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Chapter 8

Contents

CHAPTER VIII

Allergy

Walter L. Winkenwerder, M.D.

Definitive studies of the impact of allergic diseases on the U.S. Army were not described during or immediately after the First World War, and it was not until 1941 that Vaughan1 summarized the data on asthma observed during the World War I period. Vaughan emphasized asthma's importance as a cause of rejection and disability and its cost to the Government for pensions eventually granted to personnel retired from military service. Asthma was then the only allergic condition particularized in the diagnostic classification of diseases; hay fever, when so reported, was coded to a residual category of lung conditions, but if reported as any form of rhinitis it would have been classified as "rhinitis (cause not stated)."

During World War II, allergic diseases, especially asthma, caused a significant amount of disability in the Army. Knowledge concerning these diseases had accumulated rapidly between the two conflicts, and soon after mobilization many hospitals formed allergy clinics and promptly instituted formal instruction in examination, diagnosis, and therapy; these hospitals and, later, those in oversea areas submitted studies and reports on various allergic disturbances. An analysis of these data and of the comprehensive statistics compiled by the Medical Statistics Division, Office of The Surgeon General, form the basis of this chapter. The statistics illustrate the total load the allergic diseases 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 for Military Service Because of Allergic Diseases

Statistics on disqualifications for military service because of allergic diseases are presented in tables 25 and 26. They were taken from several 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.


172

TABLE 25.-Disqualifications for military service due to allergic diseases, World War II

[Rate expressed as number disqualified per 1,000 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 Allergic States in Selectees. J. Allergy 14: 386-392, July 1943. (Note that the rates are not given in the study. They were derived from the specified number of disqualified, by diagnosis, and the number examined.)
2Rowntree, L. G., McGill, K. H., and Edwards, T. I.: Causes of 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 for Military Service, World War II (in manuscript form). Medical Statistics Division, Office of The Surgeon General, U.S. Army.

TABLE 26.-Disqualifications for military service due to allergic diseases, and prevalence of these disqualifying diseases by age, World War II, (November 1943 through December 1944)

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

Diagnosis


All ages
 (18-37)

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


Total

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


Total

6.64

4.63

6.05

7.20

8.05

8.84

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, U.S. Army.

The data by Hyde and Kingsley (table 25) deal with disqualifications for allergic diseases among the first 60,000 selective service registrants examined at the Boston Recruiting and Induction Station during the winter, spring, and summer of 1942. The age range was from 21 through 24 for the first 6,000 examinees and from 21 through 44 for the remaining


173

examinees. These data indicate that allergic diseases were the 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, the allergic disease was the secondary cause of disqualification, implying that the disease was of sufficient severity to disqualify the examinee were it not for a more 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 and secondary cause). The corresponding disqualification rate for asthma was 7.3 per 1,000 examinees. It should be noted that these total rates include certain diseases (for example, allergic dermatitis and atopic eczema) which were not included among the allergic diseases in the other studies. The disqualifications for these additional diagnoses, however, were negligible.

Hyde and Kingsley were primarily interested in relating the disqualifications for allergic diseases to socioeconomic factors. They found on the basis of their "desirability" factors, such as medical care, education, and population density, that the prevalence of allergic diseases was constant in many socioeconomic backgrounds, although a relatively higher rate was noted for semirural communities and a relatively lower rate for tenement districts.

The study by Rowntree, McGill, and Edwards (table 25) deals with causes of disqualification among 18- and 19-year old selective service registrants. It covers a 3-month period, from December 1942 through February 1943. It was a sample study which included some 45,600 physical examination forms. The disqualification rates were computed by the authors as 4.5 per 1,000 examinees for all allergic diseases and as 3.7 for asthma alone. These rates are lower than those reported by Hyde and Kingsley because the study by Rowntree and his associates comprised a younger population. (Compare these rates with those given in table 26 for the 18-19 age group.)

The study by Karpinos (tables 25 and 26) covers a 14-month period, from November 1943 through December 1944. It was also a sample study which included some 147,000 physical examination forms of medically disqualified registrants. (It comprised altogether 384,000 physical examination forms, by including those of qualified examinees.)

When limited to the primary disqualification cause, Karpinos indicates that the disqualification rate for allergic diseases was 5.6 per 1,000 examinees, with asthma having a rate of 5.3. The total prevalence of disqualifying allergic diseases (including both primary and secondary diagnoses) was computed as 6.6, and that for asthma as 6.2, per 1,000 examinees. (Rowntree and his coworkers report a total prevalence of 10.6 for allergic diseases: For asthma 5.3 and for vasomotor rhinitis 5.3. These rates, however, include both disqualifying and nondisqualifying


174

diseases. In other words, the rates include men accepted with allergic diseases.)

As indicated in table 26, disqualification and prevalence rates 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 was about 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 indicate the following:

1. About 6 per 1,000 examinees were disqualified for allergic diseases and about 7 per 1,000 examinees had a disqualifying allergic disease, asthma being the main disqualifying cause.3 That many registrants with allergic diseases were knowingly taken into the military service, while others with allergic disease were apparently not properly screened out (representing about 1 percent of 1,000 examined), presented a problem in the Army, 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 a relatively small percentage of the disqualifications for all causes: 1.8 percent of the disqualification for all causes (total disqualification rate 358.0 per 1,000 examinees), as reported by Hyde and Kingsley; 1.8 percent (total disqualification rate 253.3 per 1,000 examinees), as reported by Rowntree and his associates; and 1.6 percent (total disqualification rate 353.6 per 1,000 examinees), as reported by Karpinos.

Hospital Admissions for Allergic Conditions

The number of admissions to hospitals and quarters for allergic conditions for the years 1942-45, inclusive, is given in table 27 and for 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 with allergic conditions were admitted to hospitals in the United States and in oversea theaters, in order of frequency as follows: With asthma, 87,630; with dermatitis venenata, 75,371; with urticaria, 29,811; with allergic dermatitis and other allergic disorders, 28,259; with hay fever, 15,254; with angioneurotic edema, 7,154; and with eczema, 5,201. All the allergic states were comparatively more frequent in the United States than in oversea areas, but the relative incidence overseas increased sharply after 1942 in the four major oversea areas-the European theater, the Mediterranean theater, the Southwest Pacific Area, and the Pacific Ocean Area.

3These disqualification rates might have been higher if examining physicians had adhered strictly to the provisions of MR (Mobilization Regulations) 1-9, "Standards of Physical Examination During Mobilization," 15 October 1942, as applied to allergic states.


175

TABLE 27.-Admissions to hospitals and quarters for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1942-45

[Preliminary data based on sample tabulations of 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

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 were classified as "allergic dermatitis," which included cases 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.

This trend is consistent with the relatively increased number of troops serving overseas during 1943-45 and with the well-recognized frequency with which allergic states developed or were aggravated during oversea duty. Asthma and dermatitis venenata represented the chief causes for hospitalization throughout the war period, except for the marked increase in the category "Allergic Dermatitis and Certain Other Allergic Disorders" during 1944 and 1945.

The number of admissions for urticaria seems high in view of its relatively low incidence noted in the individual studies on allergic diseases reported both in the United States and from oversea theaters (see p. 192). Allergic dermatitis and the miscellaneous allergic conditions included in the residual category increased sharply during and after 1944 while dermatitis venenata decreased, especially in 1945. These shifts may, in part, be related to changes in coding procedures and codes which were introduced beginning with the 1944 coding.

The rate of admissions per year per 1,000 average strength for allergic conditions 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

TABLE 28.-Admissions to hospitals and quarters for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1942

[Preliminary data based on sample tabulations of 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

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


Total overseas2

3,962

1,871

127

770

129

192

713

160


Total Army

32,562

12,289

800

13,456

492

862

3,890

773

1About four-fifths of the admissions shown in this category were classified as "allergic dermatitis," which included cases 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.

1945), the admission-rate data are given in tables 33, 34, 35, and 36 respectively. Asthma, dermatitis venenata, and urticaria represent the highest rates, in the order given. The higher rates in tropical theaters, namely, the China-Burma-India and the Pacific Ocean and Southwest Pacific Areas, probably reflect the unfavorable effect of tropical environment on allergic conditions. It is of interest, however, that the rate for asthma in the Latin American theater closely approximates that for the tropical areas mentioned and that the highest rates for hay fever were in the Pacific Ocean Area and in the Mediterranean theater and for angioneurotic edema in the Middle East. Definitive studies on asthma were not reported from the Latin American theater to explain its high rate; in North Africa, dust and pollen were prevalent and the considerable daily alterations in temperature, with warm days and cool nights, were reported to be of etiological importance. Why the Middle East had the highest rates for urticaria and angioneurotic edema is not explained by statistics nor by individual studies on allergic states reported from this theater. Again, the high rate for allergic dermatitis in the Southwest


177

TABLE 29.-Admissions to hospitals and quarters for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1943

[Preliminary data based on sample tabulations of 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

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


Total overseas2

13,224

5,890

745

3,055

529

551

2,041

413


Total Army

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 classified as "allergic dermatitis," which included cases 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.

Pacific probably represents the effect of tropical environment with its high humidity.

Disposition of Allergic Patients

Table 37 presents the total numbers and the rates, per year per 1,000 average strength, of disability separations and retirements due to allergic diseases for the years 1942-45, inclusive.

During the 4-year period, a total of 46,607 allergic patients were discharged or retired for disability. Asthma accounted for 38,575 (82.7 percent) of the total number; hay fever and allergic dermatitis and certain other allergic disorders, combined, for 12.9 percent; and the other categories, only insignificant totals. It is surprising how few disability discharges were caused by dermatitis venenata, considering the large number of cases (75,371) observed over the war period.

A comparison of admissions and disability separations, for selected 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

TABLE 30.-Admissions to hospitals and quarters for selected diagnotic categories of allergic conditions in the U.S. Army, by area or theater and year, 1944.

[Preliminary data based on sample tabulations of 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 admissions shown in this category were classified as "allergic dermatitis," which included cases 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.

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 admissions to hospital for asthma, received disability separations strikingly illustrates the 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 the hay fever was due to seasonal or to the more serious perennial form of allergic rhinitis is unknown. That only 454 (0.6 percent) of the 75,371 admissions for dermatitis venenata were separated from service illustrates the benign nature of this form of contact dermatitis; whereas, allergic dermatitis and certain other allergic disorders combined were second only to asthma as the basis for disability separations from the service.

CLINICAL DATA

The statistical material just presented conveys, only insofar as statistics can, some concept of the total "load" that the allergic diseases imposed


179

TABLE 31.-Admissions to hospitals and quarters for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1945

[Preliminary data based on sample tabulations of 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

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


Total overseas2

38,050

8,675

2,505

4,950

1,240

1,295

6,225

13,160


Total Army

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 classified as "allergic dermatitis," which included cases 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.

upon all branches of the military service, including the Medical Corps. A series of clinical reports by medical officers supplements the statistical data, in many instances specifying the etiology, the results of treatment, and the disposition in selected series of patients.

All reports emphasize that-

1. Of all persons with asthma and hay fever, observed in clinic or hospital or both, at least 50 percent gave an appropriate history or actually had symptoms at the time of entering the military service.

2. Many persons giving a history or having mild symptoms of asthma or hay fever on entry into the service were able, with or without appropriate treatment, to remain on duty in the United States, although aggravation of symptoms frequently developed when such persons were sent to oversea theaters.

3. Desensitization of extrinsic asthma and allergic rhinitis when indicated was relatively more successful in the United States than in oversea areas, where retention of only a small percentage of patients so treated was found possible.


180

TABLE 32.-Admission rates for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1942-45

[Preliminary data based on sample tabulations of 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

11.05

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


Total overseas2

7.98

2.40

0.48

1.48

0.28

0.31

1.23

1.80


Total Army

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 category were classified as "allergic dermatitis," which included cases 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.

4. Allergic states other than asthma, dermatitis venenata, and hay fever, namely, atopic eczema, urticaria, and angioneurotic edema, were relatively unimportant causes of disability.

During the period of partial mobilization before war was declared, special clinics or services for allergic conditions were not available in either station or general hospitals, and medical officers experienced in allergy were scarce. The need became evident with the rapid increase of the Armed Forces. In the Fourth Service Command, the organization of comprehensive facilities for the diagnosis and treatment of allergic diseases under the supervision of Col. Sanford W. French, MC, was started in March 1942. Formal instruction for medical officers was organized, and a central laboratory was established. At this laboratory, extracts for skin testing and desensitization were prepared and dispensed to the 89 individual allergy clinics eventually organized in this command and, subsequently, to many station and general hospitals in the other eight service commands.


181

TABLE 33.-Admission rates for selected diagnostic categories of allergic conditions in the U.S.  Army, by area or theater and year, 1942

[Preliminary data based on sample tabulations of 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

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


Total overseas2

6.76

3.19

0.22

1.31

0.22

0.33

1.22

0.27


Total Army

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 category were classified as "allergic dermatitis," which included cases 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.

French and Halpin,4 in 1944, compiled data from 67 of the 89 clinics (including 28 Army Air Force hospitals) for the period of one year ending in November 1943. These data provide an excellent picture of the high 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 were 6,842 with dermatitis venenata. In the 67 clinics selected for study, because they had been in operation longer than the rest, there were 25,204 allergic patients, of whom 1,785 were civilian dependents of servicemen. Among them, there were 4,573 with uncomplicated seasonal hay fever, of whom an estimated 85 percent were under desensitization therapy. The diagnosis of seasonal bronchial asthma was made in 946 patients; of seasonal hay fever accompanied by asthma, in 1,384 patients. Of the 7,261 patients with perennial bronchial asthma, 1,903 exhibited seasonal aggravation due to pollen. Perennial allergic rhinitis accounted for 3,831 patients, of whom 1,105 noted increased severity of symptoms during 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

TABLE 34.-Admission rates for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1943

[Preliminary data based on sample tabulations of 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


Total overseas2

7.83

3.49

0.44

1.81

0.31

0.33

1.21

0.24


Total Army

10.76

4.51

0.65

3.84

0.17

0.28

1.07

0.24

1About four-fifths of the admissions shown in this category were classified as "allergic dermatitis," which included cases 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.

these few figures, covering a 1-year period, it thus appears that pollen sensitivity, manifested by rhinitis or asthma or both involved 9,911 of 25,204 patients. Considering the geographic location of the Fourth Service Command, ragweed pollen, as would be anticipated, was the most important of the antigens; dust, feathers, and other environmental antigens were less important. Infection of the respiratory tract, including the paranasal sinuses, was a minor factor in ambulatory patients but was more evident in hospitals that received the more persistent and refractory cases of asthma and rhinitis. Urticaria of the acute and chronic type was noted in 1,644 cases in the 67 clinics. Gastrointestinal allergy was noted in 255 and food allergy in 1,565 patients.

Information derived from detailed studies made in Army installations has been summarized for presentation in the paragraphs which are to follow.

Asthma

History.-Careful study of clinical records revealed that at least 50 percent of the patients observed in hospitals or dispensaries had symptoms


183

TABLE 35.-Admission rates for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1944

[Preliminary data based on sample tabulations of 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

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


Total overseas2

7.98

2.46

0.47

1.87

0.28

0.33

1.10

1.47


Total Army

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 included cases 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 the respiratory 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

TABLE 36.-Admission rates for selected diagnostic categories of allergic conditions in the U.S. Army, by area or theater and year, 1945

[Preliminary data based on sample tabulations of 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

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


Total overseas2

8.19

1.87

0.54

1.07

0.27

0.28

1.34

2.82


Total Army

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 classified as "allergic dermatitis," which included cases 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.

TABLE 37.-Disability separations and retirements due to selected allergic disorders, U.S. Army, 1942-451

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

Cause of separation


1942-45

1942

1943

1944

1945


Number

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

TABLE 38.-Comparison of admissions and disability separations, for selected allergic diseases, U.S. Army, 1942-45, inclusive

Cause of admission or separation 

Number of 
admissions


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 areas revealed that aggravation or recurrence developed usually in a shorter period of time, in terms of tropical service, than the initial or primary attack in individuals who had no previous history of asthma.7 Leopold,8 in his report, questioned the significance of pollens and molds in the causation of asthma in the Tropics. He had studied 200 asthmatic patients of whom 91.5 percent had served in the Tropics, mostly in the Pacific Ocean Area. In this series of cases, the onset of initial attacks (occurring in 31.5 percent) was ascribed to factors of climate in 79.5 percent, to exposure to dust in 16 percent, and to infection in 4.5 percent. In recurrent attacks, climate, alone or in combination, was a precipitating factor in 88 percent; dust, alone or in combination, in 84 percent; and infections of the respiratory tract, in 24 percent. The botanist O. C. Durham, having been consulted, observed that tropical areas do not have the flora nor the climate conducive to the development or spread of airborne pollen and fungus. Others might object that molds grow luxuriantly in tropical islands or suggest9 that the pollens of grasses, rice, and sugarcane sometimes play a part. Leopold concluded that the hot humid climate of the Tropics was the principal determining factor in his cases. At all events, irrespective of the cause or causes, tropical service appears to be contraindicated for individuals giving a history or presenting symptoms of asthma.

Infections of the respiratory tract were reported by several authors 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 Compared to 50 Asthmatics Stationed in United States. Ann. Allergy 4: 391-396, September-October 1946.


186

present in chronic form in many of the patients with persistent symptoms.10 Actually, the incidence of infection varied considerably. In Leopold's series of 200 patients, 25 were subjected to bronchoscopic examination, but only 2 showed findings that could be interpreted as evidence of infection; a comparatively low percentage in any group of unselected patients with asthma. By contrast, Zoss11 and his coworkers, who were primarily interested in infection, reported on the bronchoscopic findings in 250 patients with asthma studied at the Finney General Hospital, Ga. Of the 250 patients, 206 had seen active duty overseas. Of the oversea group, 71 had developed asthma in the oversea area, and in 117 symptoms were intensified while overseas. Of the 250 cases, 20 percent were considered to be the extrinsic type, due to environmental and atmospheric antigens; 40 percent were considered to be the intrinsic type; and in 40 percent, the etiology was obscure. Of the total number of patients, 50 percent had chronic sinus infection. Bronchoscopic examination revealed evidence of chronic bronchitis in 220, suppurative in 123, and nonsuppurative in 97. Only in four were the mucosal changes considered typically allergic in appearance. The incidence of infection both in the sinuses and in the bronchial tree, considering the comparative youth of this series, is rather high.

Study of the cause of asthma based on bronchoscopic findings may, however, be inaccurate and misleading. The observations cited might well have had a different interpretation by other observers, for it is known that changes in the bronchial mucosa in many alleged infective asthmatic patients may be due primarily to hypersensitivity to inhaled allergens, such as dust and pollen, upon which the changes related to infection are merely superimposed. Hampton and Rand,12 however, also found a rather high incidence of infection at the Army Air Forces Regional Hospital of the San Antonio Aviation Cadet Center. Of 186 patients with asthma, chronic infection alone or in combination with inhalant or food hypersensitivity or both was found in 141; acute infections precipitated attacks in 50. That the incidence of infection varied in different theaters is illustrated in a series of 209 cases of asthma studied in a general hospital in Australia,13 of which only 14 percent were considered related to infection. Furthermore, in a series of 192 cases reported by Young, Cook, and Kawasake14 at the Tripler General Hospital in Hawaii, the great majority of cases were considered to be due to pollen and dust, with infection a minor factor.

10Rosen, F. L.: Bronchial Asthma in Young Male Adult; Study of 100 Hospitalized Patients in Army General Hospital, With Special Reference to Nasal Symptoms and Findings. Ann. Allergy 4: 247-260, July-August 1946.
11Zoss, A., Neidlinger, W. J., and Read, H. S.: Survey of Bronchial Asthma in Soldiers; Bronchoscopic Findings and Incidence of Respiratory Infection. J. Allergy 17: 87-96, March 1946.
12Hampton, S. F., and Rand, H.: Problem of Allergy at Army Air Forces Hospital; Respiratory Allergy (Hay Fever, Vasomotor Rhinitis and Bronchial Asthma). J. Allergy 15: 355-368, September 1944.
13Winkenwerder, W. L.: Asthma-As Observed in Overseas General Hospital in Southwest Pacific Area-With Special Reference to 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 in the etiology of asthma was emphasized by Fishman15 in a study of 100 patients returned from the European theater. Prolonged exposure to dampness and dust, to undue exertion and fatigue, and to infections were cited as significant causes. "Few patients would admit that fear was a precipitating or aggravating factor, but many felt that worry facilitated the onset of symptoms." A special group of 16 patients, 4 officers and 12 enlisted personnel, none of whom had had asthma before going overseas, was returned to the United States with the diagnosis of asthma plus neuropsychiatric disease. The latter diagnosis had been made in each case by the neuropsychiatric consultant. In the 16 patients, pollen and other inhalant antigens and undue fatigue 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 symptoms during the period of precombat preparation. In three patients, asthma developed as part of a generalized functional disorder after specific mental insults. All 16 patients improved on return to the United States.

In contrast, Leopold (p. 185), in his report, stated: "The importance of the rôle of psychogenic factors in the etiology of asthma was considered. Many of these patients were in actual combat, underwent air bombardment, slept in wet clothes in wet foxholes, and faced the hardships of service in the jungles." The patients in his series manifesting anxiety symptoms were studied by the psychiatrist and in no instance were emotional factors found to be of significance. Other observers, including the author of this chapter, would disagree with such an all-inclusive denial that the psyche modifies the asthmatic state; the anxiety symptoms studied in Leopold's series of patients may not represent the peculiar emotional stress recognized by many authorities as aggravating asthma. Zanfagna,16 in a study of 100 cases in a station hospital, concluded that psychic factors play an important part in the production of attacks in predisposed persons. On the other hand, Rosen17 points out that the asthmatic patient is sometimes unjustly tagged as being psychoneurotic.

Disposition of patients.-Of the several series of patients with asthma studied in detail, varying percentages were discharged from service or assigned to duty, usually of a limited nature, in the United States and in oversea areas. Of the series reported by French and Halpin (p. 181) from the Fourth Service Command, 8,139 (32.3 percent) were admitted to hospital during a 12-month period. Of these, only 602 had uncomplicated hay fever; 5,447 had bronchial asthma. Among 3,742 allergic patients discharged for disability, 3,231 had bronchial asthma. A total of 10,573 patients with various other allergies were retained in the service-appropriate

15Fishman, A. P.: Etiologic Evaluation of Asthma in 100 Cases 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 of infection, and desensitization therapy, was considered responsible in great part for returning this number to duty. The overwhelming majority of patients with asthma originating or aggravated overseas were eventually returned to the United States. In a general hospital in Australia,18 a total of 352 cases of asthma were admitted to the hospital. These represented 1.2 percent of total admissions over a 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 hospital was 12,260 days, an average of 58.6 days per patient. Of 2,980 patients returned to 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 hope of retaining men overseas even for limited service, was relatively unsuccessful-only 13 of 38 patients so treated were returned to duty status; 339 of the 352 were eventually evacuated to the United States.

There are conflicting data on the clinical course and the disposition of patients with asthma after their return to the Zone of Interior. The great majority of such patients after periods of observation and treatment were discharged from service, although Alford19 and Leider20 emphasized that in their series patients with asthma originating or aggravated overseas improved rapidly after evacuation to the United States and that the majority of them were returned to duty. In Leopold's series of 200, on the other hand, 176 patients including 125 whose symptoms improved were eventually given disability discharges.

The question of the frequency of recurrence in military service of childhood asthma with a history of remission for some years was commented on only by Alford. In his series, relapse of childhood asthma was infrequent. Patients with chronic or recurrent asthma, whether beginning in childhood 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 order being the more important agents in the United States. A summary of pollen distribution throughout the world was given by Blank and Levitt.22 Desensitization treatment was reported to be feasible and effective in the United States,23 but actual statistical data to support this statement are not available. Desensitization overseas was rarely practicable, owing to frequent change of station and lack of appropriate facilities. Even in fixed installations in rear areas, such treatment was relatively ineffective, although a few patients so treated were maintained on duty status.24 It was well known that large numbers of men in various oversea areas experienced mild symptoms of hay fever but were not disabled thereby and served throughout the war. It was the general opinion of most authors that, unless symptoms were severe and prolonged, seasonal hay fever was not incompatible with military service in the United States where adequate observation was possible and treatment was readily available, but assignment to duty overseas, especially in tropical areas where, as in cases of asthma, aggravation or recurrence was frequent, was considered inadvisable. Furthermore, service in combat units may be very hazardous not only to the person with hay fever but also to others in the unit. Golz and Kalisch,25 in a statistical analysis of allergic diseases observed at several station and general hospitals in the Mediterranean theater, cited an instance where the presence of men on secret night maneuvers was made known to enemy troops by the irrepressible sneezing of one soldier, resulting in prompt enemy fire.26

The question of the effects of flying and of the accompanying atmospheric pressure changes on allergic rhinitis (hay fever) was commented on in the study by Hampton and Rand (p. 186) of allergic diseases at the Army Air Forces Regional Hospital in San Antonio. Although adequately controlled experiments were not carried out, it was the general opinion of several observers that rapid changes in atmospheric pressure did not aggravate symptoms of allergic rhinitis nor induce aerosinusitis or pain in the middle ear. This view received some support in the field; for example, Golz and Kalisch cite the experience of the 5th Bomb Wing of the Fifteenth U.S. Army Air Force. Of approximately 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 not modified, and symptoms actually subsided during flight.

Perennial allergic rhinitis.-Perennial allergic rhinitis due to environmental antigens other than pollens was not reported on in detail. French and

22See footnote 21 (3), p. 188.
23
See 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. The nocturnal sneezing and wheezing of one of our men occupying a foxhole with two comrades on a tropical island in the South Pacific disclosed their position and brought on an enemy attack. The soldier's friends very promptly sent him to the rear with orders not to return.-W. L. W.


190

Halpin (p. 181) reported 3,831 patients with this diagnosis in their series of a total of 25,204 persons with allergic diseases and, of these, 1,105 noted increased severity of symptoms during the pollen seasons. Specific antigens other than pollen were not mentioned.

In Australia, the author personally observed and studied, in some detail, 82 unreported cases of perennial allergic rhinitis. Of these, 40 had developed before entry into service. Based on history and positive skin reactions to significant antigens, 38 were considered to be allergic in origin, 20 were associated with infection, and in 24 possible causes were not definable. Nine cases developed symptoms in the Tropics; preexisting symptoms in 18 were aggravated by tropical duty and in 4, were not. Nasal polyps were found in five, sinusitis in four, and adenoidal infection in three; significant positive skin reactions in this group were obtained in only 33 percent as compared to almost 100 percent of the allergic group. Headaches, attributed to edema of the nasal mucosa and sinuses, were frequent complications in both the infective and allergic types and occurred in 18 cases, particularly in the Tropics; in several instances, this was the chief basis for admission to hospital. All were returned to the Zone of Interior except 10 of the allergic group, who were desensitized with apparent success; of these, 4 were eventually assigned to limited nontropical service and the others to full duty.

That allergic rhinitis per se does not predispose to the development of aerosinusitis or aero-otitis media makes it important to differentiate chronic or recurring rhinitis due to allergic factors from rhinitis associated with infection in the upper respiratory tract, in the sinuses, and, particularly, in adenoid tissue of the nasopharynx which frequently impinges on and causes obstruction of the eustachian tubes. Symptoms of such a condition may closely simulate chronic allergic rhinitis, but specific therapy differs in the two conditions and depends primarily on an accurate diagnosis. On the basis of prewar studies, Crowe and Baylor27 instituted the principle of radon therapy for chronic adenoidal infection not amenable to surgical excision. This method of treatment was introduced by Bordley28 in the South Pacific Area in 1942 for the treatment of aero-otitis media, occurring frequently in aviators in whom such infections were found on nasopharyngoscopic examination. Eventually, this form of treatment was employed by the Army Air Forces in other theaters of operations.

Atopic Eczema

Although eczema of the atopic type was referred to by several authors, the question 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.


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of this form of hypersensitivity is not possible based on the published reports, which were primarily statistical.

Urticaria and Angioneurotic Edema

Again, comprehensive etiologic studies of urticaria and angioneurotic edema were not reported. The acute and chronic type of urticaria was noted in 1,644 patients 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 the possibility that the broad immunization program instituted by the military service was the inciting stimulus in many instances. Golz and Kalisch (p. 189) list 91 patients with urticaria and angioneurotic edema observed in the Mediterranean theater in 1944, but in only 3 of these cases was etiology referred to. These authors described three penicillin reactions resembling states like serum disease marked by urticaria and dermatitis, this being the only reference to penicillin hypersensitivity reactions in the various studies and reports analyzed herein. Gutmann29 reported one patient in whom the urticaria was presumably due to drinking chlorinated water, and Golz30 studied one soldier in whom urticaria was associated with recurrent tertian malarial infection, the lesions recurring subsequently a year later when relapse of infection developed. Although the causal relationship in the latter instance is very 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 of interest that urticaria and angioneurotic edema were relatively common in the acute phase of schistosomiasis32 but did not occur in early filariasis33 although sensitization to specific antigen develops and has been demonstrated in both diseases. Considering the large number of soldiers serving in tropical areas in World War II, one would have anticipated more than one report of a single instance of heat allergy manifested by urticaria. Peters and Silverman34 studied one soldier in whom the lesions were brought out by elevated environmental temperature and exercise, and on the basis of considerable experimentation they postulated that the mechanism was more related to some abnormal response of both acetylcholine 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 the cause of urticaria in this soldier, it was a rare occurrence, for descriptions of reactions similar to that reported by Golz have not been reported nor called to my attention despite the thousands of cases of malarial infection 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; Clinical Study of 337 Cases With Preliminary Report on Results of Treatment With Fuadin in 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 in Mechanism 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 to heat intolerance which developed in the Tropics, but no experimental studies were possible. In general, the total data on urticaria and angioneurotic edema are 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 the statistics on allergic diseases by the Medical Statistics Division, Office of The Surgeon General. As an allergic manifestation, it ranked next to asthma in number of hospital admissions (table 38), but contrary to asthma, 99.4 percent of admissions were returned to duty, indicating in general a self-limited condition, responding favorably to treatment.

SUMMARY AND CONCLUSIONS

Of the allergic diseases, asthma, hay fever (vasomotor rhinitis) and allergic dermatitis and certain other allergic disorders were important causes of disability in World War II.

Disqualifications.-Data on disqualifications of selective service registrants for military service in World War II indicate that some 6 per 1,000 examinees were disqualified for allergic diseases. The main diagnosis was asthma; about 5 per 1,000 examinees were disqualified for this disease. In World War II, the disqualifications for allergic diseases comprised about 1.6 percent of the disqualifications for all causes-administrative, mental, and medical.

Admissions to hospital.-There were 248,680 admissions for allergic diseases in the U.S. Army for the years 1942-45, inclusive, as follows: For asthma, 87,630; for dermatitis venenata, 75,371; for urticaria, 29,811; for hay fever, 15,254; for angioneurotic edema, 7,154; for eczema, 5,201; and for allergic dermatitis and certain other allergic disorders, 28,259. The admission rate for allergic conditions in the total Army varied from 9.06 to 10.76 per year per 1,000 average strength during the 4 years. The rate was slightly but definitely higher in the China-Burma-India, the Southwest Pacific, and the Pacific Ocean Area theaters.

Disposition.-Of patients admitted to hospitals for allergic conditions, 81.3 percent were returned to duty, and 18.7 percent were given disability discharges or were retired. In the second category, a total of 46,607 persons were released from the Army for disability due to allergic disorders during 1942-45, inclusive: For asthma, 38,575, or 1.51 per year per 1,000 average strength; for hay fever, 1,938, or 0.08 per 1,000; for dermatitis venenata, 454, or 0.02 per 1,000; for eczema, 448, or 0.02 per 1,000; for angioneurotic edema, 388, or 0.02 per 1,000; for urticaria, 948, or 0.04 per 1,000; 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 allergic conditions observed in hospitals in the United States and oversea theaters indicate that-

1. At least 50 percent of the allergic conditions, notably asthma and hay fever, observed in military service existed before entry into the service.

2. The relapse rate of asthma was high, particularly in personnel serving overseas and especially in tropical areas where dust, high humidity, and infection were considered the chief aggravating conditions.

3. Allergic rhinitis is not disqualifying for military service, but it should disqualify the individual soldier for combat duty.

4. The disability resulting from allergic diseases other than asthma, allergic rhinitis, dermatitis venenata, and allergic dermatitis was insignificant, and unless the condition is severe and protracted, military service is not contraindicated.

5. Contrary to MR (Mobilization Regulations) 1-9, October 1942, selective service registrants presenting asthma or a history of asthma were accepted for military service. The difficult question confronting medical examiners in induction centers was how to assess the severity of the particular allergic syndrome presented or, if evidence of disease was lacking, how much significance to give to a history of allergic symptoms such as hay fever and asthma. Frequently, this history was not supported by adequate records or, if symptoms and signs of asthma and hay fever were in remission, many young men intentionally omitted mention of them in order to enter the military services. In many instances, however, selectees and volunteers presenting mild symptoms or signs of asthma, not disturbing in their civilian environment, were accepted for service. The number of potential candidates for disability discharges or retirements for allergic diseases, in particular for asthma, the most important allergic syndrome, could be appreciably reduced in the future by more adequate examinations and by stricter adherence to regulations prescribing standards for physical fitness.

 

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