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Chapter III

Communicable Diseases, Table of Contents

CHAPTER III

TUBERCULOSIS

ORGANIZATION FOR ELIMINATING THE TUBERCULOUS FROM THE ARMY

Soon after the United States entered into the war against Germany it was decided by the Surgeon General that the United States Army should be reexamined for tuberculosis by the best available experts.1 The chief reason for this decision was the obvious importance, in view of the difficulties of transportation, of allowing no soldiers to be sent abroad who were doomed in advance to an early breakdown. The fact, however, had been alleged and had been given wide publicity, that the French Army had suffered severe losses from tuberculosis2 and, as it was generally admitted that that disease was rife among the French civil population, the fear that our Army would suffer in the same way as the French Army was felt by many of the medical profession and of the laity. Whether or not this fear was well founded, it would evidently be advantageous, as a matter of policy, to give the public to understand that every possible precaution would be taken to safeguard our Army against tuberculosis, and this consideration was no doubt of weight in the mind of the Surgeon General. The supervision of the accomplishment of these measures was to be the function of the division of internal medicine, Surgeon General's Office. This division was established in the summer of 1917, the tuberculosis section of that division entering upon its task on June 6, 1917.3

The first question to be decided was the manner in which the expert examinations should be made. The advice given by a committee of prominent members of the National Association for the Study and Prevention of Tuberculosisb in its report to the medical committee of the advisory board of the Council of National Defense, was that the experts should act as consultants, examining such cases as the medical officers of the Army might refer to them.4 This method presupposed painstaking and efficient examinations by examiners competent to detect the cases suspicious of tuberculosis. It afforded no guaranty that persons with manifest tuberculosis would not be admitted into the Army as the result of hurried or otherwise imperfect examination. Under the circumstances, however, in which our Army was hastily collected, it was to be expected that cases of tuberculosis would be overlooked. To overcome this it was necessary that every man should be reexamined, and, moreover, the examining should be done promptly in order that the claim might not be made with success that such chronic lung affections as were discovered were the result of military service thus permitting the pensioning of the individuals concerned. Therefore, it was at once decided that the examiners should pass upon the lungs of every man who had been admitted to the military service, notwithstanding the staggering magnitude of the total of examinations for which this decision called.

aUnless otherwise stated, all figures for the World War period are derived from sick and wounded reports sent to the Surgeon General.-Ed.
bThe members of this committee were Dr. Herman Biggs, Dr. G. M. Kober, and Dr. Charles J. Hatfield.


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Medical officers of the Regular Army who were qualified for this work were already engaged with even more important duties, chiefly of an administrative character, and could not be spared; while the Medical Reserve officers already commissioned who were competent internists had been assigned to medical organizations from which they could not be withdrawn, as a rule, without impairment of the efficiency of these organizations. It was necessary, therefore, to resort to civilian physicians, and the plan was adopted of calling upon prominent experts in internal medicine in each of the largest medical centers to recommend candidates for this work.5

A difficulty was experienced at the outset because the duty of the examiner was to be in the United States, and most ambitious and active men desired service abroad. It was soon seen that the examiners must be chiefly recruited from the class who were physically unfit for the arduous field service. But with this class the difficulty at once arose that the men especially interested in tuberculosis work had themselves had the disease, a fact which under ordinary conditions would debar them from admission into the Army. It became necessary to waive this fact for duty in the United States solely in connection with tuberculosis work and to accept applicants otherwise fitted for the duty contemplated for them whose physical condition warranted service of this kind.6 This course met with objections on the part of the officer in charge of the personnel division, Surgeon General's Office, who apprehended that it would be advanced as a precedent by the numerous physicians who besought the War Department for commissions in spite of physical defects. These objections were met by the argument that the tuberculosis examiners being a special and limited class, to be used for a specific purpose, their cases were not analogous to those of men with disabilities who sought general service as medical officers and should therefore be capable of enduring hardship in the field. These various difficulties created an enormous correspondence. At one time it seemed as if the plan must fail because examiners in sufficient numbers were not to be found. However, slowly, much too slowly, a corps of examiners was commissioned and set at work, the effort being to reach first the newly appointed officers and the troops about to sail for Europe.

Examinations did not begin until July, 1917. By an unnumbered circular of the War Department, dated July 16, 1917, it was provided that the examiners for tuberculosis should be organized into boards.7 The size of the individual boards was governed by the size of the command examined, but no board was to consist of less than three examiners. From the examiners, disability boards were appointed in order that the necessary steps for discharge might be taken at once and without the need of referring the cases elsewhere and thus requiring a repetition of the examinations.

Decision as to the physical signs which should determine rejection on account of pulmonary tuberculosis depends naturally upon our conception of the nature of the tuberculous processes as they affect the lungs. If erroneous ideas lead to the unnecessary rejection of many thousands of men, such errors may have disastrous results in the conduct of military operations. The view was formerly held by all, and is still much too widely spread, that the population is divided as regards tuberculosis into a healthy majority and a tuberculous


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minority and that tuberculosis is infectious for adults, at least for those who are not already labeled tuberculous. It is even believed by some that active forms of tuberculous disease may be made worse by contact with other cases, if this leads to exposure to large amounts of tuberculous virus, or if the tubercle bacilli in these latter cases are of a more virulent type. The elimination of the tuberculous from the Army in this view would be urgently required for the protection of their healthy comrades.

What may be called the modern view is based upon the well-established fact that practically every civilized adult has come into contact with the tubercle bacillus and has thereby acquired what in a sense is a tuberculous infection. But in the large majority of the population this tuberculous infection remains latent throughout life and amounts to a vaccination against tuberculosis. And in those less successfully protected against tuberculosis the form of the disease which declares itself is chronic and often relatively benign, differing materially from the form of tuberculosis met in young children and others who have had no previous contact with the disease before acquiring an infection with massive dosage. An individual already infected with tuberculosis can be reinfected from without, if at all, only by large amounts of tuberculosis virus. If thus capable of exogenous infection he is likewise subject to endogenous reinfection, or will be unable to prevent the extention of already existing, but perhaps latent, tuberculous processes within his body. Exogenous infection in civilized man is not, therefore, of importance; nevertheless, on account chiefly of unprotected children, every care should be taken to destroy the poisons of tuberculosis.

Circular No. 20, Surgeon General's Office, was published on June 13, 1917, for the guidance of medical officers in connection with examinations for pulmonary tuberculosis, after having received the approval of eminent clinicians. This circular indicated the duties of medical officers, called attention to physical signs of the chest often erroneously considered as signs of disease, and defined the signs of tuberculosis which should lead to rejection, including within its scope the interpretation of X-ray findings. Because of its comprehensive character it is quoted here in full:

CIRCULAR No. 20. 

WAR DEPARTMENT,
OFFICE OF THE SURGEON GENERAL,
Washington, June 13, 1917.

The following is published for the information of medical officers for use in connection with examinations for pulmonary tuberculosis in the military service.

The duties of the examiner are:

1. To exclude cases of manifest tuberculosis from the Army.

2. To hold to service men who allege tuberculosis as a ground for exemption or discharge on the basis of insufficient or incorrectly interpreted signs and symptoms.

3. To determine in the case of soldiers accepted for the military service the existence of pulmonary tuberculosis, and to decide whether or not the disease has been incurred in the line of duty.

Men who desire to serve their country may conceal, from patriotic motives, symptoms of tuberculosis which they know or suspect to exist. Some tuberculous patients will seek enlistment with a view to obtaining treatment and a pension. Some soldiers who have volunteered may repent their action and allege symptoms of tuberculosis with a view to securing discharge. Some conscripts may be expected to claim the existence of tuberculosis


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as a ground for exemption, and may fortify their claims by certificates of physicians and by radiographs. There will probably be many cases in which pulmonary tuberculosis will have been diagnosticated on the ground of subjective symptoms and of physical signs which are normal or indicate unimportant and healed lesions of some kind.

It is necessary therefore that conclusions of the examiner shall be based only on physical signs, sputum examinations, and radiographs. Statements of the subject as to symptoms will not be accepted as proof of the existence of tuberculosis unless supported by objective evidence.

It is the duty of examiners to protect the interests of the Government by preventing men from entering the service who have manifest tuberculosis. It is equally their duty to prevent the escape from service on the ground of tuberculosis of men who present slight or doubtful deviations from the normal. It is therefore necessary to insist that recommendations for discharge for tuberculosis of otherwise apparently healthy and vigorous men shall be based only upon the presence of definite and plainly marked signs of pulmonary lesions.

The following signs will not be regarded as evidence of pulmonary disease in the absence of other signs in the same portion of the lungs:

1. Slightly harsh breathing, slightly prolonged expiration over the right apex above the clavicle anteriorly and to the third dorsal vertebra posteriorly. The same signs at the extreme apex left side.

2. Same signs second interspace right anteriorly near sternum (proximity of right main bronchus).

3. Increased vocal resonance, slightly harsh breathing immediately below center of left clavicle.

4. Fine crepitations over sternum are heard when stethoscope touches the edge of that bone.

5. Clicks heard during strong respiration or after cough in the vicinity of the sternocostal articulations.

6. The so-called atelectatic râles heard at the apex during the first inspiration which follows a deeper breath than usual or a cough.

7. Sounds resembling râles at base of lung (marginal sounds), especially marked in right axilla, limited to inspiration.

8. Similar sounds heard at apex of heart on cough (lingula).

9. Slightly prolonged expiration at left base posteriorly.

10. Very slight harshness of respiratory sounds with prolonged expiration in the lower paravertebral regions of both lungs posteriorly, most marked at about angle of scapula, disappearing a short distance above that point, equal on both sides, or slightly more marked at the angle on one side, more frequently the left.

THE APICES

Incipient tuberculosis of the apex is often erroneously diagnosticated:

1. On account of misinterpretation of normal signs.

2. Because the importance of minor differences between the two sides is exaggerated.

3. Because signs of a healed lesion are considered to indicate an incipient lesion.

For No. 1, see No. 1, page 2.

With regard to No. 2, it is not too much to say that, given a sufficiently minute examination, there would be few men who would fail to show some signs which might be interpreted as having pathological significance.

No. 3. The truly incipient tuberculosis of the apex generally escapes detection when in an active state. When healed it constitutes the abortive tuberculosis of Bard. Induration of the apex has been described by Krönig as a nontuberculous affection. The important question here is whether the signs present indicate a healed or active process. They are harshness of respiratory sounds, prolongation of expiration, increased conduction of voice, and more or less dullness on percussion. These signs are caused by induration of pulmonary tissue. Induration caused by acute inflammation is relatively rare in tuberculosis. It is not characteristic of a recent but of an advanced process, when present to an extent which permits detection by clinical methods. When it does occur, the subject is usually febrile


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and evidently ill. In cases of ambulant subjects in apparently good health the presumption is that the above signs indicate an old, not an incipient lesion. The abortive tuberculosis of Bard and Krönig's apical induration, whether or not it is due to an obsolete tuberculosis, are not causes for rejection in the absence of tuberculous disease at a lower level in the upper lobe. Narrowing of Krönig's isthmus is extremely common. It is not a sign of recent disease but of contraction of the lung from old disease. In consideration of the frequent asymmetry of the bony structures about the apices slight differences in the width of the isthmus on the two sides are unimportant. A distinct contraction of one side points to the existence of a tuberculous focus of the upper lobe; whether or not this focus is of clinical importance must be determined from the signs in the individual case. Contraction of the isthmus per se is not a cause for rejection. The attention of examiners is particularly invited to the necessity of exercising great conservatism in their interpretation of physical signs over the apices. Interpretation of such signs as indicating active tuberculosis would in many cases do the Government great injustice, leading to the exclusion of men who are fit for service. The only trustworthy sign of activity of apical tuberculosis is the presence of persistent moist râles.

DIAGNOSIS OF TUBERCULOUS LESIONS IN GENERAL

THE ACUTE LESION

If small lesion is manifested by râles with or without changes in breath sounds, percussion note, and voice transmission. The more acute the lesion the greater the probability that its presence will be indicated only by râles. If of large extent the process is distinctly a broncho-pneumonia, generally caseous, characterized at first by the usual signs of pneumonia, crepitant, and subcrepitant râles; when caseated by absence of râles, except coarse and distant râles from the larger bronchi, also by impairment of expansibility of the lung, and more or less dullness or tympanitic resonance; when breaking down by cavity signs and the presence of loud moist râles of varying size. Large acute lesions are rarely found in candidates for enlistment and the small acute lesion is also comparatively rare. Tuberculosis as it presents itself to the Army examiner is usually of a chronic type.

THE ARRESTED CHRONIC LESION

It is by no means rarely the case that a tuberculous lesion will run its course and become arrested without the knowledge of the subject, who may state in perfectly good faith that he has never had tuberculosis. The arrest of a lesion is indicated by the absence of râles. Such a lesion is characterized by harshness of breath sounds and prolongation of expiration, by increased vocal fremitus and resonance and by more or less pronounced dullness on percussion.

THE ACTIVE CHRONIC LOCALIZED LESION

Activity is denoted by the presence of râles, together with the other signs described under the arrested lesion. Râles do not necessarily show that the lesion is extending nor that the activity is of much clinical importance, but in military practice the presence of râles accompanied by breath changes and other signs should be an indication for rejection. The more active and recent the chronic lesion the less marked the breath changes and the more conspicuous the râles.

DISSEMINATED TUBERCULOSIS

True miliary tuberculosis is not likely to come to the attention of the military examiner. The peribronchial type is common and frequently not recognized. In the adolescent the peribronchial tuberculosis may be extending from the deep lung without as yet developing a superficial focus. It may be manifested only by the presence of distant râles with or without slight changes in the breath sounds which are of a slight bronchovesicular quality. If the case is well marked there will be impairment of expansibility of the affected side and increased vocal resonance. Less pronounced cases are distinguished from chronic bronchitis only by the character of the râles (coarser in bronchitis) and by their topical distribution.


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More frequently the peribronchial type is found accompanying a superficial focus. Bronchovesicular breathing may extend some distance below the limits of the superficial focus with or without râles. But the most important manifestation of the peribronchial type is extension to the formerly sound side. There may be a small, obscure, apparently arrested lesion of one side, usually the right, with a peribronchial extension involving the whole or the greater pant of the other lung manifested only by the presence of râles after expiration and cough.

A definitely demonstrated tuberculous lesion of more than insignificant size below the apex is cause for rejection whether such lesion be active or inactive. But men whose qualifications make their service of especial value to the Government should not be rejected without previous report of their cases to higher authority if the lesion found is not very large and is entirely quiescent. In case of the acceptance of a man with tuberculosis a careful record of the case should be made for the protection of the Government. Such cases should be frequently reexamined.

In ambulant afebrile subjects harshness of breath sounds and prolongation of expiration characterize the old and relatively dry lesion, while the more acute the process the less marked are the breath changes and the greater are the conspicuousness and significance of râles. No examination for tuberculosis is complete without auscultation following a cough.

THE METHOD OF "EXPIRATION AND COUGH"

It is best executed as follows: Starting from the state of rest of the lung the subject forcibly expels the air from the lungs, reserving the last portion of the expiration for a short cough, after which inspiration immediately follows, but only enough air is inhaled to return the lung to the state of rest. The idea is to diminish the size of the bronchi as much as may be by expiration, then to cough to stir up forcibly such fluid as may be present in them. The moisture is more likely to be moved by the current of air and so produce râles when the tubes are of their least caliber. This procedure should invariably be employed in examinations in order to determine the activity of lesions found by other signs and also to detect the existence of fresh disseminated tuberculosis.

EXAMINATION OF SPUTUM

The presence of tubercle bacilli in the sputum is a cause for rejection. Examiners should, however, take pains to convince themselves that the sputum examined came from the lungs of the person under examination. To this end they should insist that the sputum be coughed up in their presence or in that of the pathologist who makes the microscopical examination.

TUBERCULIN

It is well recognized that a positive reaction to tuberculin, especially in the young adult, is not a proof of the presence of active clinically important tuberculosis. Tuberculin only demonstrates activity of the tuberculous process in the clinical sense when it can be shown to produce a focal reaction. Such reaction is not without danger. Since, therefore, tuberculin rarely leads to a correct diagnosis and may do injury, its general use in the diagnosis of tuberculosis in examinations for enlistment is prohibited

X RAY

Only well-marked pathological changes are revealed by radioscopy. For the accurate diagnosis of tuberculosis recourse should always be had to the study of the X-ray negative. It is not of course practicable to use radiography extensively for the determination of tuberculosis during the examination of recruits. But the X ray will doubtless be often employed in doubtful or disputed cases, so that it is necessary to consider the rules which should obtain in reading the radiograph.

Morbid changes in the lungs are shown by shadows due to two substances: First, blood; second, fully organized connective tissue. Blood imprints a shadow on the negative only when present in abundance. The congestion of lobar pneumonia is typical. Bronchopneumonia of tuberculosis origin may also cast shadows, but only when the process is acute,


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the congestion great. Frequently the tuberculous process runs so chronic a course that the inflammatory reaction is insufficient to congest the lung enough to produce a shadow. The shadow of congestion is not sharply outlined; it melts away at its borders.

Connective tissue in the parenchyma of the lung away from the hilus is not normally present in sufficient quantity to retard appreciably the passage of the X rays except as it occurs in connection with and as a part of the various tubes, bronchi, blood vessels, and lymphatics. As a result of proliferative inflammation connective tissue develops as a fibrous thickening of these tubes, particularly the bronchi and the lymph vessels which casts a shadow deeper than normal; the older the process and the better organized the tissue, the denser the shadow and the sharper its outline. Tubercle, caseations as such, cast no shadows distinguishable from the other tissues of the parenchyma. It has been found that cubes, 1 c. c. in size, of caseous tubercle when embedded in a healthy lung are indistinguishable by the X ray. But if the caseations become calcified or are even impregnated abundantly with mineral salts they become opaque to the X ray. In general, and especially if one has to do with the shadows of tubes, it may be said that fuzziness of outline means acute vascular congestion, an active process. On the other hand, when the shadows of the tubes are sharp we have a process which, if active at all, is at least not characterized by great acuity, is not congestive. There is what is called dry tuberculosis of the lung tissue, which inclines to abundant formation of connective tissue, to dry caseations and cicatrizations or to complete transformation into fibrous tissue, characterized by sharply outlined granular spots and by more or less sharply marked bands and streaks. Special attention is called to the persistence of the sharply outlined dots and lines when activity of the tuberculous process no longer exists. The sharply outlined thickenings of the bronchi and other tubes may be evidence of an old inflammation now entirely obsolete, may be simply records of the ancient history of the pulmonary tuberculosis.

We do not see tubercles in the X-ray negatives. What we see is either sharply outlined calcifications and fibroses, or fuzzy congestions, or a combination of the two condtions. Cases are seen in which the X ray in general gives the same findings in both lungs while the autopsy proves one lung severely, the other slightly, diseased. Such cases illustrate well the limitations of X-ray diagnosis. What is seen in the X-ray negative is the thickened framework of old inflammation in the two lungs, in one accompanied by much parenchymatous disease of recent origin, in the other accompanied by little, the said parenchymatous disease being invisible to the X ray because neither sufficiently congested nor sufficiently organized to cast shadows.

Extensive systems of lines, many sharply outlined spots, dense streaks do not, then, show an acute process. Persons in good health with nearly or quite arrested tuberculosis are sometimes found by the X ray to present a picture of very extensive changes of this kind. Yet the prognosis in such cases is not good if the subjects be subjected to severe strain. The radiograph is a proof that the lungs have undergone serious changes. The danger is either that hardship will lead to a reactivation of the numerous more or less quiescent tuberculous lesions or, if the process has been largely of the nature of fibrosis, that the lungs have been so damaged thereby as to unfit the person for an active life. If then the radiograph shows extensive dappled or mossy shadows or numerous spots and streaks the recruit should be rejected however good his health may appear to be. Shadows of a homogeneous opacity result from pleurisy and are not necessarily a cause for rejection in the absence of other signs.

Tuberculosis of the bronchial glands is a diagnosis often made from the radiograph on very slight foundation. The fact is that pronounced swelling of the lymph glands is characteristic of primary, not of advanced tuberculosis. It is rare that intrathoracic gland tuberculosis is of any clinical importance in the adult. With few exceptions cases of bronchial gland tuberculosis which lead to true symptoms of disease are confined to the first and second years of life. Only rarely, especially in adults, is so-called hilus gland tuberculosis a purely glandular process; it is rather a more or less pronounced disease of the surrounding hilus tissue in the form of peribronchial and infiltrative processes of the neighboring pulmonary tissues. That is, the interscapular dullness relied upon for the diagnosis of enlarged glands, if caused by lung conditions, is due to tuberculous processes in the region of the hilus, partici-


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pation in which to any important extent on the part of the glands is a matter of conjecture. The presence of masses in the neighborhood of the hilus as shown by the X ray may indeed be cause for rejection, but rejection on account of relatively small opacities in that region on the ground that they indicate a bronchial gland tuberculosis of clinical importance certainly should not be permitted.

RÉSUMÉ OF INDICATIONS FROM X-RAY NEGATIVES

The X ray shows-1. Tuberculous disease confined to region of hilus in deep lung. 2. Extension upward toward apex or downward and outward toward base, confined to deep lung. 3. A fine line or two extending to apex with or without small focus or foci there-condition not determinable by physical signs. 4. Clouding of apex without marked lines from hilus, probably largely pleuritic. 5. Well-marked lines extending to superficies of apex usually, but not necessarily, with foci there-lesion accessible to physical examination. 6. Lines extending toward shoulder as well as apex. (a) If confined to deep lung may mean early and now obsolete exacerbation. (b) If extending to superficies denote larger lesion and less immunity than 5. 7. More or less widely diffused spots, lines, and streaks through a considerable portion of lower lobe approaching periphery of lung, with few or no auscultatory signs-deep peribronchial tuberculosis. 8. More extensive streaked opacities involving greater part of one or both lungs and extending to periphery with few or many physical signs-fibrocaseous tuberculosis, fibrosis preponderating in proportion to scantiness of more or less rounded spots or dots.

Conditions as shown by 1, 2, 3, 4, and 6 (a) are not causes for rejection. Cases under 5 are to be determined by physical examination. Cases under 6 (b), 7, and 8 are to be rejected.

W. C. GORGAS,
Surgeon General United States Army.

Approved, by order of the Secretary of War, June 16, 1917. (2621428, A. G. O.)

The boards first at work were constituted by the specialists of Colorado, who had been prompt in their response, and were engaged in the examination of troops of the Regular Army at that time stationed in the Rocky Mountain region. While these examinations were proceeding in the West, in the East men at the officers' training camps were first examined. Of 53,905 examined, tuberculosis was discovered in 195, or 0.362 per cent. In the aviation service 38,835 men furnished 62 cases of pulmonary tuberculosis, or 0.159 per cent. Combining these figures we have a total of 92,740, with 257 rejections; a percentage of 0.277.8 Both of these groups consisted, in a sense, of picked men, many of them athletes. The scanty result obtained, which scarcely justified the reexaminations, shows that a sufficiently rigid selection of promising material in itself practically excludes tuberculosis.

In the Regular Army in the field 190,396 men were examined, with the rejection of 1,444 cases of tuberculosis, or 0.758 per cent. Examination of 40,396 men of the Coast Artillery Corps discovered 297 cases of tuberculosis, or 0.735 per cent.9

The National Guard was mustered in on August 5, 1917.9 Since not all of the camps, which were in preparation for them, were ready for use in September, many of the National Guard organizations were left at home for several weeks subject to call at their armories.10 On account of the scarcity of commissioned tuberculosis examiners, the expedient was adopted of employing temporarily, as examiners, physicians from the vicinity of the regimental headquarters, who were given contracts to examine some of these organizations in their armories. Reports show a total of 446,517 men of the National Guard


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examined, of whom 1.099 per cent were found to be tuberculous. Of these examinations, 69,273 men were examined at armories; the remainder after arrival at camp.11

In September, 1917, the entrainment of the men of the first call for the first draft was made, other calls succeeding one another rapidly through the remainder of the year. Boards of examiners could not be organized in number sufficient to effect the primary examination in the first draft, but the troops of the National Army were reexamined by special examiners, chiefly in the early part of 1918.12 The reports show that 361,314 men were reexamined, with the detection of 2,435 cases of tuberculosis, or 0.673 per cent. Discharges for pulmonary tuberculosis on certificates of disability, from the entire Army during the war, chiefly as the result of reexaminations by special boards, numbered in all, 11,362. According to the report of the Surgeon General for 1918, up to March, 1918, 1,200,990 men had been reexamined and 9,648 had been recommended for discharge for pulmonary tuberculosis, a percentage of 0.803.12

At the time of the second draft, orders were given by the Surgeon General that there should be but one examination of drafted men after their arrival at camp, except in doubtful or deferred cases, the necessary specialists functioning in the primary military examination instead of going over the command at a later time as boards of revision.13 All of the procedures necessary for the admission of an individual, comprising the physical examination, the administration of vaccines, and the entries upon the prescribed blank forms, were to be completed in a single day.

This change, so far at least as the physical examination was concerned, was a long step in advance, the examiners by this time having become thoroughly familiar with their duties. A difficulty at once arose, however, from the speed required in the examinations. Circular No. 20 prescribed that each examiner should examine at least 50 men per day. This number, regarded as excessive by many at first, was frequently doubled by the more alert after they had gained experience. The usual size of the board of tuberculosis for the larger camps was 10 members. If such a board examined 1,000 men per day, that was certainly all that could be required of it. Yet in some instances the orders of the War Department or of the camp commander contemplated much greater speed. Representations were made by the Surgeon General to the effect that haste necessarily resulted in insufficient examinations and that, in view of the fact that only one examination was required, it was of the highest importance that that examination should be thorough. This resulted in some improvement in the conditions, but in general the work that was required remained excessive. In some instances the boards worked all day and far into the night, or again worked all night instead of all day in order to complete their tasks within the time prescribed.11 The number of examinations made at times seems almost incredible. Thus, 1 team of 3 examiners examined 1,763, 1,854, and 1,944 men in 3 successive days. Rapid work of this kind was made possible only by the assistance of enlisted men of the Medical Department, who instructed the recruits in advance of their appearance before the examiners how to stand, how to breathe, and how to cough. The attention of the examiners was directed solely to the auscultation of the lungs for the presence of râles after expiration and


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cough, cases which showed moist sounds being referred for more careful examination. That an objective condition was revealed with remarkable regularity by this method is shown by the fact that when the number of men examined was large the cases rejected always amounted to between 0.5 and 0.6 per cent of the men examined.11

As stated above, with the increment of the draft called on March 26, 1918, primary examinations were first undertaken by the tuberculosis examiners. The total number of men rejected for pulmonary tuberculosis on primary examination in the second draft was 12,629 out of 2,040,051 examinations, or 6,174 per million. The grand total of examinations, including both reexaminations and primary examinations of recently recruited soldiers and of incoming drafted men, by special tuberculosis examiners was 3,288,669, the total number of men rejected by these boards being 22,596 or 6,871 per million.11

In addition, the boards discovered 1,461 cases of pulmonary tuberculosis which were held to limited or special service in this country, 108 cases of suspected tuberculosis, and 613 cases of tuberculosis in organs other than the lungs. The total number of cases discovered by special examiners amounts to 26,173.

From November, 1918, the examining boards were chiefly engaged in examinations previous to demobilization, 2,500,662 men having been examined up to June 30, 1919, of whom 1,356 were found to be tuberculous, or 542 per million.11 This gratifyingly small ratio of tuberculosis cases undoubtedly would have been still further reduced if all of the men demobilized had been submitted to earlier thorough examination for tuberculosis. Records are available from Camp Lewis, Wash., from which it appears that 63,575 men were examined there for demobilization.14 Of these, 8,500 who had not previously been examined by any board yielded 57 cases of tuberculosis, or 0.67 per cent; i. e., 6,700 per million; while among 55,075 men who had been examined at Camp Lewis, but 9 cases of tuberculosis were discovered: A percentage of 0.016, or 163 per million. It was pointed out further that at United States General Hospital No. 21, which received the tuberculous patients from organizations belonging to the Pacific coast and the neighboring inland Northwestern States, there were 183 cases of pulmonary tuberculosis from the region referred to, of which 170 were not mustered at Camp Lewis.14 Nine came from Camp Lewis but were not examined there, since they belonged to a group of 3,626 men of the first draft who were sent away before they could be examined. Four had been examined one of whom had been recommended by the board for discharge, but not discharged, leaving but 3 out of 13 cases for which responsibility could be fairly attached to the Camp Lewis board. Cases of pulmonary tuberculosis from the above mentioned States would naturally, in great part, be sent to United States General Hospital No. 21. Such data go far to prove that, given a sufficiently thorough and efficient examination, tuberculosis could be practically eliminated from an army. The cases that break down under the stress of military service are largely those entering with lesions capable of detection by experts.14

Over 600 physicians acted as tuberculosis examiners, but the number of examiners available was never sufficient for the needs of the service; so, as a rule, it was necessary to confine their activities to the larger camps, with special


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reference to the examination of troops who were to go abroad. Unfortunately, the work of reexamination could not be organized in time to examine many of the troops who were sent overseas early. More than 40,000 soldiers were sent abroad, therefore, in the early months of the war of whom few could have been reexamined for tuberculosis.11 Some organizations likewise were embarked for Europe at a later time which escaped reexamination, as, for example, many of the hastily assembled stevedore regiments, the difficulty being partly due to the failure to learn in time of the existence or of the contemplated departure of the organizations, military operations and especially embarkations being shrouded in the utmost secrecy, and partly to the scarcity of examiners.11

How necessary reexamination of the colored enlisted men composing the stevedore regiments was, is shown by the fact that a special board at Newport News, Va., examined 8,734 men of colored stevedore regiments and reported 68 cases of tuberculosis, or 0.812 per cent.11

In addition to the work of examination of organizations, tuberculosis experts were detailed as specialists of divisions and of base and general hospitals, as officers of tuberculosis hospitals, and as instructors.

When the need of examiners was greatest, physicians were employed temporarily as contract surgeons in order to assist in the examinations. As the qualifications of these contract surgeons were not always known, it was soon found advisable to give them a course in physical diagnosis of the chest, the primary object being to observe their work and to classify them according to their proficiency. This course, however, met with unexpected success and became popular among the medical officers. Its benefits were so manifest that from the original school, at the Army Medical School, Washington, instructors were sent out who established like courses of instruction at the medical officers training camps at Fort Oglethorpe, Ga.; Fort Riley, Kans.; and Fort Benjamin Harrison, Ind.15 A school was instituted at a later time at General Hospital No. 16, New Haven, Conn., in which, in addition to courses in physical diagnosis, instruction was imparted in the treatment of tuberculosis and in hospital administration, with a view of training medical officers for service at tuberculosis hospitals. Courses in physical diagnosis also were given to the medical officers of various camps and hospitals by travelling instructors.16 Especial attention was paid in this course to the physical signs of the normal chest.

At the beginning of their work the chief function of the special examiners was necessarily eliminative; they were to rid the Army of the tuberculous. But they also appreciated the fact that quite as important a duty was conservation. Of their own initiative many of the boards stamped the records of the soldier "Examined and passed by the tuberculosis board," with a view of preventing the later discharge of individuals presenting signs which the inexperienced might misinterpret.

The inexperienced diagnostician finding signs which may be those of tuberculous disease usually recommends discharge, giving himself the benefit of the doubt, in the fear that he will be thought to have overlooked what should have been found if at a later time the bearer of the signs in question should be diagnosticated as tuberculous. The specialist should strive to retain in the service men in whom he thinks tuberculosis is not active notwithstanding the


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presence of signs or symptoms which some might misinterpret. The conservation to the service of men with blemishes which do not disqualify is one of the most important of his functions. His duty is not only to secure the rights of the individual; it is fully as much his duty to protect the Government, which should not unnecessarily be deprived of soldiers when every man is needed. He who in time of war excuses men for trifling or doubtful deviation from the normal does not properly conceive his duty toward his country. There is no reason why the possibly tuberculous alone should be excluded from risks.

This view was emphasized in Circular No. 20 and was enforced as far as practicable. But it remained one of the chief difficulties that medical officers were reluctant to take a definite stand with regard to many cases, that in some camps, wards were filled with apparently healthy men kept under observation whose supposed deviations from the normal had been discovered only in routine examinations, as if the desideratum was to make a positive diagnosis of tuberculosis at all costs. The chief reason for this course was the fact that some one had diagnosticated active tuberculosis in these cases. It was undoubtedly of great benefit that a standard had been provided in Circular No. 20, upon which the examiner could rely and which relieved him of some of the burden of his responsibilities in the diagnosis of disputed cases. A standard, though imperfect, is believed to be an indispensable adjunct in Army tuberculosis work not only to support the examiner but also to secure the necessary uniformity of practice in the matter of discharge for tuberculosis.

OCCURRENCE

IN CAMPS IN THE UNITED STATES

When considered by camps of occurrence, during the World War, two camps only are found to be outstanding in this respect, namely, Camps Kearny, and MacArthur. Camp Kearny (situated near San Diego, Calif.) had the worst record for tuberculosis of all the large Army camps.17 In the reexamination of 19,827 men at this camp, 853 cases of tuberculosis were discovered, or 4.83 per cent. The admissions for tuberculosis at Camp Kearny in September, October, November, and December, 1917, were at the rate of 157.53 per 1,000 of strength, Camp MacArthur, Tex., the second worst camp in this respect, having the comparatively small ratio of 25.45. Camp Kearny was primarily a National Guard camp. It received 6,944 men of the National Guard from Arizona, New Mexico, Colorado, Utah, and California in September and October, 1917, and 13,680 men from other camps in November, largely drafted men. During 1918, also, additions were received largely from other camps.18

Matson's remark with reference to Camp Lewis14 that the material was largely from the Southwest and contained enormous numbers of health seekers whom the boards of the first draft sent, thinking that change of climate might benefit the manifestly tuberculous, undoubtedly applies with even greater force to the command at Camp Kearny.

The operation of this tendency above referred to is still more clearly exemplified at Fort MacArthur, Calif. Here in 501 men examined for tuberculosis, 103 cases were found, a rate of 20.55 per cent.11 On investigation it was found that the large majority of these men were drafted from Texas, 53 towns in that


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CHART XXV


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State having contributed 92 of the tuberculous cases. In any case, of course, it by no means fairly represented the drafted men of the State. Indeed, there was collected in the five howitzer companies at Fort MacArthur what in all probability constituted the majority of the tuberculous cases of the part of Texas from which the men originally came. There could hardly be more startling proof of the inefficacy of the usual routine examinations and the need of revision. The evils of the absence of an efficient medical examination previous to the transfer over long distances of large bodies of troops is also apparent enough.

New Mexico had the undesirable preeminence of furnishing the greatest number of tuberculous men per 1,000 of native population of any of the States of the Union.18 Yet there are regions in New Mexico where the climate is probably best adapted of any in the United States for the treatment of pulmonary tuberculosis, its reputation for the climatic treatment of the disease being shown by the fact that the only sanatoria which were operated by the Army and by the United States Public Health Service before the war for the treatment of the tuberculous were located with in its borders. Like the other border States of the Southwest, New Mexico is overrun by consumptives from other States, many of whom were imported originally as patients in the Army and Public Health Service sanatoria, though many others came in as civilians. This latter class contains, as a rule, cases of pulmonary tuberculosis of more than average severity, many patients who fail to improve in the North being sent to the Southwest as a place of last resort. Moreover the popularity of the Southwest as a resort for the treatment of consumption is of comparatively recent origin. Consumptives have visited the region from the first days of its occupation by the whites, but not in considerable numbers until within recent years. It is improbable, therefore, that a sufficient number of sons of military age have been born to the immigrating consumptives to affect materially the ratios of tuberculous cases to native population. But the numerous patients discharged from the Government sanatoria would naturally more readily find openings in civil life in a part of the country with which they have become familiar, and the climatic advantages of New Mexico would be expected to induce tuberculous civilians in general to make it their home in a larger percentage than would be the case in the hotter climate of Arizona and Texas. Such men, many of them familiar with Army life and fond of adventure, many of them, too, perhaps alive to the prospects of future benevolence of the Government to tuberculous soldiers, would naturally seek enlistment in the Army and would conceal as far as possible the suspicious fact that they were originally from other States.

Another factor which should be considered is the Mexican element of the native population of the State, which composed 15 per cent of the population of the southern tier of counties in the census of 1910, since which time many thousands of Mexicans, fleeing the civil war in Mexico, have immigrated to New Mexico and to the adjacent portions of Texas and Arizona.

Physicians connected with the Atchison, Topeka & Santa Fe Railway medical service have noted that when Mexicans from remote districts are employed as laborers along the railroad a certain proportion of them suffer from acute forms of tuberculosis.19 Here, according to well-known epidemiological


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laws, we have an illustration of what befalls individuals not all of whom have received the more efficient immunization against tuberculosis afforded by life in a civilized community; the men fall sick from tuberculosis not because the environment from which they come has too much but because it has in a sense too little tuberculous infection! In other words, the tuberculosis is acute because it attacks the nonimmunized or imperfectly immunized individual.

About one-third of the population of the northwestern quarter of New Mexico is stated to be composed of Indians, and there are large reservations elsewhere in the State. The various tribes differ widely as to the prevalence of tuberculosis. No recent statistics of value are available, but it was reported some years ago with regard to the Zuni Indians that tuberculosis was rare among them, but that the mortality of the disease was 100 per cent.20 Such a group would figure more largely in the statistics of mortality from tuberculosis than in the percentages of rejection upon admission to the military service; but the Indian as well as the Mexican element of the population is in general likely to become suspicious in the statistics which relate to tuberculosis. Unfortunately, the statistics as collected by the Provost Marshal General do not permit the determination of the race of the soldier. We are left to conjecture, therefore, as to the relative importance of the Indian and the Mexican in causing the high percentage of incidence of tuberculosis in New Mexico. The problem is highly complex, and it would be manifestly misleading to institute comparisons between a population like that of New Mexico, with its large percentage of health seekers and its admixtures of semicivilized races, and the more or less homogeneous American population of other portions of the United States.

IN THE AMERICAN EXPEDITIONARY FORCES

The care exercised in the United States in the elimination of tuberculosis from our Army was abundantly rewarded by the absence of any extensive prevalence of the disease among the troops in France. Cabot reported from Base Hospital No. 6 at Bordeaux that of 21,738 patients received at that hospital between September, 1917, and November 22, 1918, there were 63 positive cases of tuberculosis, pulmonary and extra-pulmonary-a percentage of 0.289.21 Of these, 51 were recognized by the presence of tubercle bacilli in the sputum and 12 were found post mortem. One hundred other cases were diagnosed as probably or possibly pulmonary tuberculosis, no other diagnosis seeming more likely, though bacilli were not found in the sputum. None of the 163 were apparently incipient cases. The incidence of tuberculosis was greatest in the early months, he says, when presumably the "combing out" of tuberculous cases by special examinations in the training camps of the United States had not begun, or was not extended to all units. Stevedores, labor companies, and engineers were especially affected. In the first 7,000 cases treated at Base Hospital No. 6 there were found 35 out of the 51 positive tuberculous cases, while in the last 6,000 cases received only 1 case was proven tuberculous. Cabot's conclusions are:21

(1) Pulmonary tuberculosis was of rare occurrence among the sick treated at Base Hospital No. 6. (2) It occurred chiefly among soldiers who had not been specially examined in the training camps of the United States with reference to its presence. (3) An even three-


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fifths of the 51 cases with tubercle bacilli in the sputa occurred in the cases between No. 1 and No. 7,000 of our series, while in the last 6,000 cases received only 1 case was proven tuberculous. (4) Few, if any, cases could have been considered as originating in line of duty. No incipient cases were recognized.

These observations by an experienced diagnostician located at a hospital at a port of embarkation through which many patients were evacuated to the United States and where, consequently, tuberculous cases must have abounded if the disease had been of frequent occurrence, are the more valuable because tuberculosis, not being a problem of magnitude in the American Army abroad, officers of hospitals, overwhelmed as they were at times by patients with wounds or acute infectious diseases, have remarked but rarely as to its prevalence. After tuberculous patients began to return to this country it was soon reported that a considerable percentage (sometimes as high as 50 per cent) had no clinically recognizable tuberculosis. It being important from a military standpoint that the Army abroad should not be drained of its men unnecessarily, a tuberculosis expert was sent to France with a view of securing a better diagnosis of tuberculous conditions. This visit culminated in an order being issued in the American Expeditionary Forces to the effect that only cases with tubercle bacilli in the sputum should receive the diagnosis "pulmonary tuberculosis," all other suspected cases to be classified as "tuberculosis observation."22 Three centers (Base Hospitals Nos. 20, 3, and 8) were designated to which cases under observation should be sent.22 No men were to be sent home as tuberculous unless their sputa contained tubercle bacilli or they had been passed as tuberculous at one of these centers. These measures rapidly reduced almost to zero the percentage of returning patients who were found to be negative for clinical pulmonary tuberculosis after observation in this country. But after the signing of the armistice, when retention of every possible man was no longer necessary, the above mentioned precautions were discontinued and large numbers of men who were simply suspected of having tuberculosis returned with a positive diagnosis of that disease. In all, 8,717 cases of pulmonary tuberculosis were received from Europe at the tuberculosis hospitals of the United States up to December 3, 1919.23 In a total number of admissions to these hospitals amounting to 18,713 the diagnosis of pulmonary tuberculosis was not confirmed in 4,305.23 What proportion of these negative cases came from Europe is not known.

EPIDEMIOLOGY

In the enrollment of millions of men in the United States and in the mobilization of the large European armies we have experiments on a grand scale in the epidemiology of tuberculosis which can not be too carefully studied. In our Army in France certain observations were made which led to the belief that our soldiers were in danger of primary infection with tuberculosis.24 Glomsett remarked at the Red Cross Conference on Tuberculosis held in November, 1918, at Paris25 that it was a pleasant surprise to learn that tuberculosis had played such an insignificant rôle, only 2.5 per cent of deaths having been due to this cause. Tuberculous lesions were found by him in 16.6 per cent of bodies of soldiers examined. He found "primary foci" in 50 per cent of his autopsies and stated that such foci were more common in the bodies of those


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who had died from other causes than in those who had died of tuberculosis, persumably meaning old foci. He found no evidence of tuberculosis in fully two-thirds of fibrous pleurisies. He had six autopsies of soldiers who had died of tuberculosis, four of which showed miliary tuberculosis. At the same conference Robertson25 reported that he had worked during the first year of the war in Freiberg, where of 100 autopsies of German soldiers 70 per cent showed tuberculous deposits in lungs or tracheobronchial glands, while in autopsies on our soldiers he was able to detect tuberculosis in less than 25 per cent.

Each pathologist, it appears, had his own standard, and the results of autopsy findings differed as widely as did the standards. The number of autopsies considered, moreover, is much too small to indicate the true status of soldiers as to tuberculosis. Caseation of lymph glands was referred to by some of the observers in support of their position without, however, giving a description of the exact condition of the glands. The behavior of the lymph glands in a given case is fundamental for the decision as to the nature of the tuberculosis that is present.

It may be remarked here that the pathology of lymphadenoma is admittedly dubious as to etiology and especially as relates to the rôle of the tubercle bacillus in the production of suppurative processes. The presence of local lesions in the vicinity of the glands, carious teeth, and the like is very significant. It would seem that a mixed infection, one infective agent which is active in the production of an unusual type of lymphadenitis being unidentified, would best explain the facts. Why should tuberculosis, if uncomplicated, pursue so unusual a course? At all events there seems to be no good reason why it should be necessary to assume continued new infections from without, and much that speaks against that hypothesis. The fact that notwithstanding the supposedly frequent reinfections the disease remained localized and the patient was in good health is the best evidence of the persistence of an immunization. A primary infection or an infection which sprang from a serious diminution, if not an entire loss, of a former immunization would tend to become generalized and fatal. This is well illustrated by the course of tuberculosis among the colonial troops of the French Army, as reported by Borrel.26 This command, the average strength of which was 50,000 men in 1917-18, was composed of negroes from Madagascar and Senegal, of Annamites, and of Kanakas. The Malgaches or Madagascans had tuberculosis of a chronic type-tuberculosis is not a rare disease in Madagascar. The Annamites, among whom the disease has long prevailed, had but a small percentage of tuberculous cases. Tuberculosis was found in about 10 per cent of the Kanakas; the disease had a duration of months and often of years. Enlargement of the cervical glands of a scrofulous type and of a chronic course, which was apparently often not incompatible with good health, was common among them. But the Senegalese were the most severely affected with tuberculosis. This is a rare disease in Senegal outside of the towns where there is contact with Europeans.

Borrel found only 4 to 5 per cent of positive reactions to the skin test among newly arrived recruits, but unfortunately used tuberculin diluted to one-tenth strength. Apical tuberculosis was found in not more than 5 per cent of the


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Senegalese. Those who had the chronic type of tuberculosis came from the towns. They spoke French. While in the command considered as a whole 50 per cent of the cases of tuberculosis were of the chronic European type, among the Senegalese who came from country districts the type of tuberculosis was that of the European infant; that is, it was primary tuberculosis. In these patients there was generally a chain of enlarged lymph glands extending from the supraclavicular or the superior cervical glands to the hilus, the largest ones of about the size of a hen's egg, having a location corresponding to that of the primary lesion-which might be situated upon the tonsil, in the posterior pharynx, the larynx, or at the level of the main bronchi; but in 80 per cent of the autopsies the disease began in the tracheobronchial glands. More than 70 per cent of the deaths from tuberculosis among them were due to miliary tuberculosis in which the lungs were not more involved than the other organs. There was sometimes a massive caseous pneumonia from direct rupture of an enlarged gland into bronchi and alveoli, the gland then often becoming the center of a great caseous mass. Or there might be primary pleurisies without caseous foci in the lungs, or more than one serous membrane might be involved simultaneously, the peritoneum as well as the pleura. Clinically after what Borrel calls the initial glandular period, lasting one to three months, in which there is no fever, the period of generalization comes on with high and irregular fever and death in from 15 days to 1 month; rarely 2 months.

Roubier's account of this disease confirms that of Borrel. He called attention to the constant presence in miliary tuberculosis of caseous mediastinal glands, sometimes so voluminous as to give rise to symptoms of compression.27

The important contribution of Borrel gives in epitome the entire pathology of tuberculosis. We see chronic localized pulmonary tuberculosis in soldiers who had been long exposed to infection, the scrofulous type, still chronic, with chronically caseated lymph glands in the imperfectly immunized Kanaka, but in the virgin soil of the Senegalese acute and enormous enlargement of glands, rapid generalization of tuberculosis, and death. It has been known from animal experiment that if the infected animal survives the primary inoculation with tuberculosis the glands acquire a certain immunization, such that they do not swell materially or at least long remain swollen in subsequent inoculations, irrespective of the fact that the animal may in reality be slowly dying as the result of the first inoculation. The same is true of man except so far as the picture is confused by the chronic caseations and suppurations of the scrofulous type. If, then, there be not found a primary lesion with enlargement of the corresponding gland, as Borrel described it, the case is not one of primary tuberculosis. Immunity is generally completely lost in the last stage of fatal human tuberculosis; miliary disseminations of tubercle shortly before death, throughout the internal organs, whether macroscopic in size or only to be determined by the microscope, are well-nigh the rule in uncomplicated cases. The glands do not swell in this secondary miliary tuberculosis, but they may be found, of course, chronically enlarged and caseated in the scrofulous type.

Evidence of chronic tuberculous changes is found in some cases of pulmonary tuberculosis with acutely fatal termination. That they are not found in all such cases which occur in civilized man is largely accounted for by the


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difficulties of the search. Even Nägeli in his classical investigations which finally resulted in finding tuberculous changes present in 97 to 98 per cent of autopsies, at the beginning found only 40 per cent.28 Opie29 showed the surprisingly large number of calcifications to be detected in the lungs by his method of radiography, most of which would have escaped detection by the ordinary methods of search. Since civilized adults are shown by tuberculin tests to be infected with tuberculosis in almost 100 per cent, it is more logical to assume that the few whose evidence of past infection is not discovered have really been infected than that they should have escaped entirely the ubiquitous tubercle bacillus. Acuity of course and of termination of tuberculous disease is encountered in many cases in which earlier infection with tuberculosis is demonstrable. They should not, therefore, be considered to indicate a primary infection though earlier tuberculous changes may not be detected, certainly not unless the case presents the characteristics of truly primary tuberculosis.

The experience of the British Army in France with Africans was somewhat similar. Thus Cummins30 stated that there were 165 deaths among British troops in 2,881 cases, which gives a case mortality of 5.7 per cent, while in the South African labor corps units consisting of "Cape boys" and Kaffirs there were 183 deaths in 372 cases of tuberculosis, a case mortality of 56 per cent. According to the same writer, the Indian divisions in France in 1916 had a tuberculosis incidence of 27.4 per 1,000, that of the British troops being 1.1 per 1,000. In comparing the mortality rates from tuberculosis, allowance must he made for the probability that in the British Army all but the most acute cases would be repatriated and that deaths which occurred after discharge, and perhaps after the individual had been returned to Great Britain though still in the service, would not appear in the mortality statistics in France, while the tuberculous negro would probably not be sent to his home. The relatively high death rate of the Africans, however, shows clearly enough that the negroes of South Africa are but imperfectly immunized against tuberculosis. The result of such imperfect tuberculization in these troops, including the Indian contingent, was a higher relative mortality from tuberculosis, though they had the same food, clothing and shelter as the white troops. If the American troops had been imperfectly tuberculized, instead of a surprisingly low death rate from tuberculosis, the mortality would have been high. The acute forms of fatal tuberculosis among our soldiers were, then, really quite exceptional. To account for such exceptions on the hypothesis of entire absence of previous opportunity is much more difficult in the case of men who do not appear to have been a peculiar class as respects their origin, mode of life, etc., than by the more natural supposition that they differed from other tuberculosis cases only in the fact that the course of their disease was more rapid; perhaps, as some German writers suggest, the fatigues and hardships of war had something to do with this outcome.

From the epidemiological standpoint the cutaneous tuberculin test is a valuable and harmless method of obtaining an approximate notion as to the degree of tuberculization of a group of individuals. It was employed for this purpose in our Army in two instances. At Coblenz 159 American soldiers between the ages of 18 and 30 years, with no family history of tuberculosis and


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for the most part men of athletic build, were tested with undiluted "old" tuberculin.31 Of these, 122 (76.7 per cent) reacted positively to the first inoculation, 26 to the second (giving a percentage of 93 positive in either the first or second test), and 3 to a third inoculation; which results in a total positive percentage of 94.9, 8 of the soldiers remaining negative. The distinction was made in this group between country dwellers, city dwellers, and (small) town dwellers, but such slight difference as existed between these subgroups showed that the men from the country were infected with tuberculosis in a very slightly larger percentage than the men who came from towns and cities, the positive percentage in the first, second and third tests combined being 96.9, 90, and 96.2, respectively, for the subgroups in the order given above. Unfortunately, the regiment to which these men belonged, being on the eve of return to this country, it was impracticable to test further those who had failed to react.31 A similar test was made at General Hospital No. 21, Denver, Colo.32 One hundred soldiers between 21 and 30 years of age belonging to the Medical Department detachment of the hospital, but employed in outdoor occupations which did not bring them into contact with the patients (this institution being a hospital for the treatment of tuberculosis), were tested in the same way as in the preceding experiment. In the first cutaneous test 71 were positive, 29 negative. The negative cases received a second inoculation after five days, 24 becoming positive and 5 remaining negative. This gives a positive percentage of 95 for the two inoculations. One of the 5 negative cases was discharged at this time; the remaining 4 were further tested by subcutaneous injections of old tuberculin. All were negative to 1 mg. and likewise failed to react to 5 mg. To the injection of 10 mg. 3 reacted positively. A fourth injection of 20 mg. was given to the man who remained negative. Though there was no rise of temperature after the injection, it was considered to have resulted positively on account of the "depot" reaction. Thus by following up the cases negative to the skin test with the subcutaneous injection, 100 per cent of positive reactions to tuberculin was obtained in 99 men.32 The above observations correspond closely with the results obtained by Freund,33 95.1 per cent of Austrian soldiers positive for the cutaneous test, and to those reported by Hamburger, 98 per cent of Austrian soldiers positive to the "stitch" reaction.34 The importance of recording such tests as those described lies in the light which they throw upon the claim that our soldiers are to a considerable extent unprotected by a precedent tuberculization against primary infection with acute and fatal forms of tuberculosis.32

DIAGNOSIS

In the view of many who belong to what we will call the school of ultra-refined diagnosis, pulmonary tuberculosis begins in the apex of the adult lung, as a rule. Incipient tuberculosis of the apex can be recognized at a very early stage, before the occurrence of râles, by slight changes in breath sounds and percussion note, even by certain symptoms before physical signs are present.

Others hold that tuberculosis of the lungs begins at the hilus, usually in childhood, and in favorable cases advances at first as a tuberculous lymphangitis along the blood vessels and bronchi. Tuberculosis of the apex is not incipient but advanced tuberculosis. The signs relied upon for the diagnosis of incipient


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tuberculosis are not evidences of a new infection, but, so far as they are not normal for the part, are signs of old, perhaps obsolete, affections of the apex which are exceedingly common, and, unless they extend widely beyond the apex or have resulted in cavity, do not necessarily demand the exclusion of the individual from the military service. The only signs of true activity of the tuberculous process are moist râles.

It should be possible to ascertain within a few years what has happened to the men who have been discharged for supposed incipient tuberculosis. If that diagnosis was correct the incipient cases should in part at least have gone on to develop manifest tuberculosis of the lungs. If such men are not discharged on account of their incipient tuberculosis and if tuberculosis is readily transmissible from one adult to another, each one who remains in service would form a center of infection for his healthy comrades, who, moreover, are likewise endangered through contact with the seriously infected civil population in billets and the like. Hence pulmonary tuberculosis is likely to grow worse in the Army the longer active service continues.

If the opposing view is correct, however, the elimination of the tuberculous individual from the Army would result in freeing the Army from tuberculosis in direct proportion to the perfection of such elimination. Such cases of active tuberculosis among soldiers as have escaped notice will break down under the conditions of military service if the disease is extensive and be successively eliminated so that active chronic pulmonary tuberculosis will become more and more rare.

The evil of the ultrarefined diagnosis of pulmonary tuberculosis is most conspicuously exhibited in the now celebrated 86,000 soldiers of Landouzy,2 who, it was generally believed, had become infected with tuberculosis in the military service, a fact that not unnaturally excited considerable apprehension in the United States lest a similar evil befall American forces. But, according to Lereboullet,35 M. Godert reported to the Senate from the War Office that from August 2, 1914, to October 31, 1917, 80,551 men were discharged for disability from tuberculosis not incident to the military service (réformés No. 2) and 8,879 men for disability in line of duty (réformés No. 1) from the same cause. The evil is infinitely less severe, M. Godert remarked, than the figures seem to show without explanation, for 65,000 were determined to be tuberculous in the first year of the war and were eliminated without having been incorporated into, and therefore without having contracted their disease in, the army. From January to October, 1917, 4,839 men were discharged from the army for tuberculosis without pension and 6,863 were pensioned. This relieved the French Army of much of its had reputation as creator of tuberculous infection, but it remained to consider the diagnosis in this large group of over 80,000 men. Late in 1917 a cablegram was received in Washington from the French War Office which stated that at that time it was believed that less than 50 per cent of this group were really tuberculous. These figures, however, are most conservative, for Rist,2 an undoubted authority, states that when clearing stations were established for the purpose of securing a better diagnosis of tuberculosis, of the first 1,000 cases examined at one of them only 193 men were found to have active tuberculosis. He thinks that we are justified


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in believing that out of the 86,000 soldiers discharged from the French Army during the first year of the war less than 20 per cent were really tuberculous, and adds "my personal impression is, much less than 20 per cent." Many of these men no doubt had other diseases, but in all probability it would not be an exaggeration to say that several divisions of soldiers (assuming 10,000 men for a division) might have been added to the French Army by a more correct diagnosis of tuberculous conditions at a time when France was most sorely beset. Between August, 1914, and December, 1918, 111,038 French soldiers were discharged for tuberculosis, of whom 25,600 were pensioned and 85,438 were granted no pension. There were 12,220 deaths from this disease in the French Army. France mobilized 8,410,000 men during the war.36

Conditions were nearly as bad in Germany. Fraenkel,37 one of the most distinguished of German internists, writing in 1916, said that in the endeavor to recognize tuberculosis as early as possible we have arrived at an overestimation of various relatively insignificant phenomena. Of those diagnosticated as tuberculous, only 40 per cent were really so; 40 per cent had other diseases; 20 per cent had no disease at all. Blümel reports that of officers and men who had been declared temporarily or permanently incapacitated for military service on account of pulmonary tuberculosis, about 80 per cent of those whom he examined proved not to be tuberculous.38 Nevertheless the tuberculosis situation in the Army of Germany seems to have become highly satisfactory, for the errors of diagnosis complained of consisted in diagnosticating tuberculosis too readily rather than in failure to find the disease when it was present in a manifest form. Goldscheider39 stated expressly that the overlooking of slight manifest conditions seemed to have rarely occurred.

Experience in our Army has long shown that pulmonary tuberculosis is discovered in the majority of cases in the early months of military service. But men with small and chronic tuberculous lesions (and occasionally with surprisingly large lesions) are often unconscious of their disease.

In connection with diagnosis, and particularly as regards tuberculosis as a cause of rejection for military service, Circular No. 20, quoted above, was written from the standpoint of what may be called the regular school. Since it was designed especially for use in connection with the examinations for entrance into the Army, it does not take up the more acute forms of tuberculosis, but notwithstanding this omission it was used in the instruction of medical officers. No change of importance was made in its test, and the chief point upon which experience showed that more light was needed was the size of the obsolete lesion which would justify rejection. The efforts of medical officers to commit the Surgeon General's Office to the definition of such a lesion by extent as measured by inches or by ribs and vertebræ were resisted for the reason that not only the extension of a lesion but also the severity of the tuberculous process which gave rise to it (determined by the density of fibrous tissue, existence of cavity, and the like) was of importance. The most radical position taken was the insistence upon moist râles as the only physical sign which justifies the diagnosis of activity. There the writer was supported not only by his own clinical experience but also by the opinions of Piéry40 of France, Goldscheider41 of Germany, and many others.


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The diagnosis of tuberculosis became more than ordinarily difficult during the war on account, first, of the prevalence of bronchopneumonia due to streptococcus infection which, with the exception of a sputum positive for the tubercle bacillus, sometimes gave all the classical signs of pulmonary tuberculosis, including hemoptysis. At a later period many unresolved pneumonias following influenza still further complicated a difficult situation. At some camps so many men were discharged without warrant for tuberculosis during these epidemics that it became necessary to issue the order that no one should be discharged with that diagnosis unless the sputum was found to contain tubercle bacilli.42 This course met with many remonstrances at first but was finally approved by all as the only possible means of averting what promised to become a great evil. And, it may be pointed out, the requirement of a positive sputum was the more warranted because the tuberculosis imitated by other diseases was not the obscure and doubtful forms of the disease, but a frank and extensive tuberculosis which would almost without doubt be attended by sputum containing many tubercle bacilli. At a later time, in order to provide for cases still occasionally encountered, the order was modified to permit the report of old and extensive cases of fibrosis, though the sputum be negative, with a view to their discharge, the decision as to each case remaining, however, in the hands of the Surgeon General.43 Such a limitation was proved to be necessary in practice because some medical officers (not specialists) appeared to be of the opinion that the denomination of cases as those of fibrosis was simply a device to get rid of any and all cases of supposed tuberculosis irrespective of the absence of any evidence of the existence of a large and old lesion.

Considerable pressure was exercised during the first months after the United States entered the war by a number of prominent physicians and radiologists to induce the Surgeon General to make the radiograph the decisive factor in the diagnosis of pulmonary tuberculosis. The claim was that the work could be done with great rapidity and accuracy, that the negatives were easily stored in a comparatively small space and would form a permanent and more or less infallible record which would not only be of great scientific value but would also decide better than the results of physical examination as to the necessity of rejection, 90 per cent approximately of the men being accepted on their radiographs without further examination of the lungs, leaving the remaining 10 per cent for further study. Even granting that all of the above claims were well founded, it was evident that the practical difficulties in the way of the adoption of this plan were insuperable. Not to mention the enormous cost of photographing the entire new Army and the impossibility of obtaining a sufficient number of plates within a reasonable time, the lack of trained radiologists had to be considered. How serious this objection was is shown by the fact that several X-ray schools were kept in operation for many months in order to train technicians who after the brief course of training could still hardly be regarded as experts in the determination of tuberculous lesions from the radiograph. A technical service of the magnitude required could evidently not be made ready to function efficiently until long after the time when the decisions of which it was claimed to be the most trustworthy


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arbiter had perforce been made and the subjects for the most part dispatched overseas. A subcommittee of the general medical board of the Council of National Defense undertook a test to determine practically the merits of the proposed scheme. All of the members of certain companies of the 69th New York Regiment, National Guard (later renumbered the 165 Regiment of United States Infantry), were photographed by the X ray. Certain men diagnosed as tuberculous by this means were examined subsequently by an examining board composed of experts in physical diagnosis from New York City. For various reasons the total number of those who could be obtained for reexamination was only 25. Of these, 21 were found to have no abnormal physical signs, 1 had distinct signs of apical involvement with râles in both apices but no symptoms, and 3 had only slight or equivocal signs, of whom but 1 gave pulmonary symptoms. The last 4 men were rejected, 1 of them, however, not on account of physical findings, but because of suspicious history and radiograph. The board was disposed, as will be noted, to be most liberal in its concessions, but its findings can hardly be said to make out a good case for the method which in this instance was put into effect by skilled radiologists

How the method would have worked out at Army camps on a large scale is best shown by the experience at Camp Lewis, Wash.-a camp the medical records of which are more than usually accurate and detailed-with men of the second draft; that is, at a time when the X-ray services had become well organized:44

Of 570 men rejected for clinically evident tuberculosis, the Roentgenologists recognized 54 per cent as tuberculous. In another group of 343 men, who, the Roentgenologists stated, were unqualifiedly tuberculous and should be rejected on X-ray findings alone, irrespective of physical findings, only 315 were rejected after physical examination. The remaining 28 were considered either to be nontuberculous or to have obsolete lesions and were accepted for service. We have been able to follow these men through their military career and none has developed tuberculosis. Among another group of 1,500 men whom the Roentgenologists diagnosed as very suspicious of tuberculosis, physical examination revealed only 128 cases of tuberculosis which were rejected. No cases of tuberculosis developed among the remaining 1,372 accepted for service.

The position taken in the Surgeon General's Office with regard to the X ray in the diagnosis of pulmonary tuberculosis was that while the radiograph is a very valuable, indeed, indispensable adjunct in the diagnosis, it can not be relied upon exclusively for that purpose because it not only fails sometimes to reveal early tuberculous changes but it also does not always indicate whether the lesions shown are active or obsolete.

Circular No. 20 forbids the general use of tuberculin for purposes of diagnosis in the individual case in Army examinations, the reasons for which hardly need to be set forth here. It may be remarked, however, that in giving the indications for the use of tuberculin in general an absolutely exact diagnosis of the condition of the lungs is always tacitly assumed as a preliminary to its administration. This assumption, however, can not be safely made with reference to the average medical officer any more than to the average practitioner in civil life. Tuberculin given blindly or with an incorrect appreciation of the degree of activity of the tuberculous process which may be present in the given case is a dangerous substance.


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MANAGEMENT AND TREATMENT

The treatment of tuberculosis as a disease does not differ, of course, in military practice from the well-recognized rules that govern in civil life. Certain difficulties, however, are met in Army hospital management to which it may be well to refer briefly. Tuberculosis being the "social disease," every layman feels competent to hold opinions on the subject of its treatment, especially its climatic treatment, and the population readily divides itself into groups which hold differing views with regard to two questions. First, shall or shall not the tuberculous patient be discharged promptly; second, shall he be treated near his home or shall he be sent far away to climates reputed to be most curative for his disease?

The officers of charitable institutions and associations hold strongly to the view that the tuberculous individual shall be retained indefinitely in the Army. To many others it seems almost self-evident that he should be discharged as soon as the diagnosis is established. The anxious mothers, especially, who, in view of much unopposed criticism of the Army and of Army methods, not unnaturally are disposed to believe anything that is bad and are quite unprepared to believe anything good of Army hospitals, generally insist that their boys shall come home at once or at least be cared for in institutions near at hand. The treatment of the tuberculous near their homes has had many advocates, while, on the other hand, there are those who demand that they shall be given the advantages of the best possible climate.

With such difference of views the demands of the opposing parties to a certain extent neutralize one another. It adds greatly, however, to the labor of administration that so many feel justified in seeking to impose their views as to the proper procedure in a given case upon the Army authorities.

The desire of the Surgeon General was to retain the tuberculous in the Army for a considerable period, long enough for them to attain the maximum degree of improvement of which they were capable.45 In a certain class of patients, those possessed of considerable wealth, the objection was raised that they were able to procure for themselves the best of sanatorium care and of medical treatment. With this class in view, an order was issued that patients might be discharged if they satisfied their commanding officers that they were able to provide and would provide for themselves care and treatment as good as that which they sought to relinquish. This provision was inevitably supposed to be a mere device for circumventing the regulations of the Army, and many illiterate affidavits from presumably poor persons as to plans for care and treatment were submitted in support of requests for discharge.

These difficulties were largely met by a campaign of education. In case of persistent application for the discharge of soldiers the aid of the nearest American Red Cross organization or tuberculosis association was solicited, which sent their workers to instruct the family as to the nature of the tuberculosis hospitals, the excellence of their medical officers, the aims of the Surgeon General, etc. Likewise the commanding officers of tuberculosis hospitals prepared circular letters which set forth the facts as to their hospitals in a similar way. In case some public man was insistent upon a particular soldier's discharge, he was asked if he was prepared to guarantee, personally, that treat-


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ment and care equal to that furnished by Army hospitals would be provided for the man whose discharge he sought, and when discharged the Red Cross or other agencies were notified and sent in a report as to what had actually been done for the individual in question. By thus bringing home responsiblity for courses recommended and by educating the families which had been making trouble, much good was effected. The trouble making was found to be largely due to pure ignorance and baseless assumptions which a little well-directed effort served to dissipate.

Early in the war a circular inquiry as to the best size of tuberculosis institutions brought forth the unanimous opinion of the civilian experts that small sanatoria were better than large. Nevertheless, the scarcity of competent medical personnel and the greater difficulties in the way of building, organizing, and properly inspecting a large number of small hospitals led to the decision to depend, ultimately at least, upon a smaller number of large hospitals.

The chief objection raised as to the large tuberculosis institution is the loss of that close personal contact of the physician with his patient which is possible in the small groups. This would be a real objection if the care of the expert were necessarily exercised over a much larger number of patients in the large institutions. It is assumed by those who object that the chief alone will be competent to exercise the proper influence over his patients. But if the staff were composed of medical officers who were all equally competent, this objection would cease to have force. This is an ideal condition which, it must be admitted, is rarely attained anywhere. However, the method adopted in the Army to meet the above objections is worthy of consideration.

In a large tuberculosis hospital the patients are divided into sections by wards or other groupings. The commanding officer, if a tuberculosis expert- if not, the chief of service-selects the best assistants to be placed in charge of the individual sections. He is responsible for the selection of those in charge of sections, and should exercise the closest supervision over them, inspecting their work frequently, visiting also the individual patients at random from time to time to learn their views as to their treatment and what they have been taught as to their own cases, the reasons why they are treated as they are, etc. He should be accessible as to purely medical matters by all of his staff, who should look up to him as their chief counsellor and fellow worker. The medical officers in charge of sections exercise equal care in the supervision of their assistants. The endeavor is to enforce in every way a treatment, consisting largely in regimen, which can only be carried on with success if the patients understand what is aimed at and how they should cooperate with their physicians, and if they are made to see that their physicians are competent and are interested personally in their welfare. Such a treatment must necessarily be standardized in the sense that there shall not be a change of diagnosis and of treatment when physicians are changed or transfers of patients elsewhere effected; otherwise there is chaos. The endeavor was made to put into effect such a program, which presupposes a high degree of enthusiasm and much hard work. A good beginning was made toward its realization by the senior medical officers of our hospitals, but unfortunately the sudden cessation of the war interrupted, to a considerable extent, the development of the method to the


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attainment of the best results, since there was a desire for discharge on the part of many medical officers, and a relaxation of the professional enthusiasm and of the energetic work which had been so gratifying during the war. The management of a large tuberculosis hospital demands a staff of the highest quality. With such a staff there seems to be no reason why the large tuberculosis hospitals shall not be conducted with success.46 But the writer ventures to express, in this connection, an opinion in which he differs from many officers of our Army, which is that the commanding officer of such a hospital should himself be a tuberculosis expert, not a mere administrator. Either that, or he should be required to efface himself, so far as medical questions are concerned, in favor of the chief of the medical service. But the commanding officer, in the writer's judgment, is, by virtue of his official position, the officer who can best coordinate the activities of his subordinates.

Before the World War, Fort Bayard, N. Mex., was the only institution in the Army devoted exclusively to the treatment of tuberculosis. It had capacity of some 400 beds. Early in the war the William Wirt Winchester Hospital, at New Haven, Conn.-a hospital built in the most substantial manner expressly for the treatment of tuberculosis-was leased for the duration of the war. By the erection of temporary wooden buildings its capacity was increased to a total of 500 beds. A sanatorium at Markleton, Pa., and a hotel at Waynesville, N. C., were also leased for temporary occupancy and increased to the capacity of 270 and 500 beds, respectively, by the use of tents and the addition of wooden buildings. Permission having been granted early in the war to use land at Otisville, N. Y., belonging to the New York City Municipal Sanatorium, it was hoped that a hospital with a capacity of 650 to 1,000 beds might be well advanced in construction before the onset of winter in 1917;47 but owing to various vexatious and unnecessary delays, chiefly due to the fact that the details of construction, of purchasing, and the like were required to be passed upon by many different departments, building operations were not begun until midwinter and the buildings were not ready for use until the summer of 1918. The capacity of the hospital was 650 beds. In the meantime a hospital with a 1,500-bed capacity was built at Azalea, near Asheville, N. C., and a permanent hospital was constructed at Denver, Colo., with foundations of concrete and walls of hollow tile, and with a capacity of 1,500 beds. The post of Whipple Barracks, near Prescott, Ariz., was also turned over to the Medical Department of the Army and its permanent buildings were supplemented at first by ward tents, at a later time by the construction of semipermanent hollow-tile structures, until the capacity of 500 beds was reached. Fort Bayard also was enlarged to a capacity of 1,000 beds by the erection of wards built of wood. At the time when tuberculous patients were being most rapidly returned from Europe, use was made temporarily of the base hospital at Camp Wadsworth, Spartanburg, S. C., as a tuberculosis hospital, with a capacity of 1,000 beds. The total maximum capacity of 6,650 beds, not including the hospitals at Markleton and Waynesville, was attained by these means.48

In making such provisions the greatest difficulty of course was the impossibility of providing properly and at the same time not excessively for the needs of an army the maximum strength of which could not be foreseen. The best


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approach to a solution of such a problem is the choice of land and the preparation of plans in such a way that in case of need the hospitals can be enlarged without becoming cumbrous. Fortunately, since many tuberculous patients are benefited by an outdoor life, the use of tentage and of easily built shacks may avert temporarily the overcrowding of permanent buildings without causing serious inconvenience.

MORTALITY

Deaths from tuberculosis (primary admissions) during the fiscal year ending June 30, 1918, among officers and enlisted men in the United States numbered 422 (ratio per 1,000 average annual strength, 0.35) and in Europe 389, the ratio per 1,000 average annual strength being 0.39. (In all the mortality statistics of the Surgeon General's Office deaths occurring in men who had developed tuberculosis in Europe are charged to Europe, wherever the deaths may have actually taken place.) Deaths from pulmonary tuberculosis in 1919, officers and enlisted men, were, in the United States, 613; in Europe, 617. Of the deaths among enlisted men from pulmonary tuberculosis, 355 (a ratio of 1.27) occurred among white troops in the United States and 326 in Europe (ratio 0.67). Among the colored troops the deaths from pulmonary tuberculosis in the United States were 243 (ratio 4.15). In addition, 42 deaths occurred from pulmonary tuberculosis in Europe, in cases in which the color is not stated. The incidence of tuberculosis among the colored soldiers and their death rates from the disease are much higher than among white soldiers of the Army in the United States and Europe as a whole, but neither admissions nor deaths of colored troops differ materially from those of the white troops from the Southern States, from which part of the country the majority of the colored troops came.49 In 1919, 674 deaths occurred from all tuberculosis, officers and men, in the United States, and 781 in Europe.50 The type of disease in fatal cases of tuberculosis appeared to be more severe and acute in the later part of the war and after than in the early part. The total number of deaths from pulmonary tuberculosis in the Army from the beginning of the war up to January 1, 1920, was 2,240.

DETERMINATION OF LINE OF DUTY

Prior to the World War, when a case came up for discharge on account of physical disability, medical officers of the Army were expected to express their opinion as to whether or not the disability in question had been incurred in the line of duty; that is, whether it was or was not incident to the military service. This was to assist in determining whether or not the individual was entitled to a pension. The tendency of those who had to do with such matters was always to give the soldier the benefit of any reasonable doubt, it being understood, however, that if the medical officer was in possession of facts, such as the admission by the patient that the disease had existed prior to enlistment, or satisfactory proof submitted by reputable individuals to the same effect, the disability was not to be regarded as incurred in line of duty. But when the personal history was negative and the affection was of a chronic nature, particularly when it was chronic pulmonary tuberculosis, if the term of service before the disease was determined to be present was brief and there was a man-


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ifest disproportion between the nature of the lesions (fibrous changes and the like) and the time within which they must have developed if first contracted after the patient had entered the military service, the disability was usually classed as not contracted in the line of duty. But even in such cases, if there was evidence of unusual exposure or of intercurrent disease which might reasonably be expected to have aggravated materially positively existing pulmonary disease, the disability was considered as incurred in the line of duty. Thus, a soldier was so classed, though of brief service and presenting evidence of extensive chronic pulmonary tuberculosis, who had been compelled to stand immersed deeply in sea water for 24 hours at the time of the Galveston flood, it being held that the excessive exposure to cold and the deprivation of food and drink for so long a period might be expected to materially aggravate his lung affection and therefore entitled the soldier to a pension. Infringement upon the rights of the individual in such matters was therefore always carefully guarded against; in fact there can be no doubt that many a man was granted a pension when there were good grounds for the belief that the disability in his case was of much longer standing than his military experience could account for.

Two views were held with regard to this matter. One was that, the soldier having submitted to the required physical examination and having been passed by the examiner, the Government was responsible for the character of the physical examinations and could not rightfully impugn the competence of its agent in claiming that he had erred, but was bound to abide by his decision that the individual at the time of his examination was free of disqualifying defects, so that any disability found at a later time was without question to be regarded as incident to the military service.51 The other view was that, as the courts are understood to have ruled, the Government can not be made to suffer on account of the error of its agents; specifically in the present instance it might be put that it is unjust that the people should be taxed to pay a pension which was not deserved. The Government had the right, therefore, to investigate each case and decide on the evidence of whether or not the disability was pensionable. This latter view was the one generally adopted.

Circular No. 24, Surgeon General's Office dated September 11, 1917, was designed to furnish a standard for disability boards. It provided that, if in pulmonary tuberculosis the disability is detected in less than three months after the entrance of a man into the service, it will be regarded as not in line of duty unless of an acute type or unless the man had been subjected to extraordinary exposure or had had an aggravating intermittent disease. This circular, conflicting as it inevitably would, with the wishes of many individuals, encountered so much opposition that it was finally revoked and in the summer of 1918 a change was made in the Manual for the Medical Department to the effect that any soldier who shall have been accepted on his first physical examination after arrival at a military station as fit for service shall be considered to have contracted any subsequently determined physical disability in the line of duty unless such disability can be shown to be the result of his own carelessness, misconduct, or vicious habits, or unless the history of the case shows unmistakably that the disability existed before entrance of the soldier into the service.


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By some medical officers "history" was understood to include the course of former pathological processes (particularly the evidence of fibrotic changes) as determined by the physical signs. It was held with regard to this point that while without doubt in many cases it can be assumed with practical certainty that the disease has existed for many years, at the same time it is not safe to give general permission to depend upon physical signs for the determination of the age of lesions, and the word "history" in the preceding paragraph should be considered to mean solely the personal recollection and such other data (recollections of relatives, of comrades, and the like) as may constitute the medical record of the past life of the individual in question. But though so much was conceded to the soldier by these orders, it was not enough, for several acts of Congress defined with increasing liberality the position of the Government toward the tuberculous individual, until at last it became the law that every commissioned officer, or enlisted man, or any other member of the military service who suffers a disability from disease contracted in line of duty shall be entitled to compensation, provided that the disease has not been caused by his own willful misconduct; that for the purpose of compensation all such persons shall be held to have been in sound condition when examined, accepted, and enrolled for service; and that these provisions shall be deemed to become effective as of April 6, 1917.52

The following data concern discharges for tuberculosis of enlisted men in the United States in 1917: In line of duty, 349; not in line of duty, 3,327.53 That is, in the opinion of the medical officers most conversant with the facts, the number of soldiers who had incurred manifest tuberculous disease as the result of military service was to the number of those who had brought the disease with them into the Army approximately as 1 to 10. In reality it is probably considerably less than 1 in 10. It is out of place to comment upon this ratio here further than to call attention to the fact that the figures as to tuberculosis in our Army do not represent the incidence of the disease under the conditions of military service. Similarly a marked rise in the number of admissions for tuberculosis at a given camp is not to be interpreted as a sudden breaking down of large numbers of men under the conditions of military service nor as an acute epidemic of tuberculosis from recent infections but, rather, as due to the activities of an examining board which detected during its routine examinations the presence of tuberculous lesions in men who before the examination had for the most part been doing full military duty and in all probability had not suspected that they were ill, such men being admitted to sick report for the better determination of their cases and as a preliminary to discharge. In some instances, however, local variations in individual commands or in special sections of the country present a more complicated problem.

REFERENCES

(1) Telegram from the Surgeon General, U. S. Army, to division surgeons (of six different camps), dated September 17, 1917. Subject: Ordering special reexamination. On file, Record Room, S. G. O., 172229 (Old Files).

(2) Rist, Edouard, Maj., M. C., French Army: The Problem of Pulmonary Tuberculosis. The Military Surgeon, Washington, 1917, xli, No. 6, 659.


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(3) S. O. No. 120, W. D., May 24, 1917, paragraph 38; S. O. No. 143, W. D., June 21, 1917, paragraph 50; also, letter from Col. George E. Bushnell, M. C., to Col. Charles Lynch, M. C., May 4, 1921. On file, Historical Division, S. G. O.

(4) Biggs, H. M.: A War Tuberculosis Program for the Nation. American Review of Tuberculosis, Baltimore, 1917, i, No. 5, 257.

(5) Examination of Soldiers for Tuberculosis, June 27, 1917. On file, Record Room, S. G. O., 181927 (Old Files).

(6) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, June 26, 1917. Subject: Detail of officers in Medical Reserve camps for duties as specialists in Army camps. On file, Record Room, S. G. O., 089101 (Old Files).

(7) Circular, War Department, July 16, 1917. Subject: Examinations of commands at camps for tuberculosis by board of medical officers. On file, Record Room, S. G. O., 189101 (Old Files).

(8) Bushnell, G. E., Col., U. S. A.: How the United States is Meeting the Tuberculosis War Problem. The Military Surgeon, Washington, 1918, xliii, No. 2, 127.

(9) G. O. No. 90, W. D., July 12, 1917.

(10) War Department Annual Reports, 1918, Vol. I, 1103.

(11) Reports, Tuberculosis Boards. On file, Record Room, S. G. O., 730.

(12) Annual Report of the Surgeon General, U. S. Army, 1918, 343.

(13) Telegram from the Surgeon General, to all camp surgeons and other senior surgeons of commands, April 29, 1918. Subject: Single examination. On file, Record Room, S. G. O., Correspondence File, 327.2 (Examinations).

(14) Matson, R. C., Maj., M. C. U. S. Army: The Elimination of Tuberculosis from the Army. American Review of Tuberculosis, Baltimore, 1920, iv, No. 5, 398.

(15) Instructors of School of Tuberculosis Examiners. On file, Record Room, S. G. O., 176001-144 (Old Files).

(16) Annual Report of the Surgeon General, U. S. Army, 1918, 344.

(17) Ibid, 119.

(18) Ibid, 219.

(19) Personal communications to the author.

(20) Brewer, Isaac W.: Tuberculosis Among the Indians of Arizona and New Mexico. New York Medical Journal, 1906, lxxxiv, No. 20, 981.

(21) Cabot, Richard C.: In Conference on Tuberculosis of the Lungs. War Medicine, Paris, 1919, ii, No. 6, 978.

(22) Annual Report of the Surgeon General, U. S. Army, 1919, Vol. II, 1070.

(23) Letter from the Surgeon General, U. S. Army, to Dr. Edouard Rist, Geneva, Switzerland, January 28, 1920. Subject: Occurrence of tuberculosis in the Army. On file, Record Room, S. G. O., 702-5.

(24) Webb, Gerald B.: Some Lessons of the War in Pulmonary Tuberculosis. Transactions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, xxxv, 114.

(25) Glomsett, D. J., Maj.: What Can We Learn Regarding Pulmonary Tuberculosis from the Opportunity Afforded by the General Postmortem? War Medicine, Paris, 1919, ii, No. 6, 993.

(26) Borrel, A.: Pneumonie et tuberculose chez les troupes noires. Annales de l'Institut Pasteur, Paris, 1920, xxxiv, No. 3, 105.

(27) Roubier, Ch.: Sur la Tuberculose chez les troupes noires. Paris médical, 1919, xxxiii, No. 37, 207.

(28) Nägeli, Otto: Ueber Häufigkeit. Localisation und Ausheilung der Tuberkulose. Virchow's Archiv für pathologische Anatomie und Psysiologie und für klinische Medicin, Berlin, 1900, clx, No. 2, 426.

(29) Opie, Eugene L.: The Focal Pulmonary Tuberculosis of Children and Adults. Journal of Experimental Medicine, New York, 1917, xxv, No. 6, 855; and xxvi, No. 2, 263; also: First Infection with Tuberculosis by Way of the Lungs. American Review of Tuberculosis, Baltimore, 1920, iv, No. 9, 629.

(30) Cummins, S. Lyle: Tuberculosis in Primitive Tribes and Its Bearing on the Tuberculosis of Civilized Communities. International Journal of Public Health, Geneva, 1920, i, No. 2, 137.


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(31) Bruns, Earl H., Lieut. Col., M. C.: The Tuberculosis Situation in the American Expeditionary Forces. Unpublished Report to the Surgeon General, U. S. Army. On file, Record Room, S. G. O.

(32) Bushnell, George E., Col., M. C., U. S. Army: A Study in the Epidemiology of Tuberculosis. William Wood and Company, New York, 1920, 97.

(33) Freund, Heinrich: Ueber cutane und conjunctivale Tuberkulinreaktion bei Gesunden und Kranken. Wiener medizinische Wochenschrift, Wien, 1908, lviii, 1242; 1302.

(34) Hamburger, F.: Die Ueberlegenheit der Stichreaktion über die Kutanreaktion. Münchener medizinische Wochenschrift, München, 1919, lxvi, part 1, No. 4, 100.

(35) Lereboullet, P.: Les questions actuelles de tuberculose. Paris médical, 1918, xxvii, No. 1, 1.

(36) Gallagher, Joseph F., First Lieut., M. C.: Statistical Résumé of the French Medical Service. The Military Surgeon, Washington, 1920, xlvi, No. 5, 579.

(37) Fraenkel, A.: Ueber Lungentuberkulose vom militäräztlichen Standpunkie aus. Münchener medizinische Wochenschrift, München, 1916, lxiii, part 2, No. 31, 1109.

(38) Blümel: Die Fehldiagnose Lungentuberkulose bei Beurteilung der Felddienstfahigkeit. Medizinische Klinik, Berlin und Wien, 1915, xi, August 8, 884.

(39) Goldscheider: Aufgaben und Probleme der inneren Medizin im Kriege. Zeitschrift für Tuberukulose, Leipzig, 1915-16, xxv, No. 1, 36.

(40) Piéry: Le Poumon de guerre. Revue génerale de pathologie de guerre, Paris, 1916, i, 509.

(41) Goldscheider: Diagnose und Prognose der Lungentuberkulose vom Standpunkt des Praktikers. Berliner klinische Wochenschrift, Berlin, 1917, liv, No. 53, 1266.

(42) Letter from the Surgeon General to commanding officers of all base and general hospitals, April 15, 1918. Subject: Discharge of tuberculosis patients. On file, Historical Division, S. G. O.

(43) Letter from the Surgeon General, U. S. Army, to The Adjutant General of the Army, July 2, 1918. Subject: Discharge on account of pulmonary tuberculosis. On file, Record Room, S. G. O., 220.8, G. H. No. 18 (k).

(44) Matson, R. C., Maj., M. C., U. S. Army: The Value of Chest Fluoroscopy. The Journal of the American Medical Association, Chicago, 1919, lxxii, No. 26, 1887.

(45) Hospitals designated for reconstruction of disabled American soldiers and policy to be pursued outlined by the Surgeon General. Official Bulletin, published daily under order of the President of the United States, by Committee on Public Information, Washington, D. C., April 2, 1918, ii, No. 273, 8.

(46) Hoagland, H. W.: The Treatment of Tuberculosis in the Army Hospitals. Transactions of the American Climatological and Clinical Association, Lancaster, Pa., 1919, xxxv, 21.

(47) Annual Report of the Surgeon General U. S. Army, 1918, 344.

(48) Ibid., 1919, ii, 1072.

(49) Ibid., 1919, i, 51.

(50) Ibid., 1920, 178.

(51) Memorandum on the question of line of duty, November 7, 1914. On file, Record Room, S. G. O., 153517 (Old Files).

(52) War risk insurance act, with amendments prior to July 1, 1918. In special Regulations No. 72, Washington, Government Printing Office, 1919, 90, and amendments to war risk insurance act in Bulletin 7, War Department, April 17, 1923, 26.

(53) Annual Report of the Surgeon General, U. S. Army, 1918, 158.