CHAPTER VIII
Allergy
Walter L. Winkenwerder, M.D.
Definitive studies of the impact of allergic diseases on theU.S. Army were not described during or immediately after the First World War,and it was not until 1941 that Vaughan1summarized the data on asthma observed during the World War I period. Vaughanemphasized asthma's importance as a cause of rejection and disability and itscost to the Government for pensions eventually granted to personnel retired frommilitary service. Asthma was then the only allergic condition particularized inthe diagnostic classification of diseases; hay fever, when so reported, wascoded to a residual category of lung conditions, but if reported as any form ofrhinitis it would have been classified as "rhinitis (cause notstated)."
During World War II, allergic diseases, especially asthma,caused a significant amount of disability in the Army. Knowledge concerningthese diseases had accumulated rapidly between the two conflicts, and soon aftermobilization many hospitals formed allergy clinics and promptly institutedformal instruction in examination, diagnosis, and therapy; these hospitals and,later, those in oversea areas submitted studies and reports on various allergicdisturbances. An analysis of these data and of the comprehensive statisticscompiled by the Medical Statistics Division, Office of The Surgeon General, formthe basis of this chapter. The statistics illustrate the total load the allergicdiseases imposed on the Military Establishment. The diseases include asthma,allergic rhinitis, dermatitis venenata, eczema, angioneurotic edema, urticaria,allergic dermatitis, and certain other allergic disorders.
STATISTICAL DATA
Disqualifications of Selective Service Registrants forMilitary Service Because of Allergic Diseases
Statistics on disqualifications for military service becauseof allergic diseases are presented in tables 25 and 26. They were taken fromseveral studies2 and relate to World War II experience.
1Vaughan, W. T.: Problems of Allergy in Wartime. Mil. Surgeon 89: 737-746, November 1941.
2(1) Hyde, R. W., and Kingsley, L. V.: Distribution of Allergic States in Selectees. J. Allergy 14: 386-392, July 1943. (2) Rowntree, L. G., McGill, K. H., and Edwards, T. I.: Causes of Rejection and the Incidence of Defects Among 18 and 19 Year Old Selective Service Registrants. J.A.M.A. 123: 181-185, 1943. (3) Karpinos, B. D.: Defects Among Registrants Examined for Military Service, World War II (in manuscript form). Medical Statistics Division, Office of The Surgeon General, U.S. Army.
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TABLE 25.-Disqualifications for militaryservice due to allergic diseases, World War II
[Rate expressed as number disqualified per1,000 examined registrants]
Source of data | Total allergic diseases | Asthma | Hay fever | Other |
Hyde and Kingsley:1 |
|
|
|
|
| Primary disqualifying cause | 6.6 | 5.9 | 0.4 | 0.3 |
| Primary and secondary disqualifying cause | 8.2 | 7.3 | .5 | .4 |
Rowntree, McGill, and Edwards:2 |
|
|
|
|
| Primary disqualifying cause | 4.5 | 3.7 | .8 | --- |
Karpinos:3 |
|
|
|
|
| Primary disqualifying cause | 5.6 | 5.3 | .2 | .1 |
| Prevalence of disqualifying cause | 6.6 | 6.2 | .4 | .1 |
1Hyde, R. W., and Kingsley, L. V.: Distribution of AllergicStates in Selectees. J. Allergy 14: 386-392, July 1943. (Note that the ratesare not given in the study. They were derived from the specified number ofdisqualified, by diagnosis, and the number examined.)
2Rowntree, L. G., McGill, K. H., and Edwards, T. I.: Causesof Rejections and the Incidence of Defects Among 18 and 19 Year Old Selective Service Registrants. J.A.M.A. 123: 181-185, 1943.
3Karpinos, B. D.: Defects Among Registrants Examined forMilitary Service, World War II (in manuscript form). Medical StatisticsDivision, Office of The Surgeon General, U.S. Army.
[Rate expressed as number per 1,000 examined registrants, byage]
Diagnosis | All ages | 18-19 | 20-24 | 25-29 | 30-34 | 35-37 |
Principal disqualifying cause: |
|
|
|
|
|
|
| Asthma | 5.34 | 3.90 | 5.01 | 5.88 | 6.23 | 6.65 |
| Hay fever | .24 | .16 | .26 | .21 | .35 | .33 |
| Other | .04 | .02 | .02 | .03 | .06 | .05 |
|
| 5.62 | 4.08 | 5.29 | 6.12 | 6.64 | 7.03 |
Prevalence of disqualifying disease: |
|
|
|
|
|
|
| Asthma | 6.18 | 4.35 | 5.72 | 6.71 | 7.38 | 8.13 |
| Hay fever | .41 | .25 | .30 | .43 | .58 | .63 |
| Other | .05 | .03 | .03 | .06 | .09 | .08 |
|
| 6.64 | 4.63 | 6.05 | 7.20 | 8.05 | 8.84 |
Source: Karpinos, B. D.: Defects Among Registrants Examinedfor Military Service, World War II (in manuscript form). Medical StatisticsDivision, Office of The Surgeon General, U.S. Army.
The data by Hyde and Kingsley (table 25) deal withdisqualifications for allergic diseases among the first 60,000 selective serviceregistrants examined at the Boston Recruiting and Induction Station during thewinter, spring, and summer of 1942. The age range was from 21 through 24 for thefirst 6,000 examinees and from 21 through 44 for the remaining
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examinees. These data indicate that allergic diseases werethe primary (or sole) cause of disqualifications for 6.6 per 1,000 examinees,with asthma being the main cause (5.9 per 1,000 examinees). In some cases, theallergic disease was the secondary cause of disqualification, implying that thedisease was of sufficient severity to disqualify the examinee were it not for amore serious defect that was taken as the primary cause. As shown in the table,8.2 per 1,000 examinees had a disqualifying allergic disease (primary andsecondary cause). The corresponding disqualification rate for asthma was 7.3 per1,000 examinees. It should be noted that these total rates include certaindiseases (for example, allergic dermatitis and atopic eczema) which were notincluded among the allergic diseases in the other studies. The disqualificationsfor these additional diagnoses, however, were negligible.
Hyde and Kingsley were primarily interested in relating thedisqualifications for allergic diseases to socioeconomic factors. They found onthe basis of their "desirability" factors, such as medical care,education, and population density, that the prevalence of allergic diseases wasconstant in many socioeconomic backgrounds, although a relatively higher ratewas noted for semirural communities and a relatively lower rate for tenementdistricts.
The study by Rowntree, McGill, and Edwards (table 25) dealswith causes of disqualification among 18- and 19-year old selective serviceregistrants. It covers a 3-month period, from December 1942 through February1943. It was a sample study which included some 45,600 physical examinationforms. The disqualification rates were computed by the authors as 4.5 per 1,000examinees for all allergic diseases and as 3.7 for asthma alone. These rates arelower than those reported by Hyde and Kingsley because the study by Rowntree andhis associates comprised a younger population. (Compare these rates with thosegiven in table 26 for the 18-19 age group.)
The study by Karpinos (tables 25 and 26) covers a 14-monthperiod, from November 1943 through December 1944. It was also a sample studywhich included some 147,000 physical examination forms of medically disqualifiedregistrants. (It comprised altogether 384,000 physical examination forms, byincluding those of qualified examinees.)
When limited to the primary disqualification cause, Karpinosindicates that the disqualification rate for allergic diseases was 5.6 per 1,000examinees, with asthma having a rate of 5.3. The total prevalence ofdisqualifying allergic diseases (including both primary and secondary diagnoses)was computed as 6.6, and that for asthma as 6.2, per 1,000 examinees. (Rowntreeand his coworkers report a total prevalence of 10.6 for allergic diseases: Forasthma 5.3 and for vasomotor rhinitis 5.3. These rates, however, include bothdisqualifying and nondisqualifying
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diseases. In other words, the rates include men accepted withallergic diseases.)
As indicated in table 26, disqualification and prevalencerates increase with age. The disqualification rate was 4.1 for the youngest (18-19)age group and 7.0 for the oldest (35-37) age group. The prevalence rate wasabout twice as high in the 35-37 age group as it was in the 18-19 age group;4.6 for the youngest age group versus 8.8 for the oldest age group.
To summarize statistically, the World War II data indicatethe following:
1. About 6 per 1,000 examinees were disqualified for allergicdiseases and about 7 per 1,000 examinees had a disqualifying allergic disease,asthma being the main disqualifying cause.3 That many registrantswith allergic diseases were knowingly taken into the military service, whileothers with allergic disease were apparently not properly screened out(representing about 1 percent of 1,000 examined), presented a problem in theArmy, as reflected later by aggravation or recurrence of allergic diseases,notably asthma, as is brought out in the succeeding section.
2. The disqualifications for allergic diseases represented arelatively small percentage of the disqualifications for all causes: 1.8 percentof the disqualification for all causes (total disqualification rate 358.0 per1,000 examinees), as reported by Hyde and Kingsley; 1.8 percent (totaldisqualification rate 253.3 per 1,000 examinees), as reported by Rowntree andhis associates; and 1.6 percent (total disqualification rate 353.6 per 1,000examinees), as reported by Karpinos.
Hospital Admissions for Allergic Conditions
The number of admissions to hospitals and quarters forallergic conditions for the years 1942-45, inclusive, is given in table 27 andfor each year in the 4-year period (1942, 1943, 1944, and 1945) in tables 28,29, 30, and 31, respectively. During this 4-year period, 248,680 patients withallergic conditions were admitted to hospitals in the United States and inoversea theaters, in order of frequency as follows: With asthma, 87,630; withdermatitis venenata, 75,371; with urticaria, 29,811; with allergic dermatitisand other allergic disorders, 28,259; with hay fever, 15,254; with angioneuroticedema, 7,154; and with eczema, 5,201. All the allergic states were comparativelymore frequent in the United States than in oversea areas, but the relativeincidence overseas increased sharply after 1942 in the four major oversea areas-theEuropean theater, the Mediterranean theater, the Southwest Pacific Area, and thePacific Ocean Area.
3These disqualification rates might have been higher ifexamining physicians had adhered strictly to the provisions of MR (MobilizationRegulations) 1-9, "Standards of Physical Examination DuringMobilization," 15 October 1942, as applied to allergic states.
175
[Preliminary data based on sample tabulations ofindividual medical records]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 162,980 | 61,785 | 10,084 | 59,452 | 2,231 | 3,868 | 16,649 | 8,911 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 22,868 | 8,014 | 2,004 | 2,843 | 784 | 980 | 4,494 | 3,749 |
| Mediterranean | 10,924 | 3,839 | 933 | 1,457 | 362 | 437 | 2,345 | 1,551 |
| Middle East | 1,147 | 419 | 51 | 99 | 20 | 84 | 301 | 173 |
| China-Burma-India | 5,108 | 1,377 | 232 | 1,362 | 248 | 187 | 852 | 850 |
| Southwest Pacific | 24,435 | 4,737 | 912 | 5,147 | 833 | 720 | 2,232 | 9,854 |
| Pacific Ocean Area | 14,969 | 5,361 | 807 | 3,761 | 474 | 588 | 1,525 | 2,453 |
| North America | 1,988 | 634 | 35 | 385 | 59 | 110 | 505 | 260 |
| Latin America | 3,355 | 1,240 | 194 | 683 | 114 | 146 | 658 | 320 |
| Total overseas2 | 85,700 | 25,845 | 5,170 | 15,919 | 2,970 | 3,286 | 13,162 | 19,348 |
| Total Army | 248,680 | 87,630 | 15,254 | 75,371 | 5,201 | 7,154 | 29,811 | 28,259 |
1About four-fifths of the admissions shown in this category wereclassified as "allergic dermatitis," which included cases reported as"atopic dermatitis," "atopic eczema," "eczematoiddermatitis," "impetiginous eczema," and "neurogenic dermatitis";the remainder were admissions reported as due to "allergicconjunctivitis," "chronic allergy," unspecified allergy, andother allergic reactions.
2Includes admissions on transports.
This trend is consistent with the relatively increased number of troopsserving overseas during 1943-45 and with the well-recognized frequency withwhich allergic states developed or were aggravated during oversea duty. Asthmaand dermatitis venenata represented the chief causes for hospitalizationthroughout the war period, except for the marked increase in the category"Allergic Dermatitis and Certain Other Allergic Disorders" during 1944and 1945.
The number of admissions for urticaria seems high in view of its relativelylow incidence noted in the individual studies on allergic diseases reported bothin the United States and from oversea theaters (see p. 192). Allergic dermatitisand the miscellaneous allergic conditions included in the residual categoryincreased sharply during and after 1944 while dermatitis venenata decreased,especially in 1945. These shifts may, in part, be related to changes in codingprocedures and codes which were introduced beginning with the 1944 coding.
The rate of admissions per year per 1,000 average strength for allergicconditions in the Army for the years 1942-45, inclusive, is given in table 32;for each of the years in the 4-year period (1942, 1943, 1944, and
176
[Preliminary data based on sample tabulations ofindividual medical records]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 28,600 | 10,418 | 673 | 12,686 | 363 | 670 | 3,177 | 613 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 433 | 233 | 16 | 34 | 28 | 20 | 49 | 53 |
| Mediterranean | 79 | 48 | 1 | 8 | 6 | 2 | 13 | 1 |
| Middle East | 61 | 25 | --- | 15 | 1 | 5 | 13 | 2 |
| China-Burma-India | 60 | 25 | 1 | 13 | 4 | 3 | 11 | 3 |
| Southwest Pacific | 565 | 246 | 27 | 117 | 18 | 31 | 107 | 19 |
| Pacific Ocean Area | 1,331 | 730 | 52 | 285 | 31 | 56 | 144 | 33 |
| North America | 475 | 179 | 2 | 93 | 12 | 23 | 150 | 16 |
| Latin America | 882 | 352 | 27 | 191 | 27 | 48 | 208 | 30 |
|
| 3,962 | 1,871 | 127 | 770 | 129 | 192 | 713 | 160 |
|
| 32,562 | 12,289 | 800 | 13,456 | 492 | 862 | 3,890 | 773 |
1About four-fifths of the admissions shown in this categorywere classified as "allergic dermatitis," which included casesreported as "atopic dermatitis," "atopic eczema," "eczematoiddermatitis," "impetiginous eczema," and "neurogenicdermatitis"; the remainder were admissions reported as due to"allergic conjunctivitis," "chronic allergy," unspecifiedallergy, and other allergic reactions.
2Includes admissions on transports.
1945), the admission-rate data are given in tables 33,34, 35, and 36 respectively. Asthma, dermatitis venenata, and urticariarepresent the highest rates, in the order given. The higher rates in tropicaltheaters, namely, the China-Burma-India and the Pacific Ocean and SouthwestPacific Areas, probably reflect the unfavorable effect of tropical environmenton allergic conditions. It is of interest, however, that the rate for asthma inthe Latin American theater closely approximates that for the tropical areasmentioned and that the highest rates for hay fever were in the Pacific OceanArea and in the Mediterranean theater and for angioneurotic edema in the MiddleEast. Definitive studies on asthma were not reported from the Latin Americantheater to explain its high rate; in North Africa, dust and pollen wereprevalent and the considerable daily alterations in temperature, with warm daysand cool nights, were reported to be of etiological importance. Why the MiddleEast had the highest rates for urticaria and angioneurotic edema is notexplained by statistics nor by individual studies on allergic states reportedfrom this theater. Again, the high rate for allergic dermatitis in the Southwest
177
[Preliminary data based on sample tabulations of individualmedical records]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 60,685 | 25,000 | 3,700 | 23,310 | 670 | 1,400 | 5,335 | 1,270 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 1,504 | 707 | 94 | 179 | 162 | 61 | 235 | 66 |
| Mediterranean | 2,904 | 1,468 | 279 | 260 | 91 | 137 | 584 | 85 |
| Middle East | 441 | 213 | 25 | 30 | 9 | 31 | 115 | 18 |
| China-Burma-India | 516 | 217 | 21 | 123 | 24 | 19 | 100 | 12 |
| Southwest Pacific | 2,440 | 893 | 86 | 933 | 71 | 92 | 304 | 61 |
| Pacific Ocean Area | 3,576 | 1,670 | 166 | 1,120 | 114 | 126 | 318 | 62 |
| North America | 718 | 272 | 10 | 143 | 18 | 33 | 174 | 68 |
| Latin America | 987 | 375 | 63 | 243 | 37 | 48 | 185 | 36 |
|
| 13,224 | 5,890 | 745 | 3,055 | 529 | 551 | 2,041 | 413 |
|
| 73,909 | 30,890 | 4,445 | 26,365 | 1,199 | 1,951 | 7,376 | 1,683 |
1About four-fifths of the admissions shown in this category were classifiedas "allergic dermatitis," which included cases reported as "atopicdermatitis," "atopic eczema," "eczematoid dermatitis,""impetiginous eczema," and "neurogenic dermatitis"; theremainder were admissions reported as due to "allergicconjunctivitis," "chronic allergy," unspecified allergy, andother allergic reactions.
2Includes admissions on transports.
Pacific probably represents the effect of tropicalenvironment with its high humidity.
Disposition of Allergic Patients
Table 37 presents the total numbers and the rates, per yearper 1,000 average strength, of disability separations and retirements due toallergic diseases for the years 1942-45, inclusive.
During the 4-year period, a total of 46,607 allergic patientswere discharged or retired for disability. Asthma accounted for 38,575 (82.7percent) of the total number; hay fever and allergic dermatitis and certainother allergic disorders, combined, for 12.9 percent; and the other categories,only insignificant totals. It is surprising how few disability discharges werecaused by dermatitis venenata, considering the large number of cases (75,371)observed over the war period.
A comparison of admissions and disability separations, forselected allergic diseases in the U.S. Army for the period 1942-45, inclusive,is shown in table 38. Of the total number of admissions, 18.7 percent were
178
[Preliminary data based on sample tabulationsof individual medical records]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 43,125 | 15,647 | 2,766 | 15,831 | 673 | 1,083 | 4,527 | 2,598 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 7,636 | 3,304 | 544 | 1,050 | 289 | 379 | 1,205 | 855 |
| Mediterranean | 5,046 | 1,658 | 458 | 759 | 155 | 198 | 978 | 840 |
| Middle East | 415 | 116 | 21 | 34 | 5 | 38 | 118 | 83 |
| China-Burma-India | 2,157 | 650 | 100 | 571 | 110 | 105 | 336 | 285 |
| Southwest Pacific | 8,415 | 1,638 | 334 | 2,717 | 289 | 247 | 691 | 2,499 |
| Pacific Ocean Area | 5,222 | 1,576 | 254 | 1,681 | 174 | 206 | 518 | 813 |
| North America | 540 | 133 | 23 | 104 | 19 | 39 | 131 | 91 |
| Latin America | 776 | 279 | 49 | 144 | 20 | 25 | 135 | 124 |
| Total overseas2 | 30,464 | 9,409 | 1,793 | 7,144 | 1,072 | 1,248 | 4,183 | 5,615 |
| Total Army | 73,589 | 25,056 | 4,559 | 22,975 | 1,745 | 2,331 | 8,710 | 8,213 |
1About four-fifths of the admissionsshown in this category were classified as "allergic dermatitis," whichincluded cases reported as "atopic dermatitis," "atopiceczema," "eczematoid dermatitis," "impetiginouseczema," and "neurogenic dermatitis"; the remainder wereadmissions reported as due to "allergic conjunctivitis," "chronicallergy," unspecified allergy, and other allergic reactions.
2Includes admissions on transports.
discharged or retired and 81.3 percent were returned to duty(how many to full or to limited status is not known).
That 38,575 patients, representing 44 percent of admissionsto hospital for asthma, received disability separations strikingly illustratesthe importance of the disease in the Army. Of 15,254 admitted for hay fever,1,938 or 12.7 percent were given disability discharges. What percentage of thehay fever was due to seasonal or to the more serious perennial form of allergicrhinitis is unknown. That only 454 (0.6 percent) of the 75,371 admissions fordermatitis venenata were separated from service illustrates the benign nature ofthis form of contact dermatitis; whereas, allergic dermatitis and certain otherallergic disorders combined were second only to asthma as the basis fordisability separations from the service.
CLINICAL DATA
The statistical material just presented conveys, only insofar as statisticscan, some concept of the total "load" that the allergic diseasesimposed
179
[Preliminary data based on sample tabulations of individualmedical records]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 30,570 | 10,720 | 2,945 | 7,625 | 525 | 715 | 3,610 | 4,430 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 13,295 | 3,770 | 1,340 | 1,580 | 305 | 520 | 3,005 | 2,775 |
| Mediterranean | 2,895 | 665 | 195 | 430 | 110 | 100 | 770 | 625 |
| Middle East | 230 | 65 | 5 | 20 | 5 | 10 | 55 | 70 |
| China-Burma-India | 2,375 | 485 | 110 | 655 | 110 | 60 | 405 | 550 |
| Southwest Pacific | 13,015 | 1,960 | 465 | 1,380 | 455 | 350 | 1,130 | 7,275 |
| Pacific Ocean Area | 4,840 | 1,385 | 335 | 675 | 155 | 200 | 545 | 1,545 |
| North America | 255 | 50 | --- | 45 | 10 | 15 | 50 | 85 |
| Latin America | 710 | 235 | 55 | 105 | 30 | 25 | 130 | 130 |
|
| 38,050 | 8,675 | 2,505 | 4,950 | 1,240 | 1,295 | 6,225 | 13,160 |
|
| 68,620 | 19,395 | 5,450 | 12,575 | 1,765 | 2,010 | 9,835 | 17,590 |
1About four-fifths of the admissions shown in this category were classifiedas "allergic dermatitis," which included cases reported as "atopicdermatitis," "atopic eczema," "eczematoid dermatitis,""impetiginous eczema," and "neurogenic dermatitis"; theremainder were admissions reported as due to "allergicconjunctivitis," "chronic allergy," unspecified allergy, andother allergic reactions.
2Includes admissions on transports.
upon all branches of the military service, including theMedical Corps. A series of clinical reports by medical officers supplements thestatistical data, in many instances specifying the etiology, the results oftreatment, and the disposition in selected series of patients.
All reports emphasize that-
1. Of all persons with asthma and hay fever, observed inclinic or hospital or both, at least 50 percent gave an appropriate history oractually had symptoms at the time of entering the military service.
2. Many persons giving a history or having mild symptoms ofasthma or hay fever on entry into the service were able, with or withoutappropriate treatment, to remain on duty in the United States, althoughaggravation of symptoms frequently developed when such persons were sent tooversea theaters.
3. Desensitization of extrinsic asthma and allergicrhinitis when indicated was relatively more successful in the United States thanin oversea areas, where retention of only a small percentage of patients sotreated was found possible.
180
[Preliminary data based on sample tabulations of individualmedical records]
[Rate expressed as number per year per 1,000 average strength]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 11.05 | 4.20 | 0.68 | 4.03 | 0.15 | 0.26 | 1.13 | 0.60 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 5.20 | 1.82 | 0.46 | 0.65 | 0.18 | 0.22 | 1.02 | 0.85 |
| Mediterranean | 7.37 | 2.60 | .63 | .98 | .24 | .29 | 1.58 | 1.05 |
| Middle East | 7.85 | 2.87 | .35 | .68 | .14 | .57 | 2.06 | 1.18 |
| China-Burma-India | 11.65 | 3.13 | .53 | 3.11 | .57 | .43 | 1.94 | 1.94 |
| Southwest Pacific | 13.31 | 2.58 | .50 | 2.80 | .45 | .39 | 1.22 | 5.37 |
| Pacific Ocean Area | 11.91 | 4.27 | .64 | 2.99 | .38 | .47 | 1.21 | 1.95 |
| North America | 4.04 | 1.29 | .07 | .78 | .12 | .22 | 1.03 | .53 |
| Latin America | 8.80 | 3.25 | .51 | 1.79 | .30 | .38 | 1.73 | .84 |
|
| 7.98 | 2.40 | 0.48 | 1.48 | 0.28 | 0.31 | 1.23 | 1.80 |
|
| 9.76 | 3.44 | 0.60 | 2.96 | 0.20 | 0.28 | 1.17 | 1.11 |
1About four-fifths of the admissions shown in this categorywere classified as "allergic dermatitis," which included casesreported as "atopic dermatitis," "atopic eczema," "eczematoiddermatitis," "impetiginous eczema," and "neurogenicdermatitis"; the remainder were admissions reported as due to"allergic conjunctivitis," "chronic allergy," unspecifiedallergy, and other allergic reactions.
2Includes admissions on transports.
4. Allergic states other than asthma, dermatitis venenata,and hay fever, namely, atopic eczema, urticaria, and angioneurotic edema, wererelatively unimportant causes of disability.
During the period of partial mobilization before war wasdeclared, special clinics or services for allergic conditions were not availablein either station or general hospitals, and medical officers experienced inallergy were scarce. The need became evident with the rapid increase of theArmed Forces. In the Fourth Service Command, the organization of comprehensivefacilities for the diagnosis and treatment of allergic diseases under thesupervision of Col. Sanford W. French, MC, was started in March 1942. Formalinstruction for medical officers was organized, and a central laboratory wasestablished. At this laboratory, extracts for skin testing and desensitizationwere prepared and dispensed to the 89 individual allergy clinics eventuallyorganized in this command and, subsequently, to many station and generalhospitals in the other eight service commands.
181
[Preliminary data based on sample tabulations of individualmedical records]
[Rate expressed as number per year per 1,000 average strength]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 10.76 | 3.92 | 0.25 | 4.77 | 0.14 | 0.25 | 1.20 | 0.23 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 5.22 | 2.81 | 0.19 | 0.41 | 0.34 | 0.24 | 0.59 | 0.64 |
| Mediterranean | 3.45 | 2.10 | .04 | .35 | .26 | .09 | .57 | .04 |
| Middle East | 10.09 | 4.13 | 0 | 2.48 | .17 | .83 | 2.15 | .33 |
| China-Burma-India | 6.87 | 2.86 | .11 | 1.49 | .46 | .34 | 1.26 | .34 |
| Southwest Pacific | 7.93 | 3.45 | .38 | 1.64 | .25 | .44 | 1.50 | .27 |
| Pacific Ocean Area | 8.82 | 4.84 | .34 | 1.89 | .21 | .37 | .95 | .22 |
| North America | 4.72 | 1.78 | .02 | .92 | .12 | .23 | 1.49 | .16 |
| Latin America | 8.65 | 3.45 | .26 | 1.87 | .26 | .47 | 2.05 | .29 |
|
| 6.76 | 3.19 | 0.22 | 1.31 | 0.22 | 0.33 | 1.22 | 0.27 |
|
| 10.04 | 3.79 | 0.25 | 4.14 | 0.15 | 0.27 | 1.20 | 0.24 |
1About four-fifths of the admissions shown in this categorywere classified as "allergic dermatitis," which included casesreported as "atopic dermatitis," "atopic eczema," "eczematoiddermatitis," "impetiginous eczema," and "neurogenicdermatitis"; the remainder were admissions reported as due to"allergic conjunctivitis," "chronic allergy," unspecifiedallergy, and other allergic reactions.
2Includes admissions on transports.
French and Halpin,4 in 1944, compiled data from 67of the 89 clinics (including 28 Army Air Force hospitals) for the period of oneyear ending in November 1943. These data provide an excellent picture of thehigh incidence of allergic diseases in personnel stationed in the United States.Among the 32,046 allergic patients in all 89 clinics at this time, there were6,842 with dermatitis venenata. In the 67 clinics selected for study, becausethey had been in operation longer than the rest, there were 25,204 allergicpatients, of whom 1,785 were civilian dependents of servicemen. Among them,there were 4,573 with uncomplicated seasonal hay fever, of whom an estimated 85percent were under desensitization therapy. The diagnosis of seasonal bronchialasthma was made in 946 patients; of seasonal hay fever accompanied by asthma, in1,384 patients. Of the 7,261 patients with perennial bronchial asthma, 1,903exhibited seasonal aggravation due to pollen. Perennial allergic rhinitisaccounted for 3,831 patients, of whom 1,105 noted increased severity of symptomsduring the pollen seasons. In
4French, S. W., and Halpin, L. J.: Army Allergy;Fourth Service Command, 1943. Ann. Allergy 2: 365-379, September-October 1944. [Includes discussion by L. E. Leider, p. 374.]
182
[Preliminary data based on sample tabulationsof individual medical records]
[Rate expressed as number per year per 1,000 average strength]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 11.71 | 4.82 | 0.71 | 4.50 | 0.13 | 0.27 | 1.03 | 0.25 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 5.64 | 2.65 | 0.35 | 0.67 | 0.61 | 0.23 | 0.88 | 0.25 |
| Mediterranean | 6.36 | 3.21 | .61 | .57 | .20 | .30 | 1.28 | .19 |
| Middle East | 8.31 | 4.01 | .47 | .57 | .17 | .58 | 2.17 | .34 |
| China-Burma-India | 13.02 | 5.48 | .53 | 3.10 | .61 | .48 | 2.52 | .30 |
| Southwest Pacific | 12.85 | 4.71 | .45 | 4.92 | .37 | .48 | 1.60 | .32 |
| Pacific Ocean Area | 12.27 | 5.71 | .57 | 3.84 | .39 | .43 | 1.09 | .21 |
| North America | 3.69 | 1.40 | .05 | .74 | .09 | .17 | .89 | .35 |
| Latin America | 8.17 | 3.10 | .52 | 2.01 | .31 | .40 | 1.53 | .30 |
|
| 7.83 | 3.49 | 0.44 | 1.81 | 0.31 | 0.33 | 1.21 | 0.24 |
|
| 10.76 | 4.51 | 0.65 | 3.84 | 0.17 | 0.28 | 1.07 | 0.24 |
1About four-fifths of theadmissions shown in this category were classified as "allergicdermatitis," which included cases reported as "atopicdermatitis," "atopic eczema," "eczematoid dermatitis,""impetiginous eczema," and "neurogenic dermatitis"; theremainder were admissions reported as due to "allergicconjunctivitis," "chronic allergy," unspecified allergy, andother allergic reactions.
2Includes admissions on transports.
these few figures, covering a 1-year period, it thus appearsthat pollen sensitivity, manifested by rhinitis or asthma or both involved 9,911of 25,204 patients. Considering the geographic location of the Fourth ServiceCommand, ragweed pollen, as would be anticipated, was the most important of theantigens; dust, feathers, and other environmental antigens were less important.Infection of the respiratory tract, including the paranasal sinuses, was a minorfactor in ambulatory patients but was more evident in hospitals that receivedthe more persistent and refractory cases of asthma and rhinitis. Urticariaof the acute and chronic type was noted in 1,644 cases in the 67 clinics. Gastrointestinalallergy was noted in 255 and food allergy in 1,565 patients.
Information derived from detailed studies made in Armyinstallations has been summarized for presentation in the paragraphs which areto follow.
Asthma
History.-Careful study of clinical records revealed thatat least 50 percent of the patients observed in hospitals or dispensaries hadsymptoms
183
[Preliminary data based on sample tabulations of individualmedical records]
[Rate expressed as number per year per 1,000 average strength]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 10.86 | 3.94 | 0.70 | 3.99 | 0.17 | 0.27 | 1.14 | 0.65 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 4.55 | 1.96 | 0.33 | 0.63 | 0.17 | 0.23 | 0.72 | 0.51 |
| Mediterranean | 7.77 | 2.55 | .71 | 1.17 | .24 | .30 | 1.51 | 1.29 |
| Middle East | 8.98 | 2.51 | .45 | .74 | .11 | .82 | 2.55 | 1.80 |
| China-Burma-India | 12.79 | 3.86 | .59 | 3.39 | .65 | .62 | 1.99 | 1.69 |
| Southwest Pacific | 15.60 | 3.04 | .62 | 5.03 | .54 | .46 | 1.28 | 4.63 |
| Pacific Ocean Area | 11.90 | 3.59 | .58 | 3.83 | .40 | .47 | 1.18 | 1.85 |
| North America | 4.18 | 1.04 | .18 | .80 | .15 | .30 | 1.01 | .70 |
| Latin America | 9.04 | 3.25 | .57 | 1.68 | .23 | .29 | 1.57 | 1.45 |
|
| 7.98 | 2.46 | 0.47 | 1.87 | 0.28 | 0.33 | 1.10 | 1.47 |
|
| 9.45 | 3.22 | 0.59 | 2.95 | 0.22 | 0.30 | 1.12 | 1.05 |
1About four-fifths of the admissions shown in this category were classified as "allergic dermatitis," which includedcases reported as "atopic dermatitis," "atopic eczema," "eczematoid dermatitis," "impetiginous eczema," and "neurogenic dermatitis"; the remainder were admissions reported as due to "allergic conjunctivitis," "chronic allergy," unspecified allergy, and other allergic reactions.
2Includes admissions on transports.
or gave a history of asthma on entering the military service.5 Recurrence in many individuals developed comparatively soon thereafter. Gold and Bazemore6 reported in 1942 that in their series 65 percent of men discharged for asthma had had less than 6 months' service and 21 percent, less than 30 days' service. All reports stressed that more adequate preinduction examinations would have resulted in disqualifying the majority of such persons who later in service were discharged or retired for disability.
Etiology.-A summary of the several studies on asthma observed in the United States and in oversea theaters indicated that pollens, dust and other environmental antigens, infections of therespiratory tract, and, in the Tropics, high humidity were the major factors responsible for chronic symptoms or recurring attacks.
5Rudolph, J. A: Study of Bronchial Asthma in General Hospital, With Statistical Report of 200 Cases. Ann. Allergy 3: 258-270, July-August 1945.
6Gold, E. M., and Bazemore, J. M.: Significance of Allergy in Military Medicine; Report of Incidence of Allergic Diseases in Large Station Hospital, and Method of Preinduction Evaluation of Allergic State. J. Allergy 15: 279-282, July 1944.
184
[Preliminary data based on sample tabulations of individualmedical records]
[Rate expressed as number per year per 1,000 average strength]
Area or theater | Total allergic diseases | Asthma | Hay fever | Dermatitis venenata | Eczema | Edema, angioneurotic | Urticaria | Allergic dermatitis and certain other allergic disorders1 |
Continental United States | 10.43 | 3.67 | 1.00 | 2.60 | 0.18 | 0.24 | 1.23 | 1.51 |
Overseas: |
|
|
|
|
|
|
|
|
| Europe | 5.60 | 1.58 | 0.56 | 0.67 | 0.13 | 0.22 | 1.27 | 1.17 |
| Mediterranean | 8.18 | 1.88 | .55 | 1.22 | .31 | .28 | 2.17 | 1.77 |
| Middle East | 5.62 | 1.59 | .12 | .49 | .12 | .24 | 1.35 | 1.71 |
| China-Burma-India | 10.73 | 2.19 | .50 | 2.96 | .50 | .27 | 1.83 | 2.48 |
| Southwest Pacific | 12.56 | 1.89 | .45 | 1.33 | .44 | .34 | 1.09 | 7.02 |
| Pacific Ocean Area | 12.88 | 3.69 | .89 | 1.80 | .41 | .53 | 1.45 | 4.11 |
| North America | 3.75 | .73 | 0 | .66 | .15 | .22 | .73 | 1.26 |
| Latin America | 9.75 | 3.24 | .76 | 1.44 | .41 | .34 | 1.78 | 1.78 |
|
| 8.19 | 1.87 | 0.54 | 1.07 | 0.27 | 0.28 | 1.34 | 2.82 |
|
| 9.06 | 2.56 | 0.72 | 1.66 | 0.23 | 0.27 | 1.30 | 2.32 |
1About four-fifths of the admissions shown in this category were classifiedas "allergic dermatitis," which included cases reported as "atopicdermatitis," "atopic eczema," "eczematoid dermatitis,""impetiginous eczema," and "neurogenic dermatitis"; theremainder were admissions reported as due to "allergicconjunctivitis," "chronic allergy," unspecified allergy, andother allergic reactions.
2Includes admissions on transports.
[Preliminary data based on tabulations of individual medicalrecords]
[Rate expressed as number per year per 1,000 average strength]
Cause of separation |
| 1942 | 1943 | 1944 | 1945 | |||||
| Rate | Number | Rate | Number | Rate | Number | Rate | Number | Rate | |
Asthma | 38,575 | 1.51 | 3,162 | .97 | 16,111 | 2.35 | 8,482 | 1.09 | 10,820 | 1.47 |
Hay fever | 1,938 | .08 | 47 | .01 | 786 | .11 | 364 | .05 | 741 | .10 |
Dermatitis venenata | 454 | .02 | 1 | 2.00 | 57 | .01 | 145 | .02 | 251 | .03 |
Eczema | 448 | .02 | 26 | .01 | 125 | .02 | 128 | .02 | 169 | .02 |
Edema, angioneurotic | 388 | .02 | 24 | .01 | 153 | .02 | 89 | .01 | 122 | .02 |
Urticaria | 948 | .04 | 32 | .01 | 264 | .04 | 248 | .03 | 404 | .05 |
Allergic dermatitis and certain other allergic disorders | 3,856 | .15 | 53 | .02 | 238 | .03 | 566 | .07 | 2,999 | .40 |
| Total | 46,607 | 1.84 | 3,345 | 1.03 | 17,734 | 2.58 | 10,022 | 1.29 | 15,506 | 2.09 |
1Year shown is year of separation for disability.
2Indicates a rate of more than zero but less than 0.005.
185
Cause of admission or separation | Number of | Disability separations | |
Number | Percent | ||
Asthma | 87,630 | 38,575 | 44.0 |
Hay fever | 15,254 | 1,938 | 12.7 |
Dermatitis venenata | 75,371 | 454 | .6 |
Eczema | 5,201 | 448 | 8.6 |
Angioneurotic edema | 7,154 | 388 | 5.4 |
Urticaria | 29,811 | 948 | 3.2 |
Allergic dermatitis and certain other allergic disorders | 28,259 | 3,856 | 13.6 |
| Total | 248,680 | 46,607 | 18.7 |
Studies on asthma originating or aggravated in tropical areasrevealed that aggravation or recurrence developed usually in a shorter period oftime, in terms of tropical service, than the initial or primary attack inindividuals who had no previous history of asthma.7Leopold,8 in his report,questioned the significance of pollens and molds in the causation of asthma inthe Tropics. He had studied 200 asthmatic patients of whom 91.5 percent hadserved in the Tropics, mostly in the Pacific Ocean Area. In this series ofcases, the onset of initial attacks (occurring in 31.5 percent) was ascribed tofactors of climate in 79.5 percent, to exposure to dust in 16 percent, and toinfection in 4.5 percent. In recurrent attacks, climate, alone or incombination, was a precipitating factor in 88 percent; dust, alone or incombination, in 84 percent; and infections of the respiratory tract, in 24percent. The botanist O. C. Durham, having been consulted, observed thattropical areas do not have the flora nor the climate conducive to thedevelopment or spread of airborne pollen and fungus. Others might object thatmolds grow luxuriantly in tropical islands or suggest9 that the pollens ofgrasses, rice, and sugarcane sometimes play a part. Leopold concluded that thehot humid climate of the Tropics was the principal determining factor in hiscases. At all events, irrespective of the cause or causes, tropical serviceappears to be contraindicated for individuals giving a history or presentingsymptoms of asthma.
Infections of the respiratory tract were reported by severalauthors as important factors precipitating acute attacks of asthma or as being
7Young, C. T., Cook, W. R., and Kawasake, I. A.:Allergic Rhinitis and Asthma in Hawaii. War Med. 3: 282-290, March 1943.
8Leopold, H. C.: Study of Asthmatics Returned From Overseas.J. Allergy 16: 30-43, January 1945.
9Rosen, F. L.: Bronchial Asthma in Young Male Adult:Study of 50 Patients Returned From Tropics for Bronchial Asthma, as Comparedto 50 Asthmatics Stationed in United States. Ann. Allergy 4: 391-396,September-October 1946.
186
present in chronic form in many of the patients withpersistent symptoms.10 Actually, the incidence of infection variedconsiderably. In Leopold's series of 200 patients, 25 were subjected tobronchoscopic examination, but only 2 showed findings that could be interpretedas evidence of infection; a comparatively low percentage in any group ofunselected patients with asthma. By contrast, Zoss11 and his coworkers, who wereprimarily interested in infection, reported on the bronchoscopic findings in 250patients with asthma studied at the Finney General Hospital, Ga. Of the 250patients, 206 had seen active duty overseas. Of the oversea group, 71 haddeveloped asthma in the oversea area, and in 117 symptoms were intensified whileoverseas. Of the 250 cases, 20 percent were considered to be the extrinsic type,due to environmental and atmospheric antigens; 40 percent were considered to bethe intrinsic type; and in 40 percent, the etiology was obscure. Of the totalnumber of patients, 50 percent had chronic sinus infection. Bronchoscopicexamination revealed evidence of chronic bronchitis in 220, suppurative in 123,and nonsuppurative in 97. Only in four were the mucosal changes consideredtypically allergic in appearance. The incidence of infection both in thesinuses and in the bronchial tree, considering the comparative youth of thisseries, is rather high.
Study of the cause of asthma based on bronchoscopic findingsmay, however, be inaccurate and misleading. The observations cited might wellhave had a different interpretation by other observers, for it is known thatchanges in the bronchial mucosa in many alleged infective asthmatic patients maybe due primarily to hypersensitivity to inhaled allergens, such as dust andpollen, upon which the changes related to infection are merely superimposed.Hampton and Rand,12 however, also found a rather high incidence ofinfection at the Army Air Forces Regional Hospital of the San Antonio AviationCadet Center. Of 186 patients with asthma, chronic infection alone or incombination with inhalant or food hypersensitivity or both was found in 141;acute infections precipitated attacks in 50. That the incidence of infectionvaried in different theaters is illustrated in a series of 209 cases of asthmastudied in a general hospital in Australia,13 of which only 14percent were considered related to infection. Furthermore, in a series of 192cases reported by Young, Cook, and Kawasake14 at theTripler GeneralHospital in Hawaii, the great majority of cases were considered to be due topollen and dust, with infection a minor factor.
10Rosen, F. L.: Bronchial Asthma in Young MaleAdult; Study of 100 Hospitalized Patients in Army General Hospital, With SpecialReference to Nasal Symptoms and Findings. Ann. Allergy 4: 247-260, July-August1946.
11Zoss, A., Neidlinger, W. J., and Read, H. S.:Survey of Bronchial Asthma in Soldiers; Bronchoscopic Findings andIncidence of Respiratory Infection. J. Allergy 17: 87-96, March 1946.
12Hampton, S. F., and Rand, H.: Problem of Allergy atArmy Air Forces Hospital; Respiratory Allergy (Hay Fever, Vasomotor Rhinitis and Bronchial Asthma). J. Allergy 15: 355-368, September 1944.
13Winkenwerder, W. L.: Asthma-As Observedin Overseas General Hospital in Southwest Pacific Area-With Special Referenceto Relationship of Tropical Service to Onset and Recurrence. Bull. Johns Hopkins Hosp. 78: 78-95, February 1946.
14See footnote 7, p. 185.
187
The question of the importance of psychosomatic elements inthe etiology of asthma was emphasized by Fishman15 in a study of 100 patientsreturned from the European theater. Prolonged exposure to dampness anddust, to undue exertion and fatigue, and to infections were cited as significantcauses. "Few patients would admit that fear was a precipitating oraggravating factor, but many felt that worry facilitated the onset ofsymptoms." A special group of 16 patients, 4 officers and 12 enlistedpersonnel, none of whom had had asthma before going overseas, was returned tothe United States with the diagnosis of asthma plus neuropsychiatric disease.The latter diagnosis had been made in each case by the neuropsychiatricconsultant. In the 16 patients, pollen and other inhalant antigens and unduefatigue could not be related to their attacks; in only 3, did dust play a role.None developed symptoms during combat; nearly all did, however, exhibit symptomsduring the period of precombat preparation. In three patients, asthma developedas part of a generalized functional disorder after specific mental insults. All16 patients improved on return to the United States.
In contrast, Leopold (p. 185), in his report, stated:"The importance of the r?le of psychogenic factors in the etiology ofasthma was considered. Many of these patients were in actual combat, underwentair bombardment, slept in wet clothes in wet foxholes, and faced the hardshipsof service in the jungles." The patients in his series manifesting anxietysymptoms were studied by the psychiatrist and in no instance were emotionalfactors found to be of significance. Other observers, including the authorof this chapter, would disagree with such an all-inclusive denial that thepsyche modifies the asthmatic state; the anxiety symptoms studied in Leopold'sseries of patients may not represent the peculiar emotional stress recognizedby many authorities as aggravating asthma. Zanfagna,16in a study of 100cases in a station hospital, concluded that psychic factors play an importantpart in the production of attacks in predisposed persons. On the otherhand, Rosen17 points out that the asthmatic patient is sometimes unjustlytagged as being psychoneurotic.
Disposition of patients.-Of the several series ofpatients with asthma studied in detail, varying percentages were discharged fromservice or assigned to duty, usually of a limited nature, in the United Statesand in oversea areas. Of the series reported by French and Halpin (p. 181) fromthe Fourth Service Command, 8,139 (32.3 percent) were admitted to hospitalduring a 12-month period. Of these, only 602 had uncomplicated hay fever; 5,447had bronchial asthma. Among 3,742 allergic patients discharged fordisability, 3,231 had bronchial asthma. A total of 10,573 patients with variousother allergies were retained in the service-appropriate
15Fishman, A. P.: Etiologic Evaluation of Asthma in 100Cases Returned From Overseas. J. Allergy 18: 115-124, March 1947.
16Zanfagna, P. E.: Perennial Bronchial Asthma;Analysis of 100 Cases. Bull. U.S. Army M. Dept. (No. 87): 100-103, April 1945.
17See footnote 10, p. 186.
188
treatment, including drugs, elimination or control ofinfection, and desensitization therapy, was considered responsible in great partfor returning this number to duty. The overwhelming majority of patients withasthma originating or aggravated overseas were eventually returned to the UnitedStates. In a general hospital in Australia,18 a total of 352 cases of asthma wereadmitted to the hospital. These represented 1.2 percent of total admissions overa 2-year period ending July 1944. Of the 352 cases, 209 were analyzed in detail,and it was found that total disability represented by time spent in the hospitalwas 12,260 days, an average of 58.6 days per patient. Of 2,980 patients returnedto the United States by this hospital, asthma represented 9.1 percent and was,next to the psychiatric group, the largest single cause for evacuation.Treatment of the asthmatics, including desensitization, instituted in the hopeof retaining men overseas even for limited service, was relatively unsuccessful-only13 of 38 patients so treated were returned to duty status; 339 of the 352 wereeventually evacuated to the United States.
There are conflicting data on the clinical course and thedisposition of patients with asthma after their return to the Zone of Interior.The great majority of such patients after periods of observation and treatmentwere discharged from service, although Alford19 and Leider20emphasizedthat in their series patients with asthma originating or aggravated overseasimproved rapidly after evacuation to the United States and that the majority ofthem were returned to duty. In Leopold's series of 200, on the other hand, 176patients including 125 whose symptoms improved were eventually given disabilitydischarges.
The question of the frequency of recurrence in militaryservice of childhood asthma with a history of remission for some years wascommented on only by Alford. In his series, relapse of childhood asthma wasinfrequent. Patients with chronic or recurrent asthma, whether beginning inchildhood or in later years, were all separated from service.
Allergic Rhinitis
Seasonal hay fever.-Seasonal hay fever observed in the United States was reported by several investigators.21 Most of the patients were studied and treated in dispensaries. The specific pollens implicated depend on geo-
18See footnote 13, p. 186.
19Alford, R. I.: Disposition of Soldiers With Bronchial Asthma. J. Allergy 15: 196-202,, May 1944.
20See footnote 4, p. 181.
21(1) Blank, P.: Military Aspects of Allergy. J. Lab. & Clin. Med. 38: 609-618, February 1943. (2) Blank, P.: Survey of Allergy in Station Hospital. Mil. Surgeon 92: 419-423, April 1943. (3) Blank, P., and Levitt, H.: Military Aspects of Allergic Rhinitis. M. Bull. North African Theat. Op. (No. 4) 2: 96, October 1944; also Ann. Allergy 3: 113-122, March-April 1945. (4) Edwards, W. M.: Diagnostic Test for Atopic Sensitivity. Mil. Surgeon 95: 222-224, September 1944. (5) See footnotes 4, p. 181; and 6, p. 183. (6) Goltz, H. H., and Kalisch, A. C.: A Monograph on the Diseases of Allergy in the Mediterranean Theater of Operations, U.S. Army. [Official record.] (7) Gutmann, M. J.: Urticaria Caused by Chlorinated Drinking Water. J. Allergy 15: 395-398, November 1944.
189
graphic location, ragweed and grass pollen in that orderbeing the more important agents in the United States. A summary of pollendistribution throughout the world was given by Blank and Levitt.22Desensitization treatment was reported to be feasible and effective in theUnited States,23 but actual statistical data to support thisstatement are not available. Desensitization overseas was rarely practicable,owing to frequent change of station and lack of appropriate facilities. Even infixed installations in rear areas, such treatment was relatively ineffective,although a few patients so treated were maintained on duty status.24 Itwas well known that large numbers of men in various oversea areas experiencedmild symptoms of hay fever but were not disabled thereby and served throughoutthe war. It was the general opinion of most authors that, unless symptoms weresevere and prolonged, seasonal hay fever was not incompatible with militaryservice in the United States where adequate observation was possible andtreatment was readily available, but assignment to duty overseas, especially intropical areas where, as in cases of asthma, aggravation or recurrence wasfrequent, was considered inadvisable. Furthermore, service in combat units maybe very hazardous not only to the person with hay fever but also to others inthe unit. Golz and Kalisch,25 in a statistical analysis of allergic diseasesobserved at several station and general hospitals in the Mediterranean theater,cited an instance where the presence of men on secret night maneuvers was madeknown to enemy troops by the irrepressible sneezing of one soldier, resulting inprompt enemy fire.26
The question of the effects of flying and of the accompanyingatmospheric pressure changes on allergic rhinitis (hay fever) was commented onin the study by Hampton and Rand (p. 186) of allergic diseases at the Army AirForces Regional Hospital in San Antonio. Although adequately controlledexperiments were not carried out, it was the general opinion of severalobservers that rapid changes in atmospheric pressure did not aggravate symptomsof allergic rhinitis nor induce aerosinusitis or pain in the middle ear. Thisview received some support in the field; for example, Golz and Kalisch cite theexperience of the 5th Bomb Wing of the Fifteenth U.S. Army Air Force. Ofapproximately 4,256 aviators, 43 had hay fever during the months of April, May,and June 1944, while serving in the Mediterranean theater. Flying status was notmodified, and symptoms actually subsided during flight.
Perennial allergic rhinitis.-Perennial allergic rhinitisdue to environmental antigens other than pollens was not reported on in detail.French and
22See footnote 21 (3), p. 188.
23See footnotes 21 (2), p. 188, and 4, p. 181.
24See footnote 13, p. 186.
25See footnote 21 (6), p. 188.
26A similar instance was called to my attention. Thenocturnal sneezing and wheezing of one of our men occupying a foxhole with twocomrades on a tropical island in the South Pacific disclosed their position andbrought on an enemy attack. The soldier's friends very promptly sent him tothe rear with orders not to return.-W. L. W.
190
Halpin (p. 181) reported 3,831 patients with this diagnosis in their seriesof a total of 25,204 persons with allergic diseases and, of these, 1,105 notedincreased severity of symptoms during the pollen seasons. Specific antigensother than pollen were not mentioned.
In Australia, the author personally observed and studied, in some detail, 82unreported cases of perennial allergic rhinitis. Of these, 40 had developedbefore entry into service. Based on history and positive skin reactions tosignificant antigens, 38 were considered to be allergic in origin, 20 wereassociated with infection, and in 24 possible causes were not definable. Ninecases developed symptoms in the Tropics; preexisting symptoms in 18 wereaggravated by tropical duty and in 4, were not. Nasal polyps were found in five,sinusitis in four, and adenoidal infection in three; significant positive skinreactions in this group were obtained in only 33 percent as compared to almost100 percent of the allergic group. Headaches, attributed to edema of the nasalmucosa and sinuses, were frequent complications in both the infective andallergic types and occurred in 18 cases, particularly in the Tropics; in severalinstances, this was the chief basis for admission to hospital. All were returnedto the Zone of Interior except 10 of the allergic group, who were desensitizedwith apparent success; of these, 4 were eventually assigned to limitednontropical service and the others to full duty.
That allergic rhinitis per se does not predispose to the development ofaerosinusitis or aero-otitis media makes it important to differentiate chronicor recurring rhinitis due to allergic factors from rhinitis associated withinfection in the upper respiratory tract, in the sinuses, and, particularly, inadenoid tissue of the nasopharynx which frequently impinges on and causesobstruction of the eustachian tubes. Symptoms of such a condition may closelysimulate chronic allergic rhinitis, but specific therapy differs in the twoconditions and depends primarily on an accurate diagnosis. On the basis ofprewar studies, Crowe and Baylor27 instituted the principle of radon therapyfor chronic adenoidal infection not amenable to surgical excision. This methodof treatment was introduced by Bordley28 in the South Pacific Area in 1942 forthe treatment of aero-otitis media, occurring frequently in aviators in whomsuch infections were found on nasopharyngoscopic examination. Eventually, thisform of treatment was employed by the Army Air Forces in other theaters ofoperations.
Atopic Eczema
Although eczema of the atopic type was referred to by several authors, thequestion of etiology in such cases was not commented on and an analysis
27Crowe, S. J., and Baylor, J. W.; Prevention of Deafness. J.A.M.A. 112: 585-590, 1939.
28Bordley, John: Personal and Special Communication to Chief Surgeon, Air Corps, U.S. Army, 7 Feb. 1943, subject: Proposal for the Treatment of Aero-otitis Media With Radon.
191
of this form of hypersensitivity is not possible based on the publishedreports, which were primarily statistical.
Urticaria and Angioneurotic Edema
Again, comprehensive etiologic studies of urticaria and angioneurotic edemawere not reported. The acute and chronic type of urticaria was noted in 1,644patients of the series of 25,204 allergic patients reported by French and Halpin(p. 181). Etiology was not specified other than by general reference to thepossibility that the broad immunization program instituted by the militaryservice was the inciting stimulus in many instances. Golz and Kalisch (p. 189)list 91 patients with urticaria and angioneurotic edema observed in theMediterranean theater in 1944, but in only 3 of these cases was etiologyreferred to. These authors described three penicillin reactions resemblingstates like serum disease marked by urticaria and dermatitis, this being theonly reference to penicillin hypersensitivity reactions in the various studiesand reports analyzed herein. Gutmann29 reported one patient in whom theurticaria was presumably due to drinking chlorinated water, and Golz30 studiedone soldier in whom urticaria was associated with recurrent tertian malarialinfection, the lesions recurring subsequently a year later when relapse ofinfection developed. Although the causal relationship in the latter instance isvery suggestive because of cyclic attacks at 48-hour intervals and remission of lesions coincident with Atabrine (quinacrine hydrochloride)therapy, actual sensitivity to malarial antigen was not demonstrated.31 It is ofinterest that urticaria and angioneurotic edema were relatively common in theacute phase of schistosomiasis32 but did not occur in early filariasis33although sensitization to specific antigen develops and has been demonstrated inboth diseases. Considering the large number of soldiers serving in tropicalareas in World War II, one would have anticipated more than one report of asingle instance of heat allergy manifested by urticaria. Peters and Silverman34 studied one soldier in whom the lesions were brought out by elevated environmentaltemperature and exercise, and on the basis of considerable experimentation theypostulated that the mechanism was more related to some abnormal response of bothacetylcholine and histamine rather than to
29See footnote 21 (7), p. 188.
30Golz, H. H.: Malaria and Urticaria. Ann. Allergy 4: 293-294, July-August 1946; also, M. Bull. North African Theat. Op.(No. 2) 2: 27-28, August 1944.
31If hypersensitivity to malarial parasitic antigen was thecause of urticaria in this soldier, it was a rare occurrence, for descriptions of reactions similar to that reported by Golz have not beenreported nor called to my attention despite the thousands of cases of malarialinfection observed during the war.-W. L. W.
32Billings, F. T., Winkenwerder, W. L., and Hunninen, A. V.:Studies on Acute Schistosomiasis Japonica in Philippine Islands; ClinicalStudy of 337 Cases With Preliminary Report on Results of Treatment With Fuadinin 110 Cases. Bull. Johns Hopkins Hosp. 78: 21-56, January 1946.
33Brown, T. M., Stifler, W. C., Jr., and Bethea, W. R., Jr.: Early Filariasis. Bull. Johns Hopkins Hosp. 78: 126-154, March 1946.
34Peters, G. A., and Silverman, J. J.: Role of Histamine and Acetylcholine inMechanism of Heat Allergy; Report of Studies on Soldier. Arch. Int. Med. 77: 526-543,May 1946.
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the latter alone. The reviewer observed one case related toheat intolerance which developed in the Tropics, but no experimental studieswere possible. In general, the total data on urticaria and angioneurotic edemaare meager and scanty, considering the large number of hospital admissions(1,336) resulting from this particular allergic syndrome (table 38).
Dermatitis Venenata
Dermatitis of the contact type has been included in thestatistics on allergic diseases by the Medical Statistics Division, Office ofThe Surgeon General. As an allergic manifestation, it ranked next to asthma innumber of hospital admissions (table 38), but contrary to asthma, 99.4 percentof admissions were returned to duty, indicating in general a self-limitedcondition, responding favorably to treatment.
SUMMARY AND CONCLUSIONS
Of the allergic diseases, asthma, hay fever (vasomotorrhinitis) and allergic dermatitis and certain other allergic disorders wereimportant causes of disability in World War II.
Disqualifications.-Data on disqualifications of selectiveservice registrants for military service in World War II indicate that some 6per 1,000 examinees were disqualified for allergic diseases. The main diagnosiswas asthma; about 5 per 1,000 examinees were disqualified for this disease. InWorld War II, the disqualifications for allergic diseases comprised about 1.6percent of the disqualifications for all causes-administrative, mental, andmedical.
Admissions to hospital.-There were 248,680 admissions forallergic diseases in the U.S. Army for the years 1942-45, inclusive, asfollows: For asthma, 87,630; for dermatitis venenata, 75,371; forurticaria, 29,811; for hay fever, 15,254; for angioneurotic edema, 7,154; foreczema, 5,201; and for allergic dermatitis and certain other allergic disorders,28,259. The admission rate for allergic conditions in the total Army varied from9.06 to 10.76 per year per 1,000 average strength during the 4 years. The ratewas slightly but definitely higher in the China-Burma-India, the SouthwestPacific, and the Pacific Ocean Area theaters.
Disposition.-Of patients admitted to hospitals for allergicconditions, 81.3 percent were returned to duty, and 18.7 percent were givendisability discharges or were retired. In the second category, a total of 46,607persons were released from the Army for disability due to allergic disordersduring 1942-45, inclusive: For asthma, 38,575, or 1.51 per year per 1,000average strength; for hay fever, 1,938, or 0.08 per 1,000; for dermatitisvenenata, 454, or 0.02 per 1,000; for eczema, 448, or 0.02 per 1,000; forangioneurotic edema, 388, or 0.02 per 1,000; for urticaria, 948, or 0.04 per1,000; and for
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allergic dermatitis and certain other allergic disorders,3,856, or 0.15 per 1,000 average strength.
Reports and special studies by medical officers of allergicconditions observed in hospitals in the United States and oversea theatersindicate that-
1. At least 50 percent of the allergic conditions, notablyasthma and hay fever, observed in military service existed before entry into theservice.
2. The relapse rate of asthma was high, particularly inpersonnel serving overseas and especially in tropical areas where dust, highhumidity, and infection were considered the chief aggravating conditions.
3. Allergic rhinitis is not disqualifying for militaryservice, but it should disqualify the individual soldier for combat duty.
4. The disability resulting from allergic diseases other thanasthma, allergic rhinitis, dermatitis venenata, and allergic dermatitis wasinsignificant, and unless the condition is severe and protracted, militaryservice is not contraindicated.
5. Contrary to MR (Mobilization Regulations) 1-9, October1942, selective service registrants presenting asthma or a history of asthmawere accepted for military service. The difficult question confronting medicalexaminers in induction centers was how to assess the severity of the particularallergic syndrome presented or, if evidence of disease was lacking, how muchsignificance to give to a history of allergic symptoms such as hay fever andasthma. Frequently, this history was not supported by adequate records or, ifsymptoms and signs of asthma and hay fever were in remission, many young menintentionally omitted mention of them in order to enter the militaryservices. In many instances, however, selectees and volunteers presenting mildsymptoms or signs of asthma, not disturbing in their civilian environment, wereaccepted for service. The number of potential candidates for disabilitydischarges or retirements for allergic diseases, in particular for asthma, themost important allergic syndrome, could be appreciably reduced in the future bymore adequate examinations and by stricter adherence to regulationsprescribing standards for physical fitness.
