Contents

CHAPTER XIV

Tuberculosis

Esmond R. Long, M. D.

TUBERCULOSIS IN WORLD WAR I ¹

Tuberculosis was first recognized as a significant medicomilitary problem in World War I. Data are available in United States Army records and previous military histories on rates and disposition of cases in the Civil and Spanish-American Wars, but the known prevalence in the Army, in comparison with that of other diseases, particularly typhoid fever and malaria, was so small that no special attention was paid to tuberculosis and no analytical studies were made of its military importance.

In World War I, on the other hand, United States Army medical officers were aware of its significance at the outset, for the disease was recognized as a grave problem in the French Army before the United States was engaged in hostilities. In the light of the French experience, The Surgeon General of the United States Army determined to have rigid physical examinations for tuberculosis (roentgen examination being then in its infancy) made by experts at the time of induction to prevent acceptance of men with this disease. In order to carry out this program, the Army assembled large numbers of distinguished experts and conducted special courses of training in physical diagnosis. The experience and shortcomings in diagnosing and excluding tuberculosis were described at great length by Col. George E. Bushnell, MC, Chief Consultant in Tuberculosis, Office of the Surgeon General, in the official history of the Medical Department of the United States Army in World War I. Although some 50,000 men with diagnosed tuberculosis were excluded at induction, the imperfections of the procedure were such that many men with early tuberculosis were accepted, as was indicated by a steady discovery of cases in the rapidly mobilized Army.

Tuberculosis in the Army was exhaustively analyzed by Colonel Bushnell. He attributed it almost entirely to breakdown of cases that escaped detention at induction. It must be recalled that this was a period when virtually all adult pulmonary tuberculosis was considered endogenous, representing the flaring up and progression of latent lesions of childhood as a result of adult strains. In favor of this view was the fact that nationwide sampling by the tuberculin test and all necropsy experience indicated almost universal infection

¹ The Medical Department of the United States Army in the World War. Communicable and Other Diseases. Washington: U. S. Government Printing Office, 1928, vol. IX, pp. 171-202.

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of the population by the age of 20 years. It was a decade or more before superinfection of adults was recognized as a frequent occurrence.

Before the war was over, more than 2,000 men had died of tuberculosis in the Army, and thousands more had been hospitalized. The admission rate in Army hospitals averaged 19 per 1,000 strength per year. Throughout World War I, tuberculosis was the leading cause of discharge for disability, accounting for 13.5 percent of all discharges. At the end of the war, a huge and costly problem was left for the newly organized Veterans' Administration.

TUBERCULOSIS BETWEEN THE TWO WORLD WARS

Between 1918 and 1941, great progress took place in the understanding of the pathogenesis of tuberculosis. Careful studies of its epidemiology brought out a clear relationship between exposure and subsequent development of manifest tuberculous lesions of the adult type, and in time the exogenous theory of adult tuberculosis assumed at least an equal standing with the endogenous. The disease was no longer considered invariably an exacerbation of an old childhood infection but rather, in many if not most cases, the result of an adult acquisition of new infection.

The new understanding was reflected in a radically changed approach to the public health attack on the disease. Two principal procedures became recognized as the nucleus for tuberculosis control: case finding and isolation of discovered cases. In the earlier years of the two decades between the wars, case finding was developed as a public health procedure on a contact basis. The family was recognized as the source of most exposure, and clinic and public health measures were taken accordingly. Later, commencing in the late 1930's, case finding by mass surveys was recognized as highly effective. A few surveys were made by affiliates of the National Tuberculosis Association and local health departments just before the United States entered World War II, which clearly demonstrated the possibilities of the method. These surveys, made by methods of cheap and rapid roentgenography, resulted in the discovery of cases at relatively low cost as compared with all previous efforts. Paper films were used at first; subsequently, methods of photofluorography were developed, which made possible a less expensive and even more rapid roentgen examination of large groups. The United States Public Health Service took great interest in the development of methods and cooperated closely with tuberculosis associations before developing an independent program of its own.

Coincidentally with this development, hospitalization for tuberculosis was increasing rapidly. Standards for the number of beds which communities should provide for proper care of the disease were developed and raised with the passage of time. Before the beginning of the war, some 75,000 beds were available, and it was universally accepted in the United States that at least two beds should be provided for every annual death in any, community. This was a, goal for which all communities with a sense of public health responsibility strove.

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During these two decades, a notable decline in tuberculosis mortality occurred throughout the country. At the close of World War I, the tuberculosis mortality rate in the registration area was 150 per 100,000 population. At the opening of World War II, the figure was less than 50.There has been extensive discussion and analysis of the reasons for the striking decrease. Specific measures, including case finding and isolation of open cases, were certainly effective. Combined with this, however, was a general rise in the standard of living, which must have affected the mortality from tuberculosis indirectly in various ways.

In addition to the development of roentgenography methods for the detection of the disease, improvements occurred in its laboratory diagnosis. The years between the two wars were fruitful in the development of new methods for examination of sputum and of other tests in the recognition of tuberculosis infection. At the same time, education of physicians with respect to the disease improved, so that the rank and file of medical officers at the opening of World War II were much better informed on the disease than were the corresponding physicians of World War I.

TUBERCULOSIS IN WORLD WAR II

Examinations for Detection of Tuberculosis at Induction

As mobilization for World War II became imminent, Army and civilian experts oil tuberculosis, the National Tuberculosis Association, and other public health organizations repeatedly called attention to the high incidence of tuberculosis in troops in World War I and to the necessity of avoiding a repetition of that unfortunate experience. They pointed out that, since World War I, roentgenologic methods had been developed to the point that they could be effectively used in detecting tuberculosis and excluding it at induction.

The principle of the roentgen method of detection was accepted by The Surgeon General long before the outbreak of the war, and standards for the exclusion of men with tuberculosis were drawn in terms of roentgenography. However, when war actually began, few places in the country were in a position to furnish the required roentgen examination. In the summer of 1940, The Surgeon General of the Army had requested the aid of the Division of Medical Sciences of the National Research Council in the formulation of proper standards. A subcommittee of the division, consisting of Drs. J. Burns Amberson, Jr., Bruce H. Douglas, Herbert R. Edwards, Paul P. McCain, and James J. Waring, with the author as chairman, drew up a set of recommendations that formed the basis for the chest section of MR (Mobilization Regulations) No. 1-9 which was in effect when examination of selective service registrants began in August 1941. This committee formulated an improved and greatly extended section in MR No. 1-9 of March 1942.² Efforts to establish roentgeno-

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² M. R. No. 1-9, Standards of Physical Examination During Mobilization, 31 Aug. 1940 and 15 Mar. 1942.

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graphy as a required routine procedure at induction were pushed vigorously by Col. (later Brig. Gen.) C. C. Hillman, MC, of the Office of the Surgeon General, and after many delays the procedure finally was universally employed.

One of the greatest difficulties in implementing the program lay in the multiplicity of stations for enlistment. Many of these were small and remote from medical centers. Equipment was not available nor were experts who could interpret roentgen films accurately. Induction stations for selective service registrants were better supplied, and the frequency of roentgen examination gradually increased throughout these stations, varying greatly, however, in speed of development in the nine corps areas or, as they were later designated, service commands. At first, chest roentgen examination was required on all registrants in whom pulmonary disease was suspected and was requested whenever local facilities made it possible.³ At the beginning of the war, only the three corps areas on the North Atlantic Coast made roentgen examinations routinely, and at first some of the stations in these areas utilized the services and equipment of affiliates of the National Tuberculosis Association and local health departments to carry out the examinations. The volunteer service rendered by these organizations was of major value to the Army in bridging the gap until Army facilities were available and at the same time tied the Army program in closely with State public health activities, which were of immediate concern to the assisting agencies.

By 1 March 1941, it was estimated by Colonel Hillman that 51 percent of all men called to induction stations had had a chest roentgen examination. With further increase in facilities and equipment, the time finally arrived, about 1 April 1942, when all selectees were subjected to roentgen examination before acceptance. Roentgen examination for appointment of officers was already universal.⁴ Nearly 100 induction stations were in operation, each of which had suitable equipment. Eight of the nine service commands used 4- by 5-inch stereoscopic photofluorograms, and one, the Fifth Service Command, used paper films.Ultimately, all stations in all service commands used 4- by 5-inch photofluorograms, supplemented as need dictated by full-size chest roentgenograms on celluloid film. A full review of the procedures for exclusion of tuberculosis from the Army was made by the author following World War II. ⁵

It is estimated that, before roentgen examination became mandatory (MR No. 1-9, 15 March 1942), one. million men had been accepted without this form of examination. Where roentgen examination was practiced, it resulted in a rejection rate of about 1 percent for tuberculosis. Applying this figure, it can be estimated that some 10,000 men were accepted who would have been rejected if they had been subjected to chest roentgen-ray study. Various studies have shown that approximately one-half of these would have been cases of active

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³ Letter, The Adjutant General, to Commanding Generals of all Corps Areas and Departments, 25 Oct. 1940, subject: Chest X-rays on Induction Examinations.

⁴ (1) Letter, The Adjutant General, to Each Corps Area and Department Commander; Each Chief of Arm or Service; and to the Chief, National Guard Bureau, 30 Jan. 1940, subject: Physical Standards and Physical Examinations, Par. 4b. (2) Letter, The Adjutant General, to Each Corps Area and Department Commander; Each Chief of Arm or Service; and to the Chief, National Guard Bureau, 28 Dec. 1940, subject: Physical Standards and Physical Examinations, Par. 4b.

⁵ Long, E. R.: Exclusion of Tuberculosis. Physical Standards for Induction and Appointment.[Official record.]

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disease. Thus, failure to employ roentgenographic methods probably resulted in the acceptance of 5,000 cases of clinically active tuberculosis. Among the large number of men accepted after roentgen examination, errors-either in interpretation or in administrative procedure-permitted the acceptance of about 1 man per 1,000, as shown by subsequent research, who should have been rejected for tuberculosis.⁶ Among the 10 million men routinely examined by roentgenographic methods and accepted, it is believed that about 10,000 with active or potentially active lesions were inducted. Altogether, therefore, there is reason to believe that some 15,000 men were taken into the Army with tuberculous lesions that could have been detected on roentgen examination and recognized as a cause for exclusion.

It would be unwarranted, however, to assume that under existing circumstances X-ray diagnosis at induction stations could have been refined to a point where a greater degree of success could have been attained. Induction station roentgenologists were subjected to a variety of conditions tending to lower the level of their performance, chief of which were fatigue from long hours, required speed of operation, and repeated pressure from command sources to reduce the rate of rejection in the interest of manpower needs. In the effort to improve accuracy, the consultant in tuberculosis in the Office of the Surgeon General visited every induction station in the United States and read sample films with the station roentgenologists. Some improvement was probably brought about in this way.

It would be fully justified, on the other hand, to stress the great benefit to public health practice in the country effected through the report of cases which were properly identified. States varied in the energy with which ad vantage was taken of Army and Selective Service reports on rejection for tuberculosis, but it appears unquestionable that those with the more progressive health departments used these returns with great success in improving their case finding and followup programs.

Breakdown from Preexisting Tuberculosis

As indicated in the last section, it is estimated that some 15,000 men with active or potentially active tuberculosis were accepted in the Army as the result of failure to carry out roentgenologic examination or to recognize lesions in photo fluorograms and roentgen films, when these were made. The majority of men so admitted had the disease in the minimal stage. In a substantial number, how ever, the disease was far advanced. It is believed that, in many of these cases, administrative errors in recording the lengthy selective service identification numbers were responsible for acceptance.

From the beginning of the war, all films of accepted men were filed with the Veterans' Administration. Reexamination of X-ray films at any time was thus
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⁶ Long, E. R., and Stearns, W. II.: Physical Examination at Induction; Standards With Respect to Tuberculosis Induction and Their Application as Illustrated by a Review of 53,400 X-ray Films of Men in the Army of the United States. Radiology 41: 144-150, August 1943.

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possible, provided film filing was up to date, which was by no means invariably the case. Reexamination of the films of accepted and discharged men has shown that, in the majority of instances, men who entered the Army with advanced tuberculosis were detected within the first 6 months of acceptance, were hospitalized, and were discharged. In a few cases, remarkably, men were able to carry advanced lesions over a period of many months or even nears before the disease finally was detected.

On the other hand, thousands of men with minimal lesions served months or years before breakdown occurred. In some instances, no deterioration in health or progression of the disease ever occurred in men whose initial films, on review, showed lesions that had the roentgenologic appearance of clinical activity. Also, large numbers of men with minute lesions which were considered well healed carried these, lesions without harm throughout the period of their service.

Careful studies have been made of circumstances leading to the breakdown of tuberculous lesions of various types during the course of service. One study, carried out by Dr. Waring and Capt. (later Maj.) William H. Roper,⁷ was organized by the Subcommittee on Tuberculosis of the Division of Medical Sciences of the National Research Council and implemented by the Office of Scientific Research and Development. This study showed that heavy physical labor and the strain of combat were particularly important circumstances favoring breakdown. Other factors, such as malnutrition and psychologic strains, played a less definite role. Waring and Roper also found that a considerable proportion of breakdowns following acceptance for military duty occurred within the first year of service. In many, the onset occurred with pleurisy with effusion. An additional observation was that assignment of "poor risks" to limited duty afforded an appreciable measure of protection against breakdown, although frankly active cases mistakenly taken into service did equally badly on limited and general duty.

During the first 2 years of the war in the Army's one special tuberculosis hospital, Fitzsimons General Hospital, Denver, Colo., the majority of admitted cases appeared to represent a breakdown of lesions present at the time of induction. Medical officers on duty in the hospital stated that during the last 2 years of the war the majority of cases occurred in men whose chests were negative by roentgen examination at induction.

Contraction of Tuberculosis

It has been pointed out that a substantial number of men with tuberculosis were admitted to the Army through failure to exclude recruits with recognizable disease at induction. Long and Jablon ⁸ made an extended postwar study of the induction and separation X-ray films of 3,099 men discharged from the Army with a diagnosis of tuberculosis and 3,000 discharged for other reasons

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⁷ Roper, W. H., and Waring, J. J.: Primary Serofibrinous Pleural Effusion in Military Personnel. Am. Rev. Tuberc. 71: 616-634, May 1955.

⁸ Long, Esmond R., and Jablon, Seymour: Tuberculosis in the Army of the United States in World War II. An Epidemiological Study with an Evaluation of X-ray Screening. Washington: U. S. Government Printing Office, 1955.

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during the years 1942 to 1945, inclusive. This study disclosed the fact that approximately one-half of the tuberculosis that led to discharge from the Army was already present in diagnosable form at the time of acceptance for military duty.

In addition to these men, presumably other men were inducted with latent infections undetectable by the X-ray screen. Men from each of these groups may have broken down as a result of progression of their preexisting disease. Over and above these, however, there is reason to believe that a considerable amount of tuberculosis resulted from new infections acquired during service, through contacts in the Army itself or through associations outside of military duty. Opportunity for contracting tuberculosis through civilian contact in the United States existed for soldiers just as for other citizens. They visited their families while on leave, and presumably in some of these families there were members with tuberculosis who were likely to spread their infection. Thus, soldiers may have carried back tuberculous infections when they returned to their stations. Also, as in civilian life, soldiers visit friends in the general population, some of whom may have tuberculosis. Therefore, troops presumably experienced a certain amount of exposure to tuberculosis from this source in the United States. The average intensity of exposure would depend upon the prevalence of tuberculosis in the sections of the population visited. Overseas, the opportunity for contraction of tuberculosis through exposure to civilians was still greater. In North Africa, Italy, France, the islands of the Pacific, the Philippine Islands, and Japan, the prevalence of tuberculosis was far higher than in the United States.Rates in the British Isles and in Germany also exceeded those in the United States but not by a great margin.

Because of the multiplicity of contacts that might be significant, it is difficult to trace new cases of tuberculosis to their source under Army conditions. However, the acceptance of some 15,000 men with active or potentially active tuberculosis as a result of defects in the induction screen was apparently a factor not to be overlooked in the total development of tuberculosis in military personnel. The study by Long and Jablon indicated that, except in the case of men who had served periods as prisoners of war and men who apparently had been exposed excessively to disease through other special circumstances, a relatively even uniformity of risk of acquiring tuberculosis occurred, regardless of arm, military occupation, overseas service, theater of service, or civilian contact. In that study, differences observed in risk seemed to be no greater than those to be expected through chance sampling.It seemed reasonable, therefore, to infer that a substantial percentage, perhaps a, majority, of cases of newly contracted tuberculosis in servicemen resulted from infection from fellow soldiers.

Admission Rates

The best measure of the prevalence of tuberculosis in the Army was the admission rate for this disease, although the figure may give an exaggerated picture of the actual prevalence. Cases admitted for tuberculosis included all

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those so diagnosed after complete examination and, in addition, cases originally judged as probably tuberculous in nature but requiring further study to establish or disprove the diagnosis. On the other hand, incidence rates failed to take into account asymptomatic cases not brought to medical attention. Possibly the error in one direction was as great as that in the other, so that the recorded prevalence may have been fairly close to the actual.

It is useful to compare the incidence rates in the Zone of Interior with those in foreign areas, in an effort to determine where cases of tuberculosis originated. Needless to say, admission in the Zone of Interior or admission in overseas areas would not necessarily mean that infection ultimately diagnosed was acquired in the same region. A soldier might be infected in the Zone of Interior and first show evidence of tuberculosis after going overseas, and, vice versa, a soldier infected overseas might return to the Zone of Interior and pass several months in service before his tuberculosis became manifest.

It is interesting to note that throughout the wax incidence rates for the Zone of Interior as recorded in periodic statistical health reports were consistently higher than those reported in the overseas theaters. Several reasons may be given in explanation. In the first place, cases of obvious tuberculosis overlooked at induction usually came to light before transfer overseas. Training in the United States prior to overseas duty was rigorous, and cases likely to break down ultimately in normal life were eliminated by what was essentially a process of natural selection before overseas assignment. Also, it is possible that there was more leisure for examination in the Zone of Interior, and there fore more cases were detected. Whether this is a fact or not is debatable, for the examination overseas of service and combat troops was probably equal most of the time to that carried out in the Zone of Interior.

Chart 23 illustrates the admission rates for the total Army in the Zone of Interior from July 1940 to October 1946, inclusive. The admission rates among white enlisted men in the continental United States in World War I for the years 1917-20 are presented for comparison. It will be noted that, in each war, a high rate prevailed shortly after the beginning of the war. This can be explained as the result of imperfection in examination for service during the early months in each war. In World War II, there was a long period from April 1942 to the middle of 1945 when examinations were excellent and the rate of recognition of tuberculosis in the Army was relatively low and constant, representing the sum of cases that escaped recognition on induction and those that actually developed within the Army. It will be noted that a high rate occurred toward the end of 1945. This rate is, of course, artificial and represents the tuberculosis rapidly discovered at the separation centers on discharge from the Army.

A fact of interest brought out in the figures is that, at all times during World War I, the admission rate for tuberculosis was approximately 10 times that in World War II. The explanation can be found, in part, in inferior screening at induction during World War I and also in the greater prevalence of tuberculosis in the civilian population during the earlier period, when the

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CHART 23. -Incidence of tuberculosis in the U. S. Army in the continental United States, World War I and World War II

mortality rate was three times as high as during World War II. Hence opportunity for chance failure of recognition at induction was much smaller during World War II as was also the opportunity for exposure to the disease after induction. Actually, the difference in prevalence in the Army in the two wars was probably considerably greater than that recorded for admission rates, since diagnostic accuracy had improved markedly in the interim and the admission rate in World War II, presumably, was therefore closer to the true prevalence rate than it had been in World War I.

Chart 24 compares incidence rates for tuberculosis for the United States and overseas theaters for the years 1942 to June 1946, inclusive. It will be seen that the rate in the United States was at all times greater than that over seas. All overseas theaters reported relatively low rates. Annual rates per 1,000 strength recorded for the European Theater of Operations by Lt. Col. Theodore L. Badger, MC, senior consultant in tuberculosis in the theater for 3 1/2 years of war, were as follows: 1942, 0.89; 1943, 1.27; 1944, 0.76; 1945 (1 January to 31 May), 0.69.⁹ The average admission rate for the Mediter-

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⁹ Semiannual Report of the Senior Consultant on Tuberculosis, Office of the Chief Surgeon, European Theater, 1 Jan. 1945 to 30 June 1945.

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ranean (formerly North African) Theater of Operations from November 1942 to May 1945, as recorded in the theater, was 0.58. Chart 25 shows the rates for all theaters for the years 1942-45 on the basis of returns in the statistical health reports.

CHART 24.-Incidence of tuberculosis among U. S. Army troops in the United States and overseas, January 1942 to June 1946, inclusive

As has been pointed out (chart 24), during World War II tuberculosis was more prevalent in troops in the United States than in troops in overseas theaters. The opposite was evident, however, at the time of discharge. Figures from separation examinations in the Zone of Interior, assembled separately for those who had service in the United States only and for those who had service overseas, showed a striking difference.¹⁰ Chart 26 illustrates the difference in withdrawals for tuberculosis in the two groups. It is evident at once that diagnoses of probable tuberculosis in soldiers with overseas experience were considerably more frequent than in troops with Zone of Interior service only.

The explanation would not seem difficult. Troops overseas presumably actually did acquire new infections to a somewhat greater extent than troops in this country. Most of these infections were minimal and therefore were

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¹⁰ Long, E. R., and Hamilton, E. L.: A Review of Induction and Discharge Examinations for Tuberculosis in the Army.Am. J. Pub. Health 37: 412-420, April 1947.

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not discovered on a symptomatic basis nor recorded in the normal admission rates in the theaters. When the millions of troops with and without foreign service were discharged at separation centers, roentgen examination was

CHART 25.-Incidence of tuberculosis in the U. S. Army, by theater and year, 1942-45

CHART 26.-Withdrawals from separation processing,for pulmonary tuberculosis ¹ in the U. S. Army separation centers, July 1945 to August 1946

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universal. ¹¹ Hundreds of small lesions, undetectable by any other means, were found. The examinations were of the same character for both groups of troops.The conclusion would seem inescapable that some significant factor operated overseas to make the rate in troops with overseas service greater. The excessive rate could not be attributed entirely to the strenuous nature of overseas service, for many overseas troops had approximately the same type of service as troops in the Zone of Interior. The simplest explanation, and the most logical, would seem to be that the excess of lesions found in troops with foreign service represented overseas infection in the numerous regions where United States troops were in close contact with populations with far higher tuberculosis rates than the rate in the United States. For such an explanation to be valid, however, it would be necessary to exclude from consideration lesions which were present at induction but which, because of their small size and apparent innocuous character, were not judged to be a cause for rejection.

Certain pitfalls in such a deduction, however, have been pointed out by Long and Jablon in the study previously cited. This study showed for white soldiers some increase in risk in service in Europe and Asia, presumably related to civilian contact. Among nonwhite troops in the Mediterranean theater, in which civilian association was known to be unusually great, the figures demonstrated an excessive rate of tuberculosis at discharge. It was impossible to establish a positive correlation between the development of tuberculosis and illness known to result from civilian contact, such as venereal disease. On the whole, the evidence did not indicate a strikingly greater risk of acquisition of tuberculosis in the Army overseas than in the Army in the United States. Certain exceptions to this conclusion were clear, however. Rates among Medical Department personnel with foreign service, among nonwhite troops stationed for long periods in port areas, and in military personnel who had been prisoners of war were found to be excessive.

The study by Long and Jablon should be consulted for detailed information concerning the development of tuberculosis with respect to age, race, home environment, and length of Army service. Space does not permit extensive review here. A definite correlation with youth was evident, and rates in general were higher for nonwhite than for white troops. The most significant factors, however, were those listed above.

Before the subject of prevalence of tuberculosis in the Army is concluded, some reference should be made to tuberculosis mortality in the Army. A proper analysis of Army mortality should take into account mortality after discharge as well as deaths in the Army, as the majority of persons destined to die of the disease were transferred from the Army to the Veterans' Administration. In an Army of approximately 4 million men in 1942, the tuberculosis mortality was less than 4 per 100,000 persons. The combined figure for personnel on duty and discharged personnel in later years, when the Army was much larger, increased to about 6 per 100,000 in 1943, 10 in 1944, and 12 in 1945. The

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¹¹ War Department Technical Manual 8-255, Terminal Physical Examination on Separation From Military Service, 10 Sept. 1945.

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higher rates of the later years reflected the time required for mortality to succeed onset of disease, as well as the cumulative increase of cases in a population originally almost free from tuberculosis. Army mortality figures have been analyzed in some detail by Aronson, ¹² who called attention to a rising mortality in Army personnel with rise in age and to the fact that, despite similarity of living conditions, income, and military duties, the Negro race, representing about 10 percent of the Army population, contributed 43.4 percent of the deaths from tuberculosis.

Preventive Measures

Theater measures.-No specific screening to exclude tuberculosis was practiced immediately prior to departure of troops for overseas. The magnitude of the task of making new roentgen examinations on such a large body of troops prohibited the procedure. On the other hand, there is every reason to believe that many soldiers with tuberculosis were automatically eliminated from troops going overseas. The rigors of basic training probably brought to light many of the cases which, in spite of the presence of small active lesions, were overlooked at induction. A few, but not many, cases were detected by the physical examination made routinely just before departure for overseas service. Cases that escaped discovery prior to departure from the United States were detected from time to time in overseas areas in the course of numerous roentgen examinations for respiratory disease or for special survey purposes. Surveys were made from time to time in Army Air Force personnel, and roentgen examination was required before assignment to officer candidate schools.

On the whole, roentgen examination of troops was a frequent procedure overseas and not a few asymptomatic cases was found. Such widespread roentgen examination resulted in the discovery of many inactive cases that had been knowingly inducted because the lesions seen were believed healed and within acceptable limits in size. These cases constituted a problem of disposition. Medical officers overseas, in ignorance of the fact that the small lesions were previously studied and considered acceptable, returned many such cases to the Zone of Interior rather than continue them as medical risks where responsibilities were so great.

Facilities for the detection of tuberculosis were first class, even up to the frontline. Not a few cases were discovered and worked up thoroughly by roentgenographic examination and laboratory tests for tubercle bacilli in evacuation hospitals within a few miles of the front.

Altogether, such measures probably detected most cases of open tuberculosis within a relatively short period of their development as open, contagious cases and prevented much dissemination within the Army.

Beyond this, relatively little precaution was taken to prevent tubercu-

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¹² Aronson, J. D.: The Occurrence and Anatomic Characteristics of Fatal Tuberculosis in the U. S. Army During World War II. Mil. Surgeon 99: 491-503, November 1946.

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losis. Specific measures that might have been used are discussed in following paragraphs. Official directives were considered necessary only in the case of one type of tuberculous infection in which the hazard was recognized and the method of prevention was clear. This infection was milkborne tuberculosis. In most countries of the world, bovine tuberculosis is far more, prevalent than in the, United States. The hazard from bovine infection in this country is virtually negligible. It is well known that much of the milk for general consumption in the British Isles during the war contained tubercle bacilli. The Army Veterinary Service was well aware of this situation and issued several directives requiring discontinuance of purchase of milk unless the source could be approved.¹³ These regulations sharply restricted the purchase of milk and imposed rigid standards with respect to its source. After the early months, very little British milk was consumed in the official ration. As a matter of fact, most of the milk consumed everywhere in the Army overseas was dried milk from the United States, in which full precautions had been taken to prevent contamination. There is little reason to believe that any significant amount of bovine tuberculosis was acquired either overseas or in the United States.

The evacuation of tuberculous soldiers presented a special problem in preventive medicine. Tuberculous patients were congregated in relatively small space for transfer back to the Zone of Interior. Theater surgeons recognized the danger of contagion, and efforts were made on hospital ships and airplanes to provide facilities minimizing transmission of infection. Unfortunately, a considerable number of tuberculous patients had to come back in troop-class quarters, and in these cases, proper precautions could not be taken. It is impossible to estimate how much transmission of tuberculosis took place in this way.

Quarters on hospital ships were usually fully adequate for tuberculous patients. Fortunately, relatively few cases of acute contagious diseases were evacuated from overseas, and, accordingly, the space originally reserved for such patients was turned over to tuberculous patients.

Insofar as possible, when troops were returned by airplane, tuberculous patients were held until a planeload accumulated. They were then transferred to the Zone of Interior in a single group, with a noncommissioned officer of the Medical Department and a nurse in charge.

Specific measures.-Measures employed for the prevention of tuberculosis in theaters of operations were general rather than specific. All medical officers were aware of the possibility of development of tuberculosis, and frequently, although by no means invariably, when cases were discovered in quarters, soldiers in the same barracks or billet were subjected to roentgen examination to determine if infection had been transmitted. In all probability, in the majority of cases, this was a gesture rather than an effective procedure because the examination so ordered was usually made too soon to discover

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¹³ (1) Circular No. 40, Headquarters, European Theater of Operations, U. S. Army, 5 Sept. 1942.(2) Circular No. 72. Headquarters, European Theater of Operations, U. S. Army, 10 Nov. 1942.

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active cases and because, adequate followup under the conditions of overseas service was impossible. Actually, such surveys not infrequently disclosed cases of inactive tuberculosis which had been admitted at induction stations knowingly or unknowingly; these, as pointed out above, at once constituted a problem of disposition.

Overseas medical officers had inadequate nutrition in mind as a possible factor predisposing to tuberculosis. Each of the several histories prepared by officers assigned the task of analyzing records with respect to tuberculosis in the specific theaters mentioned malnutrition as a possible predisposing influence. Actually, no correlation was discovered between the occasional forced periods of impaired nutrition in frontline positions and subsequent development of tuberculosis. As already pointed out, a study by Waring and Roper showed that other factors, particularly physical strain, predisposed more than any other factor, including nutrition, to breakdown from the disease.

Unfortunately, no sustained educational program with respect to tuberculosis was possible. The circumstances of military service were not conducive to such education. Occasionally, under unusual circumstances, an educational campaign was carried out. Troops in Manila, Philippine Islands, after the city was recovered, were warned against the danger of tuberculosis. The extremely high rate in the, population of the Islands impressed medical officers at the time, and the Surgeon General's Office was asked to provide educational material to indicate to the troops the danger and the way to avoid it.

Early in the war, the advisability of BCG (bacille Calmette Guérin) vaccination was discussed. Considerable pressure was brought upon the Office of the Surgeon General to make it routine in the Army. The Surgeon General decided that its value was not fully established and that, with so many other inoculations of fully demonstrated efficacy, it was impractical to add one the value of which was uncertain.

Thus, in the last analysis, the program for prevention of tuberculosis rested on the two procedures of most value in the country as a whole: early diagnosis through case finding and hospitalization for isolation and treatment.

Special Problems

Prisoners of war and displaced persons.-The recovery of American prisoners of war, captured by the Germans and Japanese in various phases of the conflict and liberated in the late months of the war, created a new problem in preventive medicine for the Medical Department of the United States Army. A still greater problem resulted from the assumption by the Medical Department of responsibility for the medical care of thousands of aliens who had been held prisoners by the Germans and Japanese and who were liberated by the advancing armies of the United States in the spring of 1945.

Admission rates for tuberculosis in recovered United States military personnel were higher than in the Army as a whole. The increase was not

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alarming nor such as to suggest that excessive exposure had taken place during the period of confinement. However, the conditions of confinement were rigorous, and malnutrition was particularly severe. There is reason to believe that these conditions caused breakdown in many men who were held prisoners over a period of several months.

In their study of the medical records and induction and separation X-ray films of 6,099 men, Long and Jablon found that among white men with overseas experience, for whom their figures were statistically significant, the prevalence of tuberculosis at the time of discharge from the Army was approximately three and one-half times as high among men who had been prisoners as among those who had not (figures chiefly for men captured by the Germans). In another investigation, Cohen and Cooper ¹⁴ found that the prevalence of active tuberculosis among United States prisoners of war at the time of their liberation was 6 per 1,000 for those captured by the Germans and 37 per 1,000 for those captured by the Japanese. The latter had experienced more rigorous prison conditions. These figures, of course, do not take into account the mortality from tuberculosis in prison camps, which is believed to have been high in Japan.

Most of the recovered prisoners were routed back to the United States through an established chain of hospitals and ports of embarkation. The problem was the same as that of ordinary personnel, except in degree. Recovered prisoners with tuberculosis returned to the United States in the normal manner, chiefly in hospital ships, and on arrival were sent to one of the special tuberculosis hospitals. The largest number of enlisted men with tuberculosis went to Bruns General Hospital, Santa Fe, N. Mex. The load was at no time severe enough to cause an undue strain on Zone of Interior hospital facilities or to constitute an excessive danger through contagion for nurses and other military personnel.

In marked contrast, the problem of care for liberated displaced personnel held by the Germans and Japanese was a severe one. At times, in eastern France, it was critical. Thousands of Russians, Poles, Hungarians, Yugoslavs, Italians, and persons of other nationality were found in hospitals or workcamps following the German retreat in eastern France. A high percentage of these inmates had tuberculosis, commonly in a far-advanced stage. It was necessary for the Army to establish several hospitals for the care of these patients. The 46th General Hospital at Besancon, with more than 1,000 tuberculosis patients of foreign nationality, was the largest tuberculosis center of the United States Army, exceeding Fitzsimons General Hospital in its census of tuberculous patients. The 50th General Hospital in Commercy also had a large number of such patients, and smaller numbers were scattered through various general hospitals throughout eastern France. The condition in which these patients were received was deplorable. Many were moribund on admission. Language difficulties and long years of abuse had destroyed all sense of discipline,

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¹⁴ Cohen, Bernard M., and Cooper, Maurice Z.: A Follow-up Study of World War 11 Prisoners of War. Washington: U. S. Government Printing Office, 1954.

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so that the problem of medical care was exceedingly difficult. The exposure of medical personnel in these hospitals was high.

Fortunately, the senior consultant in tuberculosis in the area, Colonel Badger, was aware of the possibility of contagion. At his instigation, a series of important circulars with reference to the gravity of the problem were promulgated from the Office of the Theater Chief Surgeon, and directives were issued establishing a sanitary code in these hospitals that reduced contagion to the minimum possible. ¹⁵ Ultimately, tuberculosis aliens of this type were concentrated in a small number of hospitals, particularly the 46th General, and those surviving were repatriated through displaced-personnel channels.

The problem of care of enemy prisoners of war was much less complicated, as the primary burden was thrown upon captured medical officers of the enemy nations. Almost no exposure of United States personnel was involved, and the preventive medicine problem was minor.

Military Government.-After V-E Day and V-J Day, the medical departments of the occupying forces were concerned with the public health problems of the occupied countries. The postwar tuberculosis rate was high in Italy, Germany, and Japan. Prior to the war, the tuberculosis mortality rate in Germany was little more than that in the United States. The vicissitudes of war, the hardships of the laboring population, the breakdown of tuberculosis control measures, the importation of foreign labor unscreened for tuberculosis and other factors combined to double the mortality rate from tuberculosis in Germany. Most of the tuberculosis sanatoriums were in use for other purposes, particularly for the care of wounded and sick prisoners of war. Hence, tuberculosis patients who normally would have been in tuberculosis hospitals and sanatoriums remained at home, where they served as foci for infection of others. Conditions were similar in Italy and Japan.

Immediately after the war in Germany, a tuberculosis section was established in the Public Health Branch of Military Government, and the chief consultant in tuberculosis in the Office of the Surgeon General was asked to serve in this office during the early postwar months. The first objective was to restore reporting to a normal state, so that the magnitude of the problem could be learned. Fortunately, basic laws were in effect that made this relatively easy, and the primary public health organization at the Land level had been preserved. Trustworthy figures were soon obtained, and with the passage of time both case finding and hospitalization of discovered cases improved, so that less exposure of the population took place.

In each Land in Germany, the peak of mortality occurred in 1945 or 1946, after which a steady decline in tuberculosis mortality occurred.¹⁶ The role of the medical departments of the occupying forces included such aid as could
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¹⁵ (1) Circular Letter No. 41, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U. S. Army, sec. 11, 11 May 1945. (2) Letter, Col. E. R. Long, MC, Consultant in Tuberculosis, Office of the Surgeon General, to The Surgeon General, 28 May 1945, subject: Visit of Tuberculosis Consultant in European Theater of Operations, ignited States Army.
¹⁶ Sartwell, P. E., Moseley, C. H., and Long, E. R.: Tuberculosis in the German Population, United States Zone of Germany. Am. Rev. Tuberc. 59: 481-493, May 1949.

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be given the population through surplus Army supplies and food and steady insistence on accurate reporting by the German public health authorities to the statistical service of military government.

In Japan, extraordinarily high tuberculosis rates prevailed before the war, and these became exaggerated in the late years of the conflict. Progress in control by military government was similar to that in Germany, and ultimately remarkable success in lowering the death rate occurred. In this achievement, the Japanese themselves and medical officers from the occupying forces gave great credit to BCG and related vaccines used by the Japanese. It appears doubtful, however, that vaccination could have had such a striking rate so early. Presumably, various forces, as in Germany and other countries, were concerned.

Progress in Prevention During the War

The Army's experience in the control of tuberculosis during World War II, combined with that gained in World War I, resulted in a good understanding of organization in screening for tuberculosis. This experience found application on a large scale in later case-finding programs throughout the Nation. It should be equally valuable in military orientation whenever the need for similar operations arises again. The vast program of roentgenologic, examination for tuberculosis carried out in induction stations was repeated on a mammoth scale in much more rapid fashion at discharge. Not long after the separation procedure was concluded, however, induction and separation centers were closed, and within a few months after the war roentgenologic examination at stations of enlistment was no longer an established procedure. The methods in operation before the war prevailed, and roentgen examination was not made at ordinary recruiting stations. Also, unfortunately, the requirement for roentgen examination at the first station following enlistment often was not fulfilled.

The experience of the induction stations showed the need for greater efficiency in roentgenologic screening to prevent acceptance of men with active or potentially active lesions. The cost to the United States Government of long-term care of patients with tuberculosis in the Army or in the Veterans' Administration is so great that the relatively minor expense of extreme care in acceptance of men at induction should not be opposed.

The hospitalization system carried out by the Army for tuberculosis was excellent. Army hospitals improved coincidentally with civilian hospitals in the medical and surgical treatment of tuberculosis during the years of the war. The isolation of tuberculous soldiers in Army hospitals, supplementing that of civilian hospitals and governmental hospitals of municipal, county, State, and Federal operation, was an important factor in removal of sources of contagion in the country and corresponding reduction in the spread and prevalence of tuberculosis.

Careful analysis of cases of active tuberculosis discovered during the war showed conclusively that certain types of strain paved the way for breakdown

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of latent lesions. Heavy physical labor and combat conditions were notable in this respect.¹⁷

The Army, which had had little experience, except for World War I, with the problem of tuberculosis in foreign countries, learned much about opportunity for contact and sources of contagion. If the United States con tinues to maintain occupation forces in foreign countries, the problem will remain. The experience, gained through overwhelming exposure in the care of destitute displaced personnel was excellent, though severe, training for adverse conditions that might be encountered again.

Army medical officers took advantage of current advances in the diagnosis and therapy of tuberculosis, and improvement in technique in the care of patients took place steadily. Progress in bronchoscopy and surgery was notable. As the war closed, new antibiotic methods of therapy were coming into practice, but antibiotic therapy in tuberculosis in general was a postwar rather than a war development.

Army medical officers shared with civilian tuberculosis specialists in developing new understanding of the recognition of small lesions, of the relation of pleurisy with effusion to tuberculous infection, and of the need for prompt care and isolation of cases if the progress of the disease was to be prevented and spread of infection checked. The remarkably good clinical progress made by men whose disease was detected in a minimal stage, a frequent finding on discharge, was of high value in bringing home the excellent prognosis of small tuberculous lesions when discovered and treated in time.

SUMMARY

1. Tuberculosis was first recognized clearly as a military problem in World War I. In spite of specific efforts to prevent the acceptance of recruits with tuberculosis, a considerable number of men entered the Army with this disease, and a large and costly burden in medical care and compensation was left as a Federal responsibility.
2. Between World War I and World War II, great progress was made in the diagnosis of tuberculosis. Rapid methods of examination, including the use of paper films and photofluorography, led to significant advance in case finding.In addition, the number of beds available for tuberculosis was greatly increased, and opportunities for spread of the disease correspondingly decreased. During this period, a continuing decline in tuberculosis mortality occurred in the United States, as well as in the rest of the Western World.
3. During World War II, in the light of the experience of World War I, an intensive effort was made to exclude tuberculosis at induction. An X-ray program was instituted at the outset. This program was imperfect at the start, but after March 1942 all men entering the Army had a chest roentgen examination before acceptance for service. The examination itself had its
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¹⁷ See footnotes 7 and 8, p. 264.

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imperfections, however, and it is estimated that approximately 15,000 men with active tuberculosis were admitted to the Army either as a result of omission of roentgen examination in the early months or failure to detect tuberculosis in films made after their use became routine.
4. Subsequent studies showed that a considerable number of these men broke down with clinical disease during service in the Army. The experience of Army tuberculosis hospitals indicated that, during the first 2 years of the war, a majority of the men developing tuberculosis in service were men who entered the Army with the disease already present. Postwar investigation of induction and separation X-ray films on file in the Veterans' Administration demonstrated that approximately one-half of the men ultimately discharged by reason of tuberculosis entered the Army with the disease.
5. In addition to those who developed tuberculosis as a result of the flaring up of lesions undetected on entrance into the Army, a significant number acquired tuberculosis during Army service, presumably as a result of exposure to the disease. There is reason to believe that this resulted from contact with tuberculosis both in the United States and abroad and from military as well as civilian contacts.
6. A comparison of admission rates for tuberculosis in the Army in the Zone of Interior and in overseas theaters shows that throughout the war the rate was higher for Zone of Interior than for overseas troops. However, there is reason to believe that a significant amount of early tuberculosis was overlooked overseas, because roentgen examination at time of separation disclosed a somewhat higher rate of tuberculosis in men with overseas service than in those with Zone of Interior service only.
7. The principal measures for control of tuberculosis in overseas theaters were early diagnosis and evacuation to the United States. Many examinations were made in the course of routine studies, as for promotion to officer status, and in the diagnosis of acute chest disease. Men with active tuberculosis and men in whom activity was suspected were evacuated to the Zone of Interior for further observation and care. Thus, the theaters depended upon diagnosis, isolation, and care for the control of tuberculosis.
8. Tuberculosis in recovered United States prisoners of war was a problem of some concern to the Army. The tuberculosis rate in recovered prisoners was considerably higher than in the Army as a whole, although far short of that prevailing in recovered prisoners in other armies.
9. The greatest amount of tuberculosis encountered by the Medical Department of the United States Army during the war was in displaced personnel of other nationalities recovered by the Army during the occupation of areas previously in the hands of the German Army. Huge numbers of patients with tuberculosis were found in displaced personnel camps abandoned by the Germans, and their care became a difficult problem for the hospitals of the Army.

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10. Military government assumed the control of tuberculosis as one of its public health functions during the period of occupation after the war. The principal responsibilities of medical officers of military government with respect to tuberculosis were the restoration of normal practice in reporting and the provision of an adequate number of beds for the care of tuberculous patients.
11. During the war, notable advances took place in the control of tuberculosis, in which the Army shared.Perhaps the most important of these was improvement in methods of case finding, through mass roentgen examination. In addition, provision for isolation was much improved, and advances were made in surgical therapy. At the end of the war, the antibiotic treatment of tuberculosis was under consideration. Actually, no cases of tuberculosis were so treated in the Army prior to the end of 1945, although subsequently Army hospitals contributed greatly to the development of chemotherapy in tuberculosis.
12. Research in the Army advanced the knowledge of the causes of breakdown from tuberculosis and indicated what types of strain are particularly likely to lead to relapse and what strains individuals withstand without break down of latent lesions. Light was thrown upon the relation of pleurisy with effusion to tuberculosis, and renewed emphasis was placed on the danger of small lesions whose activity is difficult to determine.
13. In general, Army experience indicated the great importance of means for exclusion of tuberculosis. It was clearly evident that measures for this purpose should be continued without fail and improved with the advance of technical methods. Inasmuch as numerous lesions believed to be inactive are seen and become a cause for later inquiry, it is desirable that in the future such lesions be recorded on each soldier's immunization or other record.