CHAPTER XI
Tuberculosis
Esmond R. Long, M.D.
Part I. Tuberculosis in the Army
HISTORICAL PERSPECTIVE
For centuries, tuberculosis has been a principal cause ofdeath in men of military age. In the 4-year period 1942-45, pulmonarytuberculosis, although steadily declining in prevalence throughout the country,was still the chief cause of disease death in the United States in men betweenthe ages of 15 and 35 years. In most countries of the world, the relativeimportance of tuberculosis was much greater than in the United States. In allarmies in all countries, whenever accurate records have been kept, it has provedto be a leading cause of disability, adding appreciably to the noneffectiverate, making disproportionate demands upon the time and effort of medicalofficers as well as upon hospital and transport facilities needed for otherdiseases and for battle casualties.
The U.S. Army has maintained records of hospital admissionsand military discharges for tuberculosis since the Civil War. An account of thisdisease as a military problem appeared in the "Medical and Surgical Historyof the War of the Rebellion" (pt. III, vol. I, Medical History) preparedunder the direction of The Surgeon General and published in 1888. During nearly51/6 years of military mobilization andoperation, 13,499 admissions for consumption and 5,286 deaths in white soldierswere reported. As calculated from these figures, the admission rate was 5.7 andthe mortality rate was 2.2 per 1,000 per annum (table 46). In view of therelatively limited diagnostic facilities of the period, it is reasonable tosuppose that the actual incidence was very much higher. As a matter of fact thereporting itself was at fault, for the figures for discharge are higher than thenumber of hospital admissions for consumption. The records indicate that 20,403white soldiers were discharged because of this disease, an excess of 12,190 overthe admissions, and this figure does not include those who died of consumption.The reasons for the discrepancy are complex, involving multiple causes ofdisability and the return of consumption cases to duty. The mean annual rate ofdischarge for consumption in the Army in the Civil War, calculated from thefigures given in the "Medical and Surgical History of the War of theRebellion," was 8.6 per 1,000 for white soldiers and 3.1 per 1,000 forNegro troops.
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[Rate expressed as number per annum per 1,000average strength]
Diagnosis and race |
| Deaths | Disability separations | |||
| Rate | Number | Rate | Number | Rate | |
Consumption: |
|
|
|
|
|
|
| White | 13,499 | 5.67 | 5,286 | 2.23 | 20,403 | 8.58 |
| Negro | 1,331 | 6.94 | 1,211 | 6.32 | 592 | 3.08 |
|
| 14,830 | 5.77 | 6,497 | 2.53 | 20,995 | 8.17 |
Scrofula: |
|
|
|
|
|
|
| White | 6,022 | 2.53 | 99 | 0.04 | 907 | 0.38 |
| Negro | 2,508 | 13.08 | 81 | .42 | 147 | .77 |
|
| 8,530 | 3.32 | 180 | 0.07 | 1,054 | 0.41 |
Other tubercular diseases: |
|
|
|
|
|
|
| White | 369 | 0.16 | 33 | 0.01 | --- | 0 |
| Negro | 20 | .10 | 4 | .02 | --- | 0 |
|
| 389 | 0.15 | 37 | 0.01 | --- | 0 |
Total tubercular diseases: |
|
|
|
|
|
|
| White | 19,890 | 8.36 | 5,418 | 2.28 | 21,310 | 8.96 |
| Negro | 3,859 | 20.12 | 1,296 | 6.76 | 739 | 3.85 |
|
| 23,749 | 9.24 | 6,714 | 2.61 | 22,049 | 8.58 |
1Data for Negro troops are for the period, July 1863-June 1866; there were no Negro troops prior to July 1863 in the Union Army.
Source: The Medical and Surgical History of the War of the Rebellion. MedicalHistory. Washington: Government Printing Office 1875, pt. I, vol. I, pp.636-637, 646, 710, and 716.
In the short Spanish-American War moderately high rates were recorded. Forthe decade preceding hostilities the average admission rate in the Army was 2.7per 1,000 per annum, but in 1898, following accelerated enlistment and the callof the National Guard to service, it rose to 3.7, and in the following yearreached 4.0.
In neither the Civil War nor the Spanish-American War,however, was tuberculosis considered of sufficient moment to call for unusualcomment in the recorded analyses of the medical aspect of military operations.It was entirely different in World War I. The French Army recorded a greatincrease in the incidence of pulmonary tuberculosis during the first 5 months,especially in French prisoners returned from Germany. The French experience wassufficiently striking to engage the prompt attention of American authorities,who set up special machinery for the control of tuberculosis in
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the U.S. Army. These procedures have been described at length by Col. GeorgeE. Bushnell, MC, and Col. Esmond R. Long, MC.1
Following demobilization, the incidence of tuberculosis in the U.S. Armydecreased continuously for 20 years. The incidence rate was 4.6 per 1,000 troopsper annum in 1920 and 1.4 in 1940. General improvement in measures for thecontrol of tuberculosis in the Army, and a steady decrease in tuberculosis inthe population were largely responsible for this decline.
DISCOVERY OF TUBERCULOSIS BEFORE INDUCTION
The magnitude of the tuberculosis problem in the Army inWorld War II, although substantial in the aggregate, was relatively much lessthan in any previous conflict. To begin with, a smaller proportion of meneligible for induction were tuberculous. In 1917, the national death rate fromthis disease was approximately 140 per 100,000 population. In 1941, it was lessthan one-third of that, or 45 per 100,000 population. The rejection ratio fortuberculosis, all forms, actual or suspected, among men examined at camps and bylocal boards during World War I was 2.3 percent. Nearly 3.8 million men wereexamined during World War I.2 Even with themuch superior diagnostic facilities of the Army in the Second World War, therejection rate was much lower from the onset, averaging less than 1 percent forthe entire period of mobilization.3
In World War I, the detection and exclusion from militaryservice of men with tuberculosis were based almost entirely on the results ofphysical examination. Roentgenology was in its infancy, and only a few thousandsoldiers were examined by X-ray. All experience since that time has indicatedthat physical diagnosis by even the most skillful, is much inferior to theroentgenographic methods in use at present. During the total course ofmobilization for World War II, not less than 20 million men were examinedroentgenographically in the Army enlistment stations and in the joint Army-Navyinduction stations. Colonel Bushnell's conclusion on the value of X-rayexamination in World War I is striking in the light of subsequent developments.It was based on the work of Matson,4 and reads:"As compared with the physical examination, the roentgenologicalexamination, even when done by an expert, occupies a place of secondaryimportance in the diagnosis of tuberculosis of clinical significance."However, as Spillman5
1(1) The Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1928, vol. IX, pp. 171-202. (2) Long, E. R.: The War and Tuberculosis. Am. Rev. Tuberc. 45: 616-636, June 1942. (3) Long, E. R.: Tuberculosis as a Military Problem. Am. Rev. Tuberc. 51: 489-504, June 1945.
2Britten, R. H., and Perrott, G. St. J.: Summary of Physical Findings on Men Drafted in the World War. Pub. Health Rep. 56: 41-62, 10 Jan. 1941.
3Medical Department, United States Army. Physical Standards in World War II. [In preparation.]
4Matson, R. C.: The Elimination of Tuberculosis From the Army. Am. Rev. Tuberc. 4: 398-416, July 1920.
5Spillman, R.: The Value of Radiography in Detecting Tuberculosis in Recruits. J.A.M.A. 115: 1371-1378, 19 Oct. 1940.
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wrote, the chest specialists of those days are "not tobe reproached for not having knowledge that came into existence only later, anymore than the chief of the army air service in 1917 is to be reproached becausemore efficient planes are available now than then."
During World War I, there were 22,812 disability separationsdue to tuberculosis, or 5.52 separations per annum per 1,000 average strength.If related to the number of men who served in the Army during the First WorldWar, the proportion would be about 0.56 percent. Tuberculosis was the leadingcause of disability separation, accounting for 11.1 percent of the total(204,765) and 13.5 percent of separations due to disease (169,039).6In World War II for enlisted men, it was 13th in the list, accounting for only1.9 percent of all discharges for disability from disease.7
The full magnitude of the tuberculosis problem incurred inWorld War I did not become evident until several years had passed. The postwarcost proved enormous. Goldberg8 calculated thatthe approximate expenditure of the Veterans' Administration forservice-connected tuberculosis, including hospitalization and pension costs,from the close of World War I through 1940 was $1,186,000,000. To this vastmonetary expense must be added millions of dollars spent by the Army and theNavy on tuberculosis patients prior to their discharge. Admissions to veterans'hospitals totaled 293,761 for the years 1921 to 1940, inclusive.
The peak load for hospitalized tuberculosis beneficiaries was reached in 1922when a total of 44,591 such patients were treated in Government hospitals at acost of almost $30 million.9 As early as 30June 1922, 36,600 veterans, or 1 in 130 persons in the Army, had been grantedcompensation for service-connected tuberculosis.
At the beginning of the Second World War, it was resolved notto repeat the experience of the First World War. It was recognized that theearlier high admission rate was largely due to the acceptance of men who werealready infected. In Colonel Bushnell's opinion, relatively few men developedfresh infection in the Army. It was clear to the Office of the Surgeon Generalthat modern methods could be highly effective in excluding the early types oftuberculosis that escaped recognition during the mobilization of 1917. Thereader is referred to the chapter on tuberculosis in another volume in thehistory of the Medical Department in World War II for the general proceduresemployed at induction stations, and for a picture of the enormous extent ofpreinduction examination by X-ray.10 Other
6The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1925, vol. XV, p. 2.
7Health of the Army, Office of the Surgeon General, vol. 1, 31 Aug. 1946.
8Goldberg, B.: Presidential Address: War and Tuberculosis. Dis. of Chest 7: 322-325, October 1941.
9Wolford, R. A.: The Tuberculosis Program of the Veterans Administration. M. Bull. V.A. 21: 127-135, October 1944.
10See footnote 3, p. 331.
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sections of the chapter describe measures to prevent the development oftuberculosis within the Army.
It is obvious that, in an army well screened to exclude menwith active tuberculosis, contagion among troops would be slight. However, itmust be realized that not all tuberculosis is visible in chest films and that acertain amount of pulmonary and nonpulmonary tuberculosis may be expected todevelop as a result of endogenous spread from undetected foci. The longer thewar, the more cases would develop from such hidden foci, and also from fresh,exogenous infections. In the Second World War, the period of mobilization and ofhostilities was more than twice as long as in the First World War. Hence, itwill not be surprising if research ultimately shows that tuberculosis spreadingfrom lesions not detectable at the time of mobilization, on the one hand, andfrom fresh infections, on the other, were together responsible for aconsiderably larger share of the total number of cases discovered in the Army inWorld War II than was believed to be the case in World War I.11
DISCOVERY OF TUBERCULOSIS IN THE ARMY
The general machinery for discovery of tuberculosis insoldiers after acceptance for service was the same as for any other chronicdisease; it was discovered both on the basis of symptoms and as a result ofroutine examination for any cause. Cases manifested by symptoms were diagnosedat sick call as suspected tuberculosis and were then referred to the stationhospital serving the post at which the call was made for necessary observationand further diagnostic procedures. All station hospitals were thus concernedwith the diagnosis of tuberculosis. Not all station hospitals, however, includedon their staffs medical personnel qualified to recognize tuberculosis of minimalextent or borderline activity. Doubtful cases were referred to general hospitalsfor followup and accurate observation.
11Long, E. R., and Jablon, S.: Tuberculosis in the Army of the United States in World War II. An Epidemiological Study With an Evaluation of X-ray Screening. VA Medical Monograph. Washington: U.S. Government Printing Office, 1 May 1955.
Postwar epidemiological and statistical study based on adequate sampling of men discharged with and without tuberculosis disclosed that approximately half of the men discharged for tuberculosis had the disease in roentgenologically detectable form at the time of acceptance for service, the lesions having been overlooked through induction station errors. There was reason to believe that of the other half a part represented new infections acquired in army service and a part the breakdown of old lesions not detectable by X-ray examination. Since routine tuberculin tests were not made at the time of induction, it was impossible to distinguish between these two groups. This study, in which all the films were read independently by two roentgenologists, with subsequent checking by two others, also disclosed a significant degree of fallibility in single chest X-ray interpretations. Not only did the two roentgenologists fail frequently to agree with each other, but in numerous cases they also failed to agree with themselves on reading the same films after an interval of a few months. It is now recognized that such discrepancy is general experience. The paper cites other reports in which similar lack of agreement was recorded. (See also Long, E. R., Stein, S. C., and Henderson, H. J.: Experiences With Dual Reading of Chest Photoroentgenograms. U.S. Armed Forces M.J. 7: 493-515, April 1956.) In the latter study, actual trial was made of dual reading in three Armed Forces examining stations. Comparison of the readings by the roentgenologist of the station of origin of the films and the roentgenologist of another station showed considerable disagreement in interpretation.
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In addition, a good many cases were discovered in the course of routine X-rayexaminations. Not a few were found in men applying for admission to officercandidate schools or for a commission at the termination of study in theseschools. Many were found also in routine examinations for special service,particularly in the Army Air Forces, where many men were reexamined.
Moreover, tuberculosis was sometimes discovered incidentallyto other illness requiring roentgenographic study. In the course of the longseries of epidemics of atypical pneumonia that occurred during World War II,vast numbers of roentgenograms were made of the chests of men with the symptomsof pneumonia. Not infrequently, shadows in the lung fields persisted afterclearing of the consolidation due to pneumonia and were shown by subsequentexamination to represent tuberculous infiltration. A high percentage of theseinfiltrations were found to be well-scarred lesions, but in an appreciablenumber the process proved to represent active tuberculosis, requiring continuedhospitalization.
INCIDENCE AND DISCHARGE RATES
Incidence rates-The average incidencerate in the First World War, approximately 12 cases of tuberculosis per 1,000men per annum for the years 1917 and 1918, was ten times that for World War II,which averaged 1.2 per 1,000 per annum between Pearl Harbor Day (7 December1941) and V-J Day (14 August 1945). (See chart 17.) Nevertheless, in spite ofbetter diagnostic facilities and techniques in the second great conflict, from10 to 15 men with active disease per 10,000 accepted escaped detection ininduction stations and were taken into the Army.12Moreover, about a million men in World War II were inducted into the Army beforeroentgenograms of the chest were a routine requirement.
There is reason to believe that in each war a high percentageof the missed cases were discovered within a few months after induction. As arule, although not invariably, symptoms soon became evident in advanced disease,leading to report at sick call, hospitalization, and diagnosis. This not greatlybelated recognition of tuberculosis in recently inducted men is believed toaccount for a peculiarity common to the admission rate curves of the two wars.In the late months of 1917 and early months of 1918, the rate of admission tohospital was excessive as compared with that for the last half of 1918. Asimilar phenomenon occurred in the last half of 1941 and first half of 1942. Itis believed that in each war imperfections in screening procedure were greaterand more frequent at the outset than later in the course of mobilization andthat an excessive number of men with disease that would soon become obvious wereinducted at that time.
12Long, E. R., and Stearns, W. H.: Physical Examination at Induction. Standards With Respect to Tuberculosis and Their Application as Illustrated by a Review of 53,400 X-ray Films of Men in the Army of the United States. Radiology 41: 144-150, August 1943.
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A second characteristic of the two curves is a terminal rise.This rise represents discovery of cases on demobilization and is in partfactitious. A number of cases per thousand that greatly exceeded the previousmonthly average were discovered in the course of the physical examinations atdischarge, which in World War II were as thorough as the induction examinationsand included routine roentgenograms of the chest. The increased
CHART 17.-Incidence of tuberculosis in theU.S. Army in the continental United States, World War I1and World War II
rate was artificially high because the strength of the Armyfrom which it was calculated in accordance with conventional practice wascontinuously decreasing in size as a result of the process of demobilization.
The admission rate was remarkable for its relative constancy over a period of3 years from mid-1942 to mid-1945, inclusive. The rate of about 1 case per 1,000troops per annum reflects the number of cases missed at induction stations, plusthe number that developed from new infections during service in the Army. At theclose of World War II, the necessary
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research to determine the amount of previously existent butunrecognized tuberculosis, as compared with that developing in the absence ofpreviously detectable disease, had not been accomplished.
The admission rates for the continental United States (chart18) were higher than those for oversea theaters. This difference during the warmight be attributed to the additional screening of troops through the rigors
CHART 18.-Incidenceof tuberculosis among U.S. Army troops in the United States and overseas,January 1942 to June 1946, inclusive
of basic training in the United States. The months ofphysically strenuous service, with daily sick call, and the frequent medicalexaminations for promotion or special service brought to light many men withtuberculosis, who were accordingly excluded from oversea assignment. Still morewould have been excluded had it been possible to examine by X-ray all menleaving for foreign service. This was impossible because of limitations both oftime and personnel, although there was a reasonably effective inspection beforedeparture, and roentgenograms of the chest were made in individual caseswhenever indicated by symptoms.
To the factors favoring the lower admission rates overseas,there existed a counterforce. In every theater of operations, the incidence oftuberculosis in the general population was higher than in the United States.There is
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reason to believe that this higher exposure was a significantfactor before the end of the war. Of men retained at separation centers in thelate months of 1945 and the first half of 1946 because of X-ray evidence oftuberculosis, a significantly large majority had seen foreign service. Thiscorrelation is indicated graphically in chart 19 and is in marked contrast tothe rates recorded for troops overseas and in the United States while at theirrespective stations. Until exhaustive research determines the origin of thelesions concerned, consideration will have to be given to twopossibilities: (1) The higher rate of apparent tuberculosis in men on theirreturn from foreign duty was the result of late development of lesions acquiredduring Army service overseas, and (2) the relatively low rate during foreignservice was due to a less effective case-finding program overseas, leaving manycases for discovery at separation centers. The latter explanation would seem notimplausible, in view of the superior facilities and more stable conditions inthe United States. As with other complex problems, it is probable that each ofthe factors named was in part responsible for the observed discrepancy.13
CHART 19.-Withdrawals from separationprocessing for pulmonary tuberculosis1in U.S. Army separation centers, July 1945 toAugust 1946
13Long, E. R., and Hamilton, E. L.: A Review of Induction and Discharge Examinations for Tuberculosis in the Army. Am. J. Pub. Health 37: 412-420, April 1947.
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Discharges from service.-With minorfluctuations, the discharge rate for tuberculosis ran parallel to the admissionrate throughout the war, averaging approximately two-thirds of the latter (chart20). The other one third comprised patients hospitalized for care and study,whose tuberculosis proved not to be active.
CHART 20.-Disability discharges fortuberculosis among enlisted men in the U.S. Army, 1942-45
Physical standards governing discharge from service by reasonof tuberculosis are discussed in another volume of the history of the MedicalDepartment in World War II.14 The generalprinciple was discharge of all men with active tuberculosis, with the exception of officerswhen there was reasonable likelihood that the disease could be thoroughlyarrested under treatment and the officer assigned to duty of a type for which hewas fitted by training and capacity. As a rule, discharge was not granted forinactive tuberculosis. Exception was made for lesions of proved activity withinthe period of military service and for lesions of such extent that breakdown wasconsidered likely even though no signs or symptoms of activity were detectedwithin the period of medical observation in the Army.
Of the several fluctuations in the rate of discharge, the only one ofsignificance, in relation to the general admission rate for tuberculosis, oc-
14See footnote 3, p. 331.
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curred in 1943. At that time, a change in administrativepolicy (War Department Circular No. 161, 14 July 1943) brought about a suddenmass discharge for disability of a large number of men classified as limitedservice. These men did not meet current mental and physical standards forinduction although at some previous period they had passed a preinductionphysical examination. Tuberculosis was not an official cause for limited servicein enlisted men, but it is believed that a good many borderline cases that hadconstituted a problem as to disposition were discharged from service during theoperation of this circular, which "brought about some relaxation in thegeneral policy of granting CDD's [certificates of disability for discharge]during that period."15 This policy wasmodified (War Department Circular No. 293, 11 November 1943) by prohibiting thedischarge for physical reasons of enlisted men who, although incapable ofserving in a physically exacting position, might render useful service in a lessexacting one.
The total number of enlisted personnel discharged from theArmy for tuberculosis in the years 1942-45 was 15,387. These were divided asfollows:
| Number |
1942 | 2,400 |
1943 | 4,643 |
1944 | 3,533 |
1945 | 4,811 |
|
| 15,387 |
The disease, as previously noted (p. 332), accounted for an average of 1.9 percent of all discharges for disability from disease, and was in 13th position in the listing of causes of disability discharge, the rate being exceeded, in numerical order, by psychoneurosis, musculoskeletal defects, psychosis, gastric and duodenal ulcers, respiratory diseases, arthritis, defects of the feet, neurological disease, ear disease, eye disease, organic cardiovascular disease, and genitourinary diseases.
Enlisted personnel discharged from the Army because oftuberculosis were transferred to the Veterans' Administration for furthertreatment if still in need of medical care, or to their own care if no longer inneed of medical therapy.
Part II. Occurrence in Oversea Areas
EUROPEAN THEATER OF OPERATIONS
Incidence rates-The incidencerate of tuberculosis in troops in the European Theater of Operations, U.S. Army,for the years 1942 to 1945, inclusive, was less than in troops in thecontinental United States, as a result of factors that have been described forthe Army as a whole (p. 336).
15See footnote 7, p. 332.
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Some men had entered the Army with undiscovered lesions, butmany of these were detected before assignment overseas. Subsequent study,however, indicated that the relatively low rate in oversea theaters could not beascribed solely to the exclusion of cases discovered during basic training,during special training, or incidentally to other illness. The rate of discoveryat separation centers in 1945 and 1946 in troops with foreign service wassignificantly higher than in those who had served only in the continental UnitedStates. It does not appear that this discrepancy was due entirely to newinfections acquired overseas, but, as has been noted, there is reason to believethat case-finding procedures were more effective in medical installations in theZone of Interior, which were relatively stable in location and personnel, thanin installations subject to all the vicissitudes of conflict.16
Lt. Col. (later Col.) Theodore L. Badger, MC, SeniorConsultant in Tuberculosis, European theater, reported a relatively low rate forall forms of tuberculosis in the theater, compared with that in the Zone ofInterior.17 Incidence rates for troops in theEuropean theater during 1942-45 and corresponding rates for troops in thecontinental United States are presented in table 47 for comparison.
[Data based on sample tabulations of individualmedical records]
[Rate expressed as number of cases per annum per 1,000 average strength]
Area |
| |||
| 1943 | 1944 | 1945 | |
Europe | 0.70 | 0.77 | 0.85 | 1.03 |
Continental United States | 1.86 | 1.27 | .97 | 2.13 |
The admission rate to a considerable extent reflects hospitalization of men reporting symptoms at sick call. X-ray surveys of unselected groups of supposedly healthy men, as a rule, reveal lesions in an early form that might not be expected to show symptoms for months. Such surveys were carried out under Colonel Badger's direction in England in 1943, on a total of 7,243 men. Seven cases of active tuberculosis were found, or 0.97 per 1,000 men examined. Ninety-one cases were discovered with small scarred lesions that appeared to be of no clinical significance; it may be assumed that a large proportion of them were within the group of healed lesions specified in Mobilization Regulations No. 1-9, 31 August 1940, as acceptable after a period of deferment and subsequent revaluation.
16See footnote 10, p. 332.
17Semiannual Report, Senior Consultant in Tuberculosis, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 1 Jan. 1945 to 30 June 1945.
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Another survey, reported in 1945, is of interest for comparison.18Chest roentgenograms of officer candidates at the Army Ground Forces Officers'Training Center, near Fontainebleau, France, carried out in April 1945 by MobileX-ray Team No. 3 of the 1st Auxiliary Surgical Group under the direction of 1stLt. (later Capt.) Harry W. Burnett, Jr., MC, brought to light only 2 cases ofactive tuberculosis and 2 cases of healed infiltrative tuberculosis among 5,240men examined. This yielded the low rate of 0.38 per 1,000 men each for activeand healed tuberculosis, and a combined rate of 0.76. This group cannot beconsidered as fully representative of the enlisted men in the theater, for itwas made up of selected men who had been sent to the officers' candidate schoolafter field demonstration of superior mental and physical fitness.
Another survey on a selected group was that made by the 365th StationHospital. In a report covering 2 years, from April 1942 to May 1944, while thishospital was stationed in Iceland, the section for respiratory disease madechest roentgenograms of 2,897 men from detachments of troops en route to theEuropean theater from the United States. The commonest disease in these men wasatypical pneumonia. Among the total number examined, however, there were 38cases of infiltrative active tuberculosis and 10 cases of pleurisy with effusionof presumed tuberculous etiology. In passing, it may be noted that this relativeproportion of cases of pleurisy with effusion to infiltrative tuberculosis wasobserved generally throughout the Army. The high proportion of activetuberculosis, namely, 1.7 percent, is not surprising in a group admitted to ahospital on the basis of respiratory symptoms. In the course of the survey, 24cases of healed infiltrative tuberculosis were seen, yielding a rate not greatlydifferent from that reported for the theater by the Senior Consultant inTuberculosis.
Disposition of tuberculous patients-Thedisposition of personnel discovered to have tuberculosis was based on the extentand severity of the lesion. An administrative memorandum, of 22 February 1944,19directed that all patients with active pulmonary tuberculosis or with largeinactive fibroid lesions the stability of which was open to question, that allpatients with serofibrinous pleuritis of known or suspected tuberculosisetiology, and that all patients with nonpulmonary tuberculosis should be"boarded" to the Zone of Interior.
Personnel with residual calcifications of healed primary tuberculosis orsmall fibrocalcific scars of infiltrative tuberculosis, apparently inactive,were returned to duty. Provision for limited duty and observation was made forborderline cases. The directive listed the tests commonly made to determineactivity, including laboratory study and observation by X-ray, and ordered
18See footnote 17, p. 340.
19Administrative Memorandum No. 22, Office of the Chief Surgeon, European Theater of Operations, to Surgeons, All Base Sections, Commanding Officers, All U.S. Army Hospitals, 22 Feb. 1944, subject: Disposition of Tuberculosis Patients.
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that "individuals presenting an undue risk of reactivation" beevacuated to the United States.
The European theater, unlike the Mediterranean Theater ofOperations, U.S. Army, had no hospitals formally established as tuberculosiscenters (p. 354). Patients with tuberculosis were treated in special sections ofmany hospitals, with established precautions to avoid exposure of hospitalpersonnel and other patients. Circular Letter No. 100, Office of the ChiefSurgeon, European theater, dated 25 July 1944, directed that "activepulmonary tuberculosis, however small the lesion, will be treated by absolutebed rest as soon as the diagnosis has been made." It was directed also thatcases of serofibrinous pleurisy of presumptively tuberculosis etiology, shouldbe treated by bed rest until at least 2 months had elapsed after return of pulseand temperature to normal. Pneumothorax was used only for emergency cases ofpulmonary tuberculosis with hemorrhage and for cases of such character that safetransport to the Zone of Interior appeared dependent on the establishment ofcollapse prior to evacuation. Finally, it was directed that "all cases ofactive tuberculosis * * * including serofibrinous pleurisy, will be boarded tothe Zone of Interior in Class II, as litter patients." Evacuation was bysea and by air. Air transportation was prohibited in pneumothorax cases and forcertain other patients with pulmonary tuberculosis by Circular Letter No. 102,Office of the Chief Surgeon, European theater, 4 August 1944. Air transportationwas authorized for patients with early tuberculosis not sufficiently advanced todisturb respiratory function.
Incidence in nurses-Many papershave been written on the special hazards of tuberculosis to nurses, usuallyascribing it to exposure to the unrecognized open case. According to most recentreports, the incidence in nurses is higher in general hospitals than ininstitutions for tuberculosis. The explanation usually given is that in thelatter the hazard is recognized and proper precautions are taken. In generalhospitals that have no special section for the care of tuberculous patients,undetected cases admitted to the wards may constitute a significant, unguardedsource for spread of the disease.
The semiannual report of the senior consultant in tuberculosis in theEuropean theater, dated 3 July 1945, called attention to an excessive andsteadily rising prevalence of tuberculosis, all forms, in nurses for the 3?years of the war. The rates, calculated from reports from the chief nurse of thetheater, as given by the senior consultant, are presented in table 48.
The mean rate for the 3? years was 3.8 times as high as the generaltuberculosis admission rate for troops in the theater. The report indicated that19 nurses developed pleurisy with effusion of presumptive tuberculous origin,and in 3 nurses other forms of active tuberculosis were found. The pleurisy witheffusion accounted for about 26 percent of the total number of cases oftuberculosis, a figure holding throughout the Army.
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TABLE 48.-Prevalence of tuberculosis, allforms, in U.S. Army nurses in the European theater, 1942-45
[Rate expressed as number of cases per annumper 1,000 average strength]
Year |
| Strength1 | Rate |
1942 | 0 | 5,832 | 0.00 |
1943 | 4 | 24,824 | 1.93 |
1944 | 30 | 133,723 | 2.69 |
19452 | 38 | 87,004 | 5.24 |
1Aggregate of end-of-month strengths.
2First 5 months only.
Colonel Badger, in analyzing the responsible factors, called attention to thecarelessness in technique that develops in times of strain and stressed thefailure of medical officers to maintain proper measures designed to preventspread of the disease in hospitals. He instituted special control measures inthose hospitals in which the greatest amount of open disease was encountered;namely, the Army hospitals in France that cared for large numbers of recoveredAllied military personnel liberated from German prison camps by the advancingAmerican Army in the Saar and Rhine regions.
After the close of hostilities in Europe, when it was expected that largenumbers of troops would be deployed to the Orient, specific directions wereissued to make routine X-ray examination of all nurses and other MedicalDepartment personnel prior to their departure.20It was impracticable to survey all personnel to be redeployed, but the specialhazard of tuberculosis to personnel of the Medical Department, and particularlynurses, warranted special consideration. A few weeks later, the Japanesesurrendered, redeployment to the Pacific areas was stopped, and special measuresfor the detection of tuberculosis were discontinued.
Incidence in Army Air Forces personnel-Exceptat the beginning of World War II, enlisted and commissioned personnel in theArmy Air Forces were accepted for enlisted services or appointment as officersin the same manner as Army Ground Forces and Army Service Forces troops; thatis, through regular induction stations, stations for enlistment, and stationsqualified to give final-type physical examinations. In the early months of thewar, the demand for air force personnel was so great that aviation cadets andothers were frequently accepted on the basis of a physical examination that didnot include roentgenograms of the chest, with the proviso that X-ray examinationwas to be made at the first duty station where it was practicable. The delayedX-ray examination was effective in discovering
20Circular Letter No. 60, Office of the Theater Chief Surgeon, Headquarters, Theater Service Forces, European Theater, 2 Aug. 1945.
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cases but had the disadvantage, from the point of view ofgovernmental obligation, that the men discovered were in the Army and usuallyeligible for compensation. Later, this unusually rapid processing wasdiscontinued, and prospective troops for the air forces were examined likeselective service registrants in general.
Careful followup studies indicated a low incidence of tuberculosis aftermonths or years of service in the Army Air Forces. A representative survey on77,016 troops of the U.S. Army Air Forces made in England, in September 1945,with the aid of two mobile trailer 35 mm. photoroentgen units, brought to lightonly 70 cases of tuberculosis considered active (5 of primary and 65 ofreinfection type), or 1 person in every 1,100 examined. Of the 65 cases ofreinfection type, 4 were far advanced, 10 moderately advanced, and 51 minimal.21The group, which was almost exclusively male, and composed of 14 percentflying and 86 percent nonflying personnel, was carefully examined to determineif there was any relation between development of disease and length and type ofservice. The evidence of the disease discovered in flying personnel wassignificantly lower than in nonflying personnel, a fact attributed to the moremeticulous and often repeated physical and roentgenographic examination of theformer. The incidence was greater than average in men who had not had an X-rayfilm on entrance, or had served a longer than average period of time without asecond or later film. These findings are as might be expected in view of theusual slow and insidious development of tuberculosis.
A study showed that a greater number of men who had consumed raw milk inEngland were among the troops with active disease than in those without disease,but the finding was believed related to the length of service rather than merelyto the ingestion of the milk. The earlier a soldier arrived, the longer hestayed, and the better acquainted he became with the civilian population, themore likely he was to consume raw milk. Vigorous efforts were made by all thoseresponsible for the health of troops to prevent consumption of raw milk in theBritish Isles, in view of its frequent contamination with tubercle bacilli. Itwas not served in army messes nor, after an initial laxity, in Red Crosscanteens (p. 368).
On the whole, the Army Air Forces exhibited a gratifyingly low incidence oftuberculosis and, at the same time, disproved the view occasionally expressedthat flying service predisposes to the development of active disease.
Incidence in recovered American prisoners of war-Whenlarge numbers of American soldiers were recovered from German prison camps inthe spring of 1945, it was no great surprise to medical officers to find anincidence of tuberculosis apparently surpassing the average incidence in theArmy as a whole. Unfortunately, no reliable figures for tuberculosis in thethousands of recovered prisoners are available. War Department orders
21Wayburn, E.: Mass Miniature Radiography. A Survey in the United States Army Air Forces. Am. Rev. Tuberc. 54: 527-540, December 1946.
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to make roentgenograms of all recovered prisoners beforetheir return to the United States were in effect at the time, but an acuteshortage of X-ray film and stringent measures to conserve it nullified theeffect of the orders. Figures for the large group processed at Lucky Strike Campand other camps near Le Havre are available only for those who werehospitalized. Even though hospitalization was not for respiratory disease aloneit is fair to assume that a higher rate would be found than in a population notin obvious need of hospitalization. The majority of recovered prisoners who werehospitalized suffered from severe malnutrition. A number had infectioushepatitis, and acute respiratory disease was common.
In his semiannual report of 3 July 1945, the senior consultant intuberculosis in the theater reported the incidence of tuberculosis in 2,750recovered American prisoners hospitalized at the 77th Field Hospital, LuckyStrike Camp, as follows:
|
| Rate per 1,000 per year |
Minimal tuberculosis | 6 | 2.2 |
Advanced tuberculosis | 6 | 2.2 |
Pleural effusion | 9 | 3.3 |
|
| 21 | 7.6 |
The rate found for all forms of active tuberculosis was thus several times the rate of approximately 1 case per 1,000 men prevailing in the Army as a whole. It is interesting to note that the incidence of pleural effusion, namely, 43 percent of the total, was higher than the usual average of 20 to 25 percent observed in hospitalized troops in the European theater and in the continental United States.
In the lack of exact studies on recovered prisoners, analysis of the reasonfor higher rates is speculative. Colonel Badger stressed as predisposing factorsmalnutrition and exposure to an environment with greater potentiality for spreadof tubercle bacilli. Malnutrition is believed to be a factor in the reactivationof small arrested lesions, which, as noted in various surveys, were present inapproximately 1 percent of troops. Excessive exposure to tuberculosis, if itoccurred, was not direct. Recovered American military personnel were notquartered with other nationals, except in some instances where they sharedbarracks with British prisoners, but frequently, in the migration from camp tocamp, as the senior consultant in tuberculosis pointed out in his report, theylived in dirty quarters, grossly contaminated by previous occupants, many ofwhom may have had tuberculosis.
At the time of writing, no significant new facts had emerged from followupstudies in the United States.22 Formerprisoners of war were reproc-
22The study made by Long and Jablon disclosed that a significant excess of tuberculosis over the incidence for the Army as a whole occurred in recovered prisoners of war. The risk for white prisoners, chiefly captives of the Germans in this study, was three and a half times as great as for men with service overseas who were not taken prisoner (Long, Esmond R., and Jablon, Seymour: Tuberculosis in the Army of the United States in World War II.An Epidemiological Study With an Evaluation of X-ray Screening. Washington: U.S.Government Printing Office, 1955).
In a special study of disease among recovered prisoners of war, Cohen andCooper found a high rate of tuberculosis among former prisoners of the Japanese,which did not take into account the many soldiers believed to have died oftuberculosis in Japanese prison camps (Cohen, Bernard M., and Cooper, MauriceZ.: A Follow-up Study of World War II Prisoners of War. Washington: U.S.Government Printing Office, 1954).
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essed at Army Ground and Army Service Forces RedistributionCenters, and X-ray examination was usually included in the routine physicalexamination. The largest single survey reported to the Office of the SurgeonGeneral was from the Army Ground Forces Redistribution Station in Asheville,N.C. Ten cases diagnosed as tuberculosis were found in 1,939 prisoners of war, arate of approximately 5 per 1,000. All of the men concerned were hospitalizedand not all cases were of proved activity, so that the rate of activetuberculosis was lower. On the other hand, it must be recognized that the groupexamined by X-ray was to some extent an already screened group, from which menobviously ill had been removed.
In summary, it appears reasonable to conclude from theevidence that the incidence of tuberculosis did rise in men who had beenprisoners of war in the European theater, to as much as five to seven times therate prevalent in the rest of the Army (p. 391).
Incidence in recovered Allied military personnel-Inadirective from the Office of the Chief Surgeon, European theater, to thesurgeons of bases, sections, and advanced sections, attention was called to thehigh incidence of tuberculosis in prisoners of Allied Nations recovered when theU.S. armies liberated them from prison and concentration camps in WesternGermany, and to the implications for the medical and nursing personnel of theArmy. Later, an order,23 based on the sudden startling experience ofArmy units in the forward areas, directed a chest survey of recovered Alliedmilitary personnel, and displaced civilians, as follows:
1. Pulmonary tuberculosis of a virulent order has proved a serious problemamong displaced civilians of all nationalities. The magnitude of this problemcannot be estimated at this time. It is probable that Recovered Allied MilitaryPersonnel will show an incidence of tuberculosis well above the experience ofthe Theater. It is imperative to establish the gravity of the situation.
2. All displaced civilians and Recovered Allied Military Personnel admittedto hospitals of the United States Army will be carefully surveyed with thisthought in mind. History, physical examination, appropriate laboratory studies,and, when indicated, x-ray of the chest, will be made on all such subjects,insofar as facilities permit. Due to film shortage, x-rays will not be takenroutinely.
In recovered prisoners of war of Allied Nations, U.S. medical officers found,for a time, the principal problem in tuberculosis confronting them in theEuropean theater. At one time, the 46th General Hospital at Besan?on, France,with more than 1,000 tuberculous patients of foreign nationality, was thelargest tuberculosis center under control of the U.S. Army, exceeding
23Circular Letter No. 41, Office of the Chief Surgeon, Headquarters,European Theater of Operations, U.S. Army, 11 May 1945.
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Fitzsimons General Hospital, the specialty center in Denver, Colo., in itscensus of tuberculous patients.
Colonel Badger's report on tuberculosis in recovered Allied militarypersonnel is quoted substantially as follows:24
a. Nature of the problem
On 18 December 1944, 304 patients of varied nationality,though mostly Russian, were admitted to the 50th General Hospital, Commercy,France. All were tuberculous. Four were dead on arrival. Ninety percent hadmoderate to advanced disease. Twenty-eight died of tuberculosis in the firstweek in the hospital, and up to 21 May 1945, 5 months after admission, a totalof 101, or 33 percent, had died. Signs and symptoms of serious nutritional andvitamin deficiencies were the principal associated complications of tuberculosisor malnutrition. In the middle of March 1945, some 1,600 military and civiliannationals were sent to the 46th General Hospital in Besan?on near Dijon. Therewere among them Russians, Yugoslavs, French, Italians, Poles, Turks, Belgians,Dutch, Czechs, Greeks, Hungarians, and Serbs. Seventy-five percent of them wereRussians. A little less than half had tuberculosis, most of which, once again,was advanced disease, complicated by very severe malnutrition. Other pockets ofdisplaced tuberculous nationals, under Third U.S. Army care in Germany, weresome 7,000 men at Mauthausen, 5,000 at Nuremberg, 3,500 at Ebensee, and 3,000 atKlam. This is a glimpse of the end result of the effects of war on Alliednational prisoners, both political and military.
* * * * * * *c. History
The story these men told was much the same from wherever theycame. They were prisoners for an average of 34 months in the Stalag camps ofWestern Germany. They were for the most part captured in 1941 in the Black Seaarea and the Ukraine. They were shifted from camp to camp, finally winding up inthe mines and heavy industries near Metz and Sarreguemines, France, and the Ruhrregion in Germany. Men were worked 12 hours or more a day with 1 day off amonth, when the coal quota was filled. Maltreatment for failure to do a fullday's quota of work was common. Housing was for the most part in wooden barracksof 40 to 100 feet in size, crowding in 100 to 150 men. Diets varied in differentcamps, but from their history and starvation state, it was apparently seriouslydeficient. Hygienic conditions were bad, recreational facilities wereprohibited, sleeping and living conditions were congested, and hospitaltreatment for illness was apparently reserved for those with high feverscombined with a good prognosis. The sick were left to die in their bunks besidethe living. Before capture, these men were recorded as being in excellentphysical condition. Supposedly, admission to the Russian Army was by completephysical examination with an X-ray of the chest; but, if the latter wasaccomplished in the Russian Army, it was a monumental task. Furthermore, if onlythose with negative X-rays were admitted to the Army, the influence ofstarvation upon unseen tuberculous infection is the more striking.
d. Clinical picture
The typical picture of tuberculosis as seen in these patientswas that of acute fulminating, rapidly fatal disease, mixed with chronic, slowlyprogressive, fibrotic tuberculosis. They were acutely ill with emaciation whichwas the combination of tuberculosis and starvation. The clinical course ofapproximately 30 percent was rapidly and progressively downhill. Extensivebilateral pulmonary disease was complicated by gastrointestinal, laryngeal, andbronchial involvement. Fever was varied. Many patients showed progressive,moderate to far-advanced disease in the presence of a normal temperature, someelevation of pulse, and reasonably good general appearance. The physi-
24See footnote 17, p. 340.
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cal findings were characteristic in the variety of signs, butthe most conspicuous single feature was the presence of widespread disease withfew or no physical signs. Cough and expectoration produced sputa which wereheavily loaded with tubercle bacilli. Examination of direct smears showed largernumbers of tubercle bacilli than we are accustomed to see in the routineexamination of sputa in the United States.
e. Pathology
(1) At post mortem examination, the tuberculosis was always bilateral withwide hematogenous dissemination to a variety of organs with extensive cavitationof the lungs. There was revealed more than the usual lymph gland involvementwith massive enlargement of glands in both the chest and abdomen. Notuncommonly, pleural adhesions were multiple and usually obliterative, givingevidence of chronicity of the disease. Miliary tuberculosis was conspicuous byits rarity, though sporadic hematogenous spread was common.
(2) Microscopically, the lesions were characteristicallyfibrocaseous tubercle formation with evidence of normal tissue response to thepresence of the tubercle bacilli. However, many cases presented a microscopicappearance of widespread confluent necrosis, without tubercle formation andwith very little tissue reaction about the periphery of the lesion and little orno epithelioid cell formation and complete absence of giant cells. Lymphatictissue often presented complete destruction of all lymphoid cells with tissuenecrosis and often very little cellular reaction in tubercle formation.
f. Etiology
Etiological factors which produced this fulminating diseasewere undoubtedly the unusual opportunities for intense and frequent recurrentcontact with seriously ill, open cases. Conditions at the German Stalag campsand at Buchenwald were such that at the latter, 46,000 people were housed in aunit originally constructed for 15,000. Sanitary conditions did not exist andwhere three to five men were in one small bunk and the ill were left to dieunattended beside the living, the opportunities for cross infection withtuberculosis were such as have probably rarely been observed before. Everythingfavored the development and spread of the disease. The starvation diet with theserious degree of malnutrition undoubtedly contributed to the rapid progress ofthe disease. The pathology in many cases was indicative of an absence of theindividual's resistance to infection.
g. Treatment
(1) These patients had treatment, first directed toward relief of starvationand the establishment of discipline. Language difficulties and years of livingunder the conditions which existed in larger work camps and Stalags made itdifficult to establish any hygienic principles, or the segregation of open fromclosed cases. The dietary problems were not difficult to handle and thosepatients who were not dying of their disease improved clinically, rapidlyovercoming the malnutrition per se.
(2) The initial problem was that of reexamining by X-ray entire groups forproper identification, diagnosis, evaluation, and therapy. Sputum-positive caseswere eventually segregated from sputum-negative cases and an attempt was made toestablish absolute bed rest. However, the latter proved to be practicallyimpossible. The concept of bed rest was foreign to these men under anycircumstances, and, with the Russians, it was against their principles oftreatment of tuberculosis, which commanded exercise and sunshine.
(3) Collapse treatment.-Definitive measures of collapse werenot instituted in the early weeks of treatment, except in those cases wherehemorrhage indicated its necessity, or the character of the disease wasunilateral and favorable to this form of treatment. It was deemed wise forthese men to have 4 to 8 weeks of bed rest before pneumothorax wasstarted, as the acuteness of the disease and the frequent presence oftracheobronchitis were not suitable for collapse therapy. Adjustment of theirnutritional
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deficiencies was immediately of greater concern than thetuberculosis itself. In acute widespread, bilateral disease, pneumothorax hasnot proved to be beneficial. Collapse therapy was never undertaken simply forthe sake of "doing something" for the patient.
(4) Seen a month after the institution of treatment, those men who had notdied of acute tuberculosis showed marked improvement. Order had emerged frominitial chaos and reasonably good discipline had been established through theassistance of a Russian officer and aidman. It was still quite impossible toestablish a regimen of absolute bed rest.
h. Prevention
Precautions against spread of tuberculosis were institutedfirst of all for the protection of U.S. Army hospital personnel and secondtoward segregation of the open and closed cases.
(1) Isolation technique was carried out in all thetuberculosis wards. All staff personnel wore masks and gowns. Patients woremasks when examined or treated and were taught to conceal their cough, toexpectorate into small pledgets of paper which were deposited into paper bags tobe burned.
(2) Floors were treated with spindle oil obtained from the British, which wasapplied according to directions extracted from a report prepared by the EighthAir Force.
(3) "Clean rooms," as islands of sterility, weremeticulously observed adjacent to tuberculosis wards for the protection ofnurses and other personnel. No contaminated person, X-rays, records, or objectsof any sort were permitted in these sanctums of cleanliness. No gowns or maskswere worn or removed in these rooms. Scrub-up solutions and contaminatedclothing were maintained in an adjacent room.
(4) By these means every effort was made to cut down airborne infection to aminimum and reduce the opportunity of contact to a minimum.
On 10 May 1945, Colonel Badger, Senior Consultant in Tuberculosis in theEuropean theater, and Col. Esmond R. Long, MC, Chief Consultant in Tuberculosis,Office of the Surgeon General, conferred with Col. B. A. Osipov, member of theMilitary Mission of the U.S.S.R. in Great Britain and Russian liaison medicalofficer in the theater, with regard to the care and treatment of Russians withtuberculosis. Points of difference in treatment in the two countries wererecognized, and shortly thereafter, it was decided in the Office of the ChiefSurgeon, European theater, to repatriate those Russians who were physically ableto travel, as rapidly as was consonant with their safety. The 46th GeneralHospital was made a collecting hospital for this purpose. It received recoveredRussian prisoners previously hospitalized in many hospitals in France andEngland and effected suitable preparations for the long journey back to Russia.
Incidence in concentration camps-In the final weeks ofthe war in Germany, Allied troops overran a large number of the notoriousconcentration camps in which the German government imprisoned political nonconformists, Jews, nationals of surrounding states, and others who had offended theNazi Party. These camps included Buchenwald, Nordhausen, Dachau, Belsen, andmany others. Thousands of dead were found in the camps at the time of theirliberation, and many more thousands of sick and dying. Among the latter werehundreds of persons with advanced tuberculosis, who constituted an immediateproblem for the evacuation hospitals of the advancing armies. U.S. Armyhospitals rapidly developed machinery for re-
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moving discovered cases from camps and placing them underdefinitive care. Barracks outside the camp were usually used, and in these thetuberculous were bathed, deloused, examined by X-ray, and put on immediate bedrest. In the transfer from camp, they were ably assisted by doctors of theconcentration camp; that is, doctors who had themselves been inmates and hadmaintained primitive hospitals for tuberculous patients in the camp.Subsequently, these patients were transferred to German hospitals in the region,against the time when they could be transferred again to their own countries, orto sanatoriums in Germany. The crowding, the lack of sanitary provisions, themalnutrition and the general medical neglect, all favored progression of thedisease in concentration camps. Although few figures are available, it wasbelieved by Medical Corps officers that much of the high mortality in thesecamps was due to tuberculosis.
A vivid description of conditions at the Dachau concentration camp, and theextent of tuberculosis in hospitalized inmates of that camp, has been given byPiatt.25 He made a statistical analysis of 2,267 roentgenograms ofthe chest of patients removed from the concentration camp hospital and examinedby X-ray on admission to the receiving and evacuation section of the 127thEvacuation Hospital. In only 45.3 percent of the films was no abnormalitydiscovered. Tuberculosis, pneumonia, and heart disease were the chiefabnormalities. Six hundred and twenty-six definite cases of tuberculosis, or27.6 percent of the total number examined, were detected. In more than half ofthese, the disease was bilateral, and in four-fifths of the cases, the processwas either moderately or far advanced. In addition to definite tuberculosisthere were 94 patients, or 4.1 percent of the total, with pleural effusion,probably tuberculous in origin. There were five cases of miliary tuberculosis.
Piatt, among others, expressed the view that the incidence oftuberculosis in Europe would increase appreciably in the years to come as aresult of the return of numerous persons with undiagnosed active disease fromconcentration camps to their homes.
The following extract from the report of the Consultant inTuberculosis, Office of the Surgeon General, dated 1 May 1945, also illustratesthe task which faced evacuation hospitals when prisoners in concentration campswere liberated:26
1. Assignment of task to 45th EvacuationHospital.-Whenthe Buchenwald camp [near Weimar] was liberated a problem immediately apparentwas the care and disposition of several hundred tuberculous patients undertreatment in the camp. It was recognized that these were a source ofdissemination of the disease, and from the point of view of medical carerepresented a long range problem. The processing and evacuation of thesepatients to a hospital appropriate for their continued care was assigned to the45th Evacuation Hospital.
25Piatt, A. D.: A Radiographic Chest Survey of Patients From the DachauConcentration Camp. Radiology 47: 234-238, September 1946.
26Semiannual Report, 45th Evacuation Hospital, 1 Jan to 30 June 1945. Appendix A, subject: Processing of TuberculosisPatients From Buchenwald Concentration Camp by 45th Evacuation Hospital.
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2. Background of tuberculosis problem atBuchenwald.-a. Theconditions under which prisoners lived at Buchenwald were conducive in every wayto the development and spread of tuberculosis. The malnutrition, from whichevery inmate suffered, together with heavy labor and harsh treatment,inevitably led to the progression of tuberculous lesions in men previouslyinfected, whether these were originally of serious or minor character, and theintense crowding and lack of any sanitary precautions led to dissemination ofinfection throughout the barracks. "Block physicians," themselvesprisoners, appointed by the prison administration, constantly discovered casesand sent them to hospitals established within the camp, since distinguished asthe "old," the "little," and the "great." The"old" hospital, an indescribably crowded and filthy place, in whichpatients lay on dirty shelves in a long series of tripledecked compartments,five feet long and two feet high, six patients to a compartment, was in noremote sense a place for treatment, and in effect simply a breeding ground forthe disease. In the others, thanks to the interest and intelligence of prisonerdoctors, standard treatment was carried out insofar as it was possible under thedesperate circumstances prevailing, with little food available, and that of theworst quality, and no relief in sight. In all of these hospitals the mortalityfrom tuberculosis was tremendous. No accurate estimate can be made, but it isprobable that many thousands of the 50,000 known to have died in the campsuccumbed to tuberculosis.
b. Following the liberation a medical organization was promptly put intoeffect by Dr. Horn, an eminent Czech surgeon, who had been a hostage in thecamp, arrested originally as a supporter of Dr. Benes. Dr. Horn was at the camp6 years. His distinguished position was recognized by the Germans, and afterNovember 1943 he did a large proportion of all the operative work. His capacitywas universally recognized by the physicians of various national groups in thecamp. Under Dr. Horn the following physicians were appointed as tuberculosisconsultants: Dr. Jozef Szmeja, a Polish tuberculosis specialist, ChiefConsultant; Dr. Stanislaw Machotka, a Jugoslav, who had been superintendent of atuberculosis sanatorium in Jugoslavia, Second Consultant; and a Russian doctorwho had specialized in tuberculosis.
In addition, three physicians with experience in the treatment oftuberculosis were retained in direct charge of the "great" and"little" tuberculosis hospitals (the "old" hospital havingbeen closed with liberation of the camp): Dr. Gerhard Arnstein, an Austrian, incharge of the treatment ward in the "great" hospital; Dr. EdmundAdams, a German political prisoner of English descent, in charge of the faradvanced cases in the "great" hospital; and, Dr. [Paul] Heller, aCzech, in charge of bilateral cases not suitable for specific therapy, but nothopelessly advanced, in the "little" hospital.
c. The treatment ward of the "great" hospital, with 116 cases,almost all of them under pneumothorax treatment by Dr. Arnstein, was a crowded,malodorous place in which patients slept in double-decker beds. Discipline wasmaintained, and patients received three times as much food as before theliberation, but no substantial improvement could be expected in suchsurroundings. Dr. Arnstein was conscientiously doing everything possible underthe circumstances. The ward for advanced cases was simply a death room. Therewere thirty-two cases where there had been seventy a few days before. The"little" hospital, containing ninety-six patients, was a formerstable, which had been improved by the patients themselves by the constructionof windows. It was a highly crowded place filled with ambulant patients who usedthree-decker beds at night. There was a total lack of discipline in spite of Dr.Heller's best efforts. Three to four patients a week died there. The most thatcould be said for it was that it served for the isolation of ambulant patientswith infectious sputum.
d. The three hospital groups just cited, made up of 244 patients, did notaccount for all the known cases of tuberculosis. The different national groupsinto which the prisoners were gathered immediately after liberation had retainedsome cases. Altogether it was believed that 100-150 tuberculous patients could belocated in the various groups.
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3. Evacuation procedure.-a. The above outline indicateswhat had been accomplished, thanks to the intelligent action of a few liberatedphysicians, in a short period preceding the assignment of the 45th EvacuationHospital to the evacuation problem. The principal accomplishment of thesephysicians was discovery, isolation, and classification of patients, whichenormously facilitated the procedure of evacuation. The institution ofpneumothorax on the scale established was heroic, but much success in treatment,under the circumstances, was not to be expected.
b. A priority system, based on the emergency care required, the advisabilityof removal for early continuation of care elsewhere, and other considerations,was set up, whereby patients already in the Buchenwald camp hospitals were to bedelivered to the 45th Evacuation Hospital at the rate of ten an hour during theworking day, commencing on 28 April 1945. On the 29th the system was found to befunctioning smoothly in spite of mechanical difficulties in the water line andconcomitant cleaning of the hospital. Under the direction of the commandingofficer, Colonel [Abner] Zehm, a remarkably rapid and effective job had beendone in taking over a terribly dirty building, fouled by unrestrained, suddenlyfreed prisoners, with no hygienic standards, who had swarmed into the buildingon their release. Dead bodies were in the corridors and excrement all over thefloors on arrival of the staff. Two days later, when evacuation operationscommenced, the place was clean and normal operation was in progress.
c. A dispensary organization has been set up by Dr. Horn in Buchenwald Campfor diagnosis of new cases from suspects sent in by physicians in the barracks,which still housed some 15,000 ex-prisoners. The selection is based entirely onsymptoms. In the opinion of the undersigned the number of cases would run farbeyond the expected 150 cases if a more careful method of selection includingX-ray examination were possible. In view of the tremendous exposure to which thegroup has been subjected, cases will inevitably arise in considerable number foryears to come. At present only the method indicated is practical. The dispensarywill hold 35 patients for observation at one time, and it is expected that bythe time the present 240-250 patients have been evacuated the dispensary canconclude the remaining task in a few days.
4. Organization of the 45th Evacuation Hospital.-a. The staffconsists of the commanding officer and 20 medical officers. Lt. Col. [IsidoreA.] Feder, MC, Chief of the Medical Service, has instituted an organizationwhich admirably combines simplicity and efficient operation. Ten 40-bed wards,each in charge of a medical officer, have been set up. In addition to thesethere is a receiving officer, a general internist, an X-ray chief, a laboratorychief, and a specialist in ear, nose, and throat work. The rest of the staff of20, composed of members of the surgical team, are at present on other duties inthe area.
b. On arrival at the hospital, patients are taken to thereceiving wards (one for ambulant and one for litter patients) and their recordsare initiated by the receiving officer. By arrangement with the doctors atBuchenwald camp, their previous medical records are sent with them. EMT's[emergency medical tags] are made out, and a simple medical record devised bythe 45th Evacuation Hospital, entirely suitable for the purpose, is started.After this, patients move across the hall, where their clothes are taken awayfrom them to be destroyed, they bathe in hot showers, and are dried and sprayedwith DDT [dichlorodiphenyltrichloroethane]. Then they receive clean pajamas andare sent to the X-ray room, where a roentgenogram is made of each man, with aPicker field unit, the subject holding the cassette in his arms. The picturesmade are remarkably good, with all the required detail and excellent contrast.Much credit is due to the technician in the dark room, for the condition of theelectrical line requires relatively long, fixed exposure and fixed kilovoltageso that careful individual processing in the development tanks is necessary.After the X-ray film is made each patient is sent to his ward. Shortlyafterwards, clinical histories are taken through an interpreter, and specimensare obtained for laboratory examination-sputum, blood,
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and urine being examined routinely. Blood sedimentation ratesare determined in cases where tuberculosis is diagnosed but the patient isafebrile. The whole procedure is handled quietly and expeditiously.
c. Special mention should be made of the work of the enlisted men. Goodtechnical work is done in the X-ray department and laboratory as well as thebath department, and the care given by the litter bearers, as observed by theundersigned, was superb. Very sick, suffering patients were transferred fromlitters to cots with infinite gentleness, which, in the light of the bestialbrutality which had been the lot of the patients in Buchenwald camp prior totheir liberation, was extraordinarily impressive.
5. Assessment of the evacuation procedure.-a. The work done by the 45thEvacuation Hospital in processing tuberculous patients is excellent. Dr. Horn,who had observed the care of tuberculous patients at Buchenwald for years, wasstrong in his tribute to the spirit and standards of the Medical Department ofthe U.S. Army. No words can describe the relief and joy of the patients. Aftertheir long misery in the filth and torture at Buchenwald, the clean sheets andblankets and personal solicitous attention of the 45th Evacuation Hospital wereincredible luxuries.
b. The medical processing meets its purpose in every way. The objective ofthe hospital is to effect machinery for suitable transfer of patients topermanent quarters. Status as ambulant and litter patients is being establishedin a sound manner. A certain number of cases misdiagnosed as tuberculous arebeing discovered, and will be returned for such medical care as they require.Some patients will be found who are too sick to move further under anycircumstances, and terminal care is being provided. Treatment is quite properlyby rest and good food, which is enormously appreciated by the patients.Pneumothorax treatment is not being given and does not appear indicated in theexpected short period of retention of the evacuation hospital. It is believedthat refills, if necessary in any cases, can be given, by special arrangement,by the camp physicians who initiated the procedure.
Under arrangements effected by the Office of the Surgeon,Headquarters, First U.S. Army, the tuberculous patients evacuated from theBuchenwald concentration camp were transferred to a permanent German hospital atBlankenhain near Bad Berka and Weimar for continued care pending later transferof suitable cases to their homes in liberated countries. It was recognized thata majority of the patients were too ill to recover and would remain a charge ofthat department of military government concerned with the hospitalization ofdisplaced personnel (pp. 397-399).
NORTH AFRICAN AND MEDITERRANEAN THEATERS OF OPERATION
Admission rates.-As in the European theater, the recognizedincidence of tuberculosis in the Army in the North African and Mediterraneantheaters was lower than in the Zone of Interior. During 1942-45, approximately1,300 cases with active or inactive tuberculosis were admitted to medicaltreatment facilities for observation or care, an incidence rate of 0.85 per1,000 per year. In a study involving 800 cases, 57 percent were classified asactive and 20 percent as probably active, the remainder as inactive oruncertain.27
27McKean, George T., and King, Donald S.: Survey ofTuberculosis and "Primary" Pleural Effusion for the Period of Activityof NATOUSA and MTOUSA to 1 Apr. 1945, vols. I and II. [Official record.]
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In the aforementioned study, diagnosis, treatment, disposition of cases, andthe epidemiology of tuberculosis in the theater were discussed at length. Inaddition, special attention was devoted to primary pleural effusion, which was aproblem of unusual significance.
In a high proportion of cases, symptoms, principally cough,led to hospitalization; a smaller number were discovered in various types ofroutine survey. Laboratory facilities varied in the theater, but even in forwardhospitals means for staining tubercle bacilli were available and X-rayexamination could be made. Films from field and evacuation hospitals were ofgood diagnostic quality; in general, the diagnostic work was of superiorcharacter.
Differential diagnosis frequently involved distinction from atypicalpneumonia, and occasionally from chronic pulmonary diseases other thantuberculosis. The chief difficulty in diagnosis was determination of activity.In sputum-positive cases this was no problem, but decision was difficult in thenumerous cases where a small fibrotic lesion was evident in X-ray films. Theusual and most important single aid, namely, a long series of films forcomparison, was not available, because circumstances did not permit retention ofpatients for the necessary length of time. Consequently, individual judgment,based on all data available, was most important.
The annual rate of admission in terms of troop strength was approximately thesame for Negro as for white soldiers. Negro soldiers constituted 9 percent ofthe total strength, but contributed only 7.5 percent of cases up to April 1944.On 31 March 1945, Negro troops constituted 13.5 percent of the total strength inthe theater and, by that time, accounted for 15 percent of the cases oftuberculosis. Analysis by type of case indicated that the disease was ofdistinctly greater average severity in Negro than in white soldiers. In theformer, there were more bilateral cases, more cases with cavity, more ofexudative character, and a lower proportion of cases considered inactive.According to data obtained from individual medical records, there were 60 deathsduring 1942-45 among U.S. Army personnel admitted for tuberculosis in theMediterranean theater. Many patients who were evacuated died elsewhere. Of the60 deaths, 50 were among male enlisted personnel; 30 of the 50 deaths were amongNegroes.
Hospitalization.-In the North African and Mediterraneantheaters, as in all theaters, tuberculous patients were initially admitted tohospitals of all types. Admissions were about equally divided among soldiersfrom the Fifth U.S. Army, the Army Air Forces, and Army Service Forces. Unlikethe other theaters, the North African and Mediterranean theaters establishedtuberculosis centers for the reception of cases from other hospitals and forstudy with a view to appropriate disposition. The following hospitals servedthis purpose: 6th General Hospital, Casablanca, French Morocco; 24th GeneralHospital, Bizerte, Tunisia; 17th General Hospital, Naples, Italy, and the 64thGeneral Hospital, Leghorn, Italy. The concentration of medical officers, withspecial training in a few centers equipped for definitive treatment, in-
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sured an adequate number of beds and a high type ofprofessional care for patients prior to their evacuation to the United States.These hospitals were frequently visited by Lt. Col. (later Col.) Donald S. King,MC, Chief, Medical Service, 6th General Hospital.
Analysis of data for a representative group showed that the average durationof hospitalization of active cases, prior to evacuation to the Zone of Interior,was 58.5 days. From this figure, based on a large sample, it was calculatedthat active cases of tuberculosis were responsible for 22,405 days ofhospitalization in the theater. Only 24 patients, however, remained in a theaterhospital more than 3 months.
Also admitted to Army hospitals in this theater were tuberculous patientsfrom the armies of our Brazilian and British allies, tuberculous prisoners ofwar, and occasional patients in other categories.
Therapy and disposition-Hospitalcare being, as a rule,of relatively short duration in the theater, definitive treatment was not sointensive as in tuberculosis centers in the United States. However, in manycases, temporizing was contraindicated; collapse measures were institutedpromptly to prevent serious progression, although this practice anticipated thetype of care to be given during prolonged hospitalization in the United Statesand the pneumothorax had to be maintained during evacuation to the Zone ofInterior, at ports of debarkation, and en route from the latter to tuberculosiscenters in the United States.
The indications for pneumothorax were the usual ones; namely, unilateralexcavation, spreading infiltration, and persistent hemoptysis. The followingpolicy was drawn up in the late months of the war with respect to collapsetherapy and the type of transportation most appropriate for different categoriesfor evacuation to the United States.28
1. Pneumothorax treatment in the theater should be limited to predominantlyunilateral cases, with evidence of cavity formation or rapid extension, forwhich transportation to the United States is not immediately available, and suchcases should be evacuated on hospital ships equipped to continue pneumothoraxafter this treatment has been established.
2. Bilateral advanced cases and advanced cases for other reasons unsuitablefor pneumothorax should be treated by continued rest and returned to the UnitedStates by hospital ship as soon as space is available.
3. Unilateral and bilateral cases of active disease of minimal extent,without gross evidence of cavitation, should be sent to the United States by airat the earliest possible moment, and treatment, other than rest and hygiene, insuch cases should not be attempted in the theater.
4. Cases of pleural effusion without other demonstrable etiology should beconsidered as probably tuberculous and evacuated to the United States byhospital ship, after termination of the acute phase of the illness, fortreatment and disposition.
5. Under ordinary circumstances moribund cases should not be evacuated to theUnited States.
28Memorandum, Col. Esmond R. Long,MC, Consultant inTuberculosis, to The Surgeon General, U.S. Army, 18 Apr. 1945, subject: Visit byConsultant in Tuberculosis, Office of the Surgeon General, in MediterraneanTheater of Operations.
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6. Individual judgment should be exercised in the case of small, scarred andprobably inactive lesions, with evacuation to the Zone of Interior in thosecases where the lesion in question is of truly doubtful stability, opportunityfor continued observation of the case is unlikely and key personnel are notinvolved.
Pleurisy with effusion-Pleurisy with effusion, presumptively tuberculous,was frequent in proportion to the total number of cases of tuberculosis. In1944, there was an apparent increase during the summer months, the reason forwhich never became clear. It was considered possible that numerous infectionsmight have occurred in crowded quarters during the winter, becoming manifestseveral months later in the form of effusion.
In 16 out of 33 carefully studied cases, the bacteriological diagnosisdetermined by guinea pig inoculation, culture, or other means, was positive fortubercle bacilli. A diagnostic problem was distinction from the effusion thatsometimes accompanies atypical pneumonia. In general, however, it was believedthat large effusions were rare with this type of pneumonia, whereas the effusionof tuberculosis was frequently massive.
Altogether, 265 cases of primary pleural effusion wereencountered, of which 229 were evacuated to the Zone of Interior. Two werereclassified to limited service and 30 were returned to duty. The wisdom of thelatter course was later seriously questioned, in view of the frequency withwhich late tuberculous parenchymal infiltration follows pleurisy with effusion.Three-fifths of the cases were in soldiers 25 years of age or less.29
Epidemiology-Much attention was devoted by medical officers to theepidemiology of the disease in the North African-Mediterranean theater. Up toJune 1944, the number of cases evacuated to the Zone of Interior, although notconsidered alarming, was recognized as significant.30 In the summer of1944, the centralization of patients in special hospitals brought to light thefact that not infrequently there was an abnormally high incidence of disease inindividual units, and an index system was set up to aid in tracing sources ofinfection. New patients were questioned as to previous contacts in the Army, andfrom time to time, new additions to already known endemic foci were thusdiscovered. In one medical battalion headquarters and headquarters company,consisting of 50 enlisted men and 7 officers, 8 cases of pulmonary tuberculosisor pleural effusion were found. Contacts with Italian civilians that may havebeen a source of contagion were believed to occur, but could not be traced withsimilar accuracy.
In this connection, Circular Letter No. 41, Office of theSurgeon, Headquarters, North African Theater of Operations, dated 29 July 1944,directed the following:
29A postwar study of 141 cases of primary serofibrinouspleural effusion in World War II soldiers, in which observation was continuedfor 5 or more years after diagnosis, disclosed a high incidence of relapse inmen returned to duty following absorption of a pleural exudate. In cases wherehospitalization was brief and return to duty correspondingly early relapseoccurred in approximately 90 percent of persons (Roper, W. H., and Waring, J.J.: Primary Serifibrinous Pleural Effusion in Military Personnel. Am. Rev.Tuberc. 71: 616-634, May 1954).
30Custer, E. A.: Tuberculosis in the North African Theater of Operations[and appended Comments by the Theater Surgeon]. M. Bull. North African Theat.Op. (No. 6) 1: 30-31, June 1944.
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It will be the responsibility of the commanding officers of"tuberculosis reception centers" to notify the medical officer of anyorganization, in which an "open case" of tuberculosis is discovered,of the existence of such a case, and it will then be the responsibility of theunit medical officer to initiate promptly such studies as are considerednecessary for the detection of pulmonary tuberculosis in intimate contacts ofthe patients.
Routine surveys, made on several units, were occasionally fruitful. In onesurvey made after discovery of an open case, no case of definitive activetuberculosis was found among 718 persons, including 52 officers and 123 women,but 16 lesions of minimal extent were discovered, 8 of which were consideredpossibly active, the remainder, probably inactive.31
Although Italian civilians were always suspected as a sourceof serious contact, adequate study was not made until after the end ofhostilities. Some evidence of special danger was found by the Chief of MedicalService, 15th Evacuation Hospital in a survey of approximately 300 civilianfoodhandlers in the Milan-Turin region. Of these, 15 (or 5 percent) hadclinically significant tuberculosis of reinfection type.
Evacuation-Patients were evacuated by sea and by air. In the early daysof the theater, most tuberculous patients came home on troop transports. Later,the majority returned in hospital ships, when these were available in sufficientnumber. It was recognized that far better care could be given them on hospitalships, where special quarters could be assigned and where X-ray andpneumothorax equipment and laboratory facilities were readily available. At thesame time, isolation technique protected other soldiers from exposure tocontagion. Fortunately, there was little communicable disease other thantuberculosis requiring evacuation from the theater. Accordingly, it waspossible, in many voyages from Italy to the United States, to use fortuberculous patients the entire section of the ship that had originally been setaside for contagious diseases. This section usually provided airy 8- and 12-bedwards.
SOUTH PACIFIC AREA
Incidence-In reports for the years 1942-45 for the South Pacific Area(New Caledonia and the Solomon Islands), an admission rate for tuberculosis of1.5 per 1,000 men per annum is shown, except for the year 1942, when theadmission rate for the last quarter only is recorded and was 2.1. Incompletereporting, mistakes in diagnosis, inclusion of readmissions and transfers arementioned as factors causing inaccuracies. It was believed by the reporter,however, that the errors did not exceed 10 percent. The totals for the 4 years,as reported, were: 1942 (last 3 months), 42; 1943, 214; 1944, 264; 1945, 57. Theincidence rates, taken from the statistical health report (WD MD Form 86ab) inthe records in the Office of the Surgeon General, were: 1942, 1.38; 1943, 1.20;1944 (consolidating South Pacific with Central Pacific Area to
31Wyman, S. M.: Report of a Roentgenologic Chest Survey. M. Bull.Mediterranean Theat. Op. 3: 15-16, January 1945.
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make Pacific Ocean Area), 0.71; 1945 (also consolidated), 0.95. Theaverage rate for the Pacific Ocean Area for 1942-45, inclusive, was 0.86.
Types of tuberculosis.-The majority admitted to hospital werecases of pulmonary tuberculosis. It is interesting to note that of 82cases of chronic reinfection type pulmonary tuberculosis admitted, 32 wererecorded as minimal, 38 as moderately advanced, and only 12 as far advanced. Ina theater where examinations were usually made on the basis of symptoms ratherthan through the medium of mass X-ray surveys, the preponderance of minimal andmoderately advanced cases indicates that medical officers were on the alert forcases and recognized the need for their discovery before the disease reached thefar advanced and generally hopeless state.
Fifteen cases of tuberculosis of the genitourinary tract werepositively identified out of a much larger number of cases of genitourinarytract disease in which the diagnosis was questionable. It is noteworthy that inthe Central and South Pacific Areas (data for the areas separately are notavailable) 40 cases of tuberculosis of the genitourinary tract were found,yielding a rate of 2.8 per annum per 100,000 average strength. This may becompared with 1.8 for the Southwest Pacific (based on 28 cases) and 2.7 for thetotal Army (based on 674 cases). It may be noted here that, although pulmonarytuberculosis was generally excluded through X-ray examination at inductionstations, facilities for detection of genitourinary tuberculosis were usuallyinadequate, so that cases that were asymptomatic at the time of induction wereunknowingly accepted.
Of the nonpulmonary forms, tuberculosis of the pleura was conspicuous (9cases). There were a few cases of tuberculosis of superficial lymph nodes,bones, joints, and meninges. The list included only one case of generalizedmiliary tuberculosis.
Diagnosis-Diagnostic facilities varied with the type of medicalinstallation and its location. First-class roentgenological facilities wereavailable throughout the theater and, according to the official reports, liberaluse was made of them at all times. Every patient with symptoms of chest diseasewas examined by X-ray. Group surveys were made when special circumstancesindicated their value. For example, a Navy steward was found to have advancedpulmonary tuberculosis and about 20 close contacts were studied. It wasinteresting to note that no active cases were found in this study but that twoor three apparently inactive cases were located.
Facilities for laboratory examinations depended upon the proximityof the installation concerned to the front. Laboratories as far forward asclearing companies had all the necessary equipment for making stains foracidfast bacilli. In installations to the rear of clearing companies, facilitieswere available for concentration methods for the detection of tubercle bacilli,and in such installations gastric lavage was performed. General hospitals madeconsiderable use of cultural methods for detection of tubercle bacilli.Guinea-pig inoculation was resorted to occasionally in medical laboratories, forexample
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in the 6th Medical Laboratory on Guadalcanal. In view of thescarcity of the animals, this was largely restricted to cases in whichtuberculosis of the kidney was suspected.
Hospitalization and care-Few officers who had specialized for a longperiod in tuberculosis were on duty in the theater, which in this respect wasworse off than the European and Mediterranean theaters. Because of the greatdistances involved, the consultant system was not used. The diagnosis andtreatment of tuberculosis thus depended upon the judgment and general medicalability of officers in the various installations.
Patients were transferred from installations where the diagnosis was made togeneral hospitals in the theater for observation, care, and disposition. Therapywas restricted largely to rest and measures directed toward improvement ingeneral nutrition, supplemented by symptomatic treatment for relief of cough andpleuritic pain. Collapse therapy was seldom attempted, since it was the policyof the theater to return all cases needing definitive care as promptly aspossible to the United States.
Special problems-Medical officers were on the lookout for specialeffects of climate and other adverse conditions peculiar to the region.
Climatic conditions were highly variable throughout the area, which, at onetime or another, extended from the equatorial latitudes of the BismarckArchipelago to the Temperate Zone of New Zealand and from the 150th meridian ofeast to the 150th meridian of west longitude. The majority of the troops in thecommand lived under tropical and semitropical conditions in the Solomon Islandsand in New Caledonia, although a certain number were stationed in New Zealandfor extended periods for training or rest. No specific effects attributable tothe climate were emphasized by medical officers in the area.
Service in these regions was arduous. Corresponding with thenumber of troops involved, the amount of tuberculosis discovered was highest inthe infantry, in which more than a quarter of the cases detected were found. Itis remarkable that the next highest number of cases were discovered in personnelof the Medical Department, and a slightly lower number, in the Corps ofEngineers. These three branches accounted for more than half of all the cases oftuberculosis discovered. The highest rate of tuberculosis recorded in thetheater was during the period of most intense combat. This, however, was aperiod when a large proportion of troops that had been relatively poorlyscreened in the United States were on duty in the theater.32 In theopinion of the reporting official, the relatively high incidence discovered inthe first 3 months of recorded data for the theater (end of 1942) was probablythe result of this imperfect screening rather than the unusual severity of theservice itself.
Likewise, no specific correlation with nutrition was discovered. Nutritionwas in fact relatively poor at the time that the troops were most heavily
32See footnote 3, p. 331.
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engaged in combat and the incidence of tuberculosis was atits highest. Some medical officers attempted to determine if tuberculosisdecreased after improvement of the diet, which consisted largely of C and Kfield rations in the earliest part of the war, but no significant conclusions inthis respect could be drawn. Certainly, nutrition improved enormously after thefirst difficult period, but it was true also that the troops chiefly concernedat this later time had been subjected to much better screening.
In view of the high prevalence of malaria and other tropicaldiseases, a number of medical officers attempted to determine if they had anyeffect in activating tuberculosis. No specific evidence of activation oftuberculosis as a result of concomitant malaria or other disease was detected.This corresponds with the results of a number of prewar studies, which failed toshow any specific connection between malaria and depression of resistance totuberculosis.
Mortality-The number of deaths from tuberculosis in the theater wasextremely small. In the theater report, only five fatal cases are listed, all ofthem of acute type. The death rate deduced from these figures was 1.3 per100,000 men per annum. The figure merely indicates that cases of ultimatelyfatal issue were transferred to the United States before death occurred.
Evacuation.-Allpatients with active tuberculosis of any part of the body were evacuated togeneral hospitals in the United States. A total of 158 patients were evacuatedfrom New Caledonia and 65 from Guadalcanal. In the early months of the war, afew patients were sent to Melbourne, Australia. Evacuation was ordinarily bydirect transfer to a medical installation in the United States. The largestnumber of transfers was to Letterman General Hospital, San Francisco, Calif.
Patients with active pulmonary tuberculosis were almostinvariably evacuated as strict litter patients, whether the transfer was by airor by sea. Patients with inactive or arrested tuberculosis and those withinvolvement of superficial lymph nodes only, as well as a good many cases ofgenitourinary and other forms of nonpulmonary tuberculosis, were evacuated asambulatory patients. Evacuation by air from New Caledonia commenced in 1943 andincreased notably in 1944 and 1945. However, even at the end of the war, fromthis distant area, the majority of patients were returned to the United Statesby ship. Approximately 13 percent were returned by air. Of the 158 patientsreturned by ship from New Caledonia, 66 percent were litter patients, 23 percentambulatory patients, and 11 percent troop-class patients.
SOUTHWEST PACIFIC AREA
Incidence-In comparison with other medical problems,tuberculosis was considered of minor military significance in the SouthwestPacific Area.33 The official report from the area states:
33Timpanelli, Alphonse E.: Tuberculosis in the Southwest Pacific Area [World War II]. [Official record.]
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* * * in 40,000 continuous admissions for all causes from allsections of the Southwest Pacific area in two large general hospitals operatingat various times in three separate areas in New Guinea and the Philippines, only64 cases of tuberculosis were found * * *. Of these 64 cases studied, 62 wereinstances of pulmonary tuberculosis and 2 of tuberculous cervical adenitiswithout clinical pulmonary involvement. Extra-pulmonary tuberculosis was rarelyencountered in the area. A review of the pulmonary cases showed that 12 werediagnosed as inactive or arrested, 33 as minimal active, 16 as moderatelyadvanced, and 1 far advanced. None of the patients were critically ill and nonedied in the theater.
The incidence rates for tuberculosis in the Southwest Pacific Area and othertheaters and areas, as computed in the Office of the Surgeon General,
CHART 21.-Incidence of tuberculosis in the U.S. Army, bytheater and year, 1942-45
are shown in chart 21. The rate for all theaters and areas during World WarII was 1.25.
Diagnosis and care-Medical installations in general wereprovided with X-ray and laboratory facilities, so that diagnosis was ordinarilymade at an early stage. Cases discovered in forward areas were evacuated togeneral hospitals where, in most instances, one or more members of the medicalstaff had had specialized training in tuberculosis. Laboratories were regularlyequipped for examination of sputum and gastric washings and the determination ofsedimentation rates.
Special medical problems-As in the South Pacific, an effort was made todetermine if climatic conditions or prevalent tropical diseases played a role inthe activation or progress of tuberculosis. No evidence was found that thesefactors played any part in increasing the incidence or severity of tuber-
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culosis. Comparative studies showed that prevalent bacterialinfections and parasitic infestations were no more common in tuberculouspatients than in the general population of patients. The official reporterrecords:
While the groups of patients admitted in various periods from areas ofprolonged and active combat showed, in general, varying degrees ofundernutrition and physical exhaustion and a greater incidence of parasiticinfestation, they presented no more tuberculosis than was seen among patientsfrom service forces operating under more favorable conditions.
Evacuation-Cases of active tuberculosis were evacuatedas rapidly as possible after the final decision was reached by the dispositionboards of the hospitals concerned. Wherever possible, tuberculous patients weretransferred to the United States by air. It was felt that the best assurancepossible for recovery was to minimize delay in the initiation of definitivetreatment in a specialized Army medical institution in the Zone of Interior."In the few instances in which evacuation from the theater for old,well-healed pulmonary lesions did not seem warranted, arrangements were made forperiodic examination and evaluation."
In general, definitive therapy was not attempted in thetheater; it was felt that the type of treatment to be employed in individualcases should be left to the installation charged with the final care of thepatient. The report states further that "the short period of time which thepatient spent in the oversea theater hospital was utilized in educating him inregard to the nature of his disease, in his personal care, and in isolationtechnique. He was kept in isolation and on bed rest during his stay in thehospital and en route to his destination."
The official report states that "air travel was welltolerated by patients in all stages of the disease. No complications incident toair travel arose in patients with tuberculous pulmonary lesions."
The average period of hospitalization between diagnosis and evacuation was 18days.
WESTERN PACIFIC BASE COMMAND
Incidence-The official report for this command statesthat about 0.6 percent of a series of approximately 18,000 medical cases werediagnosed as tuberculosis. The incidence rate in the command for the period Junethrough September 1945, as recorded on the statistical health report, was about1 per annum per 1,000 average strength. The great majority of the cases were ofpulmonary tuberculosis. In addition, there were a few cases of genitourinary,miliary, bone, and gastrointestinal tuberculosis, and tuberculosis meningitis.
Diagnosis-The most frequent problem encountered was in earlydifferentiation of tuberculosis from atypical pneumonia. Repeated examination ofsputum and gastric washings for tubercle bacilli in many cases resulted in adiagnosis that could not be made on the roentgenogram alone. Bronchiectasis andcoccidioidomycosis also required differential diagnosis. Cases of bron-
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chiectasis were not uncommonly seen, but were not accuratelydiagnosed, for the medical officers in the area were reluctant to use Lipiodolbecause of possible future confusion on reexamination at tuberculosis centers inthe United States. Cultural methods were employed in isolating tubercle bacilli;guinea pigs were rarely used because of their scarcity in the theater. Thestandard methods were used for determination of activity of tuberculosis asbearing upon disposition.
Treatment-As a rule, initial treatment only wasattempted. The principal therapeutic problem was whether to institutepneumothorax prior to evacuation. This was rarely done, because of (1)uncertainty concerning route, mode, and speed of evacuation, (2) uncertaintywhether competent personnel would be in attendance en route to give refills andhandle possible complications, such as tension pneumothorax, and (3) the needfor a long period of bed rest and observation prior to institution of collapse.Collapse was, however, induced in cases of persistent hemorrhage, cases in whichexcavation developed in rapidly progressive lesions, and cases in which therewas reason to believe adhesions were forming.
Special problems-The official report stated that "** * no medical officer contacted had definite basis for believing that thetropical climate per se influenced the development of tuberculosis, although itwas a factor in determining disposition of certain cases * * *. Nor could thetype of military service be correlated with the incidence of tuberculosis. Mostof the officers who dealt with repatriated prisoners of war believed that theirpoor nutritional status undoubtedly influenced their high rate of tuberculousinfection." The subject of tuberculosis in recovered prisoners of war istreated elsewhere. It will be noted here that a survey of troops from Iwo Jima,where supplies of fresh food were probably least adequate, failed to demonstratea clinical deficiency status that could be correlated with the progress ofinfectious disease of any type. Subclinical vitamin deficiencies were slight,and of no greater severity than were seen in a similar group in the HawaiianIslands.
Evacuation.-Evacuation by air was considered the ideal formof transportation, but was not available as often as was desired. Prior toevacuation, whether by sea or by air, sedation with barbiturates was given, andprovision was made for such complications as spontaneous pneumothorax. Allpatients with active tuberculosis were evacuated, and a good many with lesionsthat were without symptoms or signs and appeared to be inactive on X-rayexamination were, nevertheless, evacuated to the United States because medicalofficers in the command did not feel justified in calling such cases arrestedwithout prolonged observation. With the end of hostilities, as the report notes,the tendency of the theater was to be more liberal with the diagnosis ofinactive tuberculosis, and, for this reason, numerous patients of typespreviously forwarded to the United States were held for prolonged observation,and not infrequently returned to duty.
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MIDDLE PACIFIC
Incidence-The incidence of tuberculosis in the Pacific Ocean Area, whichconsisted of the combined Central and South Pacific Areas, is shown in chart 21.A sampling comprised of admissions in the Middle Pacific command during thefirst 11 months of 1945, shows a total of 164,957 cases of disease of all types,including 287 cases of tuberculosis, or 0.17 percent of all admissions.
Diagnosisand care.-Nothing unusual in diagnosis, not seen in other parts of thePacific area, was noted in the official report in the Middle Pacific command.Hospitals in the Hawaiian Islands were excellently equipped, so that everyprocedure that could be carried out in the Zone of Interior was readilyavailable. Because of the accessibility of six excellent general hospitals,definitive care was instituted more frequently than in the more remote areas inthe Pacific. Active cases were transported as soon as convenient to themainland. As in other parts of the Pacific area, medical officers concerned withthe care of tuberculous patients did not attribute any particular manifestationsof the disease to climatic peculiarities of the region, to the type of service,or to the malnutrition that from time to time affected substantial numbers oftroops in combat.
Evacuation-The majority of patients with tuberculosiswere transported to the Zone of Interior by water, except that those who weresent by way of the Hawaiian Islands accomplished this part of the journey byair.
CHINA-BURMA-INDIA THEATER
Tuberculosis in military personnel was not considered aserious problem in the India-Burma theater.34 The consultant inmedicine in the theater reported that 334 cases were admitted to hospitals therebetween the first of January 1944 and the end of July 1945. The annual incidencerates per 1,000 average strength and numbers of cases for the China-Burma-Indiatheater, based on preliminary sample tabulations of individual medical records,are as follows:
|
| Rate |
1942 | 6 | 0.69 |
1943 | 27 | .68 |
1944 | 157 | .93 |
1945 | 240 | 1.04 |
On the other hand, Army installations in the China and the India-Burma theaters recorded a high incidence of tuberculosis in Chinese troops. The great majority of tuberculous patients in U.S. Army hospitals in China and
34(1) Blumgart, Herrman L., and Pike, George M.: History ofInternal Medicine in India-Burma Theater, p. 118. [Official record.] (2) The U.S.Forces, India-Burma Theater, was created on 24 October 1944 by dividing the U.S.Forces, China-Burma-India into two separate theaters-the China Theater and theIndia-Burma Theater.
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Burma were Chinese. Because of this high incidence and thenotorious lack of sanitary precautions observed by sick Chinese soldiers,medical and nursing personnel in these hospitals were heavily exposed tocontagion. Routine checks by the 48th Evacuation Hospital of hospital personnelfailed to disclose cases of tuberculosis that could be traced to contact in thetheater. Since, however, tuberculosis is slow in its evolution, and years mayelapse between infection and manifest disease, it was recognized byadministrative officers of these hospitals that persons who had been employed inthem should be carefully observed for some time after their return to the UnitedStates.
ALASKAN DEPARTMENT
From time to time, concern was expressed over the extent oftuberculosis in Alaska. Reports from units in the Alaskan service calledattention to the excessive admission of men with tuberculosis through theenlistment process at Alaskan stations, where facilities for the detection ofthe disease were inadequate. Attention was also called to the danger of exposureof servicemen to tuberculosis in Alaska, where the prevalence of the diseasegreatly exceeded that in the United States. During the war, negotiations wereunderway for the construction of a hospital for the care of tuberculouspatients in Alaska, and the danger to servicemen, through contact withnonhospitalized cases, was cited as emphasizing the need for such a hospital.The number of nonhospitalized open cases in the territory was estimated by theOffice of the Surgeon General as approximately 1,000 and, although thedistribution of these cases was unknown, it was assumed that their presence incommunities where troops were stationed constituted a hazard in contagion.35In addition, the factor of exposure to harsh climatic conditions, with anadverse effect on small latent or unrecognized tuberculous lesions, was alsocited as reason for special consideration of the problem of tuberculosis in theAlaskan Department.
The actual incidence rates for tuberculosis during the waryears, however, did not reflect an unusual hazard. The annual rates per 1,000men, based on preliminary summary reports, were much like those recordedelsewhere:
|
| Rate |
1942 | 81 | 1.61 |
1943 | 99 | .86 |
1944 | 70 | .84 |
1945 | 44 | 1.07 |
Whether evidence of infection acquired by soldiers in Alaska will develop later, could not be predicted.
35Memorandum, Lt. Col. Robert J. Carpenter, MC, ExecutiveOfficer, Office of the Surgeon General, for Assistant Chief of Staff, G-4,attention: Col. Carroll H. Deitrick, GSC, Chief, Policy Branch, 15 Mar. 1944,subject: Hospitalization for Tuberculosis Cases in Alaska.
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LATIN AMERICAN AREA
As in Alaska, troops in the Caribbean area and in Central and South Americaserved in regions of relatively high prevalence of tuberculosis in the localpopulation. Also, as in Alaska, the troops on duty included a good manyrecruited locally from a territory of the United States where the prevalence oftuberculosis was high; for example, Puerto Rico. The total incidence rates,however, up to the end of the war did not furnish evidence of special hazard.The annual incidence rates per 1,000 average strength and the number of cases,based on tabulations of individual medical records, are as follows:
|
| Rate |
1942 | 159 | 1.56 |
1943 | 134 | 1.11 |
1944 | 115 | 1.34 |
1945 | 85 | 1.19 |
MIDDLE EAST
As the number of troops on duty in the Middle East was not large, the rateswere not highly significant. Climatic conditions were variable, and exposure tocontagion, as reflected by the mortality in the local population, was high. Theheat in Iran was excessive and made it impossible for troops on duty to getnormal rest. The annual incidence rates per 1,000 average strength and thenumber of cases, based on tabulations of individual medical records, are asfollows:
|
| Rate | |
| 1942 | 3 | 0.50 |
| 1943 | 47 | .89 |
| 1944 | 50 | 1.08 |
| 1945 | 20 | .72 |
FAR EAST
The number of cases of tuberculosis developing in the U.S.Army in Japan, between the date of initial occupation and the end of 1945, wasvery small. Only 24 cases were recorded, which yielded an annual rate of 0.24per 1,000 per annum. The surgeon of the occupying forces, however, in a laterreport on tuberculosis in Japan, called attention to the prevalence of thedisease in the native population, which suggested a correspondingly graveexposure of troops on duty in the islands. The annual mortality fromtuberculosis in Japan was recorded, on the basis of figures obtained from theJapanese Anti-Tuberculosis Association, as ranging from 209 per 100,000 in 1941to 282 per 100,000 in 1946. In view of the known great deficiency of beds forthe care of the tuberculous in Japan, it may be assumed that large
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numbers of open cases were scattered through Japanese communities withoutisolation or care.
During 1946, the hospital admission rate for tuberculosis, asrecorded in the theater, rose notably. Part of this rise, however, particularlyin the months of June, July, and August, was the result of rapid discovery ofcases in Philippine troops on discharge from the U.S. Army. As the reportindicates, however, rates considerably higher than those for troops in theUnited States prevailed in the theater at the close of 1946.
It was evident that the problem of tuberculosis in troops onduty in the Far East was serious. It was complicated by the presence of numerousPhilippine soldiers among the occupying troops, a group with a relatively highincidence of tuberculosis as compared with those recruited in the United States.Continual attention must be given in the future to the factor of contagion inthis region.
Part III. Particular Aspects of the Disease
EXTRAPULMONARY TUBERCULOSIS
Extrapulmonary tuberculosis may be a complication ofpulmonary tuberculosis, or may occur in the absence of significant pulmonarydisease. Figures indicating its prevalence in the general population are basedon mortality records, rather than incidence during life, and indicate thatabout 10 percent of all fatal tuberculosis is predominantly nonpulmonary. In theapproximate order of frequency of involvement are the urogenital tract, bones,lymph nodes, serous membranes, and other sites, such as the adrenal glands. Inmany cases, the contributing, final cause of death is miliary tuberculosis ortuberculous meningitis. The position of intestinal tuberculosis isindeterminate. In the great majority of cases, this form is simply acomplication of pulmonary tuberculosis, but not infrequently its manifestationsare so severe that they dominate the clinical picture, so that death is reportedas due to intestinal, rather than to pulmonary, disease.
Nonpulmonary tuberculosis, the scrofula of ancient times, is most prevalentamong primitive peoples and those whose hygienic environment is poor. It is alsofrequent where the alimentary intake of tubercle bacilli is common, as inlocalities where bovine tuberculosis is widespread and milk is not pasteurized.
Troops of the U.S. Army met both of these conditionsoverseas. Among the natives in the Pacific islands the scrofulous types oftuberculosis were relatively common, while bovine tuberculosis was frequent inthe British Isles and continental Europe. The reasons for prevalence ofnonpulmonary tuberculosis in primitive cultures are complex, including racialfactors as well as habits and customs. In the United States, as a result of acombination of circumstances, nonpulmonary tuberculosis is more frequent in Ne-
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groes and Indians than in white people, and this fact held for troops ofthese races.
The contagion of nonpulmonary tuberculosis, even more than of pulmonarytuberculosis, depends on the closeness of contact. There was no reason tobelieve that the contacts of American troops with a population in whichnonpulmonary tuberculosis is more common than in the United States would lead toa higher incidence of this type of tuberculosis than normally prevails in ourpopulation. Such a result would imply prolonged intimate contacts, as byadoption of primitive customs, such as eating from a common bowl or carelessskin contacts with open ulcers or draining sinuses of infected persons.
On the other hand, infection from raw milk, particularly in the BritishIsles, was clearly recognized as a danger from the outset, and precautionsagainst it during our troops' residence overseas were taken early.
An observation made in the course of military operations in World War I ispertinent.36 The American pathologist, Maj. Eugene L.Opie, MC,stationed in France, called attention to the fact that calcified tuberculosis ofprimary infection was very frequently observed in the mesenteric lymph nodes ofBritish troops, indicating an alimentary origin, presumably by ingestinginfected milk. In the bodies of Americans, in marked contrast, primaryinfections were almost always in the lungs or tracheobronchial lymph nodes,and so presumably had been acquired by inhalation of tubercle bacilli.
By far the greatest amount of the milk consumed on Army postsoverseas was dried pasteurized milk shipped from the United States. There wasalways, however, some danger from milk from private sources. In the early monthsoverseas, some of the Red Cross canteens served local milk, the safety of whichwas not assured. Later, about February 1943, this practice was stopped entirely.The U.S. Army Veterinary Corps in the British Isles was constantly on the alertfor danger. Up to July 1942, the U.S. Army was on the British ration, whichincluded milk from certain approved sources. The Veterinary Corps came to theconclusion that, in spite of a variety of precautions, "there were too manyhazards involved for its general use." Circulars Nos. 40 and 72,Headquarters, European Theater of Operations, dated 5 September and 10 November1942, respectively, sharply restricted purchase of milk and imposed rigidstandards with respect to the source. Relatively few sources satisfied thesestandards; consequently, after the early months, little British milk wasconsumed in the official ration. Consumption of raw milk by soldiers in thehomes of friends could not be so well controlled, and some infection may havebeen transmitted in this way, but the total hazard was not great, as relativelylittle milk was available to the general population.
36Opie, E. L.: First Infection With Tuberculosis By Way of theIntestinal Tract. Am. Rev. Tuberc. 4: 641-648, November 1920.
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Since tuberculosis is a disease of slow development, it isnot easy to determine the source of infection in a given case. Disease acquiredoverseas may not become manifest for several years. Therefore, it is not knownhow much nonpulmonary tuberculosis observed in American troops originated there.It can only be said that the incidence (of forms other than pleuritis) showed norise before the end of the war. The overall rates per 1,000 for the total Armyfor all forms of nonpulmonary tuberculosis, including tuberculosis of thelarynx, trachea, bronchi, and pleura, for the years 1942, 1943, 1944, and 1945,were 0.13, 0.13, 0.17, and 0.23, respectively. Tuberculosis of the pleura is ofspecial interest and is considered under the next heading and elsewhere in thisaccount. Figures for the incidence of the other more common forms ofnonpulmonary tuberculosis are presented in table 49.
[Preliminary data based on sample tabulationsof individual medical records]
[Rate expressed as number of cases per annum per 1,000 average strength]
Type |
| 1942 | 1943 | 1944 | 1945 | |||||
| Rate | Number of cases | Rate | Number of cases | Rate | Number of cases | Rate | Number of cases | Rate | |
Genitourinary | 674 | 0.03 | 50 | 0.02 | 190 | 0.03 | 210 | 0.03 | 215 | 0.03 |
Bones or joints | 673 | .03 | 100 | .03 | 174 | .03 | 194 | .02 | 205 | .03 |
External lymph nodes | 586 | .02 | 19 | .01 | 224 | .03 | 168 | 02 | 175 | .02 |
Skin | 140 | .01 | 5 | .00 | 9 | .00 | 36 | .00 | 90 | .01 |
Generalized miliary | 133 | .01 | 22 | .01 | 48 | .01 | 53 | .01 | 10 | .00 |
Meningitis | 143 | .01 | 19 | .01 | 23 | .00 | 56 | .01 | 45 | .01 |
Other1 | 928 | .04 | 214 | .07 | 242 | .04 | 242 | .03 | 230 | .03 |
1Excludes tuberculosis of trachea and of bronchi in 1942 and 1943. During 1942-43, these two conditions were coded to pulmonary tuberculosis. In 1944 and 1945 there were 30 and 45 cases, respectively, which have been included in the "Other" category.
Differences in incidence overseas and incidence in the Zoneof Interior were not significant, and accordingly combined figures for the totalArmy are given. The total amount of nonpulmonary tuberculosis, other thantuberculous pleuritis, was between 5 and 15 percent of all tuberculosis reportedeach year, a figure approximately the same as that for the civilian population.It should be noted that the methods of exclusion of nonpulmonary tuberculosis atinduction were inferior to the X-ray procedure for detection of pulmonarytuberculosis. It became evident in retrospect that small lesions of theepididymis not infrequently escaped notice, and tuberculous superficial lymphnodes were also not conspicuous enough in many instances to be noted in thecourse of the usual rapid induction examination. Tuberculosis of the kidney wasfrequently evident on the basis of symptoms, history, or presence of pus in theurine, but some cases in an early stage were certainly undetected.
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Racial differences with respect to nonpulmonary tuberculosis are discussedin the section on "Mortality From Tuberculosis." Aronson's studies37indicated that urogenital tuberculosis was more common in the white race, andtuberculosis of the lymph nodes, of the serous membranes, and of the bones wasmore common in Negroes.
PLEURISY WITH EFFUSION
Special interest is attached to the subject of tuberculous pleurisy witheffusion, because of the indications discovered by Canadian medical officersthat this form of tuberculosis in soldiers was a manifestation of recent primary tuberculosis in adult life, occurring with particular frequency in troopsfrom parts of Canada with a low rate of exposure. Figures for the U.S. Army aremore difficult to analyze in this respect than those for the Canadian Army, butthere are some indications that a similar phenomenon occurred (pp. 403-405).
The medical treatment of pleurisy with effusion in the Army was variable.There was a tendency, particularly in oversea theaters, where demand forpersonnel was critical, to return men to duty after complete absorption of fluidand a period of hospital convalescence and rest.38 In an appreciablenumber of cases of frank pulmonary tuberculosis that developed in the Army,clinical history disclosed a previous attack of pleurisy with effusion. In theZone of Interior, the medical rule that pleurisy with effusion should beconsidered tuberculous if no other etiology could be proved was generally,although not invariably, followed, and many soldiers with effusion were sent tothe Army hospitals used as tuberculosis centers and ultimately were dischargedon certificate of disability as tuberculous. Clarification of procedure wasbrought about by TB MED (War Department Technical Bulletin) 71, dated 28 July1944, and Change 1, dated 26 November 1946, in which the tuberculous nature ofthe disease was emphasized, instructions for diagnosis given, and principles fordisposition set forth.
In 1942 and 1943, tuberculosis of the pleura was coded with pulmonarytuberculosis, with pleurisy as an associated disease. In 1944 and 1945, separatespecific accounting was made of clearly diagnosed tuberculosis of the pleura andserofibrinous pleuritis of undemonstrated origin (table 50). The figures forthese 2 years may therefore be used as suitable for comparing pleurisy witheffusion with pulmonary tuberculosis, and the occurrence of pleurisy witheffusion in troops overseas and in the United States.
It will be noted that the rate was appreciably higher in troops overseas thanin those in the United States, where, it will be recalled, the admission ratefor pulmonary tuberculosis was higher than in troops overseas (chart 18).However, great significance should not be attached to this apparent
37Aronson, J. D.: The Occurrence and Anatomic Characteristics of FatalTuberculosis in the U.S. Army During World War II. Mil. Surgeon 99: 491-503,November 1946.
38See footnote 29, p. 356.
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discrepancy. The advent of pleurisy with effusion isgenerally sudden and dramatic with fever, pain, and other symptoms; thediagnosis, therefore, is relatively early and easy. Pulmonary tuberculousinfiltration, on the other hand, is usually insidious in origin and diagnosis ona symptomatic basis, relatively late. It is quite reasonable to suppose thatalmost all of the serofibrinous pleurisy developing overseas was diagnosedthere, whereas pulmonary tuberculosis acquired overseas in many instances wasnot detected until the return of the afflicted soldiers to the United States.
TABLE 50.-Incidence of tuberculosis of pleura andserofibrinous pleuritis in the U.S. Army, 1944-45
[Rate expressed as number of cases per annumper 1,000 average strength]Category | Total Army | Continental |
|
| 1944 |
|
|
|
Tuberculosis of pleura | 391 | 75 | 316 |
Serofibrinous pleuritis | 3,320 | 1,500 | 1,820 |
|
| 3,711 | 1,575 | 2,136 |
|
| 0.48 | 0.40 | 0.56 |
| 1945 |
|
|
|
Tuberculosis of pleura | 745 | 160 | 585 |
Serofibrinous pleuritis | 2,520 | 900 | 1,620 |
|
| 3,265 | 1,060 | 2,205 |
|
| 0.44 | 0.36 | 0.50 |
All clinical experience indicates that the prognosis of cases of pleurisy with effusion, even without radiologically demonstrable pulmonary infiltration, is doubtful for at least 5 years. Texts and articles on the subject, in general, emphasize the fact that 25 to 50 percent of the cases of effusion inadequately treated, that is, not subjected to a period of rest of several months following absorption of the fluid, develop pulmonary tuberculosis within 5 years; thereafter, the incidence is like that in the general population of corresponding age.39 The Army figures cannot be expected to reveal the total incidence of pulmonary tuberculosis developing in cases of pleurisy with effusion, for the critical 5-year period had only commenced in the majority of cases when demobilization began. It is possible that men who had had short attacks of pleurisy with effusion and were returned to duty with-
39(1)Thompson, B. C.: Pathogenesis of Pleurisy WithEffusion; A Clinical, Epidemiological and Follow-up Study of 190 Cases. Am. Rev. Tuberc. 54: 349-363, October-November 1946. (2) Thompson, B. C.: Prognosis ofPrimary Pleurisy With Effusion. Brit. M.J. 1: 487-488, 12 Apr. 1947.
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out residua, and ultimately discharged from the Army withnegative X-ray films of the chest or no anomaly other than a costaldiaphragmatic adhesion, may yet develop pulmonary tuberculosis as a result ofthe infection manifested originally only by the pleurisy. Care and compensationin these cases will be adjudication problems for the future.
As has been pointed out, in the various theaters the rate ofadmission for serofibrinous pleurisy in the Army was generally 25 to 30 percentof the rate of admission for pulmonary tuberculosis. In view of the probabletuberculous nature of the great majority of cases of effusion in whichtuberculosis could not be unequivocally diagnosed by laboratory methods, itmight seem appropriate to add the admissions of serofibrinous pleurisy to thosefor pulmonary tuberculosis to arrive at a true rate for the latter. This wouldnot be accurate, however, as there would be a not insignificant duplication ofcases. Men with a diagnosis of pleurisy with effusion in the admission recordswho returned to duty after recovery were subsequently, in an undeterminednumber of cases, given another diagnosis, and entered in the medical statisticsof the Army as patients with pulmonary tuberculosis.
In summary, it appears warranted to believe that tuberculouspleurisy did occur more frequently in troops serving overseas than in those whonever left the United States, and it seems reasonable, even with due allowancefor greater physical strain and other factors that might be pertinent, toattribute the greater frequency, as did the Canadians, to the greater exposureoverseas, where civilian populations were more heavily infected than in theUnited States. Much further research, taking into account the age and homeresidence of soldiers who developed tuberculous pleurisy with effusion, will beneeded to support the Canadian view that the majority of cases of effusionrepresented recent primary tuberculous infections.
The American experience also indicates the necessity for a long-range view ofthe prognosis of pleurisy with effusion, with recognition not merely ofimmediate necessities for manpower, but also the questionable prognosis in thelong run, of men seemingly recovering without residua and returned to militaryduty.
SPONTANEOUS PNEUMOTHORAX
The view once prevailed that the great majority of cases ofspontaneous pneumothorax were complications of pulmonary tuberculosis. In 1932,in his textbook on tuberculosis, Fishberg40 expressed the general opinionthat 80 percent of cases were in that category. Subsequent investigation showedspontaneous pneumothorax to be not uncommonly an independent development.41Such, as seen in the Army, it was usually found to be.
40Fishberg, Maurice: Pulmonary Tuberculosis. VolumeI.Etiology, Pathogenesis, Symptomatology, Roentgenology, Clinical Forms. 4th edition. Philadelphia: Lea& Febiger, 1932.
41For a study of 58 cases, bibliography, and discussion ofpathogenesis see Ornstein, G. G., and Lercher, L.: Spontaneous Pneumothorax inApparently Healthy Individuals. Clinical Study of Fifty-eight Cases With aDiscussion of the Pathogenesis. Quart. Bull., Sea View Hosp. 7: 149-187, April1942.
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During the years 1942 to 1945, inclusive, 3,831 admissions to Army hospitalsfor spontaneous pneumothorax were recorded. The great majority werenontuberculous. This number, in a total of approximately 11 million men,represented about 1 case per 2,700 men in the cumulative experience of 4 years.
The incidence of spontaneous pneumothorax, as indicated by rates of admissionand readmission for the continental United States and the oversea theatersduring the 4 war years, is presented in table 51.
[Preliminary data based on sample tabulationsof individual medical records]
[Rate expressed as number of new admissions per annum per 1,000 averagestrength]
Year and area of admission |
| Readmissions | |
| Rate | ||
| 1942 |
|
|
|
Continental United States | 384 | 0.14 | 8 |
Outside continental United States | 56 | .10 | --- |
|
| 440 | 0.14 | 8 |
| |
|
|
|
Continental United States | 930 | 0.18 | 25 |
Outside continental United States | 163 | .10 | 2 |
|
| 1,093 | 0.16 | 27 |
| |
|
|
|
Continental United States | 805 | 0.20 | 15 |
Outside continental United States | 353 | .09 | 6 |
|
| 1,158 | 0.15 | 21 |
| |
|
|
|
Continental United States | 585 | 0.20 | 20 |
Outside continental United States | 555 | .12 | --- |
|
| 1,140 | 0.15 | 20 |
| |
|
|
|
Continental United States | 2,704 | 0.18 | 68 |
Outside continental United States | 1,127 | .11 | 8 |
|
| 3,831 | 0.15 | 76 |
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As the figures show, the admission rate overseas was consistently less thanin the United States, a fact perhaps merely indicating that a soldierpredisposed to spontaneous pneumothorax by anatomical defect or other cause waslikely to develop it in his early Army training if at all.
In 1943, when there were 930 hospital admissions in the continental UnitedStates for this cause, and medical officers were in doubt as to propertreatment, the Subcommittee on Tuberculosis, National Research Council, wasasked to study the subject and make recommendations on treatment. This requestresulted in the publication of a document by the Office of Medical Informationof the Division of Medical Sciences, National Research Council, which was givenwide distribution in U.S. Army medical installation S.42 At the same time, anarticle was published in the Bulletin of the U.S. Army Medical Department callingattention to the frequency of spontaneous pneumothorax, the deficiencies inpresent-day treatment, the need for individualization in treatment, and thedangers inherent in the several methods available.43 The note pointedout that up to the time of its writing, spontaneous pneumothorax had beenconsidered of sufficient gravity to warrant separation from the service in 15percent of cases and that the average duration of hospitalization for thiscondition had been 40 days.
In the document published by the National Research Council, a usefulclassification was given, with pertinent material on diagnosis and prognosis.The relationship to bullae in the lung was indicated, although it is known thatvery frequently such bullae cannot be demonstrated during life by anyradiological or other method. Conservatism in treatment was recommended. Prompthospitalization was required, with avoidance of physical effort. Special warningwas given against transportation by air. It was noted that the air in thepleural space is absorbed spontaneously in most cases within a few weeks.Aspiration at short intervals may be desirable for a few days at the start.
The chief problem in spontaneous pneumothorax in the Army was recurrence.Waring's review of the literature indicated recurrence in 10 to 20 percent ofcases. Most of the discharges from the Army for spontaneous pneumothorax werefor recurrence or persistence. In many of these cases, various methods ofobliterating the pleural space to prevent recurrence were tried. Two that metwith some success were injection of whole blood from the patient andinsufflation of powdered talc. In Waring's report, the dan-
42Waring, J. J.: Spontaneous Pneumothorax. Office of Medical Information,Division of Medical Sciences, National Research Council, July 1944.
43(1) Pease, P. P., Steuer, L. G., and Chapman, A. S.:Spontaneous Pneumothorax in Soldiers. Bull. U.S. Army M. Dept. No. 82: 102-107, November 1944. (2)Spontaneous Pneumothorax. Bull. U.S. Army M. Dept. No. 82: 29, November 1944.
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gers of induced "chemical pleuritis," particularly uncontrollablethickening of the pleura, were discussed.44
In general, the Army experience indicated that spontaneouspneumothorax is a not uncommon phenomenon; that it is favored by exertion, butmay occur independently of any physical strain; that recurrence is not infrequent and may necessitate discharge; and that individualization is necessary intreatment. Account was taken of its importance for induction by the requirement,in late revisions of Army Regulations pertaining to physical standards,including Mobilization Regulations, that men with a verified history ofspontaneous pneumothorax within 3 years, or recurrent spontaneous pneumothoraxat any time, should be excluded from service.
MORTALITY FROM TUBERCULOSIS
Figures on mortality from tuberculosis in the Army are nothighly significant. Active tuberculosis was rarely compatible with return toactive duty, and accordingly Army Regulations required discharge of patientsafter diagnosis and such initial hospitalization as was necessary to insure thebest results in a Veterans' Administration hospital or civilian hospital afterdischarge. It was specifically stated in AR (Army Regulations) 615-361, 14 May1947, however, that moribund cases were not to be discharged. Hence, the deathsthat occurred from tuberculosis in the Army represented cases in which thedisease was far advanced on discovery, acute in its progression, or firstdiagnosed and hospitalized in regions where early evacuation was not possible.
During World War II, the annual mortality from tuberculosis in the Armyaveraged about 3 per 100,000 while in the civilian population of correspondingage the rate was about 50 per 100,000. The corresponding figures for WorldWar I were 67 in the military population and over 150 per 100,000 in thecivilian population.
The incidence and character of fatal tuberculosis in the Armyformed the subject of a special investigation,45 in which comparisonwas made of the pathology of the disease in white and in Negro troops. Ingeneral, the evidence favored the view that the Negro race has a lower inherentresistance to tuberculosis than the white race, for, in spite of approximateuniformity of environment, Negro troops, representing only 10 percent of thepopulation of the Army, contributed 43.4 percent of the deaths fromtuberculosis. Unusual differences were not observed in the extent or characterof tuberculosis
44(1) See footnote 42, p. 374. (2) For a further discussionof the treatment of spontaneous pneumothorax see Blades, Brian B., Carter, B.Noland, and DeBakey, Michael E.: Surgical Aspects of Diseases of the Chest. InMedical Department, United States Army. Surgery in World War II. ThoracicSurgery. Volume II, ch. X. [In preparation]-J. B. C., Jr.
45See footnote 37, p. 370.
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in the different organs in the two races. Highly destructivetuberculosis was somewhat more frequent in the lungs of Negro than in whitetroops, and healed tuberculosis was a more common incidental finding in whitethan in Negro troops. In white soldiers, the central nervous system andgenitourinary organs were more commonly affected than in Negro troops, and inthe latter there was higher incidence of tuberculosis of lymph nodes, bones, andperitoneum. Tuberculous meningitis was slightly more common in Negro than inwhite soldiers.
In both races, the duration of the disease appeared remarkably short ascompared with that in the civilian population. The reason for this has alreadybeen given; namely, the likelihood of discharge of chronic cases before deathcould occur. A relatively high incidence of fatal tuberculosis occurred inrecovered prisoners of war who had suffered privations for many months in prisoncamps overseas.
Although the mortality from tuberculosis among troops actually in servicedoes not yield statistically significant figures, such figures can be obtainedby combining the mortality totals for the military population in service anddischarged. Figures so compiled indicate that a steady rise has occurred in themortality from tuberculosis in the group of men accepted for service in the Armysince the beginning of World War II.46 During 1942, the combined rate for troopsin service and troops previously discharged was approximately 3 per 100,000 perannum; thereafter, it rose to 6 in 1943, 10 in 1944, and 12 in 1945.
This steady rise indicates that tuberculosis continued to increase with timein a group generally well screened by X-ray examination before induction. Thereis reason to believe that the rise was due to several factors, including slowand ultimately fatal development of previously unrecognized disease present atthe time of acceptance and the acquisition of infection from outside sourcesduring the years of military service. For comparison, it may be noted thatduring the years under consideration the tuberculosis death rate for thecivilian population of corresponding age remained, with minor fluctuations, atapproximately 52. Thus, the rate for the screened population was far below thatof the corresponding unscreened population, which included those screened outbecause of tuberculosis. The rate which the disease will ultimately attain willdepend on many factors, including measures against tuberculosis in the generalpopulation and special measures for veterans taken by the Veterans'Administration.
Eight hundred and six deaths from tuberculosis were recorded in Armypersonnel from 1942 to 1945, inclusive (table 52).
46Long, E. R.: Tuberculosis in a Screened Population.Am. Rev. Tuberc.54: 319-320, September 1946.
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378
Part IV. Hospitalization and Treatment in the Zone of Interior
GENERAL PRINCIPLES OF EVACUATION
For accounts of evacuation of tuberculous patients from the differenttheaters, the reader is referred to sections of this chapter in which theexperience of each theater is described. In the early days of World War II,evacuation was by transport, for neither hospital ships nor planes wereavailable. The best facilities available on troopships were accorded tuberculouspatients, but this mode of transfer to the Zone of Interior had obviousdisadvantages. Quarters were crowded, nursing attention was minimal, facilitiesfor proper care were inadequate, and suitable provision could not be made forisolation.
In contrast, when hospital ships became available in sufficient numbers, thetransfer of tuberculous patients from oversea theaters was handled in acreditable manner. As a rule, quarters designed for contagious diseases wereused, so that isolation was feasible, and both nursing and medical care weremore nearly adequate. Hospital ships had good laboratories and suitable X-rayapparatus and, as a general rule, a sufficient number of nurses. Port surgeonsissued directives in early 1945 covering the care of patients en route and thesanitary precautions to be taken.
Early in 1945, when the number of tuberculous patients returning fromoverseas was fairly high, attention was drawn to the fact that convoys wereoften so large that the surface water, which was pumped into ships for bathingand other purposes, was contaminated to a noticeable degree by sewage from theships of the convoys. Recognizing the fact that tubercle bacilli might bepresent in the discharges from tuberculous patients, and be unwittingly drawninto the water supply for scrubbing and deckwashing in rear ships of convoys,the Office of the Surgeon General forwarded a letter in March 1945 to the NewYork Port of Embarkation outlining principles to be followed to prevent thistype of contamination. Suggestions from the Office of the Surgeon General,including a statement on general measures in the care of tuberculous patients enroute, were embodied in Circular Letter No. 10 from the Port Surgeon, New YorkPort of Embarkation, 26 March 1945, entitled "Care of Tuberculous PatientsDuring Water Transportation." This circular established importantprovisions for sputum control, emphasizing (1) education of patients, (2) use ofgauze for cough, (3) use of sputtam cups, and (4) decontamination of quartersfollowing their use by tuberculous patients, as well as the principles ofisolation and proper care of utensils and laundry.
It was required that gauze, tissue, sputum cups, and bagscontaining gauze and other contaminated material be destroyed each day. It wasrecommended that if burning, the most satisfactory method of disposal, was not
379
practicable, the material to be destroyed should be placed incloth bags of appropriate size to be weighted and sunk. It was pointed out thatthis infectious material should not be cast overboard indiscriminately topossibly contaminate the water pumped into the other ships.
The danger from indiscriminate use of sea water around convoys does nothowever appear to have been great, for tests for the presence of sewage carriedout at the rear of large convoys failed to reveal any great amount ofcontamination, but the effort was considered worthwhile from the standpoint ofpublic health practice.
Circular Letter No. 10 emphasized rest for the patient, avoidance of allunnecessary activity, proper ventilation of quarters, and an adequate diet. Itwas indicated that a diet including liberal quantities of milk, eggs, butter,orange juice, tomato juice, and meat was practicable on board ship. Ordinarily,the standard diet of the ship appeared suitable if supplemented by midmorningand midafternoon feedings of orange juice, tomato juice, or milk.
Not infrequently it was necessary to administer pneumothorax en route topatients in whom this form of therapy had been instituted overseas. Qualifiedmedical personnel were not always available for this purpose, but in the latemonths of the war every effort was made to insure the presence on each hospitalship of a medical officer trained in the administration of pneumothorax.
Airplane transportation ultimately proved most desirable for the majority oftuberculous patients. It was suitable for all those with early disease, and forthe majority with moderately advanced illness. Patients with large tensioncavities and those with artificial pneumothorax were usually not transported byair. A specific study of the effects of air travel on patients with tuberculosiswas made by the Army Air Forces. The Office of the Air Surgeon, on request foran opinion, sent the following communication to the Office of the SurgeonGeneral:47
With respect to transportation of tuberculous cases, experience gatheredduring the past 24 months has shown that patients whose medical conditionwarrants movement suffer less shock and embarrassment when moved by air than byother means of transportation. Patients with active pulmonary tuberculosis havebeen flown for long distances at altitudes of 20,000 feet or more (with constantuse of oxygen) without ill effect. Air movement of patients is routinely carriedon at altitudes between 2,000 and 8,000 feet, except when weather, terrain, ormilitary operations force the planes to higher altitudes.
Sound medical judgment of the responsible medical officer in each individualcase must remain the final answer as to suitability for movement of tuberculouspatients.
A special report on the transportation by air of tuberculous patients wasprepared by the Section for Research on Minimal Tuberculosis, U.S. Army
47Transmittal Sheet, Col. A. H. Schwichtenberg, MC, AirLiaison Officer to The Surgeon General, to The Air Surgeon, 20 May 1944,subject: Evacuation of Tuberculous Patients by Air, first indorsement thereto,dated 18 July 1944.
380
Medical Research and Development Board and University of Colorado MedicalCenter, at Fitzsimons General Hospital.48
Transportation of patients with artificial pneumothorax had always to begiven serious consideration.49 Intrapleural gas doubles in volume at 18,000 feet,and proportionate increases take place at lower altitudes. The excessiveexpansion at high altitudes might be expected to lead to tearing of adhesionsand other untoward results. The problem was one of importance not only inoversea transport, which occasionally required flight at high altitudes to avoidstorms and enemy interference, but also in the Zone of Interior, for largenumbers of patients were flown to Fitzsimons General Hospital situated at analtitude of 5,000 feet in Colorado and Bruns General Hospital situated at analtitude of 7,000 feet in Santa Fe, N. Mex. Ordinarily, transportation oftuberculous and other patients was accomplished at the usual altitudes ofcommercial flying.
As the war progressed and the return movements of patients reached largedimensions, it was found that air transport, with proper safeguards, was withouthazard. It was so well developed by the end of the war that it was consideredthe method of choice wherever practicable. Most important, it insured earlydefinitive care in the United States, for such treatment, including collapsetherapy, in many cases was not initiated in the theater but left to thejudgment of the hospital charged with long-term treatment of the patient.
On such flights, it was essential to provide, against possible emergency,adequate nursing care and technical medical assistance. Ordinarily, a physiciandid not accompany a flight, but a trained nurse was always present, and thetotal time spent between the oversea theater and the Zone of Interior was short.As in transportation by water, proper isolation had to be insured. Occasionally, tuberculosus patients were sent on the same plane with other patients, butwhenever feasible all entire plane was reserved for their use. This frequentlymeant holding patients at hospitals of embarkation overseas for some days untila sufficient number had gathered.
The Office of the Surgeon General sent a civilian consultant,Dr. James J. Waring of Denver, Colo., to the San Francisco Port of Embarkationand Hamilton Field, Calif., to advise on transportation by air and by water ofpatients from the Pacific areas. Air transport from these areas was particularlyimportant because of the great distances involved. From July to December 1944,about 6,000 patients were flown from the Pacific areas to Hamilton Field, and ofthese 140 were tuberculous.
48Roper, W. H., and Waring, J. J.: Air Evacuation of Tuberculous MilitaryPatients. Am. Rev. Tuberc. 61: 678-689, May 1950.
49(1) Minutes, Subcommittees on Tuberculosis, Committee onMedicine, National Research Council, 21 Feb. 1942 and 10 June 1944. (2) Bridge,E. R., and Bridge, E. V.: Effect of Altitude on Abnormal Accumulations of Air in the Chest. Am. Rev. Tuberc. 51: 532-537, June 1945. (3) TuberculosisAbstracts, National Tuberculosis Association 19, No. 10, October 1946. (4) Duff,F. L.: Physical Factors in Air Evacuation. Bull. U.S. Army M. Dept. 7: 860-868, October 1947. (5)Air Transport of Tuberculous Patients. Bull. U.S. Army M. Dept. No. 87: 8. April 1945.
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In the United States, tuberculous patients were delivered at debarkationhospitals, whether arriving by ship or by air, and after appropriate triage weretransferred for further care to Fitzsimons and Bruns General Hospitals, a large number of them by air. Hospitalcommanders madeevery effort to forward tuberculous patients in plane and carload lots to avoidexposure of nontuberculous patients.
The final conclusion as a result of this experience was thatairplane transportation was most appropriate whenever it was practical. Forcases not suitable for air transport, hospital ships rather than transportsshould be used. Emphasis should be laid on proper isolation of cases, on safety,sanitary precautions, and avoidance of emergency. Finally, experience showedthat medical officers with training in tuberculosis should be assigned to dutyat embarkation hospitals overseas and debarkation hospitals in the Zone ofInterior to insure proper care throughout the course of transfer.
SPECIALTY CENTERS FOR TREATMENT
Discovery and treatment of tuberculosis in hospitals overseas has beendescribed for the several theaters. Hospitals at stations with a troop strengthof over 5,000 men were authorized to discharge patients with tuberculosis oncertificate of disability, and a large proportion of the total number ofcertificates of disability for discharge for this cause were granted at stationhospitals. In all cases of doubt, however, where the diagnosis could not beestablished in a station hospital, the patient concerned was sent to a generalhospital. Many were sent to Fitzsimons General Hospital which was a center fortreatment of tuberculosis throughout the entire period of the war and receivedthe majority of commissioned officers and noncommissioned officers hospitalizedfor tuberculosis.50
In the course of the War, two other hospitals were madespecialty centers for tuberculosis: Bruns General Hospital, and Moore GeneralHospital, Swannanoa, N.C. Bruns General Hospital, which was activated on 18February 1943, was made a center in August 1944,51 for the treatmentof "patients requiring special evaluation or prolonged care in an Armyhospital specializing in the treatment of tuberculosis." It had becomenecessary to supplement Fitzsimons General Hospital to provide care for thenumerous patients with tuberculosis evacuated from overseas. It was directed52that, if male tuberculous enlisted personnel and officers whose homes were inthe Eighth Service Command were evacuated from overseas, they were to betransferred from debarkation hospitals to Bruns General Hospital. Women weresent to Fitzsimons General Hospital. It may be noted incidentally that BrunsGeneral Hospital, chosen for reasons of climate and availability, by happycoincidence was named after one of the Army's outstanding specialists intuberculosis,
50War Department Circular No. 338, 18 Aug. 1944.
51War Department Circular No. 347, 25 Aug. 1944.
52See footnote 13, p. 337.
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Col. Earl Harvey Bruns, MC, who had trained many medicalofficers during and after World War I and was for years after the war, Chief ofMedical Service at Fitzsimons General Hospital.
The third specialty center for tuberculosis, Moore GeneralHospital, was established in the late months of the war, when many tuberculouspatients were being found at separation centers.
The official annual reports for the three hospitals named,which are on file in the Office of the Surgeon General, give full details on thesize of the medical and surgical staffs, the personnel changes that occurredduring the war, the number of tuberculous patients treated, the types of therapyemployed, and special problems encountered. At all hospitals, standard methodsof therapy were employed, with principal emphasis on rest and the use ofcollapse measures in appropriate cases. The extent to which different collapseprocedures were employed depended on the type of case, the special skills of thehospital staff, and the length of stay of patients. The frequency of collapsetherapy was in inverse ratio to the length of stay in the hospital. Prior to1946, except for a few special cases in which Promin (glucosulfone sodium) andPromizole (2-amino-5-sulfanilylthiazole) were employed, chemotherapy was notpracticed in the Army. Subsequently, the Army participated actively in study ofthe treatment of tuberculosis with streptomycin.53
In addition to their function as treatment centers, thehospitals trained medical personnel for positions of responsibility overseas andin the Zone of Interior. Indeed, frequent changes in personnel, inevitable underthe circumstances, interfered seriously with the efficiency of the treatmentgiven.
Fitzsimons General Hospital-Col. George F. Aycock, MC,was chief of medical service throughout the period covered by this history. Lt.Col. (later Col.) John B. Grow, MC, was chief of surgical service, and Maj.(later Lt. Col.) Richard H. Meade, MC, was assistant chief and later chief of thethoracic surgery section.
Cases of tuberculosis exceeded those of any other disease,since the chief purpose of the hospital was "to give treatment under [the]most favorable conditions to patients [suffering] with tuberculosis."54During 1942, 1,273 enlisted men were admitted to the tuberculosis section55 and106 officers including nurses were admitted for tuberculosis. At the end of theyear, 800 enlisted men were under treatment. The practice was to retain cases ofpulmonary or predominantly pulmonary tuberculosis on the medical service, andcases of genitourinary, bone, joint, and lymph node tuberculosis on the surgicalservice. Artificial pneumothorax and pneumoperitoneum were practiced on themedical service, and phrenic nerve operations, intrapleural pneumonolysis andextrapleural thoracoplasty, as well as less frequent operative proce-
53U.S. Veterans Administration: The Effect of StreptomycinUpon Pulmonary Tuberculosis. Preliminary Report of a Cooperative Study of 223Patients by the Army, Navy and Veterans Administration. Am. Rev. Tuberc. 56:485-507, December 1947.
54Army Regulations No. 40-600, 6 Oct. 1942.
55Personal communication, Executive Officer, Fitzsimons General Hospital,to Col. E. R. Long, MC, 19 Mar. 1947.
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dures, were carried out on the surgical service, with returnof patients to the medical service following convalescence. During 1942, 320artificial pneumothoraces were induced and an additional 147 were continuedafter previous induction. Thus, more than a quarter of all the patients admittedwere treated by pneumothorax. On the surgical service, 171 thoracoplasties, 187pneumonolyses, and a small number of pneumonectomies and lobectomies wereperformed during 1942.
The report for 1942 indicates that 20 percent of all cases of tuberculosishad nonpulmonary tuberculous complications, of which tuberculous laryngitis,tuberculosis of the genitourinary tract, tuberculous enterocolitis, andtuberculosis of the bones were most common. Of nontuberculous complications,diabetes was most frequent. One-third of the cases under pneumothorax treatmentdeveloped pleural effusion, a figure that had held during several years ofprevious experience.
In 1943, there were marked fluctuations in admissions and discharges oftuberculous patients. The tuberculosis section remained the largest section onthe medical service; 1,405 enlisted personnel were admitted. However, the censusdropped sharply following publication of War Department Circular No. 109, 26April 1943, which directed discharge to the Veterans' Administration of menunfit for military service and so abrogated the previous practice of holdingpatients for at least 6 months. During the year, there were 1,332 directadmissions of enlisted men for tuberculosis, and 634 tuberculous patientsremained at the end of the year. There were 1,585 discharges from the section,chiefly on certificate of discharge for disability, and 65 deaths.
The proportions on different forms of collapse therapy were approximately asin the preceding year. There were 239 pneumothoraces initiated and 12,044refills given. On the surgical service, 428 operations for tuberculosis wereperformed, including 180 thoracoplasty stages, 184 phrenic nerve operations, and49 intrapleural pneumonolyses.
As in the preceding year, pleural effusion developed in 33 percent of thepneumothorax cases, usually (85 percent) serofibrinous, but occasionally (15percent) purulent. Nonpulmonary tuberculous complications were of the samefrequency and nature as before. Among nontuberculous complications,coccidioidomycosis was the most frequent, its incidence in the Army havingnotably increased as a result of desert maneuvers.
During 1943, with the longer progress of the war, there was a noteworthyincrease in the number of officers admitted (277 males and 86 females). Of thisnumber, 132 were discharged, chiefly by retirement.
In 1944, the number of admissions for tuberculosis (1,895)was somewhat larger than in preceding years. The number of cases given collapsetherapy was somewhat smaller, and the number given pneumoperitoneum slightlylarger, the indications for the latter therapy having become more clearly defined.Pneumoperitoneum was considered of value in those cases of tuberculosis inthe exudative phase in which it was unwise to attempt pneumothorax,
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as well as in cases with basal and perihilar excavation. Aremarkable constancy was apparent in the incidence of pleural effusion as acomplication of artificial pneumothorax, as it occurred in 32 percent ascompared with 33 percent of cases in each of the preceding years.
In 1944, there was a sharp curtailment in the use of surgery; only 33thoracoplasties were performed. This was due to the shorter average stay ofpatients, owing to the heavy demands on the hospital not only for cases oftuberculosis but also for other illness. During this year, however, 15lobectomies were performed, the indications for this operation having becomeclearer within the preceding year. In general, cases with an excavated, butwell-stabilized lesion, confined to one lobe, were considered most suitable forlobectomy.
During 1944, the number of cases in enlisted men evacuated from overseas,which had heretofore formed a substantial proportion of the total, decreasedmarkedly, as a result of the designation of Bruns General Hospital as a centerfor such cases. However, the number of officers from both overseas and the Zoneof Interior increased greatly, with 647 admissions (561 male and 86 female).There were 419 tuberculous officers discharged by retirement or other procedure.
A significant development during 1944 was the activation, in January, of theSection for Research on Minimal Tuberculosis. This section was developed by theOffice of the Surgeon General on the advice of the Subcommittee onTuberculosis, National Research Council. It was sponsored and supportedfinancially by the Army Medical Research and Development Board. The subcommitteefelt that the Army, with its large number of well-studied cases, afforded aunique opportunity for investigation of the prognosis of minimal tuberculosisand the reasons for the breakdown of small or incompletely stabilized lesions. Acontract was drawn by the board with the School of Medicine, University ofColorado, Denver, located only a few miles from Fitzsimons General Hospital, andDr. Waring, Professor of Medicine, School of Medicine, was designated asresponsible investigator, with Colonel Aycock, Chief of Medical Service,Fitzsimons General Hospital, and Colonel Long as consultants. Capt. (later Maj.)William H. Roper, MC, formerly chief of the section for chest diseases at theStation Hospital, Fort Bragg, N.C., was assigned, through Seventh ServiceCommand Headquarters, to Fitzsimons General Hospital for the detailedprosecution of the investigation, which was to be based on an intimate study ofthe history and progress of 1,000 cases of tuberculosis of minimal extent.
By the end of the year, 400 cases had been studied with care.In June 1946, the final number was 1,108. This number included 648 cases ofactive and 350 cases of inactive minimal parenchymal disease; in addition, therewere 110 cases of pleural effusion presumed or proved to be tuberculous inorigin. In 397 cases, the investigation included an intensive psychiatricexamination to determine the influence of emotional and personality factors
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upon breakdown with tuberculosis. This examination wasconducted by Dr. John M. Lyon, Department of Psychiatry, School of Medicine,University of Colorado.56
During 1945, the tuberculosis section of Fitzsimons GeneralHospital was more active than in any preceding year. There were 2,474 admissionsto the enlisted men's section. The average number of patients was greater, andcollapse therapy was carried out on a larger scale than heretofore. There were448 initial pneumothoraces, and the total number of refills, in spite of therelatively short duration of residence that was necessary in order toaccommodate new cases, was 11,265. Pneumoperitoneum was induced in 136 cases. Onthe surgical service there were 3 pneumonectomies, 34 lobectomies, and 7 partiallobectomies for tuberculosis.
During the 4 years of the war, Fitzsimons General Hospital admitted more than8,100 patients with tuberculosis. The morale of both staff and patients wasexcellent, and the treatment was equal to that in the best civilian hospitals inthe country. In view of the usual early transfer of patients, rehabilitationmeasures were not extensively employed, although there was provision foroccupational therapy. Long before the maximum results of treatment could beattained, regulations required discharge of patients to the Veterans'Administration or other institutions for care. Results in terms of casesarrested or improved, or stationary or unimproved, cannot, therefore, be givenfor evaluation or comparison with results at other hospitals. Only throughcareful followup of cases handled by the Veterans' Administration will it bepossible to determine the effectiveness of several months of treatment atFitzsimons General Hospital in bringing about lasting arrest of cases.
The pathology service, under Col. Hugh W. Mahon, MC, made careful studies ofnecropsies and maintained a series of records that were of unusual value,because of the wealth of photographic reproductions included. The majoritycoming to autopsy were chronic cases, fibroulcerative in character, althoughthere were some more acute cases, including a number with fulminant tuberculousmeningitis. In general, post mortem observations made in the Army were notsignificantly different from those in large civilian hospitals and sanatoriumsfor tuberculosis.
Discharge and retirement constituted a problem that was, attimes, difficult. Since patients could not be held for the many months requiredfor complete arrest of the disease, discharge had to be effected on the basis ofdisability, with such compensatory benefits as accrued. In cases of advancedtuberculosis, no problem was involved. In cases of early tuberculosis of minimal extent, apparently well scarred after a few months of treatment, theappropriate course generally appeared to be to discharge patients on the basisof disability, even though no symptoms persisted and prognosis was excellent.This disposition also appeared generally indicated in cases of
56Waring, J. J., and Roper, W. H.: Minimal Pulmonary Tuberculosis in Military Personnel: World War II. Am. Rev. Tuberc. 75: 1-40, January 1957.
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healed pleural effusion in which all fluid was absorbed, nopulmonary infiltration was evident, and exclusion studies indicated that theprocess was presumptively tuberculous. Since tuberculosis is a disease prone torelapse if a proper regimen is not followed, it was necessary to consider suchcases as potentially active for some years. Similar considerations applied totuberculosis of lymph nodes when nodes with doubtfully active tuberculouslesions had been removed and tuberculous foci were not found elsewhere in thebody. Such cases were finally resolved in favor of the soldier, and usually onthe basis of proved tuberculous activity during military service.
Bruns General Hospital-This hospital was designated a specialty centerfor tuberculosis in August 1944, with an allocation of 750 beds fortuberculosis. Lt. Col. (later Col.) George J. Kastlin, MC, was chief of MedicalService until December 1945, when he was succeeded by Maj. (later Lt. Col.)George C. Owen, MC, with assistant chiefs in charge of two large sections fortuberculosis. When the directive of August 1944 was issued, 26 wards were setaside for patients with tuberculosis. The relatively small number of physicianson the staff at the time who were well qualified in the treatment oftuberculosis was augmented as rapidly as possible. Capt. (later Maj.) LawrenceH. Kingsbury, MC, was brought in from the surgical service at FitzsimonsGeneral Hospital as chief of thoracic surgery, and the work at the two hospitalswas coordinated by mutual visits.
The hospital had a difficult task, however, for the report57 for 1944 notedthat the rate of growth was more rapid than the officer, nurse, and enlistedpersonnel could properly handle. All services felt the impact of the abruptdesignation of the hospital as a specialty center. At the end of the year, 697tuberculous patients were in the hospital. During 1944, 6,118 X-ray films of thechest were made, out of a total of 13,752 films of all parts of the body.Pulmonary tuberculosis accounted for 17 percent (123 cases) of the dischargesfor disability. The majority of discharges were to the Veterans' Administrationand convoys seriously depleted the force of officers necessary to care forpatients.
Since Bruns General Hospital was designated to care for cases of tuberculosisfrom overseas, the morale problem was exceptionally difficult. The hospital wasisolated and filled with patients who had not seen their families for months oryears. Unusual measures, which proved notably successful, were projected to meetthe problem (pp. 388-390). Education was a principal objective, directedparticularly to teach acceptance of continuing care at the hands of theVeterans' Administration after discharge from the hospital.58
In 1945, it became necessary to increase the allocation ofbeds to more than a thousand because of the continuing influx of cases fromoverseas. The problem was complicated in the second half of the year by thearrival of many
57Annual Report, Bruns General Hospital, 1944.
58The Care of Tuberculous Patients Pending Discharge From the Army. Bull.U.S. Army M. Dept. No. 74: 44-46, March 1944.
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patients with severe disease who had been liberated fromJapanese prison camps. Personnel needs were great and, unfortunately, could notbe well met, because demobilization of medical officers was under way.
In spite of these difficulties, an excellent professional spirit wasmaintained. Staff conferences, on the model of those held at Fitzsimons GeneralHospital and leading civilian hospitals for tuberculosis, were held at regularand frequent intervals, and cases were expertly presented and discussed. Apulmonary function unit was established in order to introduce the latestmethods used in the study of respiratory physiology.
Close contact was maintained at all times with the Office ofthe Surgeon General, which was called upon for more direct assistance than wasrequired by the longer established Fitzsimons General Hospital. The system ofsupervision, the methods of treatment and disposition, the proportion of caseson collapse therapy, and the system of clinical conferences were similar tothose at Fitzsimons General Hospital and civilian hospitals for the care oftuberculous patients.
Moore General Hospital-The third specialty center for tuberculosis,established in 1945 at Moore General Hospital, was necessary becausedemobilization of men at separation centers resulted in the discovery of casesof tuberculosis in numbers exceeding the capacity of Fitzsimons and BrunsGeneral Hospitals. The lesions found were usually symptomless and of minimalextent, although occasionally moderately advanced cases were encountered in menwho, surprisingly, had been doing full duty and were not aware of anyrespiratory disease.
Since Moore General Hospital was not staffed or equipped for tuberculosis, itwas necessary to bring in new personnel and to specify that patients requiringthoracic surgery were not to be sent there. Army Service Forces Circular No.456, 29 December 1945, established the center and specified that (1) cases ofminimal extent, (2) unilateral cases of moderately advanced tuberculosisappropriate for pneumothorax treatment, (3) cases of suspected tuberculosisrequiring prolonged observation for diagnosis, and (4) cases of pleurisy witheffusion were to be sent to Moore General Hospital. Cases requiring extensivesurgical procedures and cases in which the prognosis was bad were to be referredto other general hospitals or discharged directly to the Veterans'Administration. Tuberculosis patients were placed on the medical service, ofwhich Lt. Col. J. Murray Kinsman, MC, was chief when the hospital was designatedas a specialty center for tuberculosis.
Cases within the first three categories named were frequentlyfound at separation centers, and the space assigned for tuberculosis at MooreGeneral Hospital filled rapidly. Within a few months, there were more than athousand patients at the center. Most of these had lesions of minimalcharacter, many of them difficult to establish definitely as tuberculosis, beingof slight extent and without demonstrable tubercle bacilli. Thus, many patientsremained for several months for exhaustive study to establish diagnosis of the
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disease itself, and its state of activity. The principles inpractice were later summarized in TB MED (War Department Technical Bulletin)221, dated 29 April 1946, and change 1 thereto, dated 27 December 1946. MooreGeneral Hospital was ultimately (1946) transferred to the Veterans'Administration, obviating physical transfer of patients designated for Veterans'Administration care.
The three general hospitals designated as specialty centersfor tuberculosis normally received medical records and X-ray films of casesoriginating overseas when the patients were transferred to these hospitals. Thereports from Bruns General Hospital indicate that the records were of goodquality. All three hospitals also made extensive use of induction films ofpatients obtained from the X-ray file of the Veterans' Administration inWashington, D.C., where they had been stored immediately after induction. Thesefilms proved highly useful in evaluating the age of lesions as a guide intreatment and disposition. The experience at Fitzsimons General Hospitalindicated that early in the war, when cases were not infrequently overlooked atinduction, the patients sent to the hospital were predominantly those in whoseinduction film a lesion could be seen. In the second half of the war, lesionsrequiring hospitalization did not, in the majority of cases, appear to representan extension from a lesion visible in the induction film, but rather a newdevelopment during Army service.
ORIENTATION AND REHABILITATION
The problem of rehabilitation of tuberculous patients in Army hospitals couldnot be met in the same manner as with diseases of short duration or wounds andaccidents leaving a mechanical handicap. With these, the reconditioningservices of Army hospitals were highly effective during the period ofconvalescence. As regards tuberculosis, however, it was impractical to retainpatients in Army hospitals long enough for arrest of the disease andrehabilitation. AR 615-361, 14 May 1947, required discharge when the diagnosisof active disease and the need for prolonged care were established, althoughspecifically prohibiting transfer as long as the health of the patient would bejeopardized.
In practice, this regulation was interpreted as authorizing that degree andextent of care in an Army hospital necessary to prepare patients for transfer-enlisted men to the Veterans' Administration and officers to their owncare-in the best condition to profit by continued hospital treatment. In thethree tuberculosis centers of the Army, enlisted men were retained on an averagefor 4 months. Officers were held longer on the basis of the possibility of theirretention for continued service.59
Although reconditioning of tuberculous patients in Army hospitals was thusnot possible in the same sense as for patients recovering from pneumonia
59See footnote 3, p. 331.
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or fracture of bones, the need for thorough orientation withrespect to the disease was clearly evident. In 1945, on the advice of the Officeof the Surgeon General, a department for orientation was established at BrunsGeneral Hospital under the direction of Capt. (later Maj.) Bernard D. Daitz, SnC.Captain Daitz, with an extensive background of civilian experience inrehabilitation of patients with tuberculosis, introduced modern methods ofinstruction of patients, winning their confidence, and stimulating an improvedmorale. He prepared TB MED (War Department Technical Bulletin) 222, dated 16 May1946, while assigned to Bruns General Hospital, which proved a model for otherArmy hospitals caring for tuberculous patients, and this was later modified tomeet the special problems of patients under care of Veterans' Administrationhospitals.
The ideal program in the care of tuberculous soldiersembraced a proper integration of medical treatment, social work, vocationalcounseling, and intelligent use of the patient's leisure time. The immediate andmost important objective was to educate patients concerning their need forcontinuing medical treatment. This involved, first, educational measures on thenature of tuberculosis and, second, measures to overcome the apathy, or evenresentment, with which soldiers reacted to provision for their treatment by theArmy or other Federal agencies.
To train ward officers and other hospital personnel as teachers, a system ofstaff indoctrination was devised, which included lectures and discussions on (1)problems of tuberculous patients, (2) pathogenesis and treatment oftuberculosis, (3) psychology of tuberculous patients, (4) problems in nursing,(5) problems in nutrition, (6) occupational therapy, and (7) the bestutilization of the Red Cross in the program. A tuberculosis advisory council wasestablished to implement the program of staff indoctrination and teaching ofpatients. All of the services concerned in the care of patients wererepresented.
The orientation program for patients was coordinated by an officer from themedical service. Since the great majority of the tuberculous were bed patients,ward officers were made responsible for instruction of patients on the nature ofthe disease. On arrival at the hospital, each patient was given a copy of"What You Should Know About Tuberculosis," an educational pamphletpublished by the National Tuberculosis Association and modified for Army use bythe Consultant in Tuberculosis, Office of the Surgeon General. Medical officerswith proved special capacity for instruction were sent from ward to ward todiscuss medical problems with patients.
Counseling on other than medical problems was made theresponsibility of those best qualified in the various fields concerned,including the educational reconditioning services, the personal affairsdivision, the Red Cross, the librarian, and others. It was important at theoutset, and concurrently with the program of medical instruction, to reassurepatients as far as possible with regard to the future and to ascertain anddevelop their educational
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and vocational interests and capacities. Since most of thepatients would ultimately be beneficiaries of the Veterans' Administration, thesystem of care at Veterans' Administration hospitals and their rights andprivileges as veterans under the Vocational Rehabilitation Act (Public Law 16,78th Cong.) and the Servicemen's Readjustment Act of 1944 (Public Law 346, 78thCong.), more commonly known as the G.I. Bill of Rights, were carefullyexplained. At the same time, patients were asked to discuss freely theirpersonal problems and their complaints. These principally centered on theirisolation from friends and relatives. Most of the patients had been overseas formany months, and the long separation from home brought their morale to a low ebb. Everything possible within reason was done to overcome this sense ofisolation. The specific complaints most frequently heard were about diet, andthese were more concerned with its palatability and serving than with its basicquality. Serious attention was given to these complaints, and noteworthyimprovement in dietary service was accomplished.
Motion pictures of both educational and diversional character were presentedon a schedule adapted to the strength of the different groups of patients, andextensive use was made of the library. Many patients undertook studies thatyielded academic credit. The vocational interests of patients were studied bythe Kuder vocational interest test (Kuder Preference Record), and patients weremade acquainted with the correspondence courses available through the UnitedStates Armed Forces Institute.
Occupational therapy was carried out on a scale commensurate with thepatients' strength. The various forms of light occupation used in Army hospitals were employed, and a large majority of patients availed themselves ofsome form of occupational therapy. Indeed, a major difficulty was to restrainthem. Light occupation was often sought by patients whose medical regimendemanded strict bed rest.
Orientation programs on a less formal basis were in effect atthe other Army hospitals for the tuberculosis. The period of time during whichthe plan formally established at Bruns General Hospital was in operation wastoo short to determine how effective it could be. Some good was definitelyaccomplished. This was substantiated by the information obtained fromquestionnaires filled out by patients and by their attitude later in veterans'hospitals. Had the need developed for continued hospitalization of tuberculouspatients in Army hospitals, it is believed the program as developed at BrunsGeneral Hospital would have proved highly effective.
Part V. Care of Recovered and Captured Prisoners of War
RECOVERED PRISONERS OF WAR
Tuberculosis in recovered prisoners of war has already beendiscussed in the sections on the individual theaters in this chapter. Anincreased incidence, as compared with the general rate for troops in thetheater, was found
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in men who had been prisoners of the German and Japanese military forces forsome months. Exact studies of the incidence were not made, because of a numberof circumstances arising at the time. In the European theater, the liberation ofprisoners in the course of rapid movement of American troops through Germanyoccurred at a time of grave shortage of X-ray film in the theater. Accordingly,roentgenograms of the chest were not made on all recovered prisoners, as hadbeen the hope of the Office of the Surgeon General, but only on those who werehospitalized for one or another reason. As has been pointed out (pp. 344-345), the incidence of tuberculosis discoveredin the hospitalizedrecovered prisoners in the European theater averaged about 6 men per 1,000, orapproximately six to eight times the general average for troops in the theater.However, the group examined by X-ray were selected simply because ofmalnutrition or evident illness, and it is reasonable to supposethat the incidence of tuberculosis was higher in this group than in recoveredprisoners who appeared in good health.
Rates recorded for prisoners recovered in the Pacific area were somewhathigher. Several reports indicated that approximately 1 percent of the menrecovered in the Philippines had what was believed to be active tuberculosis.However, prisoners were recovered at such a wide number of points, where facilities for X-ray study were not available, that an overall rate for thePacific is unobtainable. A board appointed by The Surgeon General, includingrepresentatives of several medical specialties, examined 4,618 repatriatedprisoners at West Coast debarkation hospitals. Out of 3,742 who were checkedwith roentgenograms of the chest, 101, or 2.7 percent, showed evidence ofactive pulmonary tuberculosis.60 A preliminary examination by MajorRoper of films made at Letterman General Hospital on prisoners recovered in thePacific area brought to light 8 cases of active minimal and 3 cases of activemoderately advanced tuberculosis, and 2 cases of pleural effusion. Of thisgroup, only 2 of the minimal and 2 of the moderately advanced cases, and 1 ofthe cases of pleural effusion, had been reported on admission to the hospital.The total incidence of active cases, assuming that the pleural effusions weretuberculous, was thus 13 in 966 or about 13 per 1,000, a figure much higher thanthe average incidence in nonprisoner groups at separation. (See chart 19 forincidence at separation in troops with and without foreign service.) Variousother individual reports on sample liberated groups, all showed rates much abovethe average for troops on duty in the Pacific theaters. Hence, there is goodreason to believe that a general increase of tuberculosis occurred in prisoners.This was attributed to one or both of two principal reasons: (1) Breakdown ofsmall latent lesions that might otherwise have remained stable, and (2) actualacquisition of new infections as a result of exposure in prison camps. Thelatter was believed to be much more of a factor in the Pacific area than in theEuropean theater.
60Morgan, H. J., Wright, I. S., and Van Ravenswaay, A. C.: Health ofRepatriated Prisoners of War From the Far East. J.A.M.A. 130: 995-999, 13 Apr.1946.
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In the European theater, as a rule, American prisoners were quartered inbarracks separate from those used for other prisoners, or were quartered withBritish prisoners. In either event, there was relatively little opportunity forexposure, as the incidence of tuberculosis was comparatively low in both armies.However, as medical officers in the theater pointed out, and as noted elsewherein this chapter, frequently prisoners lived in quarters that had been grosslycontaminated by previous occupants.61 The incidence of tuberculosis in Russian and other prisoners of war was veryhigh, and from time to time prisoners from the U.S. Army were housed in quartersthat had been previously occupied by Russian and other troops and stillcontained material that might have been infected, such as bedding, furniture,and kitchen utensils.
In many recovered prisoners of war in whom tuberculosis was discovered, thedisease was complicated by malnutrition. Prisoners in both European and Pacifictheaters had been on an extremely low caloric diet and in general had sufferedgreat loss in weight. Whether this had a specific effect upon the progress oftuberculosis could not be determined on the basis of exact studies, but arelationship between malnutrition and tuberculosis is generally accepted, and itis logical to assume that impaired nutrition in U.S. troops favored thedevelopment and spread of tuberculosis among them.
Not a few of the troops had other diseases, such as dysentery and malaria,and it is reasonable to suppose that resistance to tuberculosis was lowered alsoto some extent by these concomitant diseases.
Special attention was devoted to prisoners on their return tothe United States, as noted elsewhere in this chapter, and a good followup wasmaintained. In view of the hardships that many of these men endured, and thenotorious tendency for tuberculosis to make its appearance years after theacquisition of infection, it was considered advisable that these men be followedas a special group in the Veterans' Administration for years to come.
CAPTURED PRISONERS OF WAR
The medical treatment of captured German and Japanese soldiers who were foundto be afflicted with tuberculosis was a part of the general program of hospitalcare in each theater. As prisoners were taken, they were transferred toappropriate hospitals in the communications zone, which were usually of stationhospital type. When the number of patients became sufficiently large, entirehospitals were reserved for sick prisoners of war. Each of the hospitals devotedto the care of sick and wounded enemy prisoners had some patients withtuberculosis. As the number increased, it was found advantageous to designatecertain hospitals with suitable medical personnel for concentration of patientswith tuberculosis. The same practice, it may be stated, was followed by theGermans.
61See footnote 17, p. 340.
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Insofar as possible, hospitals designated for the care of sick and injuredprisoners of war were staffed by captured members of the Italian, German, orJapanese medical departments. Certain hospitals moved forward with the advancingarmy, so that the transportation problem in taking care of sick prisoners wasminimized. For example, the 7029th Station Hospital, which was in theneighborhood of Pisa in the last weeks of the war and housed a good manytuberculous Italians, had been designated for the care of prisoners of war manymonths previously in North Africa. The 334th Station Hospital (German staffed),near Florence, served an adjoining stockade for German prisoners and contained afew patients with tuberculosis. A group of hospitals near Isigny in Normandywere combined to form a hospital center for prisoners of war; one of these, the8274th General Hospital (Provisional), Calvados, France, was designated to housea considerable number of captured Germans proved to have tuberculosis. Certainhospitals in England, particularly those that had been previously well staffedwith officers experienced in tuberculosis, including the 304th Station Hospitalnear Henley-on-Thames and the 327th General Hospital near Blockley, weredesignated as centers to which German patients with tuberculosis could be sent.
The general principle followed was that prisoners with tuberculosis should besent to those hospitals where German doctors with particular experience in thedisease were members of the staff. A wide variation was found in the caliber ofthe men concerned, but in general it was good. Diagnosis by radiological andlaboratory methods was excellent in certain of the hospitals just named, andcare was superior within the limitations of equipment available. The disciplineamong patients was especially noteworthy. The same amenability to discipline inGerman prisoners was noted when they were treated for tuberculosis in the UnitedStates. Pneumothorax was practiced expertly by German physicians, many of whomwere graduates of medical classes after 1935.
After the termination of hostilities, as conditions becamemore stabilized for medical care in Germany, patients with tuberculosis weretransferred to hospitals within the American occupied zone in Germany.
Treatment in the United States
Cases of tuberculosis were discovered in all groups of prisoners in theUnited States, and care entirely comparable to that given American patients withtuberculosis was accorded them. Special provision was made for tuberculousprisoners of war by War Department Prisoner of War Circular No. 11, 8 February1944, which directed that those afflicted with pulmonary tuberculosis be sent tothe prisoner-of-war camp station hospital in Florence, Ariz. At this hospital,they were to be examined by a mixed medical commission of representatives fromneutral countries with a view to repatriation. It was directed that cases ofnonpulmonary tuberculosis be sent for care to certain
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general hospitals designated in each service command for thecare of prisoners of war. Subsequently, when the station hospital at Florencewas abandoned as a center for such patients, about 50 tuberculous German andItalian prisoners of war were sent to Fitzsimons General Hospital, where anumber had already been sent from other places pending final determination ofpolicies governing the treatment and disposition of sick prisoners of war. On 5January 1945, a telegram from the Office of the Provost Marshal General toseveral service command headquarters directed that, pending further revision ofpolicy, prisoner-of-war patients with pulmonary tuberculosis should betransferred as follows: German prisoners to Glennan General Hospital, Okmulgee,Okla., Italian prisoners to Bruns General Hospital, and Japanese prisoners tothe prisoner-of-war camp station hospital, Camp McCoy, Wis. Wherever Germanprisoners of war were concentrated, a sharp difference of opinion was found toexist in the Nazi and anti-Nazi groups, and it was generally necessary to housethem in entirely separate wards.
Relatively large numbers of Italians were found to have tuberculosis. TheGerman Army appeared to have been screened in a much more thorough manner thanthe Italian. In fact, the number of tuberculous Italians was so high in certainareas that it was considered advisable by Army Service Forces Circular No. 342,14 October 1944, to make mass X-ray surveys of all Italian service troops forthe discovery of cases of tuberculosis.
The total number of Japanese prisoners in the United States was relativelysmall, and therefore the problem of tuberculosis in Japanese prisoners wasminor. A small number were kept for care at the station hospital of Camp McCoy.No significant differences were noted in the character of tuberculosis in thedifferent groups, but the experience at Fitzsimons General Hospital indicatedthat the German prisoners, as a rule, made better progress than Italian, a factattributed to their better discipline and acceptance of medical direction.
A comprehensive report on the medical care of prisoners ofwar in a general hospital in the United States was made by Col. Louis B. LaPlace,MC, at Glennan General Hospital.62 Glennan General Hospital was inclose proximity to a number of large prisoner camps and was well adapted tocare for prisoners. Ninety percent of the patients were Germans and Austrians,and the remainder were nationals of Axis satellite or invaded countries. Itfunctioned as an installation specifically for prisoners of war from August 1944to May 1945. Glennan General Hospital was ultimately converted to a generalhospital for American personnel, and all of its prisoner patients weretransferred to Prisoner-of-War General Hospital No. 2, established at CampForrest, Tenn., which had the great advantage of a large barracks area wherepatients unfit for duty, but not requiring hospital care, could be accommodated.
62LaPlace, L. B.: Tuberculosis at a Prisoner of War Hospital. Bull. U.S.Army M. Dept. 7: 398-399, April 1947.
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To the greatest extent possible, Glennan General Hospital andPrisoner-of-War General Hospital No. 2 were staffed with German medicaldepartment personnel, including medical officers and enlisted men. Theprofessional aptitude of the German medical officers varied considerably. Anumber with excellent qualifications were on duty, but as among the patients,there was a definite difference in attitude among them, based on adherence oropposition to the Nazi party.
The staff of the medical service at Glennan General Hospital was composed oftwo Americans and eight German medical officers. The number of German wardattendants averaged 50 for the 11 wards utilized by the medical service. Onlyone American enlisted man was needed to supervise the entire medical service.American nurses were not utilized on the wards.
Approximately 31 percent of theGerman patients at Glennan General Hospital had tuberculosis of the respiratorytract. This relatively high incidence was due to the fact that Glennan was theonly hospital for prisoners of war designated for the specialized care oftuberculosis. As Colonel LaPlace pointed out, the tuberculosis sectionconstituted a special problem. It admitted 304 patients in whom the diagnosis oftuberculosis of the lung or pleura was established. Because of anticipatedrepatriation, active cases could receive only conservative treatment, includingpneumothorax. Since repatriation was slow, these patients accumulated in thehospital until they filled 6 of the 11 medical wards. In spite of the severityof a large percentage of the cases, only five deaths occurred on thetuberculosis section; of these, three patients were prisoners of Russian originwho had accepted service in the German Army. The clinical course of thedisease, in the majority of instances, was relatively benign.
Special diets were available to patients who needed them. All patients onthe tuberculosis section at Glennan General Hospital, according to ColonelLaPlace, received a routine diet of 2,500 calories daily, with vitaminsupplements. Colonel LaPlace's report pointed out that Glennan General Hospitalwas a noteworthy example of this country's full adherence to the terms of theGeneva Convention. Prisoners of war were hospitalized in one of the bestconstructed and equipped of any except permanent Army hospitals.
The number of tuberculous patients admitted to the medical serviceconstituted 2.6 percent of all admissions to the hospital. Among the 10 percentof patients in the tuberculosis section who were not Germans or Austrians wereRussians, Poles, Czechs, French, Yugoslavs, Arabs, and others. Most of these hadbeen persuaded to join the Wehrmacht or Arbeitsdienst by a period of starvationand exposure in a concentration camp. In many cases, it is believed thatmistreatment had caused activation of tuberculosis.
In this connection, it may be noted that the admission ratefor tuberculosis in German prisoners of war, as recorded in the MedicalStatistics Division of the Office of the Surgeon General, was 1.9 per 1,000per annum in
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1944. This, for the most part, represented admission becauseof symptoms. Occasionally, groups were surveyed more specifically fortuberculosis; such surveys increased the rate. An unusually high rate wasobserved in one conducted in the First Service Command. The combined figure foractive and inactive tuberculosis of reinfection type and chronic fibrotictuberculosis found in this survey was 55 cases in 4,041 examinations.
The tuberculosis section at Glennan General Hospital was a subdivision of themedical service and was accommodated in seven standard wards. One of these, aso-called international ward, was designated for the Russians, Poles, andanti-Nazi Germans who required protective segregation from the other Germans inthe hospital.
The tuberculosis section was supervised by an American chief and assistantchief of the medical service and one sergeant. The international ward wasadministered directly by American medical officers. Otherwise, all medicalofficers in attendance were members of the German Sanit?tsdienst who wereclassified by the Geneva Convention as protected personnel rather than asprisoners of war. The German chief of section was a relatively well qualifiedspecialist in tuberculosis who, prior to capture, had served in a submarine andat an outpost on the Arctic Circle.
Certification of patients for repatriation was an important part of the workand caused many difficulties. According to the Geneva Convention, all prisonersof war who had active pulmonary tuberculosis, as indicated by the finding ofacidfast bacilli, were to be returned to Germany as soon as possible. As aresult, patients attempted to substitute a known positive sputum for their own.According to Colonel LaPlace, the German-protected personnel were accused ofbeing collaborationists if they did not help in this subterfuge. Sputum reportswere therefore considered unreliable, and the activity of tuberculosis was oftenalmost impossible to determine.
Treatment included principally rest, a high caloric diet with vitaminsupplements, and pneumothorax as indicated. Radical surgical therapy was notundertaken because of the prospect of repatriation for definitive care. Manypatients became arrested cases in the hospital and were returned to light duty.
Of the 304 cases of tuberculosis, 267 were pulmonary and 37 had tuberculouspleurisy with effusion. In 14 cases, both pulmonary involvement and pleuraleffusion were present. Extrapulmonary cases included tuberculosis of the larynx,epididymis, joints, kidney, meninges, peritoneum, and cervical lymph nodes. Inall, there were 14 nonpulmonary cases.
The experience of Glennan General Hospital has been recorded in detail,because of the comprehensive character of the report on tuberculosis at thathospital. The problems and care as outlined may be considered as representativeof the service at the other hospitals for prisoners of war in this country.
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TREATMENT UNDER THE MILITARY GOVERNMENT IN GERMANY
The control of tuberculosis formed an important part of the public healthprogram of the office of military government in each of the occupation zones. Itwas accentuated in Germany by the total disruption of tuberculosis servicesfollowing the collapse of the Nazi government. Prior to World War II, Germanyhad a well-organized program, which was rapidly diminishing the prevalence oftuberculosis in the Reich. Following the First World War, German public healthexperts had adopted a program based on improved dispensary facilities fordiscovering cases of tuberculosis, better care in homes and sanatoriums,increase in facilities for treatment, and centralization of finance in generalmeasures for control. At the outset of the Second World War, case-findingsurveys with roentgenograms were progressing on a huge scale, but after themiddle of 1943 the intense bombing of German cities destroyed so many facilitiesthat the X-ray program came almost to a standstill.
The breakdown in the general public health program had resulted in admittingto industry a good many workers with tuberculosis who, in prewar times, wouldnot have been accepted for work. It is generally believed that this breakdown inservice resulted in the spread of tuberculosis within the German population. Theadmission of tuberculous persons to industry was rationalized by the Naziofficers for tuberculosis control by official communications stating that thedanger of transmission of tuberculosis had been exaggerated in the past.63
In addition, during the war, large numbers of laborers were imported fromadjoining countries with little or no screening for tuberculosis. It is probablethat many cases of communicable tuberculous disease were admitted in this way,for the general tuberculosis rates in surrounding countries were much higherthan in Germany.
When the U.S. Army took over the public health program for theAmerican Zone, the control of tuberculosis was proceeding on a purely localbasis. Central control, previously located in Berlin, was no longer in operationand, in fact, many of the former leaders of the program, having been prominentadherents of the Nazi party, were under detention in Army headquarters.
Thelocal unit of tuberculosis control, the F?rsorgestelle, was in operation in mostcommunities, ostensibly in the same manner as before the war. However, qualifiedpersonnel was much reduced in number, and many of the German clinics had beenforced by bombing to leave their regularly constituted quarters and to take upoperation in inferior dwellings, often with inadequate equipment. Moreover, thevisiting by F?rsorgestellerinnen to the homes of tuberculous patients had beenalmost discontinued because of the
63Dr. Kayser-Petersen, General Secretary: Arbeitseinsatz vonTuberkul?sen,Bericht ?ber das Gesch?fts jahr 1940-1941, Reichs-Tuberkulose-Ausschuss.Berlin. [Captured German document.]
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lack of transportation. No motor cars were available, as arule, and in the rare circumstances where motor transportation could beobtained, gasoline was very short, so that few visits could be made. At thesame time, facilities for reporting tuberculosis were much reduced, so that noclear picture of the prevalence of tuberculosis was obtainable in mostlocalities.
In September 1945, a tuberculosis section was organized in the PreventiveMedicine Branch of the Public Health Branch of Military Government for Germany(United States) in Frankfurt and Berlin. Preliminary surveys were made by Capt.S. C. Stein, MC, and the office was taken over by the Consultant in Tuberculosisfrom the Office of the Surgeon General on a temporary duty basis on 1 September1945. Every effort was made in the succeeding months to promote restoration ofthe German program to its prewar condition. Insofar as personnel qualifyingunder the denazification rules were obtainable, suitable public healthofficers, experienced in tuberculosis control, were appointed in the L?nder,Kreisen, and smaller units. In November 1945, the section was taken over by Lt.Col. Leo V. Schneider, MC, who, in addition, acted as aide to the chief of thepublic health branch. Under his direction, great progress was made in improvingreporting and in the provision of beds for tuberculous patients throughout theU.S. Zone. Subsequently, Lt. Col. Gilberto S. Pesquera, MC, was appointedtuberculosis consultant for the Office of Military Government. In a series ofreports to the Director of the Public Health Office of Military Government inMay 1946, further progress was indicated, including better utilization of beds-particularly with respect to the distribution of beds for German civiliansand displaced persons-and the control of dissemination of disease from opencases.
In each major division of the occupied zone, an American medical officerin the office of the chief of the local public health branch wasassigned the specific task of stimulating the program for control oftuberculosis. Forms were prepared for proper reporting, and constant effort wasmade to increase the number of beds available for care of tuberculous patientsdiscovered in the German population.
The 9 October 1945 memorandum of the Consultant inTuberculosis, Office of the Surgeon General, called attention to the progresseffected in the transfer of tuberculous German prisoners of war from Armyhospitals to German hospitals and sanatoriums for civilians and to the measuresfollowed in handling tuberculosis among displaced persons. The latter proved alarge and difficult problem, which was jointly attacked by the army ofoccupation (Third, Seventh, and Ninth U.S. Armies), the Office of MilitaryGovernment, and the United Nations Relief and Rehabilitation Administration, thechief public health officer of which was supplied by the U.S. Public HealthService. This report outlined in detail the responsibilities and shortcomings ofthe German civilian public health organization for tuberculosis control at andbelow the Land level. It laid special stress on the inadequacy of reporting, theinsufficiency of clinics and of hospital and sanatorium beds
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for tuberculosis, the number of open cases in homes, theserious housing problem and resultant crowding, and the impaired nutrition ofthe population. It was pointed out that in a typical city of about 140,000(Augsburg, Germany, was cited as the example) more than 2,000 persons with opentuberculosis were believed to be resident in homes, rather than in sanatoriums.The housing shortage in the American Zone was such that the number of occupantsper room in the large cities had more than doubled as compared with the prewarfigure. The official food ration at the time provided only 1,300 calories a day,and although this was supplemented by 300 calories of nonrationed foods by manypersons with access to rural areas around cities, at best the diet fell farshort of that believed essential to maintain normal resistance to disease.
The mortality from tuberculosis was far greater in Berlin than in other partsof the American Zone. Recorded annual rates for Berlin regularly exceeded 200per 100,000 population, whereas the rates reported in other parts of the zoneoccupied by American troops seldom exceeded 70. It is believed, however, that inthe majority of instances the records were inaccurate and incomplete. Before theend of the year, a reasonably good program was in effect, the future of whichdepended upon the full organization of the general public health program inGermany.
In the report last cited, in addition to recommendations for Americansupervision of German medical organization and the continued effort to increasefacilities and personnel for the care of tuberculosis in the U.S. Zone, the needfor some central German civilian advisory service was indicated. Thisrecommendation was entirely in line with general policies being developed notonly in the public health field but also in the realm of economics and civilgovernment. Unfortunately, German civilians of the required caliber were notavailable. The former General Secretary of the Reichs-Tuberkulose-Ausschuss wasliving in the zone but was not eligible under the regulations prevailing withrespect to persons with previous Nazi affiliations, nor was it possible duringthe period covered by this history to find anyone with comparable qualificationswho was eligible.
At the end of 1945, it appeared likely that a rise in the tuberculosis ratewould ensue, as it did after World War I, but it was believed that improvementin the local organizations, supplemented by assistance from a partially unifiedGermany, if this were ultimately effected, would stem this in time.
Part VI. Tuberculosis in British and Canadian Military Forces
Published accounts offering valuable material for comparisonwith the experience of the U.S. Army are available from the Royal Navy, theRoyal Air Force, and the Canadian Army.
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ROYAL NAVY
The military forces in Great Britain required a physical examination but notan X-ray examination prior to induction into service. A substantial fraction ofthe Royal Navy,64 however, was examined by 35-mm. fluorography after varyingperiods of service, and many of those so examined were reexamined 1 to 2 yearslater. The following summary of the first examination was made by the ConsultingPhysician in Diseases of the Chest to the Royal Navy, who was in responsiblecharge of the examinations:65
Fluorography of 479,373 apparently healthy male personnel of the Royal Navyshowed that 6,077 (12.7 per 1,000) had radiological signs of adult-typepulmonary tuberculosis. In 47.9 percent of these the lesion was"minimal."
Of 23,344 WRNS, 213 (9.1 per 1,000) had similar evidence of tuberculosis, andthe lesion was minimal in 55.4 percent of these.
Similar investigations among civilians will no doubt bring to light largenumbers of cases of pulmonary tuberculosis of this slight degree, raisingdifficult problems of disposal and treatment.
In some of these minimal cases the disease is arrested, or is retrogressive,but in others it is progressive. Careful study is needed to decide whether theinfection is active, and investigation in hospital is essential. When 2,911sailors with minimal lesions were first studied in hospital 16 percent showedevidence of active infection, while in 63 percent the disease appeared to beinactive but the stability of the lesions was doubtful. In 21 percent thedisease was arrested.
Naval personnel with apparently inactive minimal tuberculosishave been placed on light shore duties and kept under observation. Study ofthese cases shows that the younger the patient the more likely is the disease tobecome active, and the relapse to be serious.
A significant finding, quite comparable to the results in induction stationsin the United States, was a rise in the diagnosis of tuberculosis with advancingage in both males and females. In the four decades from 10 to 50 years of agethe rate per 1,000 for males was 8.8, 10.7, 19.7 and 32.8, and for females 6.9,9.1, 14.9, and 12.7. (The number of females in the 40- to 49-year period was toosmall to make the figure fully valid.)
An equally significant feature of the examination was the number of casesdiscovered in the minimal stage, the percentage being much higher than thatdiscovered by the conventional methods of physical examination.
This is in accord with general experience in massradiography. It is of interest to note that the percentage of all tuberculouscases discovered in the minimal stage did not vary significantly in thedifferent age periods. Followup studies indicated clearly that the younger thepatient with radiological evidence of minimal tuberculosis, the greater thelikelihood of its displaying activity.
64History of the Second World War, United Kingdom MedicalServices. Medicine and Pathology. London: Her Majesty's Stationery Office, 1952, pp. 319-332.
65Brooks, W. D. W.: Management of Minimal Pulmonary TuberculosisDisclosed by Fluorography. Lancet 1: 745-748, 10 June 1944.
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The average for the whole force examined was 12.7 per 1,000 for men, and 9.1for women, figures slightly greater than those for rejections for pulmonarytuberculosis at induction stations in the United States.
A later summary of the experience of the Royal Navy66 threw further light onthe relation of age to prognosis. Naval personnel with apparently inactivetuberculosis were placed on light shore duty and kept under observation. Almostall of those whose lesions proved active with the passage of time were under 25years of age.
This last summary discloses that by the end of 1944, 91,959 ratings passed asnormal on a first fluorographic examination were reexamined, and 479 cases withradiological evidence of tuberculosis were discovered. Comparison with theoriginal film showed that in 123 the lesion was previously existent but missed.This yields a figure of 1.3 per 1,000 of those fluorographed, which agrees veryclosely with the estimate of 1.0 to 1.5 cases per 1,000 of significanttuberculosis missed at induction in the United States, as calculated by Long andStearns from a rereading of 53,400 induction films. In both groups, the reasonsfor failure of detection and recording were the small size of the lesion,presence of the lesion behind skeletal structures that cast a denser shadow,proximity to the dense hilus structures, and, in some cases apparently, clericalerror.
Of the 479 cases found on reexamination, however, the great majority showedno evidence of disease in the initial film. These must have represented newinfections or manifestations of endogenous spread from an unknown focuselsewhere. It was significant that of the new group 73 percent were found in theminimal stage, a figure contrasting sharply with that of 48 percent found forminimal tuberculosis on initial fluorography. Further analysis showed that thetotal amount of new tuberculosis discovered on the second examination increasedwith the length of lapsed time since the first fluorography. In men who hadtheir second examination within a year or less, the rate was 2.4 per 1,000; inthose reexamined only after an interval of 3 years, the rate was 7.3. Theaverage for all groups was 3.4. In about one-third of the cases, there wasdefinite evidence of activity.
In studying these figures, it is of interest to note that anappreciable number of cases of tuberculosis developed in the course of time alsoin United States and Canadian troops who had been screened before acceptance andthat this increase was greater in those who had had military experience overseasthan in those who had not;67 also, that the annual mortality fromtuberculosis in the Army and in the ex-Army population rose steadily during thewar years.68
66Some Problems of Fluorography. Roy. Nav. Med. Bull. No. 20: 1-9, 1945.
67See footnote 13, p. 337.
68(1) Adamson, J. D., Warner, W. P., Keevil, R. F., and Beamish, R. E.: Tuberculosis in the Canadian Army, 1939 to 1944. Canad. M.A.J. 52: 123-127, February 1945. (2) See footnote 41, p. 372.
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The analysis published by the Royal Navy of the invasions by disease anddeaths of ratings from 1934 to 1944 indicated that approximately 2.5 men per1,000 were invalided each year for tuberculosis from 1941 on. The rate forofficers was somewhat lower. This figure is several times the discharge rate fortuberculosis in the U.S. Army, in which the relatively low rate is explained bythe radiological screening carried out prior to induction.
In this place, it is not out of order to point out that the British were atall times less conscious of the problem of compensation than the Americans.Whether tuberculosis was discovered before induction or after was a vital matterin the United States and Canada. The disposition of cases discovered in bothcategories was approximately the same in Great Britain, but the financial issuewas of less concern.
The death rate for tuberculosis in Royal Navy personnel dropped after 1942,following several years at a constant level. It was the hope of the officersconcerned that this was the forerunner of the benefits to be expected in thefuture from mass radiography in the service and discovery of cases in an earlyand favorable stage.
ROYAL AIR FORCE
The Royal Air Force also made extensive use of 35-mm. fluorography. A reporton 190,076 males and 59,951 females was made by Air Commodore R. R. Trail andassociates in 1944.69 All of the subjects of the survey were alreadyin service, and all had been accepted for service on the basis of physicalexamination. The men had been physically examined 3 to 12 months previously,some very strictly because of their special duties, and the women, all membersof the WAAF, 6 months previously on the average. The great majority of eachgroup was under 30 years of age.
The total incidence of tuberculosis was 7.7 per 1,000 in men, the difference,in comparison with the 12.7 discovered in the Royal Navy, being in partattributable to the younger age of the Air Force personnel. In women, theincidence was 9.4; that is, approximately the same as the rate of 9.1 discoveredin women in the Royal Navy. Followup examination indicated that the incidence ofactive tuberculosis was 2.8 per 1,000 in men and 3.6 in women. In men, thefigures with respect to age differed from those of the Royal Navy in that activedisease was not discovered preponderantly in the youngest age groups, but inincreasing extent in the groups up to 40 to 44 years. In women, the peak in theincidence of active disease was in the 20- to 24-year period.
An interesting finding common to the experience of both theRoyal Navy and Royal Air Force was the rise with advancing years in theincidence of calcified lesions interpreted as the residua of healed tuberculosisof childhood
69Trail, R. R., and others: Mass Miniature Radiography inthe Royal Air Force; Report on 250,027 Consecutive Examinations of R.A.F. andW.A.A.F. Personnel. Brit. J. Tuberc. 38: 116-140, October 1944.
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type. This rise could signify that childhood-typetuberculosis was much commoner years ago than now, or that the type of lesionterminating in calcification occurred in later years, so that a cumulative riseoccurred in the number of healed residua.
As in the U.S. Army, a higher increase in incidence wasobserved in recovered prisoners of war who had spent many months in prison campsin Germany. A survey of 7,146 recovered Royal Air Force personnel in Apriland May 1935 showed an incidence of active pulmonary tuberculosis abouttwice as great as that found in Royal Air Force personnel who had not beenprisoners.70
CANADIAN ARMY
The control of tuberculosis in the Canadian Army wasremarkably effective, and the scientific study to which data on tuberculosiswere subjected proved illuminating in the general understanding of thepathogenesis of tuberculosis.
X-ray examination was a requirement on induction in theCanadian Army. As in the U.S. Army, some troops were not examined by X-ray inthe early months of mobilization. Subsequently, roentgenograms were made of thechests of men who had been inducted without a film, and those found to havesignificant lesions were discharged. Approximately a million and a half persons,equivalent to a quarter of the male population and half of all persons of Armyage were examined by X-ray in the induction examinations.71 Theincidence of lesions discovered was about 1 percent; a third of the casesdiscovered, about 5,000, were considered clinically significant and reported tothe civil authorities. This byproduct of the war was of notable value to thegeneral program of tuberculosis control in Canada.
A feature of great importance, rendering the results ofexceptional value for understanding the hazards of tuberculosis in militaryservice, lay in the sharp distinction maintained by the Canadian militaryorganization between the Army in Canada and the Army overseas. In both, theprevalence was very low by civilian standards, as would be expected in agroup well screened by roentgenographic examination. The distinction lay in thefact that the Army in Canada was subjected to a hazard of exposure no greaterthan that in the civilian population of the provinces, while the Army overseaswas exposed to contagion in countries in all of which the death rate, andpresumably opportunity for contact with open cases, was much greater than inCanada. For the years 1939-44, the average incidence of tuberculosis discoveredin troops in the Army in Canada was 24 per 100,000 per annum, while in troopsoverseas it was 40. These rates were estimated, respectively, as15 and 25 percent of the rates in the civilian population in Canada. The
70Personal communication, Air Commodore R. R. Trail to author.
71Adamson, J. D., and Keevil, R. F.: Tuberculosis in the Canadian Army. J. Canad. M. Serv. 1: 404-411, July 1944.
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rates in each group increased with length of service,ranging, however, from 9 per 100,000 for home troops and 35 for oversea troopsin 1941 to 40 and 60 per 100,000, respectively, in 1944.
An even greater difference between troops at home and those overseas wasevident in the incidence of tuberculous pleurisy with effusion. In 1941, therate for the Army in Canada was 30 per 100,000 and that for the Army overseaswas 20. In marked contrast, the rates for 1944 were, respectively, 23 and 75 per100,000.
The increase in the tuberculosis rate with length of service in both groupswas attributed, in part, to the foreseeable development with the lapse of time.The excessive increase overseas, however, was explained on another basis;namely, the excessive exposure to tuberculosis in countries with a much greaterprevalence of the disease than Canada.
The figures for pleurisy with effusion were believed particularly significantin the latter respect. Analysis of the figures according to the native provinceof the men who became ill showed that the highest percentage of new casesdeveloped in men from Ontario and the western provinces, where the incidence ofinfection, as already known from civilian surveys, was low. It seemed logical tobelieve, therefore, that the high rate of effusion in troops overseasrepresented the acquisition of primary exogenous infection, a frequent earlymanifestation of which is pleurisy with effusion. In reaching this conclusion,the Canadian medical officers made allowance for the fact that some of thepleurisy with effusion, diagnosed as tuberculous, might have been due to acute,transient respiratory infections. It was in fact noted that a rise in wetpleurisy occurred in every epidemic of acute respiratory disease. However, afterdue allowance was made for the discrepancy between home troops and thoseoverseas, the similar trend in cases of pulmonary infiltration and pleurisy witheffusion lent strong weight to the view that the latter represented exogenoustuberculous infection overseas. Adamson and his coworkers believed thephenomenon "the natural epidemiological results of a tuberculin-negativegroup coming into contact with a tuberculous environment."
Canadian authorities carried the lesson into practice by specifying in twodirectives (14 November and 21 August 1944) that more strict attention be givento a history of pleural pain and to the examination of soldiers with knowncontact with tuberculosis.72
The second directive, and a subsequent note appended to it, indicated thatabout 4.3 percent of all medical discharges from the Army had been fortuberculosis and that approximately 2.9 percent of medical repatriations werefor this disease, of which 1.9 percent (or about two-thirds) were for pleurisywith effusion.
72(1) AGO Directive, 14 Nov. 1944, to departmental commanders. (2) DMSOrder 286, 21 Aug. 1944.
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These figures for the Canadian Army are of unusual interest.It is unfortunate for the study of epidemiology that in statistics for the U.S.Army, in the Zone of Interior and overseas, a comparable easy separation oftroops on the basis of origin cannot be made. Whereas in Canada a large share ofthe home Army was from the eastern provinces and remained in Canada, in theUnited States the home Army was constantly a transient force in training foroversea service, and the Army overseas had proportional representation from allparts of the country. Subsequent analysis on the basis of geographic origin maybe possible. In the meantime, it appears significant that an unusually high rateof pleurisy with effusion, presumed to be tuberculosis, occurred in young U.S.Air Force troops in Italy (pp. 353-357) .
Part VII. Significance of Army Experience for Control ofTuberculosis
For many years prior to World War II, tuberculosis mortalityin the United States had been declining. The reduction in mortality continuedduring the war, but at a somewhat lowered rate. Among the reasons for theslowing in the curve of decline were shortages in personnel for civilian publichealth and hospital practice, increased tempo of work, with correspondinggeneral strain, and absence from the country of a large number of men of an ageperiod with a low general death rate, who were removed from the population onwhich mortality rates were calculated.
Counterforces were in effect, however, which offset these factors. Althoughthe intensity of labor was increased, wages were far higher than before the war,and although prices were elevated also, the general result was a rise in thestandard of living in segments of the population in which mortality fromtuberculosis is usually high.
During the war, also, in spite of personnel shortages forpublic health work, a notable advance in machinery for tuberculosis control tookplace in the establishment, for the first time, of a Tuberculosis ControlDivision in the U.S. Public Health Service. This was organized by congressionalaction in the Bureau of State Services of the U.S. Public Health Service in July1944. Funds became available shortly thereafter to supplement measures forcombating tuberculosis through grants-in-aid to States, enabling the latter toexpand their programs in clinics, case finding, and hospitalization.
The examinations at induction stations, as indicated indetail elsewhere in this chapter, brought to light thousands of canes ofpreviously undiscovered tuberculosis. A substantial number of these were placedunder treatment immediately. In addition to the saving and prolongation of lifethus effected, there resulted a reduction in community exposure to tuberculosis,with presumably a corresponding decrease in development of new cases. Theaccomplishment in this respect was far from maximum, as reporting of cases wasnot complete, and followup programs to insure hospitalization of open cases
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discovered were not well developed in many parts of the country. In largecommunities, with well-organized public health programs, followup was good, butin other regions little or none was attempted. Although not specificallymentioned in AR (Army Regulations) 40-1080, dated 31 December 1934 and 10December 1943, tuberculosis was considered a communicable disease to which thereporting requirement applied. Because of a recognized laxity in reporting casesof tuberculosis, a reminder (specifically mentioning tuberculosis) as to thereporting requirement in AR 40-1080 was issued on 24 July 1944 in War DepartmentCircular No. 313. In some cities, however, by special arrangements betweenhealth departments and induction stations, direct report was made immediately,without waiting for report through the normal channels of the State selectiveservice organizations, and State health departments. In New York City, forexample, a representative of the Bureau of Tuberculosis of the Department ofHealth visited the large New York City induction station every night andreceived direct report on cases of tuberculosis discovered during the day.
The system of hospitalization for tuberculosis in the Army and the normaldischarge of patients to Veterans' Administration hospitals for further care,resulted in the treatment of thousands of cases and in corresponding reductionin opportunity to spread the disease to others. Army hospitals and Veterans'hospitals were required by their respective regulations to report cases to Statehealth departments. Special check, however, indicated that reporting was notcomplete. With changes in personnel, which occurred constantly in Armyhospitals, required procedures were not always continuous. To make up in partfor deficiencies in reporting, the Consultant in Tuberculosis, Office of theSurgeon General, established a direct relationship in 1944 with the newlyestablished Tuberculosis Control Division of the U.S. Public Health Service, sothat all discharges for tuberculosis were reported by States of origin of themen concerned. The Tuberculosis Control Division, in turn, forwarded thesereports to individual State health departments. With all the imperfections inthe reporting measures, and the lack of suitable followup programs in manyStates, and in spite of the many tuberculous veterans who refused sanatoriumcare in the months immediately succeeding discharge, steadily increasing controlfrom the point of view of public health resulted, which should be reflected in adecline of tuberculosis mortality in the future.
In evaluating the effect of the Army's control program on the general antituberculosis campaign, the educational efforts of Medical Corps officers shouldnot be overlooked. In addition to direct counsel given patients withtuberculosis or suspected tuberculosis, they were provided with literature fromthe National Tuberculosis Association and its affiliates, and hospital patientsin general saw motion pictures on the diagnosis, care, and aftercare oftuberculosis. Probably a still greater educational effect resulted from the vastamount of roentgenographic study of the chest done in the Army. X-ray
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examination at induction and separation, and the huge number of chestexaminations by X-ray in dispensaries and hospitals, made millions of young menand women aware of the danger of tuberculosis and the special measures availableto combat it.
On the whole, the tuberculosis control program of the Army was wellintegrated with the public health program of the country and may be expected tobe of continuing favorable influence in the reduction of tuberculosis in thepopulation in postwar years.
