CHAPTER XIV
Tuberculosis
Esmond R. Long, M. D.
TUBERCULOSIS IN WORLD WAR I 1
Tuberculosis was first recognized as asignificant medicomilitary problem in World War I. Dataare available in United States Army records and previous militaryhistories on rates anddisposition of cases in the Civil and Spanish-American Wars, but theknown prevalence in theArmy, in comparison with that of other diseases, particularly typhoidfever and malaria, was sosmall that no special attention was paid to tuberculosis and noanalytical studies were made of itsmilitary importance.
In World War I, on the other hand, United States Army medical officers were aware of its significance at the outset, for the disease was recognized as a grave problem in the French Army before the United States was engaged in hostilities. In the light of the French experience, The Surgeon General of the United States Army determined to have rigid physical examinations for tuberculosis (roentgen examination being then in its infancy) made by experts at the time of induction to prevent acceptance of men with this disease. In order to carry out this program, the Army assembled large numbers of distinguished experts and conducted special courses of training in physical diagnosis. The experience and shortcomings in diagnosing and excluding tuberculosis were described at great length by Col. George E. Bushnell, MC, Chief Consultant in Tuberculosis, Office of the Surgeon General, in the official history of the Medical Department of the United States Army in World War I. Although some 50,000 men with diagnosed tuberculosis were excluded at induction, the imperfections of the procedure were such that many men with early tuberculosis were accepted, as was indicated by a steady discovery of cases in the rapidly mobilized Army.
Tuberculosis in the Army was exhaustively analyzed by Colonel Bushnell. He attributed it almost entirely to breakdown of cases that escaped detention at induction. It must be recalled that this was a period when virtually all adult pulmonary tuberculosis was considered endogenous, representing the flaring up and progression of latent lesions of childhood as a result of adult strains. In favor of this view was the fact that nationwide sampling by the tuberculin test and all necropsy experience indicated almost universal infection
1 The Medical Department of theUnited States Army in the World War. Communicable and Other Diseases.Washington: U. S. Government Printing Office, 1928, vol. IX, pp.171-202.
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of the population by the age of 20 years. It was a decade or morebefore superinfection of adultswas recognized as a frequent occurrence.
Before the war was over, more than 2,000 men haddied of tuberculosis in the Army, andthousands more had been hospitalized. The admission rate in Armyhospitals averaged 19 per1,000 strength per year. Throughout World War I, tuberculosis was theleading cause ofdischarge for disability, accounting for 13.5 percent of alldischarges. At the end of the war, ahuge and costly problem was left for the newly organized Veterans'Administration.
TUBERCULOSIS BETWEEN THE TWO WORLD WARS
Between 1918 and 1941, great progress took place inthe understanding of the pathogenesis oftuberculosis. Careful studies of its epidemiology brought out a clearrelationship betweenexposure and subsequent development of manifest tuberculous lesions ofthe adult type, and intime the exogenous theory of adult tuberculosis assumed at least anequal standing with theendogenous. The disease was no longer considered invariably anexacerbation of an oldchildhood infection but rather, in many if not most cases, the resultof an adult acquisition ofnew infection.
The new understanding was reflected in a radically changed approach to the public health attack on the disease. Two principal procedures became recognized as the nucleus for tuberculosis control: case finding and isolation of discovered cases. In the earlier years of the two decades between the wars, case finding was developed as a public health procedure on a contact basis. The family was recognized as the source of most exposure, and clinic and public health measures were taken accordingly. Later, commencing in the late 1930's, case finding by mass surveys was recognized as highly effective. A few surveys were made by affiliates of the National Tuberculosis Association and local health departments just before the United States entered World War II, which clearly demonstrated the possibilities of the method. These surveys, made by methods of cheap and rapid roentgenography, resulted in the discovery of cases at relatively low cost as compared with all previous efforts. Paper films were used at first; subsequently, methods of photofluorography were developed, which made possible a less expensive and even more rapid roentgen examination of large groups. The United States Public Health Service took great interest in the development of methods and cooperated closely with tuberculosis associations before developing an independent program of its own.
Coincidentally with this development,hospitalization for tuberculosis was increasing rapidly.Standards for the number of beds which communities should provide forproper care of thedisease were developed and raised with the passage of time. Before thebeginning of the war,some 75,000 beds were available, and it was universally accepted in theUnited States that atleast two beds should be provided for every annual death in any,community. This was a, goalfor which all communities with a sense of public health responsibilitystrove.
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During these two decades, a notable decline intuberculosis mortality occurred throughout thecountry. At the close of World War I, the tuberculosis mortality ratein the registration area was150 per 100,000 population. At the opening of World War II, the figurewas less than 50.Therehas been extensive discussion and analysis of the reasons for thestriking decrease. Specificmeasures, including case finding and isolation of open cases, werecertainly effective. Combinedwith this, however, was a general rise in the standard of living, whichmust have affected themortality from tuberculosis indirectly in various ways.
In addition to the development of roentgenography methods for the detection of the disease, improvements occurred in its laboratory diagnosis. The years between the two wars were fruitful in the development of new methods for examination of sputum and of other tests in the recognition of tuberculosis infection. At the same time, education of physicians with respect to the disease improved, so that the rank and file of medical officers at the opening of World War II were much better informed on the disease than were the corresponding physicians of World War I.
TUBERCULOSIS IN WORLD WAR II
Examinations for Detection ofTuberculosis at Induction
As mobilization for World War II became imminent,Army and civilian experts oiltuberculosis, the National Tuberculosis Association, and other publichealth organizationsrepeatedly called attention to the high incidence of tuberculosis introops in World War I andto the necessity of avoiding a repetition of that unfortunateexperience. They pointed out that,since World War I, roentgenologic methods had been developed to thepoint that they couldbe effectively used in detecting tuberculosis and excluding it atinduction.
The principle of the roentgen method of detection was accepted by The Surgeon General long before the outbreak of the war, and standards for the exclusion of men with tuberculosis were drawn in terms of roentgenography. However, when war actually began, few places in the country were in a position to furnish the required roentgen examination. In the summer of 1940, The Surgeon General of the Army had requested the aid of the Division of Medical Sciences of the National Research Council in the formulation of proper standards. A subcommittee of the division, consisting of Drs. J. Burns Amberson, Jr., Bruce H. Douglas, Herbert R. Edwards, Paul P. McCain, and James J. Waring, with the author as chairman, drew up a set of recommendations that formed the basis for the chest section of MR (Mobilization Regulations) No. 1-9 which was in effect when examination of selective service registrants began in August 1941. This committee formulated an improved and greatly extended section in MR No. 1-9 of March 1942.2 Efforts to establish roentgeno-
2 M. R. No. 1-9, Standardsof Physical Examination During Mobilization, 31 Aug. 1940 and 15 Mar.1942.
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graphy as a required routine procedure at induction were pushedvigorously by Col. (laterBrig. Gen.) C. C. Hillman, MC, of the Office of the Surgeon General,and after many delaysthe procedure finally was universally employed.
One of the greatest difficulties in implementing the program lay in the multiplicity of stations for enlistment. Many of these were small and remote from medical centers. Equipment was not available nor were experts who could interpret roentgen films accurately. Induction stations for selective service registrants were better supplied, and the frequency of roentgen examination gradually increased throughout these stations, varying greatly, however, in speed of development in the nine corps areas or, as they were later designated, service commands. At first, chest roentgen examination was required on all registrants in whom pulmonary disease was suspected and was requested whenever local facilities made it possible.3 At the beginning of the war, only the three corps areas on the North Atlantic Coast made roentgen examinations routinely, and at first some of the stations in these areas utilized the services and equipment of affiliates of the National Tuberculosis Association and local health departments to carry out the examinations. The volunteer service rendered by these organizations was of major value to the Army in bridging the gap until Army facilities were available and at the same time tied the Army program in closely with State public health activities, which were of immediate concern to the assisting agencies.
By 1 March 1941, it was estimated by ColonelHillman that 51 percent of all men called toinduction stations had had a chest roentgen examination. With furtherincrease in facilitiesand equipment, the time finally arrived, about 1 April 1942, when allselectees weresubjected to roentgen examination before acceptance. Roentgenexamination for appointmentof officers was already universal.4 Nearly 100 inductionstations werein operation, each ofwhich had suitable equipment. Eight of the nine service commands used4- by 5-inchstereoscopic photofluorograms, and one, the Fifth Service Command, usedpaperfilms.Ultimately, all stations in all service commands used 4- by5-inch photofluorograms,supplemented as need dictated by full-size chest roentgenograms oncelluloid film. A fullreview of the procedures for exclusion of tuberculosis from the Armywas made by the authorfollowing World War II. 5
It is estimated that, before roentgen examination became mandatory (MR No. 1-9, 15 March 1942), one. million men had been accepted without this form of examination. Where roentgen examination was practiced, it resulted in a rejection rate of about 1 percent for tuberculosis. Applying this figure, it can be estimated that some 10,000 men were accepted who would have been rejected if they had been subjected to chest roentgen-ray study. Various studies have shown that approximately one-half of these would have been cases of active
3 Letter, The AdjutantGeneral, to Commanding Generals of all Corps Areas and Departments, 25Oct. 1940,subject: Chest X-rays on Induction Examinations.
4 (1) Letter,The Adjutant General, to Each Corps Area and Department Commander; EachChief of Arm orService; and to the Chief, National Guard Bureau, 30 Jan. 1940,subject: Physical Standards and PhysicalExaminations, Par. 4b. (2) Letter, The Adjutant General, to Each CorpsArea and Department Commander; EachChief of Arm or Service; and to the Chief, National Guard Bureau, 28Dec. 1940, subject: Physical Standards andPhysical Examinations, Par. 4b.
5 Long, E. R.: Exclusionof Tuberculosis. Physical Standards for Induction andAppointment.[Official record.]
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disease. Thus, failure to employ roentgenographic methods probablyresulted in theacceptance of 5,000 cases of clinically active tuberculosis. Among thelarge number of menaccepted after roentgen examination, errors-either in interpretation orin administrativeprocedure-permitted the acceptance of about 1 man per 1,000, as shownby subsequentresearch, who should have been rejected for tuberculosis.6 Among the 10 millionmenroutinely examined by roentgenographic methods and accepted, it isbelieved that about10,000 with active or potentially active lesions were inducted.Altogether, therefore, there isreason to believe that some 15,000 men were taken into the Army withtuberculous lesionsthat could have been detected on roentgen examination and recognized asa cause forexclusion.
It would be unwarranted, however, to assume that under existing circumstances X-ray diagnosis at induction stations could have been refined to a point where a greater degree of success could have been attained. Induction station roentgenologists were subjected to a variety of conditions tending to lower the level of their performance, chief of which were fatigue from long hours, required speed of operation, and repeated pressure from command sources to reduce the rate of rejection in the interest of manpower needs. In the effort to improve accuracy, the consultant in tuberculosis in the Office of the Surgeon General visited every induction station in the United States and read sample films with the station roentgenologists. Some improvement was probably brought about in this way.
It would be fully justified, on the other hand, to stress the great benefit to public health practice in the country effected through the report of cases which were properly identified. States varied in the energy with which ad vantage was taken of Army and Selective Service reports on rejection for tuberculosis, but it appears unquestionable that those with the more progressive health departments used these returns with great success in improving their case finding and followup programs.
Breakdown from Preexisting Tuberculosis
As indicated in the last section, it is estimatedthat some 15,000 men with active orpotentially active tuberculosis were accepted in the Army as the resultof failure to carry outroentgenologic examination or to recognize lesions in photo fluorogramsand roentgen films,when these were made. The majority of men so admitted had the diseasein the minimalstage. In a substantial number, how ever, the disease was far advanced.It is believed that, inmany of these cases, administrative errors in recording the lengthyselective serviceidentification numbers were responsible for acceptance.
From the beginning of the war, all films of accepted men were filed with the Veterans' Administration. Reexamination of X-ray films at any time was thus
6 Long, E. R., and Stearns, W. II.:Physical Examination at Induction; Standards WithRespect to Tuberculosis Induction and Their Application as Illustratedby a Review of 53,400X-ray Films of Men in the Army of the United States. Radiology 41:144-150, August 1943.
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possible, provided film filing was up to date, which was by no meansinvariably the case.Reexamination of the films of accepted and discharged men has shownthat, in the majorityof instances, men who entered the Army with advanced tuberculosis weredetected within thefirst 6 months of acceptance, were hospitalized, and were discharged.In a few cases,remarkably, men were able to carry advanced lesions over a period ofmany months or evennears before the disease finally was detected.
On the other hand, thousands of men with minimal lesions served months or years before breakdown occurred. In some instances, no deterioration in health or progression of the disease ever occurred in men whose initial films, on review, showed lesions that had the roentgenologic appearance of clinical activity. Also, large numbers of men with minute lesions which were considered well healed carried these, lesions without harm throughout the period of their service.
Careful studies have been made of circumstancesleading to the breakdown of tuberculouslesions of various types during the course of service. One study,carried out by Dr. Waringand Capt. (later Maj.) William H. Roper,7was organized by the Subcommittee onTuberculosis of the Division of Medical Sciences of the NationalResearch Council andimplemented by the Office of Scientific Research and Development. Thisstudy showed thatheavy physical labor and the strain of combat were particularlyimportant circumstancesfavoring breakdown. Other factors, such as malnutrition and psychologicstrains, played aless definite role. Waring and Roper also found that a considerableproportion of breakdownsfollowing acceptance for military duty occurred within the first yearof service. In many, theonset occurred with pleurisy with effusion. An additional observationwas that assignment of"poor risks" to limited duty afforded an appreciable measure ofprotection againstbreakdown, although frankly active cases mistakenly taken into servicedid equally badly onlimited and general duty.
During the first 2 years of the war in the Army's one special tuberculosis hospital, Fitzsimons General Hospital, Denver, Colo., the majority of admitted cases appeared to represent a breakdown of lesions present at the time of induction. Medical officers on duty in the hospital stated that during the last 2 years of the war the majority of cases occurred in men whose chests were negative by roentgen examination at induction.
Contraction of Tuberculosis
It has been pointed out that a substantial numberof men with tuberculosis were admitted tothe Army through failure to exclude recruits with recognizable diseaseat induction. Long andJablon 8 made an extendedpostwar study of the induction and separation X-ray films of3,099 men discharged from the Army with a diagnosis of tuberculosis and3,000 dischargedfor other reasons
7 Roper, W.H., and Waring, J. J.: Primary Serofibrinous Pleural Effusionin Military Personnel. Am. Rev.Tuberc. 71: 616-634, May 1955.
8 Long,Esmond R., and Jablon, Seymour: Tuberculosis in the Army of the UnitedStates in World War II. AnEpidemiological Study with an Evaluation of X-ray Screening.Washington: U. S. Government Printing Office,1955.
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during the years 1942 to 1945, inclusive. This study disclosed the factthat approximatelyone-half of the tuberculosis that led to discharge from the Army wasalready present indiagnosable form at the time of acceptance for military duty.
In addition to these men, presumably other men were inducted with latent infections undetectable by the X-ray screen. Men from each of these groups may have broken down as a result of progression of their preexisting disease. Over and above these, however, there is reason to believe that a considerable amount of tuberculosis resulted from new infections acquired during service, through contacts in the Army itself or through associations outside of military duty. Opportunity for contracting tuberculosis through civilian contact in the United States existed for soldiers just as for other citizens. They visited their families while on leave, and presumably in some of these families there were members with tuberculosis who were likely to spread their infection. Thus, soldiers may have carried back tuberculous infections when they returned to their stations. Also, as in civilian life, soldiers visit friends in the general population, some of whom may have tuberculosis. Therefore, troops presumably experienced a certain amount of exposure to tuberculosis from this source in the United States. The average intensity of exposure would depend upon the prevalence of tuberculosis in the sections of the population visited. Overseas, the opportunity for contraction of tuberculosis through exposure to civilians was still greater. In North Africa, Italy, France, the islands of the Pacific, the Philippine Islands, and Japan, the prevalence of tuberculosis was far higher than in the United States.Rates in the British Isles and in Germany also exceeded those in the United States but not by a great margin.
Because of the multiplicity of contacts thatmight be significant, it is difficult to trace newcases of tuberculosis to their source under Army conditions. However,the acceptance ofsome 15,000 men with active or potentially active tuberculosis as aresult of defects in theinduction screen was apparently a factor not to be overlooked in thetotal development oftuberculosis in military personnel. The study by Long and Jablonindicated that, except in thecase of men who had served periods as prisoners of war and men whoapparently had beenexposed excessively to disease through other special circumstances, arelatively evenuniformity of risk of acquiring tuberculosis occurred, regardless ofarm, military occupation,overseas service, theater of service, or civilian contact. In thatstudy, differences observed inrisk seemed to be no greater than those to be expected through chancesampling.It seemedreasonable, therefore, to infer that a substantial percentage, perhapsa, majority, of cases ofnewly contracted tuberculosis in servicemen resulted from infectionfrom fellow soldiers.
Admission Rates
The best measure of the prevalence of tuberculosis in the Army was theadmission rate forthis disease, although the figure may give an exaggerated picture ofthe actual prevalence.Cases admitted for tuberculosis included all
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those so diagnosed after complete examination and, in addition,cases originally judged asprobably tuberculous in nature but requiring further study to establishor disprove thediagnosis. On the other hand, incidence rates failed to take intoaccount asymptomatic casesnot brought to medical attention. Possibly the error in one directionwas as great as that in theother, so that the recorded prevalence may have been fairly close tothe actual.
It is useful to compare the incidence rates in the Zone of Interior with those in foreign areas, in an effort to determine where cases of tuberculosis originated. Needless to say, admission in the Zone of Interior or admission in overseas areas would not necessarily mean that infection ultimately diagnosed was acquired in the same region. A soldier might be infected in the Zone of Interior and first show evidence of tuberculosis after going overseas, and, vice versa, a soldier infected overseas might return to the Zone of Interior and pass several months in service before his tuberculosis became manifest.
It is interesting to note that throughout the waxincidence rates for the Zone of Interior asrecorded in periodic statistical health reports were consistentlyhigher than those reported inthe overseas theaters. Several reasons may be given in explanation. Inthe first place, cases ofobvious tuberculosis overlooked at induction usually came to lightbefore transfer overseas.Training in the United States prior to overseas duty was rigorous, andcases likely to breakdown ultimately in normal life were eliminated by what was essentiallya process of naturalselection before overseas assignment. Also, it is possible that therewas more leisure forexamination in the Zone of Interior, and there fore more cases weredetected. Whether this isa fact or not is debatable, for the examination overseas of service andcombat troops wasprobably equal most of the time to that carried out in the Zone ofInterior.
Chart 23 illustrates the admission rates for the total Army in the Zone of Interior from July 1940 to October 1946, inclusive. The admission rates among white enlisted men in the continental United States in World War I for the years 1917-20 are presented for comparison. It will be noted that, in each war, a high rate prevailed shortly after the beginning of the war. This can be explained as the result of imperfection in examination for service during the early months in each war. In World War II, there was a long period from April 1942 to the middle of 1945 when examinations were excellent and the rate of recognition of tuberculosis in the Army was relatively low and constant, representing the sum of cases that escaped recognition on induction and those that actually developed within the Army. It will be noted that a high rate occurred toward the end of 1945. This rate is, of course, artificial and represents the tuberculosis rapidly discovered at the separation centers on discharge from the Army.
A fact of interest brought out in the figures isthat, at all timesduring World War I, theadmission rate for tuberculosis was approximately 10 times that inWorld War II. Theexplanation can be found, in part, in inferior screening at inductionduring World War I andalso in the greater prevalence of tuberculosis in the civilianpopulation during the earlierperiod, when the
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mortality rate was three times as high as during World War II. Henceopportunity for chancefailure of recognition at induction was much smaller during World WarII as was also theopportunity for exposure to the disease after induction. Actually, thedifference in prevalencein the Army in the two wars was probably considerably greater than thatrecorded foradmission rates, since diagnostic accuracy had improved markedly in theinterim and theadmission rate in World War II, presumably, was therefore closer to thetrue prevalence ratethan it had been in World War I.
Chart 24 compares incidence rates for tuberculosis for the United States and overseas theaters for the years 1942 to June 1946, inclusive. It will be seen that the rate in the United States was at all times greater than that over seas. All overseas theaters reported relatively low rates. Annual rates per 1,000 strength recorded for the European Theater of Operations by Lt. Col. Theodore L. Badger, MC, senior consultant in tuberculosis in the theater for 3 1/2 years of war, were as follows: 1942, 0.89; 1943, 1.27; 1944, 0.76; 1945 (1 January to 31 May), 0.69.9 The average admission rate for the Mediter-
9 Semiannual Report of the Senior Consultant on Tuberculosis, Office of the Chief Surgeon, European Theater, 1 Jan. 1945 to 30 June 1945.
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ranean (formerly North African) Theater of Operations from November1942 to May 1945, asrecorded in the theater, was 0.58. Chart 25 shows the rates for alltheaters for the years 1942-45 on the basis of returns in thestatistical health reports.
As has beenpointed out (chart 24), during World War II tuberculosis was moreprevalent introops in the United States than in troops in overseas theaters. Theopposite was evident,however, at the time of discharge. Figures from separation examinationsin the Zone ofInterior, assembled separately for those who had service in the UnitedStates only and forthose who had service overseas, showed a striking difference.10Chart 26 illustrates thedifference in withdrawals for tuberculosis in the two groups. It isevident at once thatdiagnoses of probable tuberculosis in soldiers with overseas experiencewere considerablymore frequent than in troops with Zone of Interior service only.
The explanation would not seem difficult. Troops overseas presumably actually did acquire new infections to a somewhat greater extent than troops in this country. Most of these infections were minimal and therefore were
10Long, E. R., and Hamilton, E. L.: A Review of Induction and DischargeExaminations forTuberculosis in the Army.Am. J. Pub. Health 37: 412-420, April 1947.
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not discovered on a symptomatic basisnor recorded in the normal admission rates in thetheaters. When the millions of troops with and without foreign servicewere discharged atseparation centers, roentgen examination was
CHART 25.-Incidence of tuberculosis in the U. S. Army, by theater and year, 1942-45
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universal. 11 Hundreds of small lesions, undetectable by any other means, were found.Theexaminations were of the same character for both groups of troops.Theconclusion wouldseem inescapable that some significant factor operated overseas to makethe rate in troopswith overseas service greater. The excessive rate could not beattributed entirely to thestrenuous nature of overseas service, for many overseas troops hadapproximately the sametype of service as troops in the Zone of Interior. The simplestexplanation, and the mostlogical, would seem to be that the excess of lesions found in troopswith foreign servicerepresented overseas infection in the numerous regions where UnitedStates troops were inclose contact with populations with far higher tuberculosis rates thanthe rate in the UnitedStates. For such an explanation to be valid, however, it would benecessary to exclude fromconsideration lesions which were present at induction but which,because of their small sizeand apparent innocuous character, were not judged to be a cause forrejection.
Certain pitfalls in such a deduction, however, have been pointed out by Long and Jablon in the study previously cited. This study showed for white soldiers some increase in risk in service in Europe and Asia, presumably related to civilian contact. Among nonwhite troops in the Mediterranean theater, in which civilian association was known to be unusually great, the figures demonstrated an excessive rate of tuberculosis at discharge. It was impossible to establish a positive correlation between the development of tuberculosis and illness known to result from civilian contact, such as venereal disease. On the whole, the evidence did not indicate a strikingly greater risk of acquisition of tuberculosis in the Army overseas than in the Army in the United States. Certain exceptions to this conclusion were clear, however. Rates among Medical Department personnel with foreign service, among nonwhite troops stationed for long periods in port areas, and in military personnel who had been prisoners of war were found to be excessive.
The study by Long and Jablon should be consulted for detailed information concerning the development of tuberculosis with respect to age, race, home environment, and length of Army service. Space does not permit extensive review here. A definite correlation with youth was evident, and rates in general were higher for nonwhite than for white troops. The most significant factors, however, were those listed above.
Before the subject of prevalence of tuberculosis in the Army is concluded, some reference should be made to tuberculosis mortality in the Army. A proper analysis of Army mortality should take into account mortality after discharge as well as deaths in the Army, as the majority of persons destined to die of the disease were transferred from the Army to the Veterans' Administration. In an Army of approximately 4 million men in 1942, the tuberculosis mortality was less than 4 per 100,000 persons. The combined figure for personnel on duty and discharged personnel in later years, when the Army was much larger, increased to about 6 per 100,000 in 1943, 10 in 1944, and 12 in 1945. The
11 WarDepartment Technical Manual 8-255, Terminal Physical Examination onSeparationFrom Military Service, 10 Sept. 1945.
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higher rates of the later yearsreflected the time required for mortality to succeed onset ofdisease, as well as the cumulative increase of cases in a populationoriginally almost freefrom tuberculosis. Army mortality figures have been analyzed in somedetail by Aronson, 12who called attention to a rising mortality in Army personnel with risein age and to the factthat, despite similarity of living conditions, income, and militaryduties, the Negro race,representing about 10 percent of the Army population, contributed 43.4percent of the deathsfrom tuberculosis.
Preventive Measures
Theater measures.-No specific screening toexclude tuberculosis was practiced immediatelyprior to departure of troops for overseas. The magnitude of the task ofmaking new roentgenexaminations on such a large body of troops prohibited the procedure.On the other hand,there is every reason to believe that many soldiers with tuberculosiswere automaticallyeliminated from troops going overseas. The rigors of basic trainingprobably brought to lightmany of the cases which, in spite of the presence of small activelesions, were overlooked atinduction. A few, but not many, cases were detected by the physicalexamination maderoutinely just before departure for overseas service. Cases thatescaped discovery prior todeparture from the United States were detected from time to time inoverseas areas in thecourse of numerous roentgen examinations for respiratory disease or forspecial surveypurposes. Surveys were made from time to time in Army Air Forcepersonnel, and roentgenexamination was required before assignment to officer candidate schools.
On the whole, roentgen examination of troops was a frequent procedure overseas and not a few asymptomatic cases was found. Such widespread roentgen examination resulted in the discovery of many inactive cases that had been knowingly inducted because the lesions seen were believed healed and within acceptable limits in size. These cases constituted a problem of disposition. Medical officers overseas, in ignorance of the fact that the small lesions were previously studied and considered acceptable, returned many such cases to the Zone of Interior rather than continue them as medical risks where responsibilities were so great.
Facilities for thedetection of tuberculosis were first class, even up to the frontline.Not a fewcases were discovered and worked up thoroughly by roentgenographicexamination andlaboratory tests for tubercle bacilli in evacuation hospitals within afew miles of the front.
Altogether, suchmeasures probably detected most cases of open tuberculosis within arelatively short period of their development as open, contagious casesand prevented muchdissemination within the Army.
Beyond this, relatively little precaution was taken to prevent tubercu-
12 Aronson, J. D.: The Occurrence and AnatomicCharacteristics of Fatal Tuberculosis in the U. S. Army DuringWorld War II. Mil. Surgeon 99: 491-503, November 1946.
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losis. Specific measures that mighthave been used are discussed in following paragraphs.Official directives were considered necessary only in the case of onetype of tuberculousinfection in which the hazard was recognized and the method ofprevention was clear. Thisinfection was milkborne tuberculosis. In most countries of the world,bovine tuberculosis isfar more, prevalent than in the, United States. The hazard from bovineinfection in thiscountry is virtually negligible. It is well known that much of the milkfor generalconsumption in the British Isles during the war contained tuberclebacilli. The ArmyVeterinary Service was well aware of this situation and issued severaldirectives requiringdiscontinuance of purchase of milk unless the source could be approved.13These regulationssharply restricted the purchase of milk and imposed rigid standardswith respect to its source.After the early months, very little British milk was consumed in theofficial ration. As amatter of fact, most of the milk consumed everywhere in the Armyoverseas was dried milkfrom the United States, in which full precautions had been taken toprevent contamination.There is little reason to believe that any significant amount of bovinetuberculosis wasacquired either overseas or in the United States.
The evacuation of tuberculous soldiers presented a special problem in preventive medicine. Tuberculous patients were congregated in relatively small space for transfer back to the Zone of Interior. Theater surgeons recognized the danger of contagion, and efforts were made on hospital ships and airplanes to provide facilities minimizing transmission of infection. Unfortunately, a considerable number of tuberculous patients had to come back in troop-class quarters, and in these cases, proper precautions could not be taken. It is impossible to estimate how much transmission of tuberculosis took place in this way.
Quarters on hospital ships were usually fully adequate for tuberculous patients. Fortunately, relatively few cases of acute contagious diseases were evacuated from overseas, and, accordingly, the space originally reserved for such patients was turned over to tuberculous patients.
Insofar as possible, when troops were returned by airplane, tuberculous patients were held until a planeload accumulated. They were then transferred to the Zone of Interior in a single group, with a noncommissioned officer of the Medical Department and a nurse in charge.
Specific measures.-Measures employed for the prevention of tuberculosis in theaters of operations were general rather than specific. All medical officers were aware of the possibility of development of tuberculosis, and frequently, although by no means invariably, when cases were discovered in quarters, soldiers in the same barracks or billet were subjected to roentgen examination to determine if infection had been transmitted. In all probability, in the majority of cases, this was a gesture rather than an effective procedure because the examination so ordered was usually made too soon to discover
13 (1)Circular No. 40, Headquarters, European Theater ofOperations, U. S. Army, 5 Sept. 1942.(2) Circular No.72. Headquarters, European Theater of Operations, U. S. Army, 10 Nov.1942.
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active cases and because, adequatefollowup under the conditions of overseas service wasimpossible. Actually, such surveys not infrequently disclosed cases ofinactive tuberculosiswhich had been admitted at induction stations knowingly or unknowingly;these, as pointedout above, at once constituted a problem of disposition.
Overseas medical officers had inadequate nutrition in mind as a possible factor predisposing to tuberculosis. Each of the several histories prepared by officers assigned the task of analyzing records with respect to tuberculosis in the specific theaters mentioned malnutrition as a possible predisposing influence. Actually, no correlation was discovered between the occasional forced periods of impaired nutrition in frontline positions and subsequent development of tuberculosis. As already pointed out, a study by Waring and Roper showed that other factors, particularly physical strain, predisposed more than any other factor, including nutrition, to breakdown from the disease.
Unfortunately, nosustained educational program with respect to tuberculosis waspossible.The circumstances of military service were not conducive to sucheducation. Occasionally,under unusual circumstances, an educational campaign was carried out.Troops in Manila,Philippine Islands, after the city was recovered, were warned againstthe danger oftuberculosis. The extremely high rate in the, population of the Islandsimpressed medicalofficers at the time, and the Surgeon General's Office was asked toprovide educationalmaterial to indicate to the troops the danger and the way to avoid it.
Early in the war, the advisability of BCG (bacille Calmette Gu?rin) vaccination was discussed. Considerable pressure was brought upon the Office of the Surgeon General to make it routine in the Army. The Surgeon General decided that its value was not fully established and that, with so many other inoculations of fully demonstrated efficacy, it was impractical to add one the value of which was uncertain.
Thus, in the lastanalysis, the program for prevention of tuberculosis rested on the twoprocedures of most value in the country as a whole: early diagnosisthrough case finding andhospitalization for isolation and treatment.
SpecialProblems
Prisoners of war and displaced persons.-The recovery ofAmerican prisoners of war,captured by the Germans and Japanese in various phases of the conflictand liberated in thelate months of the war, created a new problem in preventive medicinefor the MedicalDepartment of the United States Army. A still greater problem resultedfrom the assumptionby the Medical Department of responsibility for the medical care ofthousands of aliens whohad been held prisoners by the Germans and Japanese and who wereliberated by theadvancing armies of the United States in the spring of 1945.
Admission rates for tuberculosis in recovered United States military personnel were higher than in the Army as a whole. The increase was not
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alarming nor such as to suggest thatexcessive exposure had taken place during the period ofconfinement. However, the conditions of confinement were rigorous, andmalnutrition wasparticularly severe. There is reason to believe that these conditionscaused breakdown inmany men who were held prisoners over a period of several months.
In their study of the medical records and induction and separation X-ray films of 6,099 men, Long and Jablon found that among white men with overseas experience, for whom their figures were statistically significant, the prevalence of tuberculosis at the time of discharge from the Army was approximately three and one-half times as high among men who had been prisoners as among those who had not (figures chiefly for men captured by the Germans). In another investigation, Cohen and Cooper 14 found that the prevalence of active tuberculosis among United States prisoners of war at the time of their liberation was 6 per 1,000 for those captured by the Germans and 37 per 1,000 for those captured by the Japanese. The latter had experienced more rigorous prison conditions. These figures, of course, do not take into account the mortality from tuberculosis in prison camps, which is believed to have been high in Japan.
Most of the recovered prisoners were routed back to the United States through an established chain of hospitals and ports of embarkation. The problem was the same as that of ordinary personnel, except in degree. Recovered prisoners with tuberculosis returned to the United States in the normal manner, chiefly in hospital ships, and on arrival were sent to one of the special tuberculosis hospitals. The largest number of enlisted men with tuberculosis went to Bruns General Hospital, Santa Fe, N. Mex. The load was at no time severe enough to cause an undue strain on Zone of Interior hospital facilities or to constitute an excessive danger through contagion for nurses and other military personnel.
In markedcontrast, the problem of care for liberated displaced personnel held bytheGermans and Japanese was a severe one. At times, in eastern France, itwas critical.Thousands of Russians, Poles, Hungarians, Yugoslavs, Italians, andpersons of othernationality were found in hospitals or workcamps following the Germanretreat in easternFrance. A high percentage of these inmates had tuberculosis, commonlyin a far-advancedstage. It was necessary for the Army to establish several hospitals forthe care of thesepatients. The 46th General Hospital at Besancon, with more than 1,000tuberculosis patientsof foreign nationality, was the largest tuberculosis center of theUnited States Army,exceeding Fitzsimons General Hospital in its census of tuberculouspatients. The 50thGeneral Hospital in Commercy also had a large number of such patients,and smallernumbers were scattered through various general hospitals throughouteastern France. Thecondition in which these patients were received was deplorable. Manywere moribund onadmission. Language difficulties and long years of abuse had destroyedall sense ofdiscipline,
14 Cohen,Bernard M., and Cooper, Maurice Z.: A Follow-up Study of World War 11Prisoners of War. Washington: U. S. Government Printing Office, 1954.
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so that the problem of medical care was exceedingly difficult. The exposure of medical personnel in these hospitals was high.
Fortunately, the senior consultant in tuberculosis in the area, Colonel Badger, was aware of the possibility of contagion. At his instigation, a series of important circulars with reference to the gravity of the problem were promulgated from the Office of the Theater Chief Surgeon, and directives were issued establishing a sanitary code in these hospitals that reduced contagion to the minimum possible. 15 Ultimately, tuberculosis aliens of this type were concentrated in a small number of hospitals, particularly the 46th General, and those surviving were repatriated through displaced-personnel channels.
The problem of care of enemy prisoners of war was much less complicated, as the primary burden was thrown upon captured medical officers of the enemy nations. Almost no exposure of United States personnel was involved, and the preventive medicine problem was minor.
Military Government.-After V-E Day and V-J Day, the medical departments of the occupying forces were concerned with the public health problems of the occupied countries. The postwar tuberculosis rate was high in Italy, Germany, and Japan. Prior to the war, the tuberculosis mortality rate in Germany was little more than that in the United States. The vicissitudes of war, the hardships of the laboring population, the breakdown of tuberculosis control measures, the importation of foreign labor unscreened for tuberculosis and other factors combined to double the mortality rate from tuberculosis in Germany. Most of the tuberculosis sanatoriums were in use for other purposes, particularly for the care of wounded and sick prisoners of war. Hence, tuberculosis patients who normally would have been in tuberculosis hospitals and sanatoriums remained at home, where they served as foci for infection of others. Conditions were similar in Italy and Japan.
Immediately after the war in Germany, a tuberculosis section was established in the Public Health Branch of Military Government, and the chief consultant in tuberculosis in the Office of the Surgeon General was asked to serve in this office during the early postwar months. The first objective was to restore reporting to a normal state, so that the magnitude of the problem could be learned. Fortunately, basic laws were in effect that made this relatively easy, and the primary public health organization at the Land level had been preserved. Trustworthy figures were soon obtained, and with the passage of time both case finding and hospitalization of discovered cases improved, so that less exposure of the population took place.
In each Land in Germany, the peak of mortality occurred in 1945 or 1946, after which a steady decline in tuberculosis mortality occurred.16 The role of the medical departments of the occupying forces included such aid as could
15 (1) Circular Letter No. 41, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U. S. Army, sec. 11, 11 May 1945. (2) Letter, Col. E. R. Long, MC, Consultant in Tuberculosis, Office of the Surgeon General, to The Surgeon General, 28 May 1945, subject: Visit of Tuberculosis Consultant in European Theater of Operations, ignited States Army.
16 Sartwell, P. E., Moseley, C. H., and Long, E. R.: Tuberculosis in the German Population, United States Zone of Germany. Am. Rev. Tuberc. 59: 481-493, May 1949.
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be given the population through surplus Army supplies and food and steady insistence on accurate reporting by the German public health authorities to the statistical service of military government.
In Japan, extraordinarily high tuberculosis rates prevailed before the war, and these became exaggerated in the late years of the conflict. Progress in control by military government was similar to that in Germany, and ultimately remarkable success in lowering the death rate occurred. In this achievement, the Japanese themselves and medical officers from the occupying forces gave great credit to BCG and related vaccines used by the Japanese. It appears doubtful, however, that vaccination could have had such a striking rate so early. Presumably, various forces, as in Germany and other countries, were concerned.
Progress in Prevention During the War
The Army's experience in the control of tuberculosis during World War II, combined with that gained in World War I, resulted in a good understanding of organization in screening for tuberculosis. This experience found application on a large scale in later case-finding programs throughout the Nation. It should be equally valuable in military orientation whenever the need for similar operations arises again. The vast program of roentgenologic, examination for tuberculosis carried out in induction stations was repeated on a mammoth scale in much more rapid fashion at discharge. Not long after the separation procedure was concluded, however, induction and separation centers were closed, and within a few months after the war roentgenologic examination at stations of enlistment was no longer an established procedure. The methods in operation before the war prevailed, and roentgen examination was not made at ordinary recruiting stations. Also, unfortunately, the requirement for roentgen examination at the first station following enlistment often was not fulfilled.
The experience of the induction stations showed the need for greater efficiency in roentgenologic screening to prevent acceptance of men with active or potentially active lesions. The cost to the United States Government of long-term care of patients with tuberculosis in the Army or in the Veterans' Administration is so great that the relatively minor expense of extreme care in acceptance of men at induction should not be opposed.
The hospitalization system carried out by the Army for tuberculosis was excellent. Army hospitals improved coincidentally with civilian hospitals in the medical and surgical treatment of tuberculosis during the years of the war. The isolation of tuberculous soldiers in Army hospitals, supplementing that of civilian hospitals and governmental hospitals of municipal, county, State, and Federal operation, was an important factor in removal of sources of contagion in the country and corresponding reduction in the spread and prevalence of tuberculosis.
Careful analysis of cases of active tuberculosis discovered during the war showed conclusively that certain types of strain paved the way for breakdown
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of latent lesions. Heavy physical labor and combat conditions were notable in this respect.17
The Army, which had had little experience, except for World War I, with the problem of tuberculosis in foreign countries, learned much about opportunity for contact and sources of contagion. If the United States con tinues to maintain occupation forces in foreign countries, the problem will remain. The experience, gained through overwhelming exposure in the care of destitute displaced personnel was excellent, though severe, training for adverse conditions that might be encountered again.
Army medical officers took advantage of current advances in the diagnosis and therapy of tuberculosis, and improvement in technique in the care of patients took place steadily. Progress in bronchoscopy and surgery was notable. As the war closed, new antibiotic methods of therapy were coming into practice, but antibiotic therapy in tuberculosis in general was a postwar rather than a war development.
Army medical officers shared with civilian tuberculosis specialists in developing new understanding of the recognition of small lesions, of the relation of pleurisy with effusion to tuberculous infection, and of the need for prompt care and isolation of cases if the progress of the disease was to be prevented and spread of infection checked. The remarkably good clinical progress made by men whose disease was detected in a minimal stage, a frequent finding on discharge, was of high value in bringing home the excellent prognosis of small tuberculous lesions when discovered and treated in time.
SUMMARY
1. Tuberculosis was first recognized clearly as a military problem in World War I. In spite of specific efforts to prevent the acceptance of recruits with tuberculosis, a considerable number of men entered the Army with this disease, and a large and costly burden in medical care and compensation was left as a Federal responsibility.
2. Between World War I and World War II, great progress was made in the diagnosis of tuberculosis. Rapid methods of examination, including the use of paper films and photofluorography, led to significant advance in case finding.In addition, the number of beds available for tuberculosis was greatly increased, and opportunities for spread of the disease correspondingly decreased. During this period, a continuing decline in tuberculosis mortality occurred in the United States, as well as in the rest of the Western World.
3. During World War II, in the light of the experience of World War I, an intensive effort was made to exclude tuberculosis at induction. An X-ray program was instituted at the outset. This program was imperfect at the start, but after March 1942 all men entering the Army had a chest roentgen examination before acceptance for service. The examination itself had its
17 See footnotes 7 and 8, p. 264.
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imperfections, however, and it is estimated that approximately 15,000 men with active tuberculosis were admitted to the Army either as a result of omission of roentgen examination in the early months or failure to detect tuberculosis in films made after their use became routine.
4. Subsequent studies showed that a considerable number of these men broke down with clinical disease during service in the Army. The experience of Army tuberculosis hospitals indicated that, during the first 2 years of the war, a majority of the men developing tuberculosis in service were men who entered the Army with the disease already present. Postwar investigation of induction and separation X-ray films on file in the Veterans' Administration demonstrated that approximately one-half of the men ultimately discharged by reason of tuberculosis entered the Army with the disease.
5. In addition to those who developed tuberculosis as a result of the flaring up of lesions undetected on entrance into the Army, a significant number acquired tuberculosis during Army service, presumably as a result of exposure to the disease. There is reason to believe that this resulted from contact with tuberculosis both in the United States and abroad and from military as well as civilian contacts.
6. A comparison of admission rates for tuberculosis in the Army in the Zone of Interior and in overseas theaters shows that throughout the war the rate was higher for Zone of Interior than for overseas troops. However, there is reason to believe that a significant amount of early tuberculosis was overlooked overseas, because roentgen examination at time of separation disclosed a somewhat higher rate of tuberculosis in men with overseas service than in those with Zone of Interior service only.
7. The principal measures for control of tuberculosis in overseas theaters were early diagnosis and evacuation to the United States. Many examinations were made in the course of routine studies, as for promotion to officer status, and in the diagnosis of acute chest disease. Men with active tuberculosis and men in whom activity was suspected were evacuated to the Zone of Interior for further observation and care. Thus, the theaters depended upon diagnosis, isolation, and care for the control of tuberculosis.
8. Tuberculosis in recovered United States prisoners of war was a problem of some concern to the Army. The tuberculosis rate in recovered prisoners was considerably higher than in the Army as a whole, although far short of that prevailing in recovered prisoners in other armies.
9. The greatest amount of tuberculosis encountered by the Medical Department of the United States Army during the war was in displaced personnel of other nationalities recovered by the Army during the occupation of areas previously in the hands of the German Army. Huge numbers of patients with tuberculosis were found in displaced personnel camps abandoned by the Germans, and their care became a difficult problem for the hospitals of the Army.
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10. Military government assumed the control of tuberculosis as one of its public health functions during the period of occupation after the war. The principal responsibilities of medical officers of military government with respect to tuberculosis were the restoration of normal practice in reporting and the provision of an adequate number of beds for the care of tuberculous patients.
11. During the war, notable advances took place in the control of tuberculosis, in which the Army shared.Perhaps the most important of these was improvement in methods of case finding, through mass roentgen examination. In addition, provision for isolation was much improved, and advances were made in surgical therapy. At the end of the war, the antibiotic treatment of tuberculosis was under consideration. Actually, no cases of tuberculosis were so treated in the Army prior to the end of 1945, although subsequently Army hospitals contributed greatly to the development of chemotherapy in tuberculosis.
12. Research in the Army advanced the knowledge of the causes of breakdown from tuberculosis and indicated what types of strain are particularly likely to lead to relapse and what strains individuals withstand without break down of latent lesions. Light was thrown upon the relation of pleurisy with effusion to tuberculosis, and renewed emphasis was placed on the danger of small lesions whose activity is difficult to determine.
13. In general, Army experience indicated the great importance of means for exclusion of tuberculosis. It was clearly evident that measures for this purpose should be continued without fail and improved with the advance of technical methods. Inasmuch as numerous lesions believed to be inactive are seen and become a cause for later inquiry, it is desirable that in the future such lesions be recorded on each soldier's immunization or other record.
