Communicable Diseases, Table of Contents
CHAPTER III
TUBERCULOSIS
ORGANIZATION FOR ELIMINATING THE TUBERCULOUS FROM THE ARMY
Soon after the United States entered into the war againstGermany it was decided by the Surgeon General that the United States Army shouldbe reexamined for tuberculosis by the best available experts.1The chief reason for this decision was the obvious importance, in view of thedifficulties of transportation, of allowing no soldiers to be sent abroad whowere doomed in advance to an early breakdown. The fact, however, had beenalleged and had been given wide publicity, that the French Army had sufferedsevere losses from tuberculosis2 and, as it wasgenerally admitted that that disease was rife among the French civil population,the fear that our Army would suffer in the same way as the French Army was feltby many of the medical profession and of the laity. Whether or not this fear waswell founded, it would evidently be advantageous, as a matter of policy, to givethe public to understand that every possible precaution would be taken tosafeguard our Army against tuberculosis, and this consideration was no doubt ofweight in the mind of the Surgeon General. The supervision of the accomplishmentof these measures was to be the function of the division of internal medicine,Surgeon General's Office. This division was established in the summer of 1917,the tuberculosis section of that division entering upon its task on June 6,1917.3
The first question to be decided was the manner in which theexpert examinations should be made. The advice given by a committee ofprominent members of the National Association for the Study and Prevention ofTuberculosisb in its report to the medical committee of theadvisory board of the Council of National Defense, was that the experts shouldact as consultants, examining such cases as the medical officers of the Armymight refer to them.4 This methodpresupposed painstaking and efficient examinations by examiners competent todetect the cases suspicious of tuberculosis. It afforded no guaranty thatpersons with manifest tuberculosis would not be admitted into the Army as theresult of hurried or otherwise imperfect examination. Under the circumstances,however, in which our Army was hastily collected, it was to be expected thatcases of tuberculosis would be overlooked. To overcome this it was necessarythat every man should be reexamined, and, moreover, the examining should be donepromptly in order that the claim might not be made with success that suchchronic lung affections as were discovered were the result of military servicethus permitting the pensioning of the individuals concerned. Therefore, it wasat once decided that the examiners should pass upon the lungs of every man whohad been admitted to the military service, notwithstanding the staggeringmagnitude of the total of examinations for which this decision called.
aUnless otherwise stated,all figures for the World War period are derived from sick and wounded reportssent to the Surgeon General.-Ed.
bThe members of this committee were Dr. Herman Biggs, Dr. G.M. Kober, and Dr. Charles J. Hatfield.
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Medical officers of the Regular Army who were qualified forthis work were already engaged with even more important duties, chiefly of anadministrative character, and could not be spared; while the Medical Reserveofficers already commissioned who were competent internists had been assigned tomedical organizations from which they could not be withdrawn, as a rule, withoutimpairment of the efficiency of these organizations. It was necessary,therefore, to resort to civilian physicians, and the plan was adopted of callingupon prominent experts in internal medicine in each of the largest medicalcenters to recommend candidates for this work.5
A difficulty was experienced at the outset because the dutyof the examiner was to be in the United States, and most ambitious and activemen desired service abroad. It was soon seen that the examiners must be chieflyrecruited from the class who were physically unfit for the arduous fieldservice. But with this class the difficulty at once arose that the menespecially interested in tuberculosis work had themselves had the disease, afact which under ordinary conditions would debar them from admission into theArmy. It became necessary to waive this fact for duty in the United Statessolely in connection with tuberculosis work and to accept applicants otherwisefitted for the duty contemplated for them whose physical condition warrantedservice of this kind.6 This coursemet with objections on the part of the officer in charge of the personneldivision, Surgeon General's Office, who apprehended that it would be advanced asa precedent by the numerous physicians who besought the War Department forcommissions in spite of physical defects. These objections were met by theargument that the tuberculosis examiners being a special and limited class, tobe used for a specific purpose, their cases were not analogous to those of menwith disabilities who sought general service as medical officers and shouldtherefore be capable of enduring hardship in the field. These variousdifficulties created an enormous correspondence. At one time it seemed as if theplan must fail because examiners in sufficient numbers were not to be found.However, slowly, much too slowly, a corps of examiners was commissioned and setat work, the effort being to reach first the newly appointed officers and thetroops about to sail for Europe.
Examinations did not begin until July, 1917. By an unnumberedcircular of the War Department, dated July 16, 1917, it was provided that theexaminers for tuberculosis should be organized into boards.7The size of the individual boards was governed by the size of the commandexamined, but no board was to consist of less than three examiners. From theexaminers, disability boards were appointed in order that the necessary stepsfor discharge might be taken at once and without the need of referring the caseselsewhere and thus requiring a repetition of the examinations.
Decision as to the physical signs which should determinerejection on account of pulmonary tuberculosis depends naturally upon ourconception of the nature of the tuberculous processes as they affect the lungs.If erroneous ideas lead to the unnecessary rejection of many thousands of men,such errors may have disastrous results in the conduct of military operations.The view was formerly held by all, and is still much too widely spread, that thepopulation is divided as regards tuberculosis into a healthy majority and atuberculous
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minority and that tuberculosis is infectious for adults, atleast for those who are not already labeled tuberculous. It is even believed bysome that active forms of tuberculous disease may be made worse by contact withother cases, if this leads to exposure to large amounts of tuberculous virus, orif the tubercle bacilli in these latter cases are of a more virulent type. Theelimination of the tuberculous from the Army in this view would be urgentlyrequired for the protection of their healthy comrades.
What may be called the modern view is based upon thewell-established fact that practically every civilized adult has come intocontact with the tubercle bacillus and has thereby acquired what in a sense is atuberculous infection. But in the large majority of the population thistuberculous infection remains latent throughout life and amounts to avaccination against tuberculosis. And in those less successfully protectedagainst tuberculosis the form of the disease which declares itself is chronicand often relatively benign, differing materially from the form of tuberculosismet in young children and others who have had no previous contact with thedisease before acquiring an infection with massive dosage. An individual alreadyinfected with tuberculosis can be reinfected from without, if at all, only bylarge amounts of tuberculosis virus. If thus capable of exogenous infection heis likewise subject to endogenous reinfection, or will be unable to prevent theextention of already existing, but perhaps latent, tuberculous processes withinhis body. Exogenous infection in civilized man is not, therefore, of importance;nevertheless, on account chiefly of unprotected children, every care should betaken to destroy the poisons of tuberculosis.
Circular No. 20, Surgeon General's Office, was published onJune 13, 1917, for the guidance of medical officers in connection withexaminations for pulmonary tuberculosis, after having received the approval ofeminent clinicians. This circular indicated the duties of medical officers,called attention to physical signs of the chest often erroneously considered assigns of disease, and defined the signs of tuberculosis which should lead torejection, including within its scope the interpretation of X-ray findings.Because of its comprehensive character it is quoted here in full:
CIRCULAR No. 20.
WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, June 13, 1917.
The following is published for the informationof medical officers for use in connection with examinations for pulmonarytuberculosis in the military service.
The duties of the examiner are:
1. To exclude cases of manifest tuberculosisfrom the Army.
2. To hold to service men who allegetuberculosis as a ground for exemption or discharge on the basis of insufficientor incorrectly interpreted signs and symptoms.
3. To determine in the case of soldiersaccepted for the military service the existence of pulmonary tuberculosis, andto decide whether or not the disease has been incurred in the line of duty.
Men who desire to serve their country mayconceal, from patriotic motives, symptoms of tuberculosis which they know orsuspect to exist. Some tuberculous patients will seek enlistment with a view toobtaining treatment and a pension. Some soldiers who have volunteered may repenttheir action and allege symptoms of tuberculosis with a view to securingdischarge. Some conscripts may be expected to claim the existence oftuberculosis
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as a ground for exemption, and may fortifytheir claims by certificates of physicians and by radiographs. There willprobably be many cases in which pulmonary tuberculosis will have beendiagnosticated on the ground of subjective symptoms and of physical signs whichare normal or indicate unimportant and healed lesions of some kind.
It is necessary therefore that conclusions ofthe examiner shall be based only on physical signs, sputum examinations, andradiographs. Statements of the subject as to symptoms will not be accepted asproof of the existence of tuberculosis unless supported by objective evidence.
It is the duty of examiners to protect theinterests of the Government by preventing men from entering the service who havemanifest tuberculosis. It is equally their duty to prevent the escape fromservice on the ground of tuberculosis of men who present slight or doubtfuldeviations from the normal. It is therefore necessary to insist thatrecommendations for discharge for tuberculosis of otherwise apparently healthyand vigorous men shall be based only upon the presence of definite and plainlymarked signs of pulmonary lesions.
The following signs will not be regarded asevidence of pulmonary disease in the absence of other signs in the same portionof the lungs:
1. Slightly harsh breathing, slightlyprolonged expiration over the right apex above the clavicle anteriorly and tothe third dorsal vertebra posteriorly. The same signs at the extreme apex leftside.
2. Same signs second interspace rightanteriorly near sternum (proximity of right main bronchus).
3. Increased vocal resonance, slightly harshbreathing immediately below center of left clavicle.
4. Fine crepitations over sternum are heardwhen stethoscope touches the edge of that bone.
5. Clicks heard during strong respiration orafter cough in the vicinity of the sternocostal articulations.
6. The so-called atelectatic r?les heard atthe apex during the first inspiration which follows a deeper breath than usualor a cough.
7. Sounds resembling r?les at base of lung(marginal sounds), especially marked in right axilla, limited to inspiration.
8. Similar sounds heard at apex of heart oncough (lingula).
9. Slightly prolonged expiration atleft base posteriorly.
10. Very slight harshness of respiratorysounds with prolonged expiration in the lower paravertebral regions of bothlungs posteriorly, most marked at about angle of scapula, disappearing a shortdistance above that point, equal on both sides, or slightly more marked at theangle on one side, more frequently the left.
THE APICES
Incipient tuberculosis of the apex is oftenerroneously diagnosticated:
1. On account of misinterpretation of normalsigns.
2. Because the importance of minor differencesbetween the two sides is exaggerated.
3. Because signs of a healed lesion areconsidered to indicate an incipient lesion.
For No. 1, see No. 1, page 2.
With regard to No. 2, it is not too much tosay that, given a sufficiently minute examination, there would be few men whowould fail to show some signs which might be interpreted as having pathologicalsignificance.
No. 3. The truly incipient tuberculosis of theapex generally escapes detection when in an active state. When healed itconstitutes the abortive tuberculosis of Bard. Induration of the apex has beendescribed by Kr?nig as a nontuberculous affection. The important question hereis whether the signs present indicate a healed or active process. They areharshness of respiratory sounds, prolongation of expiration, increasedconduction of voice, and more or less dullness on percussion. These signs arecaused by induration of pulmonary tissue. Induration caused by acuteinflammation is relatively rare in tuberculosis. It is not characteristic of arecent but of an advanced process, when present to an extent which permitsdetection by clinical methods. When it does occur, the subject is usuallyfebrile
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and evidently ill. In cases of ambulantsubjects in apparently good health the presumption is that the above signsindicate an old, not an incipient lesion. The abortive tuberculosis of Bard andKr?nig's apical induration, whether or not it is due to an obsoletetuberculosis, are not causes for rejection in the absence of tuberculous diseaseat a lower level in the upper lobe. Narrowing of Kr?nig's isthmus isextremely common. It is not a sign of recent disease but of contraction of thelung from old disease. In consideration of the frequent asymmetry of the bonystructures about the apices slight differences in the width of the isthmus onthe two sides are unimportant. A distinct contraction of one side points to theexistence of a tuberculous focus of the upper lobe; whether or not this focus isof clinical importance must be determined from the signs in the individual case.Contraction of the isthmus per se is not a cause for rejection. Theattention of examiners is particularly invited to the necessity of exercisinggreat conservatism in their interpretation of physical signs over the apices.Interpretation of such signs as indicating active tuberculosis would in manycases do the Government great injustice, leading to the exclusion of men who arefit for service. The only trustworthy sign of activity of apical tuberculosis isthe presence of persistent moist r?les.
DIAGNOSIS OF TUBERCULOUS LESIONS IN GENERAL
THE ACUTE LESION
If small lesion is manifested by r?les with orwithout changes in breath sounds, percussion note, and voice transmission. Themore acute the lesion the greater the probability that its presence will beindicated only by r?les. If of large extent the process is distinctly a broncho-pneumonia,generally caseous, characterized at first by the usual signs of pneumonia,crepitant, and subcrepitant r?les; when caseated by absence of r?les, exceptcoarse and distant r?les from the larger bronchi, also by impairment ofexpansibility of the lung, and more or less dullness or tympanitic resonance;when breaking down by cavity signs and the presence of loud moist r?les ofvarying size. Large acute lesions are rarely found in candidates for enlistmentand the small acute lesion is also comparatively rare. Tuberculosis as itpresents itself to the Army examiner is usually of a chronic type.
THE ARRESTED CHRONIC LESION
It is by no means rarely the case that atuberculous lesion will run its course and become arrested without the knowledgeof the subject, who may state in perfectly good faith that he has never hadtuberculosis. The arrest of a lesion is indicated by the absence of r?les. Sucha lesion is characterized by harshness of breath sounds and prolongation ofexpiration, by increased vocal fremitus and resonance and by more or lesspronounced dullness on percussion.
THE ACTIVE CHRONIC LOCALIZED LESION
Activity is denoted by the presence of r?les,together with the other signs described under the arrested lesion. R?les do notnecessarily show that the lesion is extending nor that the activity is of muchclinical importance, but in military practice the presence of r?les accompaniedby breath changes and other signs should be an indication for rejection. Themore active and recent the chronic lesion the less marked the breath changes andthe more conspicuous the r?les.
DISSEMINATED TUBERCULOSIS
True miliary tuberculosis is not likely to cometo the attention of the military examiner. The peribronchial type is common andfrequently not recognized. In the adolescent the peribronchial tuberculosis maybe extending from the deep lung without as yet developing a superficial focus.It may be manifested only by the presence of distant r?les with or withoutslight changes in the breath sounds which are of a slight bronchovesicularquality. If the case is well marked there will be impairment of expansibility ofthe affected side and increased vocal resonance. Less pronounced cases aredistinguished from chronic bronchitis only by the character of the r?les(coarser in bronchitis) and by their topical distribution.
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More frequently the peribronchial type isfound accompanying a superficial focus. Bronchovesicular breathing may extendsome distance below the limits of the superficial focus with or without r?les.But the most important manifestation of the peribronchial type is extension tothe formerly sound side. There may be a small, obscure, apparently arrestedlesion of one side, usually the right, with a peribronchial extension involvingthe whole or the greater pant of the other lung manifested only by the presenceof r?les after expiration and cough.
A definitely demonstrated tuberculous lesionof more than insignificant size below the apex is cause for rejection whethersuch lesion be active or inactive. But men whose qualifications make theirservice of especial value to the Government should not be rejected withoutprevious report of their cases to higher authority if the lesion found is notvery large and is entirely quiescent. In case of the acceptance of a man withtuberculosis a careful record of the case should be made for the protection ofthe Government. Such cases should be frequently reexamined.
In ambulant afebrile subjects harshness ofbreath sounds and prolongation of expiration characterize the old and relativelydry lesion, while the more acute the process the less marked are the breathchanges and the greater are the conspicuousness and significance of r?les. Noexamination for tuberculosis is complete without auscultation following a cough.
THE METHOD OF "EXPIRATION AND COUGH"
It is best executed as follows: Starting fromthe state of rest of the lung the subject forcibly expels the air from thelungs, reserving the last portion of the expiration for a short cough, afterwhich inspiration immediately follows, but only enough air is inhaled to returnthe lung to the state of rest. The idea is to diminish the size of the bronchias much as may be by expiration, then to cough to stir up forcibly such fluid asmay be present in them. The moisture is more likely to be moved by the currentof air and so produce r?les when the tubes are of their least caliber. Thisprocedure should invariably be employed in examinations in order to determinethe activity of lesions found by other signs and also to detect the existence offresh disseminated tuberculosis.
EXAMINATION OF SPUTUM
The presence of tubercle bacilli in the sputum isa cause for rejection. Examiners should, however, take pains to convincethemselves that the sputum examined came from the lungs of the person underexamination. To this end they should insist that the sputum be coughed up intheir presence or in that of the pathologist who makes the microscopicalexamination.
TUBERCULIN
It is well recognized that a positive reaction totuberculin, especially in the young adult, is not a proof of the presence ofactive clinically important tuberculosis. Tuberculin only demonstrates activityof the tuberculous process in the clinical sense when it can be shown to producea focal reaction. Such reaction is not without danger. Since, therefore,tuberculin rarely leads to a correct diagnosis and may do injury, its generaluse in the diagnosis of tuberculosis in examinations for enlistment isprohibited
X RAY
Only well-marked pathological changes arerevealed by radioscopy. For the accurate diagnosis of tuberculosis recourseshould always be had to the study of the X-ray negative. It is not of coursepracticable to use radiography extensively for the determination of tuberculosisduring the examination of recruits. But the X ray will doubtless be oftenemployed in doubtful or disputed cases, so that it is necessary to consider therules which should obtain in reading the radiograph.
Morbid changes in the lungs are shown byshadows due to two substances: First, blood; second, fully organized connectivetissue. Blood imprints a shadow on the negative only when present in abundance.The congestion of lobar pneumonia is typical. Bronchopneumonia of tuberculosisorigin may also cast shadows, but only when the process is acute,
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the congestion great. Frequently thetuberculous process runs so chronic a course that the inflammatory reaction isinsufficient to congest the lung enough to produce a shadow. The shadow ofcongestion is not sharply outlined; it melts away at its borders.
Connective tissue in the parenchyma of thelung away from the hilus is not normally present in sufficient quantity toretard appreciably the passage of the X rays except as it occurs in connectionwith and as a part of the various tubes, bronchi, blood vessels, and lymphatics.As a result of proliferative inflammation connective tissue develops as afibrous thickening of these tubes, particularly the bronchi and the lymphvessels which casts a shadow deeper than normal; the older the process and thebetter organized the tissue, the denser the shadow and the sharper its outline.Tubercle, caseations as such, cast no shadows distinguishable from the othertissues of the parenchyma. It has been found that cubes, 1 c. c. in size, ofcaseous tubercle when embedded in a healthy lung are indistinguishable by the Xray. But if the caseations become calcified or are even impregnated abundantlywith mineral salts they become opaque to the X ray. In general, and especiallyif one has to do with the shadows of tubes, it may be said that fuzziness ofoutline means acute vascular congestion, an active process. On the other hand,when the shadows of the tubes are sharp we have a process which, if active atall, is at least not characterized by great acuity, is not congestive. There iswhat is called dry tuberculosis of the lung tissue, which inclines to abundantformation of connective tissue, to dry caseations and cicatrizations or tocomplete transformation into fibrous tissue, characterized by sharply outlinedgranular spots and by more or less sharply marked bands and streaks. Specialattention is called to the persistence of the sharply outlined dots and lineswhen activity of the tuberculous process no longer exists. The sharply outlinedthickenings of the bronchi and other tubes may be evidence of an oldinflammation now entirely obsolete, may be simply records of the ancient historyof the pulmonary tuberculosis.
We do not see tubercles in the X-raynegatives. What we see is either sharply outlined calcifications and fibroses,or fuzzy congestions, or a combination of the two condtions. Cases are seen inwhich the X ray in general gives the same findings in both lungs while theautopsy proves one lung severely, the other slightly, diseased. Such casesillustrate well the limitations of X-ray diagnosis. What is seen in the X-raynegative is the thickened framework of old inflammation in the two lungs, in oneaccompanied by much parenchymatous disease of recent origin, in the otheraccompanied by little, the said parenchymatous disease being invisible to the Xray because neither sufficiently congested nor sufficiently organized to castshadows.
Extensive systems of lines, many sharplyoutlined spots, dense streaks do not, then, show an acute process. Persons ingood health with nearly or quite arrested tuberculosis are sometimes found bythe X ray to present a picture of very extensive changes of this kind. Yet theprognosis in such cases is not good if the subjects be subjected to severestrain. The radiograph is a proof that the lungs have undergone serious changes.The danger is either that hardship will lead to a reactivation of the numerousmore or less quiescent tuberculous lesions or, if the process has been largelyof the nature of fibrosis, that the lungs have been so damaged thereby as tounfit the person for an active life. If then the radiograph shows extensivedappled or mossy shadows or numerous spots and streaks the recruit should berejected however good his health may appear to be. Shadows of a homogeneousopacity result from pleurisy and are not necessarily a cause for rejection inthe absence of other signs.
Tuberculosis of the bronchial glands is adiagnosis often made from the radiograph on very slight foundation. The fact isthat pronounced swelling of the lymph glands is characteristic of primary, notof advanced tuberculosis. It is rare that intrathoracic gland tuberculosis is ofany clinical importance in the adult. With few exceptions cases of bronchialgland tuberculosis which lead to true symptoms of disease are confined to thefirst and second years of life. Only rarely, especially in adults, is so-calledhilus gland tuberculosis a purely glandular process; it is rather a more or lesspronounced disease of the surrounding hilus tissue in the form of peribronchialand infiltrative processes of the neighboring pulmonary tissues. That is, theinterscapular dullness relied upon for the diagnosis of enlarged glands, ifcaused by lung conditions, is due to tuberculous processes in the region of thehilus, partici-
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pation in which to any important extent on thepart of the glands is a matter of conjecture. The presence of masses in theneighborhood of the hilus as shown by the X ray may indeed be cause forrejection, but rejection on account of relatively small opacities in that regionon the ground that they indicate a bronchial gland tuberculosis of clinicalimportance certainly should not be permitted.
R?SUM? OF INDICATIONS FROM X-RAY NEGATIVES
The X ray shows-1. Tuberculous disease confinedto region of hilus in deep lung. 2. Extension upward toward apex or downward andoutward toward base, confined to deep lung. 3. A fine line or two extending toapex with or without small focus or foci there-condition not determinable byphysical signs. 4. Clouding of apex without marked lines from hilus, probablylargely pleuritic. 5. Well-marked lines extending to superficies of apexusually, but not necessarily, with foci there-lesion accessible to physicalexamination. 6. Lines extending toward shoulder as well as apex. (a) Ifconfined to deep lung may mean early and now obsolete exacerbation. (b) Ifextending to superficies denote larger lesion and less immunity than 5. 7. Moreor less widely diffused spots, lines, and streaks through a considerable portionof lower lobe approaching periphery of lung, with few or no auscultatory signs-deepperibronchial tuberculosis. 8. More extensive streaked opacities involvinggreater part of one or both lungs and extending to periphery with few or manyphysical signs-fibrocaseous tuberculosis, fibrosis preponderating inproportion to scantiness of more or less rounded spots or dots.
Conditions as shown by 1, 2, 3, 4, and 6 (a)are not causes for rejection. Cases under 5 are to be determined by physicalexamination. Cases under 6 (b), 7, and 8 are to be rejected.
W. C. GORGAS,
Surgeon General United States Army.
Approved, by order of the Secretary of War,June 16, 1917. (2621428, A. G. O.)
The boards first at work were constituted by the specialistsof Colorado, who had been prompt in their response, and were engaged in theexamination of troops of the Regular Army at that time stationed in the RockyMountain region. While these examinations were proceeding in the West, in theEast men at the officers' training camps were first examined. Of 53,905examined, tuberculosis was discovered in 195, or 0.362 per cent. In the aviationservice 38,835 men furnished 62 cases of pulmonary tuberculosis, or 0.159 percent. Combining these figures we have a total of 92,740, with 257 rejections; apercentage of 0.277.8 Both of these groupsconsisted, in a sense, of picked men, many of them athletes. The scanty resultobtained, which scarcely justified the reexaminations, shows that a sufficientlyrigid selection of promising material in itself practically excludestuberculosis.
In the Regular Army in the field 190,396 men were examined,with the rejection of 1,444 cases of tuberculosis, or 0.758 per cent.Examination of 40,396 men of the Coast Artillery Corps discovered 297 cases oftuberculosis, or 0.735 per cent.9
The National Guard was mustered in on August 5, 1917.9Since not all of the camps, which were in preparation for them, were ready foruse in September, many of the National Guard organizations were left at home forseveral weeks subject to call at their armories.10On account of the scarcity of commissioned tuberculosis examiners, theexpedient was adopted of employing temporarily, as examiners, physicians fromthe vicinity of the regimental headquarters, who were given contracts to examinesome of these organizations in their armories. Reports show a total of 446,517men of the National Guard
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examined, of whom 1.099 per cent were found to be tuberculous.Of these examinations, 69,273 men were examined at armories; the remainder afterarrival at camp.11
In September, 1917, the entrainment of the men of the firstcall for the first draft was made, other calls succeeding one another rapidlythrough the remainder of the year. Boards of examiners could not be organized innumber sufficient to effect the primary examination in the first draft, but thetroops of the National Army were reexamined by special examiners, chiefly in theearly part of 1918.12 The reports show that361,314 men were reexamined, with the detection of 2,435 cases of tuberculosis,or 0.673 per cent. Discharges for pulmonary tuberculosis on certificates ofdisability, from the entire Army during the war, chiefly as the result ofreexaminations by special boards, numbered in all, 11,362. According to thereport of the Surgeon General for 1918, up to March, 1918, 1,200,990 men hadbeen reexamined and 9,648 had been recommended for discharge for pulmonarytuberculosis, a percentage of 0.803.12
At the time of the second draft, orders were given by theSurgeon General that there should be but one examination of drafted men aftertheir arrival at camp, except in doubtful or deferred cases, the necessaryspecialists functioning in the primary military examination instead of goingover the command at a later time as boards of revision.13All of the procedures necessary for the admission of an individual,comprising the physical examination, the administration of vaccines, and theentries upon the prescribed blank forms, were to be completed in a single day.
This change, so far at least as the physical examination wasconcerned, was a long step in advance, the examiners by this time having becomethoroughly familiar with their duties. A difficulty at once arose, however, fromthe speed required in the examinations. Circular No. 20 prescribed that eachexaminer should examine at least 50 men per day. This number, regarded asexcessive by many at first, was frequently doubled by the more alert after theyhad gained experience. The usual size of the board of tuberculosis for thelarger camps was 10 members. If such a board examined 1,000 men per day, thatwas certainly all that could be required of it. Yet in some instances the ordersof the War Department or of the camp commander contemplated much greater speed.Representations were made by the Surgeon General to the effect that hastenecessarily resulted in insufficient examinations and that, in view of the factthat only one examination was required, it was of the highest importance thatthat examination should be thorough. This resulted in some improvement in theconditions, but in general the work that was required remained excessive. Insome instances the boards worked all day and far into the night, or again workedall night instead of all day in order to complete their tasks within the timeprescribed.11 The number ofexaminations made at times seems almost incredible. Thus, 1 team of 3 examinersexamined 1,763, 1,854, and 1,944 men in 3 successive days. Rapid work of thiskind was made possible only by the assistance of enlisted men of the MedicalDepartment, who instructed the recruits in advance of their appearance beforethe examiners how to stand, how to breathe, and how to cough. The attention ofthe examiners was directed solely to the auscultation of the lungs for thepresence of r?les after expiration and
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cough, cases which showed moist sounds being referred formore careful examination. That an objective condition was revealed withremarkable regularity by this method is shown by the fact that when the numberof men examined was large the cases rejected always amounted to between 0.5 and0.6 per cent of the men examined.11
As stated above, with the increment of the draft called onMarch 26, 1918, primary examinations were first undertaken by the tuberculosisexaminers. The total number of men rejected for pulmonary tuberculosis onprimary examination in the second draft was 12,629 out of 2,040,051examinations, or 6,174 per million. The grand total of examinations, includingboth reexaminations and primary examinations of recently recruited soldiers andof incoming drafted men, by special tuberculosis examiners was 3,288,669, thetotal number of men rejected by these boards being 22,596 or 6,871 per million.11
In addition, the boards discovered 1,461 cases of pulmonarytuberculosis which were held to limited or special service in this country, 108cases of suspected tuberculosis, and 613 cases of tuberculosis in organs otherthan the lungs. The total number of cases discovered by special examinersamounts to 26,173.
From November, 1918, the examining boards were chieflyengaged in examinations previous to demobilization, 2,500,662 men having beenexamined up to June 30, 1919, of whom 1,356 were found to be tuberculous, or 542per million.11 This gratifyinglysmall ratio of tuberculosis cases undoubtedly would have been still furtherreduced if all of the men demobilized had been submitted to earlier thoroughexamination for tuberculosis. Records are available from Camp Lewis, Wash., fromwhich it appears that 63,575 men were examined there for demobilization.14Of these, 8,500 who had not previously been examined by any board yielded57 cases of tuberculosis, or 0.67 per cent; i. e., 6,700 per million; whileamong 55,075 men who had been examined at Camp Lewis, but 9 cases oftuberculosis were discovered: A percentage of 0.016, or 163 per million. It waspointed out further that at United States General Hospital No. 21, whichreceived the tuberculous patients from organizations belonging to the Pacificcoast and the neighboring inland Northwestern States, there were 183 cases ofpulmonary tuberculosis from the region referred to, of which 170 were notmustered at Camp Lewis.14 Nine camefrom Camp Lewis but were not examined there, since they belonged to a group of3,626 men of the first draft who were sent away before they could be examined.Four had been examined one of whom had been recommended by the board fordischarge, but not discharged, leaving but 3 out of 13 cases for whichresponsibility could be fairly attached to the Camp Lewis board. Cases ofpulmonary tuberculosis from the above mentioned States would naturally, in greatpart, be sent to United States General Hospital No. 21. Such data go far toprove that, given a sufficiently thorough and efficient examination,tuberculosis could be practically eliminated from an army. The cases that breakdown under the stress of military service are largely those entering withlesions capable of detection by experts.14
Over 600 physicians acted as tuberculosis examiners, but thenumber of examiners available was never sufficient for the needs of the service;so, as a rule, it was necessary to confine their activities to the larger camps,with special
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reference to the examination of troops who were to go abroad.Unfortunately, the work of reexamination could not be organized in time toexamine many of the troops who were sent overseas early. More than 40,000soldiers were sent abroad, therefore, in the early months of the war of whom fewcould have been reexamined for tuberculosis.11Some organizations likewise were embarked for Europe at a later time whichescaped reexamination, as, for example, many of the hastily assembled stevedoreregiments, the difficulty being partly due to the failure to learn in time ofthe existence or of the contemplated departure of the organizations, militaryoperations and especially embarkations being shrouded in the utmost secrecy, andpartly to the scarcity of examiners.11
How necessary reexamination of the colored enlisted mencomposing the stevedore regiments was, is shown by the fact that a special boardat Newport News, Va., examined 8,734 men of colored stevedore regiments andreported 68 cases of tuberculosis, or 0.812 per cent.11
In addition to the work of examination of organizations,tuberculosis experts were detailed as specialists of divisions and of base andgeneral hospitals, as officers of tuberculosis hospitals, and as instructors.
When the need of examiners was greatest, physicians wereemployed temporarily as contract surgeons in order to assist in theexaminations. As the qualifications of these contract surgeons were not alwaysknown, it was soon found advisable to give them a course in physical diagnosisof the chest, the primary object being to observe their work and to classifythem according to their proficiency. This course, however, met with unexpectedsuccess and became popular among the medical officers. Its benefits were somanifest that from the original school, at the Army Medical School, Washington,instructors were sent out who established like courses of instruction at themedical officers training camps at Fort Oglethorpe, Ga.; Fort Riley, Kans.; andFort Benjamin Harrison, Ind.15 Aschool was instituted at a later time at General Hospital No. 16, New Haven,Conn., in which, in addition to courses in physical diagnosis, instruction wasimparted in the treatment of tuberculosis and in hospital administration, with aview of training medical officers for service at tuberculosis hospitals. Coursesin physical diagnosis also were given to the medical officers of various campsand hospitals by travelling instructors.16Especial attention was paid in this course to the physical signs of thenormal chest.
At the beginning of their work the chief function of thespecial examiners was necessarily eliminative; they were to rid the Army of thetuberculous. But they also appreciated the fact that quite as important a dutywas conservation. Of their own initiative many of the boards stamped the recordsof the soldier "Examined and passed by the tuberculosis board," with aview of preventing the later discharge of individuals presenting signs which theinexperienced might misinterpret.
The inexperienced diagnostician finding signs which may bethose of tuberculous disease usually recommends discharge, giving himself thebenefit of the doubt, in the fear that he will be thought to have overlookedwhat should have been found if at a later time the bearer of the signs inquestion should be diagnosticated as tuberculous. The specialist should striveto retain in the service men in whom he thinks tuberculosis is not activenotwithstanding the
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presence of signs or symptoms which some might misinterpret.The conservation to the service of men with blemishes which do not disqualify isone of the most important of his functions. His duty is not only to secure therights of the individual; it is fully as much his duty to protect theGovernment, which should not unnecessarily be deprived of soldiers when everyman is needed. He who in time of war excuses men for trifling or doubtfuldeviation from the normal does not properly conceive his duty toward hiscountry. There is no reason why the possibly tuberculous alone should beexcluded from risks.
This view was emphasized in Circular No. 20 and was enforcedas far as practicable. But it remained one of the chief difficulties thatmedical officers were reluctant to take a definite stand with regard to manycases, that in some camps, wards were filled with apparently healthy men keptunder observation whose supposed deviations from the normal had been discoveredonly in routine examinations, as if the desideratum was to make a positivediagnosis of tuberculosis at all costs. The chief reason for this course was thefact that some one had diagnosticated active tuberculosis in these cases. It wasundoubtedly of great benefit that a standard had been provided in Circular No.20, upon which the examiner could rely and which relieved him of some of theburden of his responsibilities in the diagnosis of disputed cases. A standard,though imperfect, is believed to be an indispensable adjunct in Armytuberculosis work not only to support the examiner but also to secure thenecessary uniformity of practice in the matter of discharge for tuberculosis.
OCCURRENCE
IN CAMPS IN THE UNITED STATES
When considered by camps of occurrence, during the World War,two camps only are found to be outstanding in this respect, namely, CampsKearny, and MacArthur. Camp Kearny (situated near San Diego, Calif.) had theworst record for tuberculosis of all the large Army camps.17In the reexamination of 19,827 men at this camp, 853 cases of tuberculosiswere discovered, or 4.83 per cent. The admissions for tuberculosis at CampKearny in September, October, November, and December, 1917, were at the rate of157.53 per 1,000 of strength, Camp MacArthur, Tex., the second worst camp inthis respect, having the comparatively small ratio of 25.45. Camp Kearny wasprimarily a National Guard camp. It received 6,944 men of the National Guardfrom Arizona, New Mexico, Colorado, Utah, and California in September andOctober, 1917, and 13,680 men from other camps in November, largely drafted men.During 1918, also, additions were received largely from other camps.18
Matson's remark with reference to Camp Lewis14that the material was largely from the Southwest and contained enormousnumbers of health seekers whom the boards of the first draft sent, thinking thatchange of climate might benefit the manifestly tuberculous, undoubtedly applieswith even greater force to the command at Camp Kearny.
The operation of this tendency above referred to is stillmore clearly exemplified at Fort MacArthur, Calif. Here in 501 men examined fortuberculosis, 103 cases were found, a rate of 20.55 per cent.11On investigation it was found that the large majority of these men were draftedfrom Texas, 53 towns in that
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State having contributed 92 of the tuberculous cases. In anycase, of course, it by no means fairly represented the drafted men of the State.Indeed, there was collected in the five howitzer companies at Fort MacArthurwhat in all probability constituted the majority of the tuberculous cases of thepart of Texas from which the men originally came. There could hardly be morestartling proof of the inefficacy of the usual routine examinations and the needof revision. The evils of the absence of an efficient medical examinationprevious to the transfer over long distances of large bodies of troops is alsoapparent enough.
New Mexico had the undesirable preeminence of furnishing thegreatest number of tuberculous men per 1,000 of native population of any of theStates of the Union.18 Yet there areregions in New Mexico where the climate is probably best adapted of any in theUnited States for the treatment of pulmonary tuberculosis, its reputation forthe climatic treatment of the disease being shown by the fact that the onlysanatoria which were operated by the Army and by the United States Public HealthService before the war for the treatment of the tuberculous were located with inits borders. Like the other border States of the Southwest, New Mexico isoverrun by consumptives from other States, many of whom were imported originallyas patients in the Army and Public Health Service sanatoria, though many otherscame in as civilians. This latter class contains, as a rule, cases of pulmonarytuberculosis of more than average severity, many patients who fail to improve inthe North being sent to the Southwest as a place of last resort. Moreover thepopularity of the Southwest as a resort for the treatment of consumption is ofcomparatively recent origin. Consumptives have visited the region from the firstdays of its occupation by the whites, but not in considerable numbers untilwithin recent years. It is improbable, therefore, that a sufficient number ofsons of military age have been born to the immigrating consumptives to affectmaterially the ratios of tuberculous cases to native population. But thenumerous patients discharged from the Government sanatoria would naturally morereadily find openings in civil life in a part of the country with which theyhave become familiar, and the climatic advantages of New Mexico would beexpected to induce tuberculous civilians in general to make it their home in alarger percentage than would be the case in the hotter climate of Arizona andTexas. Such men, many of them familiar with Army life and fond of adventure,many of them, too, perhaps alive to the prospects of future benevolence of theGovernment to tuberculous soldiers, would naturally seek enlistment in the Armyand would conceal as far as possible the suspicious fact that they wereoriginally from other States.
Another factor which should be considered is the Mexicanelement of the native population of the State, which composed 15 per cent of thepopulation of the southern tier of counties in the census of 1910, since whichtime many thousands of Mexicans, fleeing the civil war in Mexico, haveimmigrated to New Mexico and to the adjacent portions of Texas and Arizona.
Physicians connected with the Atchison, Topeka & Santa FeRailway medical service have noted that when Mexicans from remote districts areemployed as laborers along the railroad a certain proportion of them suffer fromacute forms of tuberculosis.19 Here,according to well-known epidemiological
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laws, we have an illustration of what befalls individuals notall of whom have received the more efficient immunization against tuberculosisafforded by life in a civilized community; the men fall sick from tuberculosisnot because the environment from which they come has too much but because it hasin a sense too little tuberculous infection! In other words, the tuberculosis isacute because it attacks the nonimmunized or imperfectly immunized individual.
About one-third of the population of the northwestern quarterof New Mexico is stated to be composed of Indians, and there are largereservations elsewhere in the State. The various tribes differ widely as to theprevalence of tuberculosis. No recent statistics of value are available, but itwas reported some years ago with regard to the Zuni Indians that tuberculosiswas rare among them, but that the mortality of the disease was 100 per cent.20Such a group would figure more largely in the statistics of mortality fromtuberculosis than in the percentages of rejection upon admission to the militaryservice; but the Indian as well as the Mexican element of the population is ingeneral likely to become suspicious in the statistics which relate totuberculosis. Unfortunately, the statistics as collected by the Provost MarshalGeneral do not permit the determination of the race of the soldier. We are leftto conjecture, therefore, as to the relative importance of the Indian and theMexican in causing the high percentage of incidence of tuberculosis in NewMexico. The problem is highly complex, and it would be manifestly misleading toinstitute comparisons between a population like that of New Mexico, with itslarge percentage of health seekers and its admixtures of semicivilized races,and the more or less homogeneous American population of other portions of theUnited States.
IN THE AMERICAN EXPEDITIONARY FORCES
The care exercised in the United States in the elimination oftuberculosis from our Army was abundantly rewarded by the absence of anyextensive prevalence of the disease among the troops in France. Cabot reportedfrom Base Hospital No. 6 at Bordeaux that of 21,738 patients received at thathospital between September, 1917, and November 22, 1918, there were 63 positivecases of tuberculosis, pulmonary and extra-pulmonary-a percentage of 0.289.21Of these, 51 were recognized by the presence of tubercle bacilli in the sputumand 12 were found post mortem. One hundred other cases were diagnosed asprobably or possibly pulmonary tuberculosis, no other diagnosis seeming morelikely, though bacilli were not found in the sputum. None of the 163 wereapparently incipient cases. The incidence of tuberculosis was greatest in theearly months, he says, when presumably the "combing out" oftuberculous cases by special examinations in the training camps of the UnitedStates had not begun, or was not extended to all units. Stevedores, laborcompanies, and engineers were especially affected. In the first 7,000 casestreated at Base Hospital No. 6 there were found 35 out of the 51 positivetuberculous cases, while in the last 6,000 cases received only 1 case was proventuberculous. Cabot's conclusions are:21
(1) Pulmonary tuberculosis was of rareoccurrence among the sick treated at Base Hospital No. 6. (2) It occurredchiefly among soldiers who had not been specially examined in the training campsof the United States with reference to its presence. (3) An even three-
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fifths of the 51 cases with tubercle bacilliin the sputa occurred in the cases between No. 1 and No. 7,000 of our series,while in the last 6,000 cases received only 1 case was proven tuberculous. (4)Few, if any, cases could have been considered as originating in line of duty. Noincipient cases were recognized.
These observations by an experienced diagnostician located ata hospital at a port of embarkation through which many patients were evacuatedto the United States and where, consequently, tuberculous cases must haveabounded if the disease had been of frequent occurrence, are the more valuablebecause tuberculosis, not being a problem of magnitude in the American Armyabroad, officers of hospitals, overwhelmed as they were at times by patientswith wounds or acute infectious diseases, have remarked but rarely as to itsprevalence. After tuberculous patients began to return to this country it wassoon reported that a considerable percentage (sometimes as high as 50 per cent)had no clinically recognizable tuberculosis. It being important from a militarystandpoint that the Army abroad should not be drained of its men unnecessarily,a tuberculosis expert was sent to France with a view of securing a betterdiagnosis of tuberculous conditions. This visit culminated in an order beingissued in the American Expeditionary Forces to the effect that only cases withtubercle bacilli in the sputum should receive the diagnosis "pulmonarytuberculosis," all other suspected cases to be classified as"tuberculosis observation."22 Threecenters (Base Hospitals Nos. 20, 3, and 8) were designated to which cases underobservation should be sent.22 No menwere to be sent home as tuberculous unless their sputa contained tuberclebacilli or they had been passed as tuberculous at one of these centers. Thesemeasures rapidly reduced almost to zero the percentage of returning patients whowere found to be negative for clinical pulmonary tuberculosis after observationin this country. But after the signing of the armistice, when retention of everypossible man was no longer necessary, the above mentioned precautions werediscontinued and large numbers of men who were simply suspected of havingtuberculosis returned with a positive diagnosis of that disease. In all, 8,717cases of pulmonary tuberculosis were received from Europe at the tuberculosishospitals of the United States up to December 3, 1919.23In a total number of admissions to these hospitals amounting to 18,713 thediagnosis of pulmonary tuberculosis was not confirmed in 4,305.23What proportion of these negative cases came from Europe is not known.
EPIDEMIOLOGY
In the enrollment of millions of men in the United States and inthe mobilization of the large European armies we have experiments on a grandscale in the epidemiology of tuberculosis which can not be too carefullystudied. In our Army in France certain observations were made which led to thebelief that our soldiers were in danger of primary infection with tuberculosis.24Glomsett remarked at the Red Cross Conference on Tuberculosis held inNovember, 1918, at Paris25 that itwas a pleasant surprise to learn that tuberculosis had played such aninsignificant r?le, only 2.5 per cent of deaths having been due to this cause.Tuberculous lesions were found by him in 16.6 per cent of bodies of soldiersexamined. He found "primary foci" in 50 per cent of his autopsies andstated that such foci were more common in the bodies of those
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who had died from other causes than in those who had died oftuberculosis, persumably meaning old foci. He found no evidence of tuberculosisin fully two-thirds of fibrous pleurisies. He had six autopsies of soldiers whohad died of tuberculosis, four of which showed miliary tuberculosis. At the sameconference Robertson25 reported that he hadworked during the first year of the war in Freiberg, where of 100 autopsies ofGerman soldiers 70 per cent showed tuberculous deposits in lungs ortracheobronchial glands, while in autopsies on our soldiers he was able todetect tuberculosis in less than 25 per cent.
Each pathologist, it appears, had his own standard, and theresults of autopsy findings differed as widely as did the standards. The numberof autopsies considered, moreover, is much too small to indicate the true statusof soldiers as to tuberculosis. Caseation of lymph glands was referred to bysome of the observers in support of their position without, however, giving adescription of the exact condition of the glands. The behavior of the lymphglands in a given case is fundamental for the decision as to the nature of thetuberculosis that is present.
It may be remarked here that the pathology of lymphadenoma isadmittedly dubious as to etiology and especially as relates to the r?le of thetubercle bacillus in the production of suppurative processes. The presence oflocal lesions in the vicinity of the glands, carious teeth, and the like is verysignificant. It would seem that a mixed infection, one infective agent which isactive in the production of an unusual type of lymphadenitis being unidentified,would best explain the facts. Why should tuberculosis, if uncomplicated, pursueso unusual a course? At all events there seems to be no good reason why itshould be necessary to assume continued new infections from without, and muchthat speaks against that hypothesis. The fact that notwithstanding thesupposedly frequent reinfections the disease remained localized and the patientwas in good health is the best evidence of the persistence of an immunization. Aprimary infection or an infection which sprang from a serious diminution, if notan entire loss, of a former immunization would tend to become generalized andfatal. This is well illustrated by the course of tuberculosis among the colonialtroops of the French Army, as reported by Borrel.26This command, the average strength of which was 50,000 men in 1917-18, wascomposed of negroes from Madagascar and Senegal, of Annamites, and of Kanakas.The Malgaches or Madagascans had tuberculosis of a chronic type-tuberculosisis not a rare disease in Madagascar. The Annamites, among whom the disease haslong prevailed, had but a small percentage of tuberculous cases. Tuberculosiswas found in about 10 per cent of the Kanakas; the disease had a duration ofmonths and often of years. Enlargement of the cervical glands of a scrofuloustype and of a chronic course, which was apparently often not incompatible withgood health, was common among them. But the Senegalese were the most severelyaffected with tuberculosis. This is a rare disease in Senegal outside of thetowns where there is contact with Europeans.
Borrel found only 4 to 5 per cent of positive reactions tothe skin test among newly arrived recruits, but unfortunately used tuberculindiluted to one-tenth strength. Apical tuberculosis was found in not more than 5per cent of the
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Senegalese. Those who had the chronic type of tuberculosiscame from the towns. They spoke French. While in the command considered as awhole 50 per cent of the cases of tuberculosis were of the chronic Europeantype, among the Senegalese who came from country districts the type oftuberculosis was that of the European infant; that is, it was primarytuberculosis. In these patients there was generally a chain of enlarged lymphglands extending from the supraclavicular or the superior cervical glands to thehilus, the largest ones of about the size of a hen's egg, having a locationcorresponding to that of the primary lesion-which might be situated upon thetonsil, in the posterior pharynx, the larynx, or at the level of the mainbronchi; but in 80 per cent of the autopsies the disease began in thetracheobronchial glands. More than 70 per cent of the deaths from tuberculosisamong them were due to miliary tuberculosis in which the lungs were not moreinvolved than the other organs. There was sometimes a massive caseous pneumoniafrom direct rupture of an enlarged gland into bronchi and alveoli, the glandthen often becoming the center of a great caseous mass. Or there might beprimary pleurisies without caseous foci in the lungs, or more than one serousmembrane might be involved simultaneously, the peritoneum as well as the pleura.Clinically after what Borrel calls the initial glandular period, lasting one tothree months, in which there is no fever, the period of generalization comes onwith high and irregular fever and death in from 15 days to 1 month; rarely 2months.
Roubier's account of this disease confirms that of Borrel.He called attention to the constant presence in miliary tuberculosis of caseousmediastinal glands, sometimes so voluminous as to give rise to symptoms ofcompression.27
The important contribution of Borrel gives in epitome theentire pathology of tuberculosis. We see chronic localized pulmonarytuberculosis in soldiers who had been long exposed to infection, the scrofuloustype, still chronic, with chronically caseated lymph glands in the imperfectlyimmunized Kanaka, but in the virgin soil of the Senegalese acute and enormousenlargement of glands, rapid generalization of tuberculosis, and death. It hasbeen known from animal experiment that if the infected animal survives theprimary inoculation with tuberculosis the glands acquire a certain immunization,such that they do not swell materially or at least long remain swollen insubsequent inoculations, irrespective of the fact that the animal may in realitybe slowly dying as the result of the first inoculation. The same is true of manexcept so far as the picture is confused by the chronic caseations andsuppurations of the scrofulous type. If, then, there be not found a primarylesion with enlargement of the corresponding gland, as Borrel described it, thecase is not one of primary tuberculosis. Immunity is generally completely lostin the last stage of fatal human tuberculosis; miliary disseminations oftubercle shortly before death, throughout the internal organs, whethermacroscopic in size or only to be determined by the microscope, are well-nighthe rule in uncomplicated cases. The glands do not swell in this secondarymiliary tuberculosis, but they may be found, of course, chronically enlarged andcaseated in the scrofulous type.
Evidence of chronic tuberculous changes is found in somecases of pulmonary tuberculosis with acutely fatal termination. That they arenot found in all such cases which occur in civilized man is largely accountedfor by the
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difficulties of the search. Even N?geli in his classicalinvestigations which finally resulted in finding tuberculous changes present in97 to 98 per cent of autopsies, at the beginning found only 40 per cent.28Opie29 showed the surprisingly largenumber of calcifications to be detected in the lungs by his method ofradiography, most of which would have escaped detection by the ordinary methodsof search. Since civilized adults are shown by tuberculin tests to be infectedwith tuberculosis in almost 100 per cent, it is more logical to assume that thefew whose evidence of past infection is not discovered have really been infectedthan that they should have escaped entirely the ubiquitous tubercle bacillus.Acuity of course and of termination of tuberculous disease is encountered inmany cases in which earlier infection with tuberculosis is demonstrable. Theyshould not, therefore, be considered to indicate a primary infection thoughearlier tuberculous changes may not be detected, certainly not unless the casepresents the characteristics of truly primary tuberculosis.
The experience of the British Army in France with Africanswas somewhat similar. Thus Cummins30 statedthat there were 165 deaths among British troops in 2,881 cases, which gives acase mortality of 5.7 per cent, while in the South African labor corps unitsconsisting of "Cape boys" and Kaffirs there were 183 deaths in 372cases of tuberculosis, a case mortality of 56 per cent. According to the samewriter, the Indian divisions in France in 1916 had a tuberculosis incidence of27.4 per 1,000, that of the British troops being 1.1 per 1,000. In comparing themortality rates from tuberculosis, allowance must he made for the probabilitythat in the British Army all but the most acute cases would be repatriated andthat deaths which occurred after discharge, and perhaps after the individual hadbeen returned to Great Britain though still in the service, would not appear inthe mortality statistics in France, while the tuberculous negro would probablynot be sent to his home. The relatively high death rate of the Africans,however, shows clearly enough that the negroes of South Africa are butimperfectly immunized against tuberculosis. The result of such imperfecttuberculization in these troops, including the Indian contingent, was a higherrelative mortality from tuberculosis, though they had the same food, clothingand shelter as the white troops. If the American troops had been imperfectlytuberculized, instead of a surprisingly low death rate from tuberculosis, themortality would have been high. The acute forms of fatal tuberculosis among oursoldiers were, then, really quite exceptional. To account for such exceptions onthe hypothesis of entire absence of previous opportunity is much more difficultin the case of men who do not appear to have been a peculiar class as respectstheir origin, mode of life, etc., than by the more natural supposition that theydiffered from other tuberculosis cases only in the fact that the course of theirdisease was more rapid; perhaps, as some German writers suggest, the fatiguesand hardships of war had something to do with this outcome.
From the epidemiological standpoint the cutaneous tuberculintest is a valuable and harmless method of obtaining an approximate notion as tothe degree of tuberculization of a group of individuals. It was employed forthis purpose in our Army in two instances. At Coblenz 159 American soldiersbetween the ages of 18 and 30 years, with no family history of tuberculosis and
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for the most part men of athletic build, were tested withundiluted "old" tuberculin.31 Ofthese, 122 (76.7 per cent) reacted positively to the first inoculation, 26 tothe second (giving a percentage of 93 positive in either the first or secondtest), and 3 to a third inoculation; which results in a total positivepercentage of 94.9, 8 of the soldiers remaining negative. The distinction wasmade in this group between country dwellers, city dwellers, and (small) towndwellers, but such slight difference as existed between these subgroups showedthat the men from the country were infected with tuberculosis in a very slightlylarger percentage than the men who came from towns and cities, the positivepercentage in the first, second and third tests combined being 96.9, 90, and96.2, respectively, for the subgroups in the order given above. Unfortunately,the regiment to which these men belonged, being on the eve of return to thiscountry, it was impracticable to test further those who had failed to react.31A similar test was made at General Hospital No. 21, Denver, Colo.32One hundred soldiers between 21 and 30 years of age belonging to theMedical Department detachment of the hospital, but employed in outdooroccupations which did not bring them into contact with the patients (thisinstitution being a hospital for the treatment of tuberculosis), were tested inthe same way as in the preceding experiment. In the first cutaneous test 71 werepositive, 29 negative. The negative cases received a second inoculation afterfive days, 24 becoming positive and 5 remaining negative. This gives a positivepercentage of 95 for the two inoculations. One of the 5 negative cases wasdischarged at this time; the remaining 4 were further tested by subcutaneousinjections of old tuberculin. All were negative to 1 mg. and likewise failed toreact to 5 mg. To the injection of 10 mg. 3 reacted positively. A fourthinjection of 20 mg. was given to the man who remained negative. Though there wasno rise of temperature after the injection, it was considered to have resultedpositively on account of the "depot" reaction. Thus by following upthe cases negative to the skin test with the subcutaneous injection, 100 percent of positive reactions to tuberculin was obtained in 99 men.32The above observations correspond closely with the results obtained byFreund,33 95.1 per cent of Austriansoldiers positive for the cutaneous test, and to those reported by Hamburger, 98per cent of Austrian soldiers positive to the "stitch" reaction.34The importance of recording such tests as those described lies in thelight which they throw upon the claim that our soldiers are to a considerableextent unprotected by a precedent tuberculization against primary infection withacute and fatal forms of tuberculosis.32
DIAGNOSIS
In the view of many who belong to what we will call theschool of ultra-refined diagnosis, pulmonary tuberculosis begins in the apex ofthe adult lung, as a rule. Incipient tuberculosis of the apex can be recognizedat a very early stage, before the occurrence of r?les, by slight changes inbreath sounds and percussion note, even by certain symptoms before physicalsigns are present.
Others hold that tuberculosis of the lungs begins at thehilus, usually in childhood, and in favorable cases advances at first as atuberculous lymphangitis along the blood vessels and bronchi. Tuberculosis ofthe apex is not incipient but advanced tuberculosis. The signs relied upon forthe diagnosis of incipient
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tuberculosis are not evidences of a new infection, but, sofar as they are not normal for the part, are signs of old, perhaps obsolete,affections of the apex which are exceedingly common, and, unless they extendwidely beyond the apex or have resulted in cavity, do not necessarily demand theexclusion of the individual from the military service. The only signs of trueactivity of the tuberculous process are moist r?les.
It should be possible to ascertain within a few years whathas happened to the men who have been discharged for supposed incipienttuberculosis. If that diagnosis was correct the incipient cases should in partat least have gone on to develop manifest tuberculosis of the lungs. If such menare not discharged on account of their incipient tuberculosis and iftuberculosis is readily transmissible from one adult to another, each one whoremains in service would form a center of infection for his healthy comrades,who, moreover, are likewise endangered through contact with the seriouslyinfected civil population in billets and the like. Hence pulmonary tuberculosisis likely to grow worse in the Army the longer active service continues.
If the opposing view is correct, however, the elimination ofthe tuberculous individual from the Army would result in freeing the Army fromtuberculosis in direct proportion to the perfection of such elimination. Suchcases of active tuberculosis among soldiers as have escaped notice will breakdown under the conditions of military service if the disease is extensive and besuccessively eliminated so that active chronic pulmonary tuberculosis willbecome more and more rare.
The evil of the ultrarefined diagnosis of pulmonarytuberculosis is most conspicuously exhibited in the now celebrated 86,000soldiers of Landouzy,2 who, it was generallybelieved, had become infected with tuberculosis in the military service, a factthat not unnaturally excited considerable apprehension in the United States lesta similar evil befall American forces. But, according to Lereboullet,35M. Godert reported to the Senate from the War Office that from August 2,1914, to October 31, 1917, 80,551 men were discharged for disability fromtuberculosis not incident to the military service (r?form?s No. 2) and 8,879men for disability in line of duty (r?form?s No. 1) from the same cause. Theevil is infinitely less severe, M. Godert remarked, than the figures seem toshow without explanation, for 65,000 were determined to be tuberculous in thefirst year of the war and were eliminated without having been incorporated into,and therefore without having contracted their disease in, the army. From Januaryto October, 1917, 4,839 men were discharged from the army for tuberculosiswithout pension and 6,863 were pensioned. This relieved the French Army of muchof its had reputation as creator of tuberculous infection, but it remained toconsider the diagnosis in this large group of over 80,000 men. Late in 1917 acablegram was received in Washington from the French War Office which statedthat at that time it was believed that less than 50 per cent of this group werereally tuberculous. These figures, however, are most conservative, for Rist,2an undoubted authority, states that when clearing stations wereestablished for the purpose of securing a better diagnosis of tuberculosis, ofthe first 1,000 cases examined at one of them only 193 men were found to haveactive tuberculosis. He thinks that we are justified
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in believing that out of the 86,000 soldiers discharged fromthe French Army during the first year of the war less than 20 per cent werereally tuberculous, and adds "my personal impression is, much less than 20per cent." Many of these men no doubt had other diseases, but in allprobability it would not be an exaggeration to say that several divisions ofsoldiers (assuming 10,000 men for a division) might have been added to theFrench Army by a more correct diagnosis of tuberculous conditions at a time whenFrance was most sorely beset. Between August, 1914, and December, 1918, 111,038French soldiers were discharged for tuberculosis, of whom 25,600 were pensionedand 85,438 were granted no pension. There were 12,220 deaths from this diseasein the French Army. France mobilized 8,410,000 men during the war.36
Conditions were nearly as bad in Germany. Fraenkel,37 oneof the most distinguished of German internists, writing in 1916, said that inthe endeavor to recognize tuberculosis as early as possible we have arrived atan overestimation of various relatively insignificant phenomena. Of thosediagnosticated as tuberculous, only 40 per cent were really so; 40 per cent hadother diseases; 20 per cent had no disease at all. Bl?mel reports that ofofficers and men who had been declared temporarily or permanently incapacitatedfor military service on account of pulmonary tuberculosis, about 80 per cent ofthose whom he examined proved not to be tuberculous.38 Neverthelessthe tuberculosis situation in the Army of Germany seems to have become highlysatisfactory, for the errors of diagnosis complained of consisted indiagnosticating tuberculosis too readily rather than in failure to find thedisease when it was present in a manifest form. Goldscheider39 stated expresslythat the overlooking of slight manifest conditions seemed to have rarelyoccurred.
Experience in our Army has long shown that pulmonarytuberculosis is discovered in the majority of cases in the early months ofmilitary service. But men with small and chronic tuberculous lesions (andoccasionally with surprisingly large lesions) are often unconscious of theirdisease.
In connection with diagnosis, and particularly as regardstuberculosis as a cause of rejection for military service, Circular No. 20,quoted above, was written from the standpoint of what may be called the regularschool. Since it was designed especially for use in connection with theexaminations for entrance into the Army, it does not take up the more acuteforms of tuberculosis, but notwithstanding this omission it was used in theinstruction of medical officers. No change of importance was made in its test,and the chief point upon which experience showed that more light was needed wasthe size of the obsolete lesion which would justify rejection. The efforts ofmedical officers to commit the Surgeon General's Office to the definition ofsuch a lesion by extent as measured by inches or by ribs and vertebr? wereresisted for the reason that not only the extension of a lesion but also theseverity of the tuberculous process which gave rise to it (determined by thedensity of fibrous tissue, existence of cavity, and the like) was of importance.The most radical position taken was the insistence upon moist r?les as the onlyphysical sign which justifies the diagnosis of activity. There the writer wassupported not only by his own clinical experience but also by the opinions ofPi?ry40 of France, Goldscheider41 of Germany, and many others.
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The diagnosis of tuberculosis became more than ordinarilydifficult during the war on account, first, of the prevalence ofbronchopneumonia due to streptococcus infection which, with the exception of asputum positive for the tubercle bacillus, sometimes gave all the classicalsigns of pulmonary tuberculosis, including hemoptysis. At a later period manyunresolved pneumonias following influenza still further complicated a difficultsituation. At some camps so many men were discharged without warrant fortuberculosis during these epidemics that it became necessary to issue the orderthat no one should be discharged with that diagnosis unless the sputum was foundto contain tubercle bacilli.42 This course met with manyremonstrances at first but was finally approved by all as the only possiblemeans of averting what promised to become a great evil. And, it may be pointedout, the requirement of a positive sputum was the more warranted because thetuberculosis imitated by other diseases was not the obscure and doubtful formsof the disease, but a frank and extensive tuberculosis which would almostwithout doubt be attended by sputum containing many tubercle bacilli. At a latertime, in order to provide for cases still occasionally encountered, the orderwas modified to permit the report of old and extensive cases of fibrosis, thoughthe sputum be negative, with a view to their discharge, the decision as to eachcase remaining, however, in the hands of the Surgeon General.43 Sucha limitation was proved to be necessary in practice because some medicalofficers (not specialists) appeared to be of the opinion that the denominationof cases as those of fibrosis was simply a device to get rid of any and allcases of supposed tuberculosis irrespective of the absence of any evidence ofthe existence of a large and old lesion.
Considerable pressure was exercised during the first monthsafter the United States entered the war by a number of prominent physicians andradiologists to induce the Surgeon General to make the radiograph the decisivefactor in the diagnosis of pulmonary tuberculosis. The claim was that the workcould be done with great rapidity and accuracy, that the negatives were easilystored in a comparatively small space and would form a permanent and more orless infallible record which would not only be of great scientific value butwould also decide better than the results of physical examination as to thenecessity of rejection, 90 per cent approximately of the men being accepted ontheir radiographs without further examination of the lungs, leaving theremaining 10 per cent for further study. Even granting that all of the aboveclaims were well founded, it was evident that the practical difficulties in theway of the adoption of this plan were insuperable. Not to mention the enormouscost of photographing the entire new Army and the impossibility of obtaining asufficient number of plates within a reasonable time, the lack of trainedradiologists had to be considered. How serious this objection was is shown bythe fact that several X-ray schools were kept in operation for many months inorder to train technicians who after the brief course of training could stillhardly be regarded as experts in the determination of tuberculous lesions fromthe radiograph. A technical service of the magnitude required could evidentlynot be made ready to function efficiently until long after the time when thedecisions of which it was claimed to be the most trustworthy
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arbiter had perforce been made and the subjects for the mostpart dispatched overseas. A subcommittee of the general medical board of theCouncil of National Defense undertook a test to determine practically the meritsof the proposed scheme. All of the members of certain companies of the 69th NewYork Regiment, National Guard (later renumbered the 165 Regiment of UnitedStates Infantry), were photographed by the X ray. Certain men diagnosed astuberculous by this means were examined subsequently by an examining boardcomposed of experts in physical diagnosis from New York City. For variousreasons the total number of those who could be obtained for reexamination wasonly 25. Of these, 21 were found to have no abnormal physical signs, 1 haddistinct signs of apical involvement with r?les in both apices but no symptoms,and 3 had only slight or equivocal signs, of whom but 1 gave pulmonary symptoms.The last 4 men were rejected, 1 of them, however, not on account of physicalfindings, but because of suspicious history and radiograph. The board wasdisposed, as will be noted, to be most liberal in its concessions, but itsfindings can hardly be said to make out a good case for the method which in thisinstance was put into effect by skilled radiologists
How the method would have worked out at Army camps on a largescale is best shown by the experience at Camp Lewis, Wash.-a camp the medicalrecords of which are more than usually accurate and detailed-with men of thesecond draft; that is, at a time when the X-ray services had become wellorganized:44
Of 570 men rejected for clinically evident tuberculosis, theRoentgenologists recognized 54 per cent as tuberculous. In another group of 343men, who, the Roentgenologists stated, were unqualifiedly tuberculous andshould be rejected on X-ray findings alone, irrespective of physical findings,only 315 were rejected after physical examination. The remaining 28 wereconsidered either to be nontuberculous or to have obsolete lesions and wereaccepted for service. We have been able to follow these men through theirmilitary career and none has developed tuberculosis. Among another group of1,500 men whom the Roentgenologists diagnosed as very suspicious oftuberculosis, physical examination revealed only 128 cases of tuberculosis whichwere rejected. No cases of tuberculosis developed among the remaining 1,372accepted for service.
The position taken in the Surgeon General's Office withregard to the X ray in the diagnosis of pulmonary tuberculosis was that whilethe radiograph is a very valuable, indeed, indispensable adjunct in thediagnosis, it can not be relied upon exclusively for that purpose because it notonly fails sometimes to reveal early tuberculous changes but it also does notalways indicate whether the lesions shown are active or obsolete.
Circular No. 20 forbids the general use of tuberculin forpurposes of diagnosis in the individual case in Army examinations, the reasonsfor which hardly need to be set forth here. It may be remarked, however, that ingiving the indications for the use of tuberculin in general an absolutely exactdiagnosis of the condition of the lungs is always tacitly assumed as apreliminary to its administration. This assumption, however, can not be safelymade with reference to the average medical officer any more than to the averagepractitioner in civil life. Tuberculin given blindly or with an incorrectappreciation of the degree of activity of the tuberculous process which may bepresent in the given case is a dangerous substance.
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MANAGEMENT AND TREATMENT
The treatment of tuberculosis as a disease does not differ,of course, in military practice from the well-recognized rules that govern incivil life. Certain difficulties, however, are met in Army hospital managementto which it may be well to refer briefly. Tuberculosis being the "socialdisease," every layman feels competent to hold opinions on the subject ofits treatment, especially its climatic treatment, and the population readilydivides itself into groups which hold differing views with regard to twoquestions. First, shall or shall not the tuberculous patient be dischargedpromptly; second, shall he be treated near his home or shall he be sent far awayto climates reputed to be most curative for his disease?
The officers of charitable institutions and associations holdstrongly to the view that the tuberculous individual shall be retainedindefinitely in the Army. To many others it seems almost self-evident that heshould be discharged as soon as the diagnosis is established. The anxiousmothers, especially, who, in view of much unopposed criticism of the Army and ofArmy methods, not unnaturally are disposed to believe anything that is bad andare quite unprepared to believe anything good of Army hospitals, generallyinsist that their boys shall come home at once or at least be cared for ininstitutions near at hand. The treatment of the tuberculous near their homeshas had many advocates, while, on the other hand, there are those who demandthat they shall be given the advantages of the best possible climate.
With such difference of views the demands of the opposingparties to a certain extent neutralize one another. It adds greatly, however, tothe labor of administration that so many feel justified in seeking to imposetheir views as to the proper procedure in a given case upon the Armyauthorities.
The desire of the Surgeon General was to retain thetuberculous in the Army for a considerable period, long enough for them toattain the maximum degree of improvement of which they were capable.45 Ina certain class of patients, those possessed of considerable wealth, theobjection was raised that they were able to procure for themselves the best ofsanatorium care and of medical treatment. With this class in view, an order wasissued that patients might be discharged if they satisfied their commandingofficers that they were able to provide and would provide for themselves careand treatment as good as that which they sought to relinquish. This provisionwas inevitably supposed to be a mere device for circumventing the regulationsof the Army, and many illiterate affidavits from presumably poor persons as toplans for care and treatment were submitted in support of requests fordischarge.
These difficulties were largely met by a campaign ofeducation. In case of persistent application for the discharge of soldiers theaid of the nearest American Red Cross organization or tuberculosis associationwas solicited, which sent their workers to instruct the family as to the natureof the tuberculosis hospitals, the excellence of their medical officers, theaims of the Surgeon General, etc. Likewise the commanding officers oftuberculosis hospitals prepared circular letters which set forth the facts as totheir hospitals in a similar way. In case some public man was insistent upon aparticular soldier's discharge, he was asked if he was prepared to guarantee,personally, that treat-
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ment and care equal to that furnished by Army hospitals wouldbe provided for the man whose discharge he sought, and when discharged the RedCross or other agencies were notified and sent in a report as to what hadactually been done for the individual in question. By thus bringing homeresponsiblity for courses recommended and by educating the families which hadbeen making trouble, much good was effected. The trouble making was found to belargely due to pure ignorance and baseless assumptions which a littlewell-directed effort served to dissipate.
Early in the war a circular inquiry as to the best size oftuberculosis institutions brought forth the unanimous opinion of the civilianexperts that small sanatoria were better than large. Nevertheless, the scarcityof competent medical personnel and the greater difficulties in the way ofbuilding, organizing, and properly inspecting a large number of small hospitalsled to the decision to depend, ultimately at least, upon a smaller number oflarge hospitals.
The chief objection raised as to the large tuberculosisinstitution is the loss of that close personal contact of the physician with hispatient which is possible in the small groups. This would be a real objection ifthe care of the expert were necessarily exercised over a much larger number ofpatients in the large institutions. It is assumed by those who object that thechief alone will be competent to exercise the proper influence over hispatients. But if the staff were composed of medical officers who were allequally competent, this objection would cease to have force. This is an idealcondition which, it must be admitted, is rarely attained anywhere. However, themethod adopted in the Army to meet the above objections is worthy ofconsideration.
In a large tuberculosis hospital the patients are dividedinto sections by wards or other groupings. The commanding officer, if atuberculosis expert- if not, the chief of service-selects the bestassistants to be placed in charge of the individual sections. He is responsiblefor the selection of those in charge of sections, and should exercise theclosest supervision over them, inspecting their work frequently, visiting alsothe individual patients at random from time to time to learn their views as totheir treatment and what they have been taught as to their own cases, thereasons why they are treated as they are, etc. He should be accessible as topurely medical matters by all of his staff, who should look up to him as theirchief counsellor and fellow worker. The medical officers in charge of sectionsexercise equal care in the supervision of their assistants. The endeavor is toenforce in every way a treatment, consisting largely in regimen, which can onlybe carried on with success if the patients understand what is aimed at and howthey should cooperate with their physicians, and if they are made to see thattheir physicians are competent and are interested personally in their welfare.Such a treatment must necessarily be standardized in the sense that there shallnot be a change of diagnosis and of treatment when physicians are changed ortransfers of patients elsewhere effected; otherwise there is chaos. The endeavorwas made to put into effect such a program, which presupposes a high degree ofenthusiasm and much hard work. A good beginning was made toward its realizationby the senior medical officers of our hospitals, but unfortunately the suddencessation of the war interrupted, to a considerable extent, the development ofthe method to the
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attainment of the best results, since there was a desire fordischarge on the part of many medical officers, and a relaxation of theprofessional enthusiasm and of the energetic work which had been so gratifyingduring the war. The management of a large tuberculosis hospital demands a staffof the highest quality. With such a staff there seems to be no reason why thelarge tuberculosis hospitals shall not be conducted with success.46 Butthe writer ventures to express, in this connection, an opinion in which hediffers from many officers of our Army, which is that the commanding officer ofsuch a hospital should himself be a tuberculosis expert, not a mereadministrator. Either that, or he should be required to efface himself, so faras medical questions are concerned, in favor of the chief of the medicalservice. But the commanding officer, in the writer's judgment, is, by virtueof his official position, the officer who can best coordinate the activities ofhis subordinates.
Before the World War, Fort Bayard, N. Mex., was the onlyinstitution in the Army devoted exclusively to the treatment of tuberculosis. Ithad capacity of some 400 beds. Early in the war the William Wirt WinchesterHospital, at New Haven, Conn.-a hospital built in the most substantial mannerexpressly for the treatment of tuberculosis-was leased for the duration of thewar. By the erection of temporary wooden buildings its capacity was increased toa total of 500 beds. A sanatorium at Markleton, Pa., and a hotel at Waynesville,N. C., were also leased for temporary occupancy and increased to the capacity of270 and 500 beds, respectively, by the use of tents and the addition of woodenbuildings. Permission having been granted early in the war to use land atOtisville, N. Y., belonging to the New York City Municipal Sanatorium, it washoped that a hospital with a capacity of 650 to 1,000 beds might be welladvanced in construction before the onset of winter in 1917;47 but owing tovarious vexatious and unnecessary delays, chiefly due to the fact that thedetails of construction, of purchasing, and the like were required to be passedupon by many different departments, building operations were not begun untilmidwinter and the buildings were not ready for use until the summer of 1918. Thecapacity of the hospital was 650 beds. In the meantime a hospital with a1,500-bed capacity was built at Azalea, near Asheville, N. C., and a permanenthospital was constructed at Denver, Colo., with foundations of concrete and wallsof hollow tile, and with a capacity of 1,500 beds. The post of Whipple Barracks,near Prescott, Ariz., was also turned over to the Medical Department of the Armyand its permanent buildings were supplemented at first by ward tents, at a latertime by the construction of semipermanent hollow-tile structures, until thecapacity of 500 beds was reached. Fort Bayard also was enlarged to a capacity of1,000 beds by the erection of wards built of wood. At the time when tuberculouspatients were being most rapidly returned from Europe, use was made temporarilyof the base hospital at Camp Wadsworth, Spartanburg, S. C., as a tuberculosishospital, with a capacity of 1,000 beds. The total maximum capacity of 6,650beds, not including the hospitals at Markleton and Waynesville, was attained bythese means.48
In making such provisions the greatest difficulty of coursewas the impossibility of providing properly and at the same time not excessivelyfor the needs of an army the maximum strength of which could not be foreseen.The best
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approach to a solution of such a problem is the choice ofland and the preparation of plans in such a way that in case of need thehospitals can be enlarged without becoming cumbrous. Fortunately, since manytuberculous patients are benefited by an outdoor life, the use of tentage and ofeasily built shacks may avert temporarily the overcrowding of permanentbuildings without causing serious inconvenience.
MORTALITY
Deaths from tuberculosis (primary admissions) during thefiscal year ending June 30, 1918, among officers and enlisted men in the UnitedStates numbered 422 (ratio per 1,000 average annual strength, 0.35) and inEurope 389, the ratio per 1,000 average annual strength being 0.39. (In all themortality statistics of the Surgeon General's Office deaths occurring in menwho had developed tuberculosis in Europe are charged to Europe, wherever thedeaths may have actually taken place.) Deaths from pulmonary tuberculosis in1919, officers and enlisted men, were, in the United States, 613; in Europe,617. Of the deaths among enlisted men from pulmonary tuberculosis, 355 (a ratioof 1.27) occurred among white troops in the United States and 326 in Europe(ratio 0.67). Among the colored troops the deaths from pulmonary tuberculosis inthe United States were 243 (ratio 4.15). In addition, 42 deaths occurred frompulmonary tuberculosis in Europe, in cases in which the color is not stated. Theincidence of tuberculosis among the colored soldiers and their death rates fromthe disease are much higher than among white soldiers of the Army in the UnitedStates and Europe as a whole, but neither admissions nor deaths of coloredtroops differ materially from those of the white troops from the SouthernStates, from which part of the country the majority of the colored troops came.49In 1919, 674 deaths occurred from all tuberculosis, officers and men, inthe United States, and 781 in Europe.50 The type of disease in fatalcases of tuberculosis appeared to be more severe and acute in the later part ofthe war and after than in the early part. The total number of deaths frompulmonary tuberculosis in the Army from the beginning of the war up to January1, 1920, was 2,240.
DETERMINATION OF LINE OF DUTY
Prior to the World War, when a case came up for discharge onaccount of physical disability, medical officers of the Army were expected toexpress their opinion as to whether or not the disability in question had beenincurred in the line of duty; that is, whether it was or was not incident to themilitary service. This was to assist in determining whether or not theindividual was entitled to a pension. The tendency of those who had to do withsuch matters was always to give the soldier the benefit of any reasonable doubt,it being understood, however, that if the medical officer was in possession offacts, such as the admission by the patient that the disease had existed priorto enlistment, or satisfactory proof submitted by reputable individuals to thesame effect, the disability was not to be regarded as incurred in line of duty.But when the personal history was negative and the affection was of a chronicnature, particularly when it was chronic pulmonary tuberculosis, if the term ofservice before the disease was determined to be present was brief and there wasa man-
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ifest disproportion between the nature of the lesions(fibrous changes and the like) and the time within which they must havedeveloped if first contracted after the patient had entered the militaryservice, the disability was usually classed as not contracted in the line ofduty. But even in such cases, if there was evidence of unusual exposure or ofintercurrent disease which might reasonably be expected to have aggravatedmaterially positively existing pulmonary disease, the disability was consideredas incurred in the line of duty. Thus, a soldier was so classed, though of briefservice and presenting evidence of extensive chronic pulmonary tuberculosis, whohad been compelled to stand immersed deeply in sea water for 24 hours at thetime of the Galveston flood, it being held that the excessive exposure to coldand the deprivation of food and drink for so long a period might be expected tomaterially aggravate his lung affection and therefore entitled the soldier to apension. Infringement upon the rights of the individual in such matters wastherefore always carefully guarded against; in fact there can be no doubt thatmany a man was granted a pension when there were good grounds for the beliefthat the disability in his case was of much longer standing than his militaryexperience could account for.
Two views were held with regard to this matter. One was that,the soldier having submitted to the required physical examination and havingbeen passed by the examiner, the Government was responsible for the character ofthe physical examinations and could not rightfully impugn the competence of itsagent in claiming that he had erred, but was bound to abide by his decision thatthe individual at the time of his examination was free of disqualifying defects,so that any disability found at a later time was without question to be regardedas incident to the military service.51 The other view was that, asthe courts are understood to have ruled, the Government can not be made tosuffer on account of the error of its agents; specifically in the presentinstance it might be put that it is unjust that the people should be taxed topay a pension which was not deserved. The Government had the right, therefore,to investigate each case and decide on the evidence of whether or not thedisability was pensionable. This latter view was the one generally adopted.
Circular No. 24, Surgeon General's Office dated September11, 1917, was designed to furnish a standard for disability boards. It providedthat, if in pulmonary tuberculosis the disability is detected in less than threemonths after the entrance of a man into the service, it will be regarded as notin line of duty unless of an acute type or unless the man had been subjected toextraordinary exposure or had had an aggravating intermittent disease. Thiscircular, conflicting as it inevitably would, with the wishes of manyindividuals, encountered so much opposition that it was finally revoked and inthe summer of 1918 a change was made in the Manual for the Medical Department tothe effect that any soldier who shall have been accepted on his first physicalexamination after arrival at a military station as fit for service shall beconsidered to have contracted any subsequently determined physical disability inthe line of duty unless such disability can be shown to be the result of his owncarelessness, misconduct, or vicious habits, or unless the history of the caseshows unmistakably that the disability existed before entrance of the soldierinto the service.
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By some medical officers "history" was understoodto include the course of former pathological processes (particularly theevidence of fibrotic changes) as determined by the physical signs. It was heldwith regard to this point that while without doubt in many cases it can beassumed with practical certainty that the disease has existed for many years, atthe same time it is not safe to give general permission to depend upon physicalsigns for the determination of the age of lesions, and the word"history" in the preceding paragraph should be considered to meansolely the personal recollection and such other data (recollections ofrelatives, of comrades, and the like) as may constitute the medical record ofthe past life of the individual in question. But though so much was conceded tothe soldier by these orders, it was not enough, for several acts of Congressdefined with increasing liberality the position of the Government toward thetuberculous individual, until at last it became the law that every commissionedofficer, or enlisted man, or any other member of the military service whosuffers a disability from disease contracted in line of duty shall be entitledto compensation, provided that the disease has not been caused by his ownwillful misconduct; that for the purpose of compensation all such persons shallbe held to have been in sound condition when examined, accepted, and enrolledfor service; and that these provisions shall be deemed to become effective as ofApril 6, 1917.52
The following data concern discharges for tuberculosis ofenlisted men in the United States in 1917: In line of duty, 349; not in line ofduty, 3,327.53 That is, in the opinion of the medical officers most conversantwith the facts, the number of soldiers who had incurred manifest tuberculousdisease as the result of military service was to the number of those who hadbrought the disease with them into the Army approximately as 1 to 10. In realityit is probably considerably less than 1 in 10. It is out of place to commentupon this ratio here further than to call attention to the fact that the figuresas to tuberculosis in our Army do not represent the incidence of the diseaseunder the conditions of military service. Similarly a marked rise in the numberof admissions for tuberculosis at a given camp is not to be interpreted as asudden breaking down of large numbers of men under the conditions of militaryservice nor as an acute epidemic of tuberculosis from recent infections but,rather, as due to the activities of an examining board which detected during itsroutine examinations the presence of tuberculous lesions in men who before theexamination had for the most part been doing full military duty and in all probabilityhad not suspected that they were ill, such men being admitted to sickreport for the better determination of their cases and as a preliminary todischarge. In some instances, however, local variations in individual commandsor in special sections of the country present a more complicated problem.
REFERENCES
(1) Telegram from the Surgeon General, U. S. Army, to division surgeons (of six different camps), dated September 17, 1917. Subject: Ordering special reexamination. On file, Record Room, S. G. O., 172229 (Old Files).
(2) Rist, Edouard, Maj., M. C., French Army: The Problem of Pulmonary Tuberculosis. The Military Surgeon, Washington, 1917, xli, No. 6, 659.
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(3) S. O. No. 120, W. D., May 24, 1917, paragraph 38; S. O. No. 143, W. D., June 21, 1917, paragraph 50; also, letter from Col. George E. Bushnell, M. C., to Col. Charles Lynch, M. C., May 4, 1921. On file, Historical Division, S. G. O.
(4) Biggs, H. M.: A War Tuberculosis Program for the Nation. American Review of Tuberculosis, Baltimore, 1917, i, No. 5, 257.
(5) Examination of Soldiers for Tuberculosis, June 27, 1917. On file, Record Room, S. G. O., 181927 (Old Files).
(6) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, June 26, 1917. Subject: Detail of officers in Medical Reserve camps for duties as specialists in Army camps. On file, Record Room, S. G. O., 089101 (Old Files).
(7) Circular, War Department, July 16, 1917. Subject: Examinations of commands at camps for tuberculosis by board of medical officers. On file, Record Room, S. G. O., 189101 (Old Files).
(8) Bushnell, G. E., Col., U. S. A.: How the United States is Meeting the Tuberculosis War Problem. The Military Surgeon, Washington, 1918, xliii, No. 2, 127.
(9) G. O. No. 90, W. D., July 12, 1917.
(10) War Department Annual Reports, 1918, Vol. I, 1103.
(11) Reports, Tuberculosis Boards. On file, Record Room, S. G. O., 730.
(12) Annual Report of the Surgeon General, U. S. Army, 1918, 343.
(13) Telegram from the Surgeon General, to all camp surgeons and other senior surgeons of commands, April 29, 1918. Subject: Single examination. On file, Record Room, S. G. O., Correspondence File, 327.2 (Examinations).
(14) Matson, R. C., Maj., M. C. U. S. Army: The Elimination of Tuberculosis from the Army. American Review of Tuberculosis, Baltimore, 1920, iv, No. 5, 398.
(15) Instructors of School of Tuberculosis Examiners. On file, Record Room, S. G. O., 176001-144 (Old Files).
(16) Annual Report of the Surgeon General, U. S. Army, 1918, 344.
(17) Ibid, 119.
(18) Ibid, 219.
(19) Personal communications to the author.
(20) Brewer, Isaac W.: Tuberculosis Among the Indians of Arizona and New Mexico. New York Medical Journal, 1906, lxxxiv, No. 20, 981.
(21) Cabot, Richard C.: In Conference on Tuberculosis of the Lungs. War Medicine, Paris, 1919, ii, No. 6, 978.
(22) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1070.
(23) Letter from the Surgeon General, U. S. Army, to Dr. Edouard Rist, Geneva, Switzerland, January 28, 1920. Subject: Occurrence of tuberculosis in the Army. On file, Record Room, S. G. O., 702-5.
(24) Webb, Gerald B.: Some Lessons of the War in Pulmonary Tuberculosis. Transactions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, xxxv, 114.
(25) Glomsett, D. J., Maj.: What Can We Learn Regarding Pulmonary Tuberculosis from the Opportunity Afforded by the General Postmortem? War Medicine, Paris, 1919, ii, No. 6, 993.
(26) Borrel, A.: Pneumonie et tuberculose chez les troupes noires. Annales de l'Institut Pasteur, Paris, 1920, xxxiv, No. 3, 105.
(27) Roubier, Ch.: Sur la Tuberculose chez les troupes noires. Paris m?dical, 1919, xxxiii, No. 37, 207.
(28) N?geli, Otto: Ueber H?ufigkeit. Localisation und Ausheilung der Tuberkulose. Virchow's Archiv f?r pathologische Anatomie und Psysiologie und f?r klinische Medicin, Berlin, 1900, clx, No. 2, 426.
(29) Opie, Eugene L.: The Focal Pulmonary Tuberculosis of Children and Adults. Journal of Experimental Medicine, New York, 1917, xxv, No. 6, 855; and xxvi, No. 2, 263; also: First Infection with Tuberculosis by Way of the Lungs. American Review of Tuberculosis, Baltimore, 1920, iv, No. 9, 629.
(30) Cummins, S. Lyle: Tuberculosis in Primitive Tribes and Its Bearing on the Tuberculosis of Civilized Communities. International Journal of Public Health, Geneva, 1920, i, No. 2, 137.
202
(31) Bruns, Earl H., Lieut. Col., M. C.: The Tuberculosis Situation in the American Expeditionary Forces. Unpublished Report to the Surgeon General, U. S. Army. On file, Record Room, S. G. O.
(32) Bushnell, George E., Col., M. C., U. S. Army: A Study in the Epidemiology of Tuberculosis. William Wood and Company, New York, 1920, 97.
(33) Freund, Heinrich: Ueber cutane und conjunctivale Tuberkulinreaktion bei Gesunden und Kranken. Wiener medizinische Wochenschrift, Wien, 1908, lviii, 1242; 1302.
(34) Hamburger, F.: Die Ueberlegenheit der Stichreaktion ?ber die Kutanreaktion. M?nchener medizinische Wochenschrift, M?nchen, 1919, lxvi, part 1, No. 4, 100.
(35) Lereboullet, P.: Les questions actuelles de tuberculose. Paris m?dical, 1918, xxvii, No. 1, 1.
(36) Gallagher, Joseph F., First Lieut., M. C.: Statistical R?sum? of the French Medical Service. The Military Surgeon, Washington, 1920, xlvi, No. 5, 579.
(37) Fraenkel, A.: Ueber Lungentuberkulose vom milit?r?ztlichen Standpunkie aus. M?nchener medizinische Wochenschrift, M?nchen, 1916, lxiii, part 2, No. 31, 1109.
(38) Bl?mel: Die Fehldiagnose Lungentuberkulose bei Beurteilung der Felddienstfahigkeit. Medizinische Klinik, Berlin und Wien, 1915, xi, August 8, 884.
(39) Goldscheider: Aufgaben und Probleme der inneren Medizin imKriege. Zeitschrift f?r Tuberukulose, Leipzig, 1915-16, xxv, No. 1, 36.
(40) Pi?ry: Le Poumon de guerre. Revue g?nerale de pathologie de guerre, Paris, 1916, i, 509.
(41) Goldscheider: Diagnose und Prognose der Lungentuberkulose vom Standpunkt des Praktikers. Berliner klinische Wochenschrift, Berlin, 1917, liv, No. 53, 1266.
(42) Letter from the Surgeon General to commanding officers of all base and general hospitals, April 15, 1918. Subject: Discharge of tuberculosis patients. On file, Historical Division, S. G. O.
(43) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, July 2, 1918. Subject: Discharge on account of pulmonary tuberculosis. On file, Record Room, S. G. O., 220.8, G. H. No. 18 (k).
(44) Matson, R. C., Maj., M. C., U. S. Army: The Value of Chest Fluoroscopy. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 26, 1887.
(45) Hospitals designated for reconstruction of disabled American soldiers and policy to be pursued outlined by the Surgeon General. Official Bulletin, published daily under order of the President of the United States, by Committee on Public Information, Washington, D. C., April 2, 1918, ii, No. 273, 8.
(46) Hoagland, H. W.: The Treatment of Tuberculosis in the Army Hospitals. Transactions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, xxxv, 21.
(47) Annual Report of the Surgeon General U. S. Army, 1918, 344.
(48) Ibid., 1919, ii, 1072.
(49) Ibid., 1919, i, 51.
(50) Ibid., 1920, 178.
(51) Memorandum on the question of line of duty, November 7, 1914. On file, Record Room, S. G. O., 153517 (Old Files).
(52) War risk insurance act, with amendments prior to July 1, 1918. In special Regulations No. 72, Washington, Government Printing Office, 1919, 90, and amendments to war risk insurance act in Bulletin 7, War Department, April 17, 1923, 26.
(53) Annual Report of the Surgeon General, U. S. Army, 1918, 158.
