
In all, there were 60 reported deaths from diabetic coma inArmy or other personnel treated in Army hospitals. These were distributed asfollows: 33 Army personnel, 1 sailor, 1 marine, 3 retired military personnel, 5beneficiaries of Veterans' Administration, 2 Civilian Conservation Corps
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TABLE 57.-Incidence of diabetesin the U.S. Army, by area and year, 1944
[Rate expressed as number of cases per annum per 1,000 averagestrength]
Age |
| |
| Rates | |
Continental United States | 1,300 | 0.33 |
Overseas: |
|
|
| North America2 | 19 | 0.15 |
| Latin America | 21 | .24 |
| Europe | 179 | .10 |
| Mediterranean3 | 101 | .16 |
| China-Burma-India | 16 | .09 |
| Central and South Pacific | 99 | .23 |
| Southwest Pacific | 58 | .11 |
| Middle East | 13 | .28 |
|
| 503 | 0.13 |
|
| 1,803 | 0.23 |
1Includes primary and secondarydiagnoses.
2Includes Alaska and Iceland.
3Includes North Africa.
4Includes 6 cases on transports.
enrollees, 10 civilian dependents, and 5 (3German, 2 Italian) prisoners of war.
In examining the data, it soonbecame evident that there was a difference in the type ofpatient in the 33 cases grouped as Army personnel in comparison with the 27cases otherwise grouped. Since the majority of the latter were chiefly retiredmilitary personnel, beneficiaries of the Veterans' Administration, andcivilian dependents, they included persons in the older age periods. A highpercentage of them had had known diabetes of variable duration, and the terminaldiabetic acidosis was often associated with complications serious enough inthemselves to cause death. Accordingly, the following is a commentary only onthe 33 deaths from diabetic coma of persons on active duty in the Army:
Of these, 32 were men and 1 was a young enlisted woman; 32were enlisted personnel and 1, an officer. The age at death ranged from 18 to 38years, inclusive. The length of time in the Army ranged from 2 days to 2 years;only 3 had been in service 12 months or more. Three died in hospitals overseas,one on a troop transport, and twenty-nine in hospitals in the continental UnitedStates.
Only three were patients with previously known diabetes.These soldiers entered hospitals in diabetic coma 2 days, 1 month, and 2 months,
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respectively, after induction into the Army. Two concealedthe fact that they had diabetes; an adequate history is lacking regarding thethird.
Of the 33 patients, 21 died in less than 48 hours afteradmission to the hospital, 14 of them during the first day. Thesymptoms and signs in most instanceswere classical, as were also the laboratory findings. Of 16patients whose mental state on admission was recorded, 8were unconscious and 4 were drowsy. In 10 of the 33, theblood sugar was 500 mg. per 100 cc. or higher. In only 9 of the 33 cases didnecropsy disclose associated conditions of importance; that is, in the greatmajority death occurred from uncomplicated diabetic coma. It is of note that inseven of the nine patients with complications, acute pancreatitis of varyingdegree was recorded by the pathologist.
Once the diagnosis was made in the Army hospital, treatmentwas in general reasonably adequate,although not infrequently much larger doses of insulin were indicatedthan were given. The chief difficulty lay inthe fact that often there was considerable delay in making thediagnosis, owing chiefly to the length of time-in some instances several hours-that elapsed before analyses of urine andblood were carried out and reported. It will be recalled that 29 of the 33deaths under consideration occurred not overseas but in the continental UnitedStates, where ample facilities shouldhave existed, and almost invariably did exist, for promptdiagnosis and early institution of energetic treatment. Furthermore,in the age group concerned, the mortality from diabetic coma should approachzero. Accordingly, although relatively few deaths from diabetic coma occurred inWorld War II, even fewer might havebeen expected had diagnoses been more promptly made andfollowed by vigorous treatment with insulin.
Promptness in diagnosis depends upon the alertness, interest,and industry of the individual ward surgeon. The examination of the urine forsugar and acetone should be carried out immediately on admission. Such tests aresimple and, if necessary, can be made easily on the ward by the physician ornurse. Furthermore, a simple and quick nitroprusside test for acetone (using, ifdesired, commercially prepared powder or tablets) can be carried out directly onthe plasma by the physician as an aid in diagnosis. If positive, the degree ofketonemia may be used as a rough guide in determining the initial dose ofinsulin.
NONDIABETIC GLYCOSURIA
Persistent glycosuria of significant degree (0.5 percent ormore in random specimens) was commonly considered disqualifying for militaryservice even though not caused by diabetes. This was generally agreed tobe a desirable rule even with benign, symptomless glycosurias. This seemingparadox is explained by what might be termed the "nuisance value" ofsuch conditions. Whenever the soldier with glycosuria came under MedicalDepartment supervision and sugar was found in the urine,the medical officer concerned-most probably unacquainted with the pa-
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tient-was likely to decide that the condition warrantedadmission to the hospital for specialstudies. This might be repeated over and over, with inconvenience to the soldierand expense to the Government. A simple solution mighthave been to issue the soldier a statement to carry with him,explaining his condition. However, this would still leave the medical officerin reasonable doubt whether the presenting condition might not be different fromthat prevailing at the time of last study. Moreover, it is unlikely that soldierswould preserve and carry such papers over a longperiod of time.
Once the man was in the Army, and persistent, but nondiabetic,glycosuria of significant degree was found, decision as to dispositionwas, at times, difficult. In actualpractice in World War II, the great majority of such men were retained in theservice. As shown in table 58, no more than 16.5 percent were separated for disabilityin any year and usually considerablyless. In general, key personnel could be, and were, retained with profit.
TABLE 58.-Summary of data fornondiabetic glycosuria1inWorld War II, by year, 1941-45
Year |
| Treatment | Disposition | ||
Number |
| Average duration (days) | Separated for disability (percent) | Returned to duty (percent) | |
1941 | 176 | 0.13 | 22 | --- | --- |
1942 | 420 | .13 | 18 | 6.0 | 94.0 |
1943 | 923 | .13 | 25 | 16.5 | 82.3 |
1944 | 699 | .09 | 20 | 5.3 | 94.7 |
1945 | 635 | .08 | 19 | 0 | 98.4 |
1Includes renal glycosuria and alimentary glycosuria.
2Primary diagnosis only.
TREATMENT OF DIABETES IN THE ARMY
Success in the treatment of diabetes in the Army, as incivilian practice, depends upon the interest, training, and experience of theindividual doctor perhaps more than in most diseases. The inadequate treatmentof diabetic coma in certain cases has been commented on. Since there are varyingopinions both in military and civilian practice on details regardingdiet, insulin, and other aspects of therapy, it became apparent in World War IIthat some attempt should be made to standardize methods ofdiagnosis and treatment. Consequently, War Department Technical Bulletin (TBMED) 168, entitled "Diabetes Mellitus," was prepared by Col.Garfield G. Duncan, MC, and released inJune 1945. In this bulletin,
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the basic principles of the diagnosis and treatment ofdiabetes and its complications were outlined for the guidance of medicalofficers.15
Certain features of the care of diabetic patients and of themilitary physician's responsibility for them deserve special mention at thispoint. First, medical officers should realize the vital importance of theeducation of patients. If the greatest success in treatment is to be realizedin length of life and freedom from complications, patients must be taughtsimply, yet thoroughly, known facts regarding diabetes, its home care and theavoidance of complications. Secondly, treatment with a restricted, yetnutritionally adequate, diet and an appropriate dose of insulin must be arrangedso that careful and continuous control of the disease is possible. Thirdly,the patient must be urged to seek competent medical advice at frequent andregular intervals following discharge from the service, either from a privatephysician or from the Veterans' Administration.
THE PLACE OF THE DIABETIC IN THE ARMY
Regulations of the Army and of mobilization boards in effectthroughoutWorld War II listed diabetes mellitus as a cause for rejection even for limited service. Altshuler16questionedthe advisability of this. He recommended that at leastsome individuals might be accepted to the advantage of the Armed Forces and thatthose accepted could perform useful duty at fixed installations in continentalUnited States. The opposite point of view was taken by Joslin,17 whoconcluded:
The diabetic quota useful for military service isrelativelyso insignificant, the hazards which both the diabetic and the Government wouldundergo if they were inducted are so great and the need for their services incivilian occupations, where they would be less exposed to complications, soapparent, that the present rule to omit them from the draft appears proper.
Table 59 shows the days lost in World War II by casesadmitted for diabetes during the years 1942-45.
Considered as a loss of more than 1,000 person-years, thefigures in table 59 present a cogent argument in favor of maintaining thegeneral policy of rejecting those with diabetes. It has been noted (p. 300) thatmuch of the time spent in hospital was incidental to separation from the serviceof approximately three-quarters of the diabetics found.
Although the general rule is fully justified,provision should be, and has been, madefor exceptions18 toit, when individuals are needed in assignments in which appropriatetreatment (with diet and, if required,insulin) is feasible. Such posts may be available in fixed installations,usually in continental United States. Similarly, both officers and enlisted
15It should be noted that certain new measures in treatmenthave become generally available since 1945; for example, in October 1950, NPHinsulin was admitted to the market, and in 1954, Lente insulin became available.
16Altshuler, S. S.: Diabetes in theArmed Services. Proc. Am. Diabetes A. (1944) 4: 111-118, 1945.
17Joslin, E. P.: Diabetes and MilitaryService. J.A.M.A. 121: 198-199, 16 Jan. 1943.
18For example, the Defense Department's directive of 12 January 1953on special registrants under the "Doctors' Draft Law" (24 Dec. 1952)provides that physicians with diabetes may be accepted for service under certainconditions.
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personnel in whom diabetes has been discovered while in the service may, withprofit, be retained, especially those who are in scarce categories or those whoare otherwise hard to replace.
TABLE 59.-Days lost by casesadmitted for diabetes, by year, 1942-45
| Average duration of treatment1 (days) | Total days lost |
1942 | 58 | 64,650 |
1943 | 58 | 106,989 |
1944 | 55 | 79,189 |
1945 | 72 | 127,350 |
|
| 61 | 378,178 |
1Based only on cases with days lost from active duty.
