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Chapter XI

Contents

CHAPTER XI

Diabetes Mellitus

Alexander Marble, M.D.

Although the incidence of diabetes mellitus in the U.S. Army during World War II was relatively low, those diabetic patients who were encountered presented problems in diagnosis, treatment, and disposition, which in individual cases were often of considerable moment. The small number of diabetics 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 (18 to 37 years) in which the incidence of diabetes is relatively low in the general population, and (2) routine examination of the urine was made at induction stations, with rejection for military service of all found to have diabetes by analyses of urine and blood.

OBSERVATIONS AT INDUCTION STATIONS

General.-Several sources of data1 relating to the prevalence of diabetes mellitus among registrants examined for military service in World War II are presented in table 51. As may be seen from the table, the reported prevalence rates are quite different. They range from as high as 11.0 (Blotner) to as low as 0.3 (Spellberg and Leff), per 1,000 examinees.

The initial study by Blotner and Hyde2 was based on registrants examined at an induction station in Boston, Mass. These authors found that of the 45,650 examined selectees and volunteers, 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. In other words, 4.6 per 1,000 men examined were diagnosed as having diabetes.

1(1) Causes of Rejection and Incidence of Defects: Local Board Examinations of Selective Service Registrants in Peacetime. Medical Statistics Bulletin 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 England J. Med. 229: 885-892, 9 Dec. 1943. (4) Spellberg, M. A., and Leff, W. A.: The Incidence of Diabetes Mellitus and Glycosuria in Inductees. 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). Medical Statistics Division, Office of The Surgeon General, Department of the Army.
2See footnote 1 (3).


294

TABLE 51.-Prevalence of diabetes mellitus among registrants examined for military service, World War II

[Rate expressed as number per 1,000 examined registrants]

Source and period


Total

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 Board Examinations of Selective Service Registrants in Peacetime. Medical Statistics Bulletin No. 2, National Headquarters, Selective Service System, Washington, D.C., 1 Aug. 1943 (table 7).
2Physical 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).
3Blotner, H., and Hyde, R. W.: Studies in Diabetes Mellitus and 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 Diabetes Mellitus and Glycosuria in Inductees. J.A.M.A. 129: 246-250, 22 Sept. 1945.
5Blotner, H.: Studies in Glycosuria and Diabetes Mellitus in Selectees. J.A.M.A. 131: 1109-1114, 3 Aug. 1946.
6Karpinos, B. D.: Defects Among Registrants Examined for Military Service, World War II (in manuscript form). Medical Statistics Division, Office of The Surgeon General, Department of the Army.

Of the diabetics, 107 were classified as mild, 58 as moderate, and 43 as severe. Only 42 of the diabetics were aware of their disease.

Spellberg and Leff3 in a later study, based on examinations of some 32,000 registrants at an induction station in New Orleans, La., found a far lower prevalence of glycosuria and diabetes. They found only 37 cases of glycosuria among those examinees, and only 9 of these were diagnosed as having diabetes. The prevalence rates were thus 1.2 for glycosuria and 0.3 for diabetes, per 1,000 examinees.

These wide discrepancies in rates led Blotner4 to continue his studies which gave him more surprising results 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 in 1,383 cases; that is, 20 per 1,000 men examined. About 57 percent of these (11 per 1,000 examinees) had diabetes mellitus as judged either by clinical manifestations or, more often, by well-marked glycosuria or by the results of a glucose-tolerance test.

Blotner has explained these discrepancies to be due, in part, to age differentials-the selectees at New Orleans being somewhat younger; in part, to race differentials-one-third of these examinees being Negroes

3See footnote 1 (4), p 293.
4See footnote 1 (5), p. 293.


295

who had lower prevalence rates; and, in part, to differences in the applied diagnostic methods and criteria.

The studies just cited are regional in character. The other studies to be cited were derived from nationwide data.

The first study by the National Headquarters, Selective Service System, deals with the emergency period preceding World War II (November 1940 through September 1941); their second study deals with the period from April 1942 through December 1943. Both were sample studies.5 The first study comprised some 122,000 medical examination reports; the second was based on an approximate 20 percent sample of over 9 million men examined during this period. Both studies indicate about identical prevalence rates of diabetes mellitus for the total (white and Negro) groups: 2.9 and 2.6 per 1,000 examined registrants, during the first and second periods, respectively. The corresponding rates, by period and race, were: 3.0 and 2.9, per 1,000 white; and 1.9 and 0.8, per 1,000 Negro examinees.

The quoted Selective Service data are from tables showing prevalence rates of all defects, without distinguishing between defects of a disqualifying and of a nondisqualifying nature. Though MR (Mobilization Regulations) 1-9, War Department, 1940, 1942, 1943, and 1944, provide that diabetes mellitus, if so diagnosed is disqualifying, it is possible that these rates include some borderline cases of diabetes which would not have been considered disqualifying.

The study by Karpinos6 is limited to cases in which diabetes mellitus was either the principal or, at least, the secondary cause of disqualification. (It excludes defects of a nondisqualifying nature.)

This study covers a 14-month period from November 1943 through December 1944. It was a sample study, containing some 384,000 physical examination forms. According to this study, the disqualification rate for diabetes 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, was somewhat higher; namely, 1.3-per 1,000 total (white and Negro); 1.4-per 1,000 white, and 0.5-per 1,000 Negro examinees.

Race and age differentials-The cited studies clearly indicate race and age differences. The disqualification rates 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.


296

TABLE 52.-Disqualifications of registrants for military service due to diabetes mellitus, by age and race, World War II

[Rate expressed as number disqualified per 1,000 registrants examined]

Age


Principal disqualifying defect

Prevalence of disqualifying defect


Total

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


Total

1.20

1.32

0.45

1.28

1.40

0.53


Source: Karpinos, B. D.: Defects Among Registrants Examined for Military Service, World War II (in manuscript form). Medical Statistics Division, Office of The Surgeon General, Department of the Army. (This study covers the period from November 1943 through December 1944.)

Number disqualified for diabetes mellitus-The National Headquarters Selective Service System,7 estimated that, of the total number of registants (4,828,000) in class IV-F and in classes with "F" designation, 45,300 registrants were so classified because of endocrine diseases. It has been found from the 1943-44 Selective Service experience8 that some 42.7 percent of the endocrine diseases are cases of diabetes mellitus. Accordingly, some 19,300 registrants were seemingly classified as IV-F, as of 1 August 1945, because of diabetes mellitus. This constitutes a disqualification rate of about 1.2 per 1,000 examinees, as indicated by the rate limited to disqualifying diabetes mellitus (Karpinos, table 51).

The IV-F figures exclude examinees disqualified by the local boards, given in the IV-F table9 as "Manifestly Disqualifying Defects," without a diagnostic breakdown. It has been estimated that, if the cases disqualified by the local boards for diabetes mellitus were added to the number of registrants classified as IV-F because of this disease as a result of the induction station examinations, the adjusted number would be 23,500.10

The overall disqualification for diabetes mellitus in World War II was thus apparently 1.5 per 1,000 examinees.

7Physical Examinations of Selective Service Registrants in the Final Months of the War. Medical Statistics Bulletin No. 4, National Headquarters, Selective Service System, Washington, D.C., June 1946, app. B, table 4.
8Physical Examination 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 5.
9See footnote 7.
10The estimate of cases of diabetes mellitus among the "Manifestly Disqualifying Defects" was made by the Medical Statistics Division, Office of The Surgeon General, Department of the Army, from diagnostic data of local board disqualifications.


297

INCIDENCE, DISPOSITION, AND MORTALITY

World War I

Experience with diabetes mellitus in World War I, in the total Army with an average strength of 1,500,000 for the war period,11 is summarized in the tabulation which is to follow. During this period, from 1 April 1917 to 31 December 1919, which was before the discovery of insulin, the mortality was 14.5 percent, or one death for each seven admissions.

Summary of data:

Absolute numbers


Rate per 1,000 men
1

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 of admission.
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 of the United States and those evacuated from overseas. Actually, from July 1918 to May 1919, only 37 cases were treated.12

World War II

Essential data.-It is not the purpose of the present account to give detailed statistics on the incidence of diabetes in the Second World War, since these are to be found in complete tables elsewhere. However, enough data13 will be 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 to medical 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 strength of approximately 7 million men. The rate for 1944 was only 0.19 for approximately 8 million soldiers. The last figure 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, the incidence 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 the United 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 Service at 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 on pages 300-302 regarding diabetic coma) were furnished by the Medical Statistics Division, Office of The Surgeon General, Department of the Army.


298

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


Admissions2

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 to medical treatment facilities with a primary diagnosis of diabetes. For a summary of cases admitted with a primary diagnosis other than diabetes, see page 297.
3Figures are those of eventual death or disposition, not necessarily in the calendar year of admission.
4Approximately 11 percent of the 1945 admissions were separated for nonmedical reasons. This, for the most part, accounts for the difference between the percent of duty dispositions in 1945 and that of preceding years.

As may be seen in table 53, approximately three-fourths of the soldiers with diabetes were separated for disability.14 Most of the remaining soldiers were retained in the service, presumably because they either 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 through 1945, death occurred in a minimum of 0.5 percent to a maximum of 1.1 percent, as contrasted with 14.5 percent in World War I (p. 297). Actually, however, there were 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 with another primary diagnosis. (Conversely, in the deaths summarized in table 53, diabetes mellitus need not necessarily have been the underlying cause of deaths.) Deaths (1942-45) attributable to diabetes according to the calendar year of death without regard to the year of admission, or the original cause of admission 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 68 deaths. Although the number was small, it would appear overly large for the age group concerned.

Race.-In view of the frequently expressed opinion that diabetes is less common in Negroes than in white people, the data in table 54 are of interest. It is evident that diabetes was at least as common among Negro as among white enlisted men, taking into account the much smaller numbers of Negro soldiers.

14The percentages, shown in table 53, for those separated for disability are somewhat understated, and conversely the percentages of duty dispositions somewhat overstated, as the result of coding as duty disposition cases which were returned to duty pending separation for disability.


299

Rank.-The admission rate for officers was consistently higher than that for enlisted personnel (table 55). It should be kept in mind that among commissioned officers there was a higher percentage of older men, in whom diabetes is more common.

Age.-The influence of age upon incidence is shown in table 56. The rate per 1,000 rises from 0.09 at ages under 20 years to 1.60 for ages 45 and over.

TABLE 54.-Admissions for diabetes mellitus1 among male enlisted personnel, U.S. Army, by race and year, 1941-45

[Rate expressed as number of admissions per annum per 1,000 average strength]
[Preliminary data based on sample tabulations of individual medical records]

Year 


Total male enlisted

White2

Negro


Number

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 1,000 average strength]
[Preliminary data based on sample tabulations of individual medical records]

Year 


Total Army

Officers

Enlisted personnel


Number

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 female personnel 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 1,000 persons in 1943 was 0.15; in 1944, 0.44; and in 1945, 0.21.

Theater.-Throughout the war, the admission rate for diabetes reported from oversea theaters was appreciably less than that reported from the continental United States. Illustrative are the data for 1944


300

TABLE 56.-Admissions for diabetes mellitus,1 U.S. Army, by age, 1944

[Rate expressed as number of admissions per annum per 1,000 average strength]
[Preliminary data based on sample tabulations of individual medical records]

Age


Admission


Number

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


Total

1,463

.19


1Includes diabetic coma and diabetic gangrene.

shown in table 57. Undoubtedly, an important factor in the difference was the screening out of those unable to meet medical standards for oversea service. Another factor may have been that personnel overseas usually were 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 medical facilities for patients with diabetes was slightly under 2 months. The actual figures 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 hospital care in terms of time lost, it must be kept in mind that approximately three-fourths of the diabetics were separated from service. The time in hospital was spent not only in regulation of the diabetic condition with diet and insulin, if indicated, and in instruction to prepare the patients for return to civilian life, but also in effecting the separation itself.

DIABETIC COMA

In December 1945, the files of the Army Institute of Pathology, Washington, D.C., were examined to ascertain the number of deaths from diabetic coma reported since September 1940. Although not all of the autopsy reports for 1945 had been received, study of the available material proved to be instructive.

In all, there were 60 reported deaths from diabetic coma in Army or other personnel treated in Army hospitals. These were distributed as follows: 33 Army personnel, 1 sailor, 1 marine, 3 retired military personnel, 5 beneficiaries of Veterans' Administration, 2 Civilian Conservation Corps


301

TABLE 57.-Incidence of diabetes in the U.S. Army, by area and year, 1944

[Rate expressed as number of cases per annum per 1,000 average strength]

Age


Incidence1


Number of cases

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


Total overseas4

503

0.13


Total Army

1,803

0.23


1Includes primary and secondary diagnoses.
2Includes Alaska and Iceland.
3Includes North Africa.
4Includes 6 cases on transports.

enrollees, 10 civilian dependents, and 5 (3 German, 2 Italian) prisoners of war.

In examining the data, it soon became evident that there was a difference in the type of patient in the 33 cases grouped as Army personnel in comparison with the 27 cases otherwise grouped. Since the majority of the latter were chiefly retired military personnel, beneficiaries of the Veterans' Administration, and civilian dependents, they included persons in the older age periods. A high percentage of them had had known diabetes of variable duration, and the terminal diabetic acidosis was often associated with complications serious enough in themselves to cause death. Accordingly, the following is a commentary only on the 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; 32 were enlisted personnel and 1, an officer. The age at death ranged from 18 to 38 years, 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 United States.

Only three were patients with previously known diabetes. These soldiers entered hospitals in diabetic coma 2 days, 1 month, and 2 months,


302

respectively, after induction into the Army. Two concealed the fact that they had diabetes; an adequate history is lacking regarding the third.

Of the 33 patients, 21 died in less than 48 hours after admission to the hospital, 14 of them during the first day. The symptoms and signs in most instances were classical, as were also the laboratory findings. Of 16 patients whose mental state on admission was recorded, 8 were unconscious and 4 were drowsy. In 10 of the 33, the blood sugar was 500 mg. per 100 cc. or higher. In only 9 of the 33 cases did necropsy disclose associated conditions of importance; that is, in the great majority death occurred from uncomplicated diabetic coma. It is of note that in seven of the nine patients with complications, acute pancreatitis of varying degree was recorded by the pathologist.

Once the diagnosis was made in the Army hospital, treatment was in general reasonably adequate, although not infrequently much larger doses of insulin were indicated than were given. The chief difficulty lay in the fact that often there was considerable delay in making the diagnosis, owing chiefly to the length of time-in some instances several hours-that elapsed before analyses of urine and blood were carried out and reported. It will be recalled that 29 of the 33 deaths under consideration occurred not overseas but in the continental United States, where ample facilities should have existed, and almost invariably did exist, for prompt diagnosis and early institution of energetic treatment. Furthermore, in the age group concerned, the mortality from diabetic coma should approach zero. Accordingly, although relatively few deaths from diabetic coma occurred in World War II, even fewer might have been expected had diagnoses been more promptly made and followed 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 for sugar and acetone should be carried out immediately on admission. Such tests are simple and, if necessary, can be made easily on the ward by the physician or nurse. Furthermore, a simple and quick nitroprusside test for acetone (using, if desired, commercially prepared powder or tablets) can be carried out directly on the plasma by the physician as an aid in diagnosis. If positive, the degree of ketonemia may be used as a rough guide in determining the initial dose of insulin.

NONDIABETIC GLYCOSURIA

Persistent glycosuria of significant degree (0.5 percent or more in random specimens) was commonly considered disqualifying for military service even though not caused by diabetes. This was generally agreed to be a desirable rule even with benign, symptomless glycosurias. This seeming paradox is explained by what might be termed the "nuisance value" of such conditions. Whenever the soldier with glycosuria came under Medical Department supervision and sugar was found in the urine, the medical officer concerned-most probably unacquainted with the pa-


303

tient-was likely to decide that the condition warranted admission to the hospital for special studies. This might be repeated over and over, with inconvenience to the soldier and expense to the Government. A simple solution might have been to issue the soldier a statement to carry with him, explaining his condition. However, this would still leave the medical officer in reasonable doubt whether the presenting condition might not be different from that prevailing at the time of last study. Moreover, it is unlikely that soldiers would preserve and carry such papers over a long period of time.

Once the man was in the Army, and persistent, but nondiabetic, glycosuria of significant degree was found, decision as to disposition was, at times, difficult. In actual practice in World War II, the great majority of such men were retained in the service. As shown in table 58, no more than 16.5 percent were separated for disability in any year and usually considerably less. In general, key personnel could be, and were, retained with profit.

TABLE 58.-Summary of data for nondiabetic glycosuria1in World War II, by year, 1941-45

Year


Admissions2

Treatment

Disposition

Number


Annual rate per 1,000 average strength

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 in civilian practice, depends upon the interest, training, and experience of the individual doctor perhaps more than in most diseases. The inadequate treatment of diabetic coma in certain cases has been commented on. Since there are varying opinions both in military and civilian practice on details regarding diet, insulin, and other aspects of therapy, it became apparent in World War II that some attempt should be made to standardize methods of diagnosis and treatment. Consequently, War Department Technical Bulletin (TB MED) 168, entitled "Diabetes Mellitus," was prepared by Col. Garfield G. Duncan, MC, and released in June 1945. In this bulletin,


304

the basic principles of the diagnosis and treatment of diabetes and its complications were outlined for the guidance of medical officers.15

Certain features of the care of diabetic patients and of the military physician's responsibility for them deserve special mention at this point. First, medical officers should realize the vital importance of the education of patients. If the greatest success in treatment is to be realized in length of life and freedom from complications, patients must be taught simply, yet thoroughly, known facts regarding diabetes, its home care and the avoidance of complications. Secondly, treatment with a restricted, yet nutritionally adequate, diet and an appropriate dose of insulin must be arranged so that careful and continuous control of the disease is possible. Thirdly, the patient must be urged to seek competent medical advice at frequent and regular intervals following discharge from the service, either from a private physician or from the Veterans' Administration.

THE PLACE OF THE DIABETIC IN THE ARMY

Regulations of the Army and of mobilization boards in effect throughout World War II listed diabetes mellitus as a cause for rejection even for limited service. Altshuler16 questioned the advisability of this. He recommended that at least some individuals might be accepted to the advantage of the Armed Forces and that those accepted could perform useful duty at fixed installations in continental United States. The opposite point of view was taken by Joslin,17 who concluded:

The diabetic quota useful for military service is relatively so insignificant, the hazards which both the diabetic and the Government would undergo if they were inducted are so great and the need for their services in civilian occupations, where they would be less exposed to complications, so apparent, that the present rule to omit them from the draft appears proper.

Table 59 shows the days lost in World War II by cases admitted for diabetes during the years 1942-45.

Considered as a loss of more than 1,000 person-years, the figures in table 59 present a cogent argument in favor of maintaining the general policy of rejecting those with diabetes. It has been noted (p. 300) that much of the time spent in hospital was incidental to separation from the service of approximately three-quarters of the diabetics found.

Although the general rule is fully justified, provision should be, and has been, made for exceptions18 to it, when individuals are needed in assignments in which appropriate treatment (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 treatment have become generally available since 1945; for example, in October 1950, NPH insulin was admitted to the market, and in 1954, Lente insulin became available.
16Altshuler, S. S.: Diabetes in the Armed Services. Proc. Am. Diabetes A. (1944) 4: 111-118, 1945.
17Joslin, E. P.: Diabetes and Military Service. J.A.M.A. 121: 198-199, 16 Jan. 1943.
18For example, the Defense Department's directive of 12 January 1953 on special registrants under the "Doctors' Draft Law" (24 Dec. 1952) provides that physicians with diabetes may be accepted for service under certain conditions.


305

personnel in whom diabetes has been discovered while in the service may, with profit, be retained, especially those who are in scarce categories or those who are otherwise hard to replace.

TABLE 59.-Days lost by cases admitted for diabetes, by year, 1942-45


Year

Average duration of treatment1 (days)

Total days lost

1942

58

64,650

1943

58

106,989

1944

55

79,189

1945

72

127,350


Total

61

378,178


1Based only on cases with days lost from active duty.

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