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Chapter XI

Contents

CHAPTER XI

Tuberculosis

Esmond R. Long, M.D.

Part I. Tuberculosis in the Army

HISTORICAL PERSPECTIVE

For centuries, tuberculosis has been a principal cause of death in men of military age. In the 4-year period 1942-45, pulmonary tuberculosis, although steadily declining in prevalence throughout the country, was still the chief cause of disease death in the United States in men between the ages of 15 and 35 years. In most countries of the world, the relative importance of tuberculosis was much greater than in the United States. In all armies in all countries, whenever accurate records have been kept, it has proved to be a leading cause of disability, adding appreciably to the noneffective rate, making disproportionate demands upon the time and effort of medical officers as well as upon hospital and transport facilities needed for other diseases and for battle casualties.

The U.S. Army has maintained records of hospital admissions and military discharges for tuberculosis since the Civil War. An account of this disease as a military problem appeared in the "Medical and Surgical History of the War of the Rebellion" (pt. III, vol. I, Medical History) prepared under the direction of The Surgeon General and published in 1888. During nearly 51/6 years of military mobilization and operation, 13,499 admissions for consumption and 5,286 deaths in white soldiers were reported. As calculated from these figures, the admission rate was 5.7 and the mortality rate was 2.2 per 1,000 per annum (table 46). In view of the relatively limited diagnostic facilities of the period, it is reasonable to suppose that the actual incidence was very much higher. As a matter of fact the reporting itself was at fault, for the figures for discharge are higher than the number of hospital admissions for consumption. The records indicate that 20,403 white soldiers were discharged because of this disease, an excess of 12,190 over the admissions, and this figure does not include those who died of consumption. The reasons for the discrepancy are complex, involving multiple causes of disability and the return of consumption cases to duty. The mean annual rate of discharge for consumption in the Army in the Civil War, calculated from the figures given in the "Medical and Surgical History of the War of the Rebellion," was 8.6 per 1,000 for white soldiers and 3.1 per 1,000 for Negro troops.


330

TABLE 46.-Admissions, deaths, and disability separations due to tubercular diseases in the U.S. Army (Union only), by diagnosis and race, May 1861-June 18661

[Rate expressed as number per annum per 1,000 average strength]

Diagnosis and race


Admissions

Deaths

Disability separations


Number

Rate

Number

Rate

Number

Rate

Consumption:

 

 

 

 

 

 

    

White

13,499

5.67

5,286

2.23

20,403

8.58

    

Negro

1,331

6.94

1,211

6.32

592

3.08


Total

14,830

5.77

6,497

2.53

20,995

8.17

Scrofula:

 

 

 

 

 

 

    

White

6,022

2.53

99

0.04

907

0.38

    

Negro

2,508

13.08

81

.42

147

.77


Total

8,530

3.32

180

0.07

1,054

0.41

Other tubercular diseases:

 

 

 

 

 

 

    

White

369

0.16

33

0.01

---

0

    

Negro

20

.10

4

.02

---

0


Total

389

0.15

37

0.01

---

0

Total tubercular diseases:

 

 

 

 

 

 

    

White

19,890

8.36

5,418

2.28

21,310

8.96

    

Negro

3,859

20.12

1,296

6.76

739

3.85


Total

23,749

9.24

6,714

2.61

22,049

8.58


1Data for Negro troops are for the period, July 1863-June 1866; there were no Negro troops prior to July 1863 in the Union Army.
Source: The Medical and Surgical History of the War of the Rebellion. Medical History. Washington: Government Printing Office 1875, pt. I, vol. I, pp. 636-637, 646, 710, and 716.

In the short Spanish-American War moderately high rates were recorded. For the decade preceding hostilities the average admission rate in the Army was 2.7 per 1,000 per annum, but in 1898, following accelerated enlistment and the call of the National Guard to service, it rose to 3.7, and in the following year reached 4.0.

In neither the Civil War nor the Spanish-American War, however, was tuberculosis considered of sufficient moment to call for unusual comment in the recorded analyses of the medical aspect of military operations. It was entirely different in World War I. The French Army recorded a great increase in the incidence of pulmonary tuberculosis during the first 5 months, especially in French prisoners returned from Germany. The French experience was sufficiently striking to engage the prompt attention of American authorities, who set up special machinery for the control of tuberculosis in


331

the U.S. Army. These procedures have been described at length by Col. George E. Bushnell, MC, and Col. Esmond R. Long, MC.1

Following demobilization, the incidence of tuberculosis in the U.S. Army decreased continuously for 20 years. The incidence rate was 4.6 per 1,000 troops per annum in 1920 and 1.4 in 1940. General improvement in measures for the control of tuberculosis in the Army, and a steady decrease in tuberculosis in the population were largely responsible for this decline.

DISCOVERY OF TUBERCULOSIS BEFORE INDUCTION

The magnitude of the tuberculosis problem in the Army in World War II, although substantial in the aggregate, was relatively much less than in any previous conflict. To begin with, a smaller proportion of men eligible for induction were tuberculous. In 1917, the national death rate from this disease was approximately 140 per 100,000 population. In 1941, it was less than one-third of that, or 45 per 100,000 population. The rejection ratio for tuberculosis, all forms, actual or suspected, among men examined at camps and by local boards during World War I was 2.3 percent. Nearly 3.8 million men were examined during World War I.2 Even with the much superior diagnostic facilities of the Army in the Second World War, the rejection rate was much lower from the onset, averaging less than 1 percent for the entire period of mobilization.3

In World War I, the detection and exclusion from military service of men with tuberculosis were based almost entirely on the results of physical examination. Roentgenology was in its infancy, and only a few thousand soldiers were examined by X-ray. All experience since that time has indicated that physical diagnosis by even the most skillful, is much inferior to the roentgenographic methods in use at present. During the total course of mobilization for World War II, not less than 20 million men were examined roentgenographically in the Army enlistment stations and in the joint Army-Navy induction stations. Colonel Bushnell's conclusion on the value of X-ray examination in World War I is striking in the light of subsequent developments. It was based on the work of Matson,4 and reads: "As compared with the physical examination, the roentgenological examination, even when done by an expert, occupies a place of secondary importance in the diagnosis of tuberculosis of clinical significance." However, as Spillman5

1(1) The Medical Department of the United States Army in the World War. Washington: U.S. Government Printing Office, 1928, vol. IX, pp. 171-202. (2) Long, E. R.: The War and Tuberculosis. Am. Rev. Tuberc. 45: 616-636, June 1942. (3) Long, E. R.: Tuberculosis as a Military Problem. Am. Rev. Tuberc. 51: 489-504, June 1945.
2Britten, R. H., and Perrott, G. St. J.: Summary of Physical Findings on Men Drafted in the World War. Pub. Health Rep. 56: 41-62, 10 Jan. 1941.
3Medical Department, United States Army. Physical Standards in World War II. [In preparation.]
4Matson, R. C.: The Elimination of Tuberculosis From the Army. Am. Rev. Tuberc. 4: 398-416, July 1920.
5Spillman, R.: The Value of Radiography in Detecting Tuberculosis in Recruits. J.A.M.A. 115: 1371-1378, 19 Oct. 1940.


332

wrote, the chest specialists of those days are "not to be reproached for not having knowledge that came into existence only later, any more than the chief of the army air service in 1917 is to be reproached because more efficient planes are available now than then."

During World War I, there were 22,812 disability separations due to tuberculosis, or 5.52 separations per annum per 1,000 average strength. If related to the number of men who served in the Army during the First World War, the proportion would be about 0.56 percent. Tuberculosis was the leading cause of disability separation, accounting for 11.1 percent of the total (204,765) and 13.5 percent of separations due to disease (169,039).6 In World War II for enlisted men, it was 13th in the list, accounting for only 1.9 percent of all discharges for disability from disease.7

The full magnitude of the tuberculosis problem incurred in World War I did not become evident until several years had passed. The postwar cost proved enormous. Goldberg8 calculated that the approximate expenditure of the Veterans' Administration for service-connected tuberculosis, including hospitalization and pension costs, from the close of World War I through 1940 was $1,186,000,000. To this vast monetary expense must be added millions of dollars spent by the Army and the Navy on tuberculosis patients prior to their discharge. Admissions to veterans' hospitals totaled 293,761 for the years 1921 to 1940, inclusive.

The peak load for hospitalized tuberculosis beneficiaries was reached in 1922 when a total of 44,591 such patients were treated in Government hospitals at a cost of almost $30 million.9 As early as 30 June 1922, 36,600 veterans, or 1 in 130 persons in the Army, had been granted compensation for service-connected tuberculosis.

At the beginning of the Second World War, it was resolved not to repeat the experience of the First World War. It was recognized that the earlier high admission rate was largely due to the acceptance of men who were already infected. In Colonel Bushnell's opinion, relatively few men developed fresh infection in the Army. It was clear to the Office of the Surgeon General that modern methods could be highly effective in excluding the early types of tuberculosis that escaped recognition during the mobilization of 1917. The reader is referred to the chapter on tuberculosis in another volume in the history of the Medical Department in World War II for the general procedures employed at induction stations, and for a picture of the enormous extent of preinduction examination by X-ray.10 Other

6The Medical Department of the United States Army in the World War. Washington: Government Printing Office, 1925, vol. XV, p. 2.
7Health of the Army, Office of the Surgeon General, vol. 1, 31 Aug. 1946.
8Goldberg, B.: Presidential Address: War and Tuberculosis. Dis. of Chest 7: 322-325, October 1941.
9Wolford, R. A.: The Tuberculosis Program of the Veterans Administration. M. Bull. V.A. 21: 127-135, October 1944.
10See footnote 3, p. 331.


333

sections of the chapter describe measures to prevent the development of tuberculosis within the Army.

It is obvious that, in an army well screened to exclude men with active tuberculosis, contagion among troops would be slight. However, it must be realized that not all tuberculosis is visible in chest films and that a certain amount of pulmonary and nonpulmonary tuberculosis may be expected to develop as a result of endogenous spread from undetected foci. The longer the war, the more cases would develop from such hidden foci, and also from fresh, exogenous infections. In the Second World War, the period of mobilization and of hostilities was more than twice as long as in the First World War. Hence, it will not be surprising if research ultimately shows that tuberculosis spreading from lesions not detectable at the time of mobilization, on the one hand, and from fresh infections, on the other, were together responsible for a considerably larger share of the total number of cases discovered in the Army in World War II than was believed to be the case in World War I.11

DISCOVERY OF TUBERCULOSIS IN THE ARMY

The general machinery for discovery of tuberculosis in soldiers after acceptance for service was the same as for any other chronic disease; it was discovered both on the basis of symptoms and as a result of routine examination for any cause. Cases manifested by symptoms were diagnosed at sick call as suspected tuberculosis and were then referred to the station hospital serving the post at which the call was made for necessary observation and further diagnostic procedures. All station hospitals were thus concerned with the diagnosis of tuberculosis. Not all station hospitals, however, included on their staffs medical personnel qualified to recognize tuberculosis of minimal extent or borderline activity. Doubtful cases were referred to general hospitals for followup and accurate observation.

11Long, E. R., and Jablon, S.: Tuberculosis in the Army of the United States in World War II. An Epidemiological Study With an Evaluation of X-ray Screening. VA Medical Monograph. Washington: U.S. Government Printing Office, 1 May 1955.
Postwar epidemiological and statistical study based on adequate sampling of men discharged with and without tuberculosis disclosed that approximately half of the men discharged for tuberculosis had the disease in roentgenologically detectable form at the time of acceptance for service, the lesions having been overlooked through induction station errors. There was reason to believe that of the other half a part represented new infections acquired in army service and a part the breakdown of old lesions not detectable by X-ray examination. Since routine tuberculin tests were not made at the time of induction, it was impossible to distinguish between these two groups. This study, in which all the films were read independently by two roentgenologists, with subsequent checking by two others, also disclosed a significant degree of fallibility in single chest X-ray interpretations. Not only did the two roentgenologists fail frequently to agree with each other, but in numerous cases they also failed to agree with themselves on reading the same films after an interval of a few months. It is now recognized that such discrepancy is general experience. The paper cites other reports in which similar lack of agreement was recorded. (See also Long, E. R., Stein, S. C., and Henderson, H. J.: Experiences With Dual Reading of Chest Photoroentgenograms. U.S. Armed Forces M.J. 7: 493-515, April 1956.) In the latter study, actual trial was made of dual reading in three Armed Forces examining stations. Comparison of the readings by the roentgenologist of the station of origin of the films and the roentgenologist of another station showed considerable disagreement in interpretation.


334

In addition, a good many cases were discovered in the course of routine X-ray examinations. Not a few were found in men applying for admission to officer candidate schools or for a commission at the termination of study in these schools. Many were found also in routine examinations for special service, particularly in the Army Air Forces, where many men were reexamined.

Moreover, tuberculosis was sometimes discovered incidentally to other illness requiring roentgenographic study. In the course of the long series of epidemics of atypical pneumonia that occurred during World War II, vast numbers of roentgenograms were made of the chests of men with the symptoms of pneumonia. Not infrequently, shadows in the lung fields persisted after clearing of the consolidation due to pneumonia and were shown by subsequent examination to represent tuberculous infiltration. A high percentage of these infiltrations were found to be well-scarred lesions, but in an appreciable number the process proved to represent active tuberculosis, requiring continued hospitalization.

INCIDENCE AND DISCHARGE RATES

Incidence rates-The average incidence rate in the First World War, approximately 12 cases of tuberculosis per 1,000 men per annum for the years 1917 and 1918, was ten times that for World War II, which averaged 1.2 per 1,000 per annum between Pearl Harbor Day (7 December 1941) and V-J Day (14 August 1945). (See chart 17.) Nevertheless, in spite of better diagnostic facilities and techniques in the second great conflict, from 10 to 15 men with active disease per 10,000 accepted escaped detection in induction stations and were taken into the Army.12 Moreover, about a million men in World War II were inducted into the Army before roentgenograms of the chest were a routine requirement.

There is reason to believe that in each war a high percentage of the missed cases were discovered within a few months after induction. As a rule, although not invariably, symptoms soon became evident in advanced disease, leading to report at sick call, hospitalization, and diagnosis. This not greatly belated recognition of tuberculosis in recently inducted men is believed to account for a peculiarity common to the admission rate curves of the two wars. In the late months of 1917 and early months of 1918, the rate of admission to hospital was excessive as compared with that for the last half of 1918. A similar phenomenon occurred in the last half of 1941 and first half of 1942. It is believed that in each war imperfections in screening procedure were greater and more frequent at the outset than later in the course of mobilization and that an excessive number of men with disease that would soon become obvious were inducted at that time.

12Long, E. R., and Stearns, W. H.: Physical Examination at Induction. Standards With Respect to Tuberculosis and Their Application as Illustrated by a Review of 53,400 X-ray Films of Men in the Army of the United States. Radiology 41: 144-150, August 1943.


335

A second characteristic of the two curves is a terminal rise. This rise represents discovery of cases on demobilization and is in part factitious. A number of cases per thousand that greatly exceeded the previous monthly average were discovered in the course of the physical examinations at discharge, which in World War II were as thorough as the induction examinations and included routine roentgenograms of the chest. The increased

CHART 17.-Incidence of tuberculosis in the U.S. Army in the continental United States, World War I1 and World War II

rate was artificially high because the strength of the Army from which it was calculated in accordance with conventional practice was continuously decreasing in size as a result of the process of demobilization.

The admission rate was remarkable for its relative constancy over a period of 3 years from mid-1942 to mid-1945, inclusive. The rate of about 1 case per 1,000 troops per annum reflects the number of cases missed at induction stations, plus the number that developed from new infections during service in the Army. At the close of World War II, the necessary


336

research to determine the amount of previously existent but unrecognized tuberculosis, as compared with that developing in the absence of previously detectable disease, had not been accomplished.

The admission rates for the continental United States (chart 18) were higher than those for oversea theaters. This difference during the war might be attributed to the additional screening of troops through the rigors

CHART 18.-Incidence of tuberculosis among U.S. Army troops in the United States and overseas, January 1942 to June 1946, inclusive

of basic training in the United States. The months of physically strenuous service, with daily sick call, and the frequent medical examinations for promotion or special service brought to light many men with tuberculosis, who were accordingly excluded from oversea assignment. Still more would have been excluded had it been possible to examine by X-ray all men leaving for foreign service. This was impossible because of limitations both of time and personnel, although there was a reasonably effective inspection before departure, and roentgenograms of the chest were made in individual cases whenever indicated by symptoms.

To the factors favoring the lower admission rates overseas, there existed a counterforce. In every theater of operations, the incidence of tuberculosis in the general population was higher than in the United States. There is


337

reason to believe that this higher exposure was a significant factor before the end of the war. Of men retained at separation centers in the late months of 1945 and the first half of 1946 because of X-ray evidence of tuberculosis, a significantly large majority had seen foreign service. This correlation is indicated graphically in chart 19 and is in marked contrast to the rates recorded for troops overseas and in the United States while at their respective stations. Until exhaustive research determines the origin of the lesions concerned, consideration will have to be given to two possibilities: (1) The higher rate of apparent tuberculosis in men on their return from foreign duty was the result of late development of lesions acquired during Army service overseas, and (2) the relatively low rate during foreign service was due to a less effective case-finding program overseas, leaving many cases for discovery at separation centers. The latter explanation would seem not implausible, in view of the superior facilities and more stable conditions in the United States. As with other complex problems, it is probable that each of the factors named was in part responsible for the observed discrepancy.13

CHART 19.-Withdrawals from separation processing for pulmonary tuberculosis1 in U.S. Army separation centers, July 1945 to August 1946

13Long, E. R., and Hamilton, E. L.: A Review of Induction and Discharge Examinations for Tuberculosis in the Army. Am. J. Pub. Health 37: 412-420, April 1947.


338

Discharges from service.-With minor fluctuations, the discharge rate for tuberculosis ran parallel to the admission rate throughout the war, averaging approximately two-thirds of the latter (chart 20). The other one third comprised patients hospitalized for care and study, whose tuberculosis proved not to be active.

CHART 20.-Disability discharges for tuberculosis among enlisted men in the U.S. Army, 1942-45

Physical standards governing discharge from service by reason of tuberculosis are discussed in another volume of the history of the Medical Department in World War II.14 The general principle was discharge of all men with active tuberculosis, with the exception of officers when there was reasonable likelihood that the disease could be thoroughly arrested under treatment and the officer assigned to duty of a type for which he was fitted by training and capacity. As a rule, discharge was not granted for inactive tuberculosis. Exception was made for lesions of proved activity within the period of military service and for lesions of such extent that breakdown was considered likely even though no signs or symptoms of activity were detected within the period of medical observation in the Army.

Of the several fluctuations in the rate of discharge, the only one of significance, in relation to the general admission rate for tuberculosis, oc-

14See footnote 3, p. 331.


339

curred in 1943. At that time, a change in administrative policy (War Department Circular No. 161, 14 July 1943) brought about a sudden mass discharge for disability of a large number of men classified as limited service. These men did not meet current mental and physical standards for induction although at some previous period they had passed a preinduction physical examination. Tuberculosis was not an official cause for limited service in enlisted men, but it is believed that a good many borderline cases that had constituted a problem as to disposition were discharged from service during the operation of this circular, which "brought about some relaxation in the general policy of granting CDD's [certificates of disability for discharge] during that period."15 This policy was modified (War Department Circular No. 293, 11 November 1943) by prohibiting the discharge for physical reasons of enlisted men who, although incapable of serving in a physically exacting position, might render useful service in a less exacting one.

The total number of enlisted personnel discharged from the Army for tuberculosis in the years 1942-45 was 15,387. These were divided as follows:


Year

Number

1942

2,400

1943

4,643

1944

3,533

1945

4,811


Total

15,387


The disease, as previously noted (p. 332), accounted for an average of 1.9 percent of all discharges for disability from disease, and was in 13th position in the listing of causes of disability discharge, the rate being exceeded, in numerical order, by psychoneurosis, musculoskeletal defects, psychosis, gastric and duodenal ulcers, respiratory diseases, arthritis, defects of the feet, neurological disease, ear disease, eye disease, organic cardiovascular disease, and genitourinary diseases.

Enlisted personnel discharged from the Army because of tuberculosis were transferred to the Veterans' Administration for further treatment if still in need of medical care, or to their own care if no longer in need of medical therapy.

Part II. Occurrence in Oversea Areas

EUROPEAN THEATER OF OPERATIONS

Incidence rates-The incidence rate of tuberculosis in troops in the European Theater of Operations, U.S. Army, for the years 1942 to 1945, inclusive, was less than in troops in the continental United States, as a result of factors that have been described for the Army as a whole (p. 336).

15See footnote 7, p. 332.


340

Some men had entered the Army with undiscovered lesions, but many of these were detected before assignment overseas. Subsequent study, however, indicated that the relatively low rate in oversea theaters could not be ascribed solely to the exclusion of cases discovered during basic training, during special training, or incidentally to other illness. The rate of discovery at separation centers in 1945 and 1946 in troops with foreign service was significantly higher than in those who had served only in the continental United States. It does not appear that this discrepancy was due entirely to new infections acquired overseas, but, as has been noted, there is reason to believe that case-finding procedures were more effective in medical installations in the Zone of Interior, which were relatively stable in location and personnel, than in installations subject to all the vicissitudes of conflict.16

Lt. Col. (later Col.) Theodore L. Badger, MC, Senior Consultant in Tuberculosis, European theater, reported a relatively low rate for all forms of tuberculosis in the theater, compared with that in the Zone of Interior.17 Incidence rates for troops in the European theater during 1942-45 and corresponding rates for troops in the continental United States are presented in table 47 for comparison.

TABLE 47.-Incidence rates for tuberculosis in the Army in the European theater of operations and in the continental United States, 1942-45

[Data based on sample tabulations of individual medical records]
[Rate expressed as number of cases per annum per 1,000 average strength]

Area


Year of admission


1942

1943

1944

1945

Europe

0.70

0.77

0.85

1.03

Continental United States

1.86

1.27

.97

2.13


The admission rate to a considerable extent reflects hospitalization of men reporting symptoms at sick call. X-ray surveys of unselected groups of supposedly healthy men, as a rule, reveal lesions in an early form that might not be expected to show symptoms for months. Such surveys were carried out under Colonel Badger's direction in England in 1943, on a total of 7,243 men. Seven cases of active tuberculosis were found, or 0.97 per 1,000 men examined. Ninety-one cases were discovered with small scarred lesions that appeared to be of no clinical significance; it may be assumed that a large proportion of them were within the group of healed lesions specified in Mobilization Regulations No. 1-9, 31 August 1940, as acceptable after a period of deferment and subsequent revaluation.

16See footnote 10, p. 332.
17Semiannual Report, Senior Consultant in Tuberculosis, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 1 Jan. 1945 to 30 June 1945.


341

Another survey, reported in 1945, is of interest for comparison.18 Chest roentgenograms of officer candidates at the Army Ground Forces Officers' Training Center, near Fontainebleau, France, carried out in April 1945 by Mobile X-ray Team No. 3 of the 1st Auxiliary Surgical Group under the direction of 1st Lt. (later Capt.) Harry W. Burnett, Jr., MC, brought to light only 2 cases of active tuberculosis and 2 cases of healed infiltrative tuberculosis among 5,240 men examined. This yielded the low rate of 0.38 per 1,000 men each for active and healed tuberculosis, and a combined rate of 0.76. This group cannot be considered as fully representative of the enlisted men in the theater, for it was made up of selected men who had been sent to the officers' candidate school after field demonstration of superior mental and physical fitness.

Another survey on a selected group was that made by the 365th Station Hospital. In a report covering 2 years, from April 1942 to May 1944, while this hospital was stationed in Iceland, the section for respiratory disease made chest roentgenograms of 2,897 men from detachments of troops en route to the European theater from the United States. The commonest disease in these men was atypical pneumonia. Among the total number examined, however, there were 38 cases of infiltrative active tuberculosis and 10 cases of pleurisy with effusion of presumed tuberculous etiology. In passing, it may be noted that this relative proportion of cases of pleurisy with effusion to infiltrative tuberculosis was observed generally throughout the Army. The high proportion of active tuberculosis, namely, 1.7 percent, is not surprising in a group admitted to a hospital on the basis of respiratory symptoms. In the course of the survey, 24 cases of healed infiltrative tuberculosis were seen, yielding a rate not greatly different from that reported for the theater by the Senior Consultant in Tuberculosis.

Disposition of tuberculous patients-The disposition of personnel discovered to have tuberculosis was based on the extent and severity of the lesion. An administrative memorandum, of 22 February 1944,19 directed that all patients with active pulmonary tuberculosis or with large inactive fibroid lesions the stability of which was open to question, that all patients with serofibrinous pleuritis of known or suspected tuberculosis etiology, and that all patients with nonpulmonary tuberculosis should be "boarded" to the Zone of Interior.

Personnel with residual calcifications of healed primary tuberculosis or small fibrocalcific scars of infiltrative tuberculosis, apparently inactive, were returned to duty. Provision for limited duty and observation was made for borderline cases. The directive listed the tests commonly made to determine activity, including laboratory study and observation by X-ray, and ordered

18See footnote 17, p. 340.
19Administrative Memorandum No. 22, Office of the Chief Surgeon, European Theater of Operations, to Surgeons, All Base Sections, Commanding Officers, All U.S. Army Hospitals, 22 Feb. 1944, subject: Disposition of Tuberculosis Patients.


342

that "individuals presenting an undue risk of reactivation" be evacuated to the United States.

The European theater, unlike the Mediterranean Theater of Operations, U.S. Army, had no hospitals formally established as tuberculosis centers (p. 354). Patients with tuberculosis were treated in special sections of many hospitals, with established precautions to avoid exposure of hospital personnel and other patients. Circular Letter No. 100, Office of the Chief Surgeon, European theater, dated 25 July 1944, directed that "active pulmonary tuberculosis, however small the lesion, will be treated by absolute bed rest as soon as the diagnosis has been made." It was directed also that cases of serofibrinous pleurisy of presumptively tuberculosis etiology, should be treated by bed rest until at least 2 months had elapsed after return of pulse and temperature to normal. Pneumothorax was used only for emergency cases of pulmonary tuberculosis with hemorrhage and for cases of such character that safe transport to the Zone of Interior appeared dependent on the establishment of collapse prior to evacuation. Finally, it was directed that "all cases of active tuberculosis * * * including serofibrinous pleurisy, will be boarded to the Zone of Interior in Class II, as litter patients." Evacuation was by sea and by air. Air transportation was prohibited in pneumothorax cases and for certain other patients with pulmonary tuberculosis by Circular Letter No. 102, Office of the Chief Surgeon, European theater, 4 August 1944. Air transportation was authorized for patients with early tuberculosis not sufficiently advanced to disturb respiratory function.

Incidence in nurses-Many papers have been written on the special hazards of tuberculosis to nurses, usually ascribing it to exposure to the unrecognized open case. According to most recent reports, the incidence in nurses is higher in general hospitals than in institutions for tuberculosis. The explanation usually given is that in the latter the hazard is recognized and proper precautions are taken. In general hospitals that have no special section for the care of tuberculous patients, undetected cases admitted to the wards may constitute a significant, unguarded source for spread of the disease.

The semiannual report of the senior consultant in tuberculosis in the European theater, dated 3 July 1945, called attention to an excessive and steadily rising prevalence of tuberculosis, all forms, in nurses for the 3½ years of the war. The rates, calculated from reports from the chief nurse of the theater, as given by the senior consultant, are presented in table 48.

The mean rate for the 3½ years was 3.8 times as high as the general tuberculosis admission rate for troops in the theater. The report indicated that 19 nurses developed pleurisy with effusion of presumptive tuberculous origin, and in 3 nurses other forms of active tuberculosis were found. The pleurisy with effusion accounted for about 26 percent of the total number of cases of tuberculosis, a figure holding throughout the Army.


343

TABLE 48.-Prevalence of tuberculosis, all forms, in U.S. Army nurses in the European theater, 1942-45

[Rate expressed as number of cases per annum per 1,000 average strength]

Year


Number of cases

Strength1

Rate

1942

0

5,832

0.00

1943

4

24,824

1.93

1944

30

133,723

2.69

19452

38

87,004

5.24


1Aggregate of end-of-month strengths.
2First 5 months only.

Colonel Badger, in analyzing the responsible factors, called attention to the carelessness in technique that develops in times of strain and stressed the failure of medical officers to maintain proper measures designed to prevent spread of the disease in hospitals. He instituted special control measures in those hospitals in which the greatest amount of open disease was encountered; namely, the Army hospitals in France that cared for large numbers of recovered Allied military personnel liberated from German prison camps by the advancing American Army in the Saar and Rhine regions.

After the close of hostilities in Europe, when it was expected that large numbers of troops would be deployed to the Orient, specific directions were issued to make routine X-ray examination of all nurses and other Medical Department personnel prior to their departure.20 It was impracticable to survey all personnel to be redeployed, but the special hazard of tuberculosis to personnel of the Medical Department, and particularly nurses, warranted special consideration. A few weeks later, the Japanese surrendered, redeployment to the Pacific areas was stopped, and special measures for the detection of tuberculosis were discontinued.

Incidence in Army Air Forces personnel-Except at the beginning of World War II, enlisted and commissioned personnel in the Army Air Forces were accepted for enlisted services or appointment as officers in the same manner as Army Ground Forces and Army Service Forces troops; that is, through regular induction stations, stations for enlistment, and stations qualified to give final-type physical examinations. In the early months of the war, the demand for air force personnel was so great that aviation cadets and others were frequently accepted on the basis of a physical examination that did not include roentgenograms of the chest, with the proviso that X-ray examination was to be made at the first duty station where it was practicable. The delayed X-ray examination was effective in discovering

20Circular Letter No. 60, Office of the Theater Chief Surgeon, Headquarters, Theater Service Forces, European Theater, 2 Aug. 1945.


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cases but had the disadvantage, from the point of view of governmental obligation, that the men discovered were in the Army and usually eligible for compensation. Later, this unusually rapid processing was discontinued, and prospective troops for the air forces were examined like selective service registrants in general.

Careful followup studies indicated a low incidence of tuberculosis after months or years of service in the Army Air Forces. A representative survey on 77,016 troops of the U.S. Army Air Forces made in England, in September 1945, with the aid of two mobile trailer 35 mm. photoroentgen units, brought to light only 70 cases of tuberculosis considered active (5 of primary and 65 of reinfection type), or 1 person in every 1,100 examined. Of the 65 cases of reinfection type, 4 were far advanced, 10 moderately advanced, and 51 minimal.21 The group, which was almost exclusively male, and composed of 14 percent flying and 86 percent nonflying personnel, was carefully examined to determine if there was any relation between development of disease and length and type of service. The evidence of the disease discovered in flying personnel was significantly lower than in nonflying personnel, a fact attributed to the more meticulous and often repeated physical and roentgenographic examination of the former. The incidence was greater than average in men who had not had an X-ray film on entrance, or had served a longer than average period of time without a second or later film. These findings are as might be expected in view of the usual slow and insidious development of tuberculosis.

A study showed that a greater number of men who had consumed raw milk in England were among the troops with active disease than in those without disease, but the finding was believed related to the length of service rather than merely to the ingestion of the milk. The earlier a soldier arrived, the longer he stayed, and the better acquainted he became with the civilian population, the more likely he was to consume raw milk. Vigorous efforts were made by all those responsible for the health of troops to prevent consumption of raw milk in the British Isles, in view of its frequent contamination with tubercle bacilli. It was not served in army messes nor, after an initial laxity, in Red Cross canteens (p. 368).

On the whole, the Army Air Forces exhibited a gratifyingly low incidence of tuberculosis and, at the same time, disproved the view occasionally expressed that flying service predisposes to the development of active disease.

Incidence in recovered American prisoners of war-When large numbers of American soldiers were recovered from German prison camps in the spring of 1945, it was no great surprise to medical officers to find an incidence of tuberculosis apparently surpassing the average incidence in the Army as a whole. Unfortunately, no reliable figures for tuberculosis in the thousands of recovered prisoners are available. War Department orders

21Wayburn, E.: Mass Miniature Radiography. A Survey in the United States Army Air Forces. Am. Rev. Tuberc. 54: 527-540, December 1946.


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to make roentgenograms of all recovered prisoners before their return to the United States were in effect at the time, but an acute shortage of X-ray film and stringent measures to conserve it nullified the effect of the orders. Figures for the large group processed at Lucky Strike Camp and other camps near Le Havre are available only for those who were hospitalized. Even though hospitalization was not for respiratory disease alone it is fair to assume that a higher rate would be found than in a population not in obvious need of hospitalization. The majority of recovered prisoners who were hospitalized suffered from severe malnutrition. A number had infectious hepatitis, and acute respiratory disease was common.

In his semiannual report of 3 July 1945, the senior consultant in tuberculosis in the theater reported the incidence of tuberculosis in 2,750 recovered American prisoners hospitalized at the 77th Field Hospital, Lucky Strike Camp, as follows:

 


Number of cases

Rate per 1,000 per year

Minimal tuberculosis

6

2.2

Advanced tuberculosis

6

2.2

Pleural effusion

9

3.3


Total

21

7.6


The rate found for all forms of active tuberculosis was thus several times the rate of approximately 1 case per 1,000 men prevailing in the Army as a whole. It is interesting to note that the incidence of pleural effusion, namely, 43 percent of the total, was higher than the usual average of 20 to 25 percent observed in hospitalized troops in the European theater and in the continental United States.

In the lack of exact studies on recovered prisoners, analysis of the reason for higher rates is speculative. Colonel Badger stressed as predisposing factors malnutrition and exposure to an environment with greater potentiality for spread of tubercle bacilli. Malnutrition is believed to be a factor in the reactivation of small arrested lesions, which, as noted in various surveys, were present in approximately 1 percent of troops. Excessive exposure to tuberculosis, if it occurred, was not direct. Recovered American military personnel were not quartered with other nationals, except in some instances where they shared barracks with British prisoners, but frequently, in the migration from camp to camp, as the senior consultant in tuberculosis pointed out in his report, they lived in dirty quarters, grossly contaminated by previous occupants, many of whom may have had tuberculosis.

At the time of writing, no significant new facts had emerged from followup studies in the United States.22 Former prisoners of war were reproc-

22The study made by Long and Jablon disclosed that a significant excess of tuberculosis over the incidence for the Army as a whole occurred in recovered prisoners of war. The risk for white prisoners, chiefly captives of the Germans in this study, was three and a half times as great as for men with service overseas who were not taken prisoner (Long, Esmond R., and Jablon, Seymour: Tuberculosis in the Army of the United States in World War II. An Epidemiological Study With an Evaluation of X-ray Screening. Washington: U.S. Government Printing Office, 1955).
In a special study of disease among recovered prisoners of war, Cohen and Cooper found a high rate of tuberculosis among former prisoners of the Japanese, which did not take into account the many soldiers believed to have died of tuberculosis in Japanese prison camps (Cohen, Bernard M., and Cooper, Maurice Z.: A Follow-up Study of World War II Prisoners of War. Washington: U.S. Government Printing Office, 1954).


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essed at Army Ground and Army Service Forces Redistribution Centers, and X-ray examination was usually included in the routine physical examination. The largest single survey reported to the Office of the Surgeon General was from the Army Ground Forces Redistribution Station in Asheville, N.C. Ten cases diagnosed as tuberculosis were found in 1,939 prisoners of war, a rate of approximately 5 per 1,000. All of the men concerned were hospitalized and not all cases were of proved activity, so that the rate of active tuberculosis was lower. On the other hand, it must be recognized that the group examined by X-ray was to some extent an already screened group, from which men obviously ill had been removed.

In summary, it appears reasonable to conclude from the evidence that the incidence of tuberculosis did rise in men who had been prisoners of war in the European theater, to as much as five to seven times the rate prevalent in the rest of the Army (p. 391).

Incidence in recovered Allied military personnel-In a directive from the Office of the Chief Surgeon, European theater, to the surgeons of bases, sections, and advanced sections, attention was called to the high incidence of tuberculosis in prisoners of Allied Nations recovered when the U.S. armies liberated them from prison and concentration camps in Western Germany, and to the implications for the medical and nursing personnel of the Army. Later, an order,23 based on the sudden startling experience of Army units in the forward areas, directed a chest survey of recovered Allied military personnel, and displaced civilians, as follows:

1. Pulmonary tuberculosis of a virulent order has proved a serious problem among displaced civilians of all nationalities. The magnitude of this problem cannot be estimated at this time. It is probable that Recovered Allied Military Personnel will show an incidence of tuberculosis well above the experience of the Theater. It is imperative to establish the gravity of the situation.

2. All displaced civilians and Recovered Allied Military Personnel admitted to hospitals of the United States Army will be carefully surveyed with this thought in mind. History, physical examination, appropriate laboratory studies, and, when indicated, x-ray of the chest, will be made on all such subjects, insofar as facilities permit. Due to film shortage, x-rays will not be taken routinely.

In recovered prisoners of war of Allied Nations, U.S. medical officers found, for a time, the principal problem in tuberculosis confronting them in the European theater. At one time, the 46th General Hospital at Besançon, France, with more than 1,000 tuberculous patients of foreign nationality, was the largest tuberculosis center under control of the U.S. Army, exceeding

23Circular Letter No. 41, Office of the Chief Surgeon, Headquarters, European Theater of Operations, U.S. Army, 11 May 1945.


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Fitzsimons General Hospital, the specialty center in Denver, Colo., in its census of tuberculous patients.

Colonel Badger's report on tuberculosis in recovered Allied military personnel is quoted substantially as follows:24

a. Nature of the problem

On 18 December 1944, 304 patients of varied nationality, though mostly Russian, were admitted to the 50th General Hospital, Commercy, France. All were tuberculous. Four were dead on arrival. Ninety percent had moderate to advanced disease. Twenty-eight died of tuberculosis in the first week in the hospital, and up to 21 May 1945, 5 months after admission, a total of 101, or 33 percent, had died. Signs and symptoms of serious nutritional and vitamin deficiencies were the principal associated complications of tuberculosis or malnutrition. In the middle of March 1945, some 1,600 military and civilian nationals were sent to the 46th General Hospital in Besançon near Dijon. There were among them Russians, Yugoslavs, French, Italians, Poles, Turks, Belgians, Dutch, Czechs, Greeks, Hungarians, and Serbs. Seventy-five percent of them were Russians. A little less than half had tuberculosis, most of which, once again, was advanced disease, complicated by very severe malnutrition. Other pockets of displaced tuberculous nationals, under Third U.S. Army care in Germany, were some 7,000 men at Mauthausen, 5,000 at Nuremberg, 3,500 at Ebensee, and 3,000 at Klam. This is a glimpse of the end result of the effects of war on Allied national prisoners, both political and military.

*     *     *     *     *     *      *

c. History

The story these men told was much the same from wherever they came. They were prisoners for an average of 34 months in the Stalag camps of Western Germany. They were for the most part captured in 1941 in the Black Sea area and the Ukraine. They were shifted from camp to camp, finally winding up in the mines and heavy industries near Metz and Sarreguemines, France, and the Ruhr region in Germany. Men were worked 12 hours or more a day with 1 day off a month, when the coal quota was filled. Maltreatment for failure to do a full day's quota of work was common. Housing was for the most part in wooden barracks of 40 to 100 feet in size, crowding in 100 to 150 men. Diets varied in different camps, but from their history and starvation state, it was apparently seriously deficient. Hygienic conditions were bad, recreational facilities were prohibited, sleeping and living conditions were congested, and hospital treatment for illness was apparently reserved for those with high fevers combined with a good prognosis. The sick were left to die in their bunks beside the living. Before capture, these men were recorded as being in excellent physical condition. Supposedly, admission to the Russian Army was by complete physical examination with an X-ray of the chest; but, if the latter was accomplished in the Russian Army, it was a monumental task. Furthermore, if only those with negative X-rays were admitted to the Army, the influence of starvation upon unseen tuberculous infection is the more striking.

d. Clinical picture

The typical picture of tuberculosis as seen in these patients was that of acute fulminating, rapidly fatal disease, mixed with chronic, slowly progressive, fibrotic tuberculosis. They were acutely ill with emaciation which was the combination of tuberculosis and starvation. The clinical course of approximately 30 percent was rapidly and progressively downhill. Extensive bilateral pulmonary disease was complicated by gastrointestinal, laryngeal, and bronchial involvement. Fever was varied. Many patients showed progressive, moderate to far-advanced disease in the presence of a normal temperature, some elevation of pulse, and reasonably good general appearance. The physi-

24See footnote 17, p. 340.


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cal findings were characteristic in the variety of signs, but the most conspicuous single feature was the presence of widespread disease with few or no physical signs. Cough and expectoration produced sputa which were heavily loaded with tubercle bacilli. Examination of direct smears showed larger numbers of tubercle bacilli than we are accustomed to see in the routine examination of sputa in the United States.

e. Pathology

(1) At post mortem examination, the tuberculosis was always bilateral with wide hematogenous dissemination to a variety of organs with extensive cavitation of the lungs. There was revealed more than the usual lymph gland involvement with massive enlargement of glands in both the chest and abdomen. Not uncommonly, pleural adhesions were multiple and usually obliterative, giving evidence of chronicity of the disease. Miliary tuberculosis was conspicuous by its rarity, though sporadic hematogenous spread was common.

(2) Microscopically, the lesions were characteristically fibrocaseous tubercle formation with evidence of normal tissue response to the presence of the tubercle bacilli. However, many cases presented a microscopic appearance of widespread confluent necrosis, without tubercle formation and with very little tissue reaction about the periphery of the lesion and little or no epithelioid cell formation and complete absence of giant cells. Lymphatic tissue often presented complete destruction of all lymphoid cells with tissue necrosis and often very little cellular reaction in tubercle formation.

f. Etiology

Etiological factors which produced this fulminating disease were undoubtedly the unusual opportunities for intense and frequent recurrent contact with seriously ill, open cases. Conditions at the German Stalag camps and at Buchenwald were such that at the latter, 46,000 people were housed in a unit originally constructed for 15,000. Sanitary conditions did not exist and where three to five men were in one small bunk and the ill were left to die unattended beside the living, the opportunities for cross infection with tuberculosis were such as have probably rarely been observed before. Everything favored the development and spread of the disease. The starvation diet with the serious degree of malnutrition undoubtedly contributed to the rapid progress of the disease. The pathology in many cases was indicative of an absence of the individual's resistance to infection.

g. Treatment

(1) These patients had treatment, first directed toward relief of starvation and the establishment of discipline. Language difficulties and years of living under the conditions which existed in larger work camps and Stalags made it difficult to establish any hygienic principles, or the segregation of open from closed cases. The dietary problems were not difficult to handle and those patients who were not dying of their disease improved clinically, rapidly overcoming the malnutrition per se.

(2) The initial problem was that of reexamining by X-ray entire groups for proper identification, diagnosis, evaluation, and therapy.  Sputum-positive cases were eventually segregated from sputum-negative cases and an attempt was made to establish absolute bed rest. However, the latter proved to be practically impossible. The concept of bed rest was foreign to these men under any circumstances, and, with the Russians, it was against their principles of treatment of tuberculosis, which commanded exercise and sunshine.

(3) Collapse treatment.-Definitive measures of collapse were not instituted in the early weeks of treatment, except in those cases where hemorrhage indicated its necessity, or the character of the disease was unilateral and favorable to this form of treatment. It was deemed wise for these men to have 4 to 8 weeks of bed rest before pneumothorax was started, as the acuteness of the disease and the frequent presence of tracheobronchitis were not suitable for collapse therapy. Adjustment of their nutritional


349

deficiencies was immediately of greater concern than the tuberculosis itself. In acute widespread, bilateral disease, pneumothorax has not proved to be beneficial. Collapse therapy was never undertaken simply for the sake of "doing something" for the patient.

(4) Seen a month after the institution of treatment, those men who had not died of acute tuberculosis showed marked improvement. Order had emerged from initial chaos and reasonably good discipline had been established through the assistance of a Russian officer and aidman. It was still quite impossible to establish a regimen of absolute bed rest.

h. Prevention

Precautions against spread of tuberculosis were instituted first of all for the protection of U.S. Army hospital personnel and second toward segregation of the open and closed cases.

(1) Isolation technique was carried out in all the tuberculosis wards. All staff personnel wore masks and gowns. Patients wore masks when examined or treated and were taught to conceal their cough, to expectorate into small pledgets of paper which were deposited into paper bags to be burned.

(2) Floors were treated with spindle oil obtained from the British, which was applied according to directions extracted from a report prepared by the Eighth Air Force. 

(3) "Clean rooms," as islands of sterility, were meticulously observed adjacent to tuberculosis wards for the protection of nurses and other personnel. No contaminated person, X-rays, records, or objects of any sort were permitted in these sanctums of cleanliness. No gowns or masks were worn or removed in these rooms. Scrub-up solutions and contaminated clothing were maintained in an adjacent room.

(4) By these means every effort was made to cut down airborne infection to a minimum and reduce the opportunity of contact to a minimum.

On 10 May 1945, Colonel Badger, Senior Consultant in Tuberculosis in the European theater, and Col. Esmond R. Long, MC, Chief Consultant in Tuberculosis, Office of the Surgeon General, conferred with Col. B. A. Osipov, member of the Military Mission of the U.S.S.R. in Great Britain and Russian liaison medical officer in the theater, with regard to the care and treatment of Russians with tuberculosis. Points of difference in treatment in the two countries were recognized, and shortly thereafter, it was decided in the Office of the Chief Surgeon, European theater, to repatriate those Russians who were physically able to travel, as rapidly as was consonant with their safety. The 46th General Hospital was made a collecting hospital for this purpose. It received recovered Russian prisoners previously hospitalized in many hospitals in France and England and effected suitable preparations for the long journey back to Russia.

Incidence in concentration camps-In the final weeks of the war in Germany, Allied troops overran a large number of the notorious concentration camps in which the German government imprisoned political nonconformists, Jews, nationals of surrounding states, and others who had offended the Nazi Party. These camps included Buchenwald, Nordhausen, Dachau, Belsen, and many others. Thousands of dead were found in the camps at the time of their liberation, and many more thousands of sick and dying. Among the latter were hundreds of persons with advanced tuberculosis, who constituted an immediate problem for the evacuation hospitals of the advancing armies. U.S. Army hospitals rapidly developed machinery for re-


350

moving discovered cases from camps and placing them under definitive care. Barracks outside the camp were usually used, and in these the tuberculous were bathed, deloused, examined by X-ray, and put on immediate bed rest. In the transfer from camp, they were ably assisted by doctors of the concentration camp; that is, doctors who had themselves been inmates and had maintained primitive hospitals for tuberculous patients in the camp. Subsequently, these patients were transferred to German hospitals in the region, against the time when they could be transferred again to their own countries, or to sanatoriums in Germany. The crowding, the lack of sanitary provisions, the malnutrition and the general medical neglect, all favored progression of the disease in concentration camps. Although few figures are available, it was believed by Medical Corps officers that much of the high mortality in these camps was due to tuberculosis.

A vivid description of conditions at the Dachau concentration camp, and the extent of tuberculosis in hospitalized inmates of that camp, has been given by Piatt.25 He made a statistical analysis of 2,267 roentgenograms of the chest of patients removed from the concentration camp hospital and examined by X-ray on admission to the receiving and evacuation section of the 127th Evacuation Hospital. In only 45.3 percent of the films was no abnormality discovered. Tuberculosis, pneumonia, and heart disease were the chief abnormalities. Six hundred and twenty-six definite cases of tuberculosis, or 27.6 percent of the total number examined, were detected. In more than half of these, the disease was bilateral, and in four-fifths of the cases, the process was either moderately or far advanced. In addition to definite tuberculosis there were 94 patients, or 4.1 percent of the total, with pleural effusion, probably tuberculous in origin. There were five cases of miliary tuberculosis.

Piatt, among others, expressed the view that the incidence of tuberculosis in Europe would increase appreciably in the years to come as a result of the return of numerous persons with undiagnosed active disease from concentration camps to their homes.

The following extract from the report of the Consultant in Tuberculosis, Office of the Surgeon General, dated 1 May 1945, also illustrates the task which faced evacuation hospitals when prisoners in concentration camps were liberated:26

1. Assignment of task to 45th Evacuation Hospital.-When the Buchenwald camp [near Weimar] was liberated a problem immediately apparent was the care and disposition of several hundred tuberculous patients under treatment in the camp. It was recognized that these were a source of dissemination of the disease, and from the point of view of medical care represented a long range problem. The processing and evacuation of these patients to a hospital appropriate for their continued care was assigned to the 45th Evacuation Hospital.

25Piatt, A. D.: A Radiographic Chest Survey of Patients From the Dachau Concentration Camp. Radiology 47: 234-238, September 1946.
26Semiannual Report, 45th Evacuation Hospital, 1 Jan to 30 June 1945. Appendix A, subject: Processing of Tuberculosis Patients From Buchenwald Concentration Camp by 45th Evacuation Hospital.


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2. Background of tuberculosis problem at Buchenwald.-a. The conditions under which prisoners lived at Buchenwald were conducive in every way to the development and spread of tuberculosis. The malnutrition, from which every inmate suffered, together with heavy labor and harsh treatment, inevitably led to the progression of tuberculous lesions in men previously infected, whether these were originally of serious or minor character, and the intense crowding and lack of any sanitary precautions led to dissemination of infection throughout the barracks. "Block physicians," themselves prisoners, appointed by the prison administration, constantly discovered cases and sent them to hospitals established within the camp, since distinguished as the "old," the "little," and the "great." The "old" hospital, an indescribably crowded and filthy place, in which patients lay on dirty shelves in a long series of tripledecked compartments, five feet long and two feet high, six patients to a compartment, was in no remote sense a place for treatment, and in effect simply a breeding ground for the disease. In the others, thanks to the interest and intelligence of prisoner doctors, standard treatment was carried out insofar as it was possible under the desperate circumstances prevailing, with little food available, and that of the worst quality, and no relief in sight. In all of these hospitals the mortality from tuberculosis was tremendous. No accurate estimate can be made, but it is probable that many thousands of the 50,000 known to have died in the camp succumbed to tuberculosis.

b. Following the liberation a medical organization was promptly put into effect by Dr. Horn, an eminent Czech surgeon, who had been a hostage in the camp, arrested originally as a supporter of Dr. Benes. Dr. Horn was at the camp 6 years. His distinguished position was recognized by the Germans, and after November 1943 he did a large proportion of all the operative work. His capacity was universally recognized by the physicians of various national groups in the camp. Under Dr. Horn the following physicians were appointed as tuberculosis consultants: Dr. Jozef Szmeja, a Polish tuberculosis specialist, Chief Consultant; Dr. Stanislaw Machotka, a Jugoslav, who had been superintendent of a tuberculosis sanatorium in Jugoslavia, Second Consultant; and a Russian doctor who had specialized in tuberculosis.

In addition, three physicians with experience in the treatment of tuberculosis were retained in direct charge of the "great" and "little" tuberculosis hospitals (the "old" hospital having been closed with liberation of the camp): Dr. Gerhard Arnstein, an Austrian, in charge of the treatment ward in the "great" hospital; Dr. Edmund Adams, a German political prisoner of English descent, in charge of the far advanced cases in the "great" hospital; and, Dr. [Paul] Heller, a Czech, in charge of bilateral cases not suitable for specific therapy, but not hopelessly advanced, in the "little" hospital.

c. The treatment ward of the "great" hospital, with 116 cases, almost all of them under pneumothorax treatment by Dr. Arnstein, was a crowded, malodorous place in which patients slept in double-decker beds. Discipline was maintained, and patients received three times as much food as before the liberation, but no substantial improvement could be expected in such surroundings. Dr. Arnstein was conscientiously doing everything possible under the circumstances. The ward for advanced cases was simply a death room. There were thirty-two cases where there had been seventy a few days before. The "little" hospital, containing ninety-six patients, was a former stable, which had been improved by the patients themselves by the construction of windows. It was a highly crowded place filled with ambulant patients who used three-decker beds at night. There was a total lack of discipline in spite of Dr. Heller's best efforts. Three to four patients a week died there. The most that could be said for it was that it served for the isolation of ambulant patients with infectious sputum.

d. The three hospital groups just cited, made up of 244 patients, did not account for all the known cases of tuberculosis. The different national groups into which the prisoners were gathered immediately after liberation had retained some cases. Altogether it was believed that 100-150 tuberculous patients could be located in the various groups.


352

3. Evacuation procedure.-a. The above outline indicates what had been accomplished, thanks to the intelligent action of a few liberated physicians, in a short period preceding the assignment of the 45th Evacuation Hospital to the evacuation problem. The principal accomplishment of these physicians was discovery, isolation, and classification of patients, which enormously facilitated the procedure of evacuation. The institution of pneumothorax on the scale established was heroic, but much success in treatment, under the circumstances, was not to be expected.

b. A priority system, based on the emergency care required, the advisability of removal for early continuation of care elsewhere, and other considerations, was set up, whereby patients already in the Buchenwald camp hospitals were to be delivered to the 45th Evacuation Hospital at the rate of ten an hour during the working day, commencing on 28 April 1945. On the 29th the system was found to be functioning smoothly in spite of mechanical difficulties in the water line and concomitant cleaning of the hospital. Under the direction of the commanding officer, Colonel [Abner] Zehm, a remarkably rapid and effective job had been done in taking over a terribly dirty building, fouled by unrestrained, suddenly freed prisoners, with no hygienic standards, who had swarmed into the building on their release. Dead bodies were in the corridors and excrement all over the floors on arrival of the staff. Two days later, when evacuation operations commenced, the place was clean and normal operation was in progress.

c. A dispensary organization has been set up by Dr. Horn in Buchenwald Camp for diagnosis of new cases from suspects sent in by physicians in the barracks, which still housed some 15,000 ex-prisoners. The selection is based entirely on symptoms. In the opinion of the undersigned the number of cases would run far beyond the expected 150 cases if a more careful method of selection including X-ray examination were possible. In view of the tremendous exposure to which the group has been subjected, cases will inevitably arise in considerable number for years to come. At present only the method indicated is practical. The dispensary will hold 35 patients for observation at one time, and it is expected that by the time the present 240-250 patients have been evacuated the dispensary can conclude the remaining task in a few days.

4. Organization of the 45th Evacuation Hospital.-a. The staff consists of the commanding officer and 20 medical officers. Lt. Col. [Isidore A.] Feder, MC, Chief of the Medical Service, has instituted an organization which admirably combines simplicity and efficient operation. Ten 40-bed wards, each in charge of a medical officer, have been set up. In addition to these there is a receiving officer, a general internist, an X-ray chief, a laboratory chief, and a specialist in ear, nose, and throat work. The rest of the staff of 20, composed of members of the surgical team, are at present on other duties in the area.

b. On arrival at the hospital, patients are taken to the receiving wards (one for ambulant and one for litter patients) and their records are initiated by the receiving officer. By arrangement with the doctors at Buchenwald camp, their previous medical records are sent with them. EMT's [emergency medical tags] are made out, and a simple medical record devised by the 45th Evacuation Hospital, entirely suitable for the purpose, is started. After this, patients move across the hall, where their clothes are taken away from them to be destroyed, they bathe in hot showers, and are dried and sprayed with DDT [dichlorodiphenyltrichloroethane]. Then they receive clean pajamas and are sent to the X-ray room, where a roentgenogram is made of each man, with a Picker field unit, the subject holding the cassette in his arms. The pictures made are remarkably good, with all the required detail and excellent contrast. Much credit is due to the technician in the dark room, for the condition of the electrical line requires relatively long, fixed exposure and fixed kilovoltage so that careful individual processing in the development tanks is necessary. After the X-ray film is made each patient is sent to his ward. Shortly afterwards, clinical histories are taken through an interpreter, and specimens are obtained for laboratory examination-sputum, blood,


353

and urine being examined routinely. Blood sedimentation rates are determined in cases where tuberculosis is diagnosed but the patient is afebrile. The whole procedure is handled quietly and expeditiously.

c. Special mention should be made of the work of the enlisted men. Good technical work is done in the X-ray department and laboratory as well as the bath department, and the care given by the litter bearers, as observed by the undersigned, was superb. Very sick, suffering patients were transferred from litters to cots with infinite gentleness, which, in the light of the bestial brutality which had been the lot of the patients in Buchenwald camp prior to their liberation, was extraordinarily impressive.

5. Assessment of the evacuation procedure.-a. The work done by the 45th Evacuation Hospital in processing tuberculous patients is excellent. Dr. Horn, who had observed the care of tuberculous patients at Buchenwald for years, was strong in his tribute to the spirit and standards of the Medical Department of the U.S. Army. No words can describe the relief and joy of the patients. After their long misery in the filth and torture at Buchenwald, the clean sheets and blankets and personal solicitous attention of the 45th Evacuation Hospital were incredible luxuries.

b. The medical processing meets its purpose in every way. The objective of the hospital is to effect machinery for suitable transfer of patients to permanent quarters. Status as ambulant and litter patients is being established in a sound manner. A certain number of cases misdiagnosed as tuberculous are being discovered, and will be returned for such medical care as they require. Some patients will be found who are too sick to move further under any circumstances, and terminal care is being provided. Treatment is quite properly by rest and good food, which is enormously appreciated by the patients. Pneumothorax treatment is not being given and does not appear indicated in the expected short period of retention of the evacuation hospital. It is believed that refills, if necessary in any cases, can be given, by special arrangement, by the camp physicians who initiated the procedure.

Under arrangements effected by the Office of the Surgeon, Headquarters, First U.S. Army, the tuberculous patients evacuated from the Buchenwald concentration camp were transferred to a permanent German hospital at Blankenhain near Bad Berka and Weimar for continued care pending later transfer of suitable cases to their homes in liberated countries. It was recognized that a majority of the patients were too ill to recover and would remain a charge of that department of military government concerned with the hospitalization of displaced personnel (pp. 397-399).

NORTH AFRICAN AND MEDITERRANEAN THEATERS OF OPERATION

Admission rates.-As in the European theater, the recognized incidence of tuberculosis in the Army in the North African and Mediterranean theaters was lower than in the Zone of Interior. During 1942-45, approximately 1,300 cases with active or inactive tuberculosis were admitted to medical treatment facilities for observation or care, an incidence rate of 0.85 per 1,000 per year. In a study involving 800 cases, 57 percent were classified as active and 20 percent as probably active, the remainder as inactive or uncertain.27

27McKean, George T., and King, Donald S.: Survey of Tuberculosis and "Primary" Pleural Effusion for the Period of Activity of NATOUSA and MTOUSA to 1 Apr. 1945, vols. I and II. [Official record.]


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In the aforementioned study, diagnosis, treatment, disposition of cases, and the epidemiology of tuberculosis in the theater were discussed at length. In addition, special attention was devoted to primary pleural effusion, which was a problem of unusual significance.

In a high proportion of cases, symptoms, principally cough, led to hospitalization; a smaller number were discovered in various types of routine survey. Laboratory facilities varied in the theater, but even in forward hospitals means for staining tubercle bacilli were available and X-ray examination could be made. Films from field and evacuation hospitals were of good diagnostic quality; in general, the diagnostic work was of superior character.

Differential diagnosis frequently involved distinction from atypical pneumonia, and occasionally from chronic pulmonary diseases other than tuberculosis. The chief difficulty in diagnosis was determination of activity. In sputum-positive cases this was no problem, but decision was difficult in the numerous cases where a small fibrotic lesion was evident in X-ray films. The usual and most important single aid, namely, a long series of films for comparison, was not available, because circumstances did not permit retention of patients for the necessary length of time. Consequently, individual judgment, based on all data available, was most important.

The annual rate of admission in terms of troop strength was approximately the same for Negro as for white soldiers. Negro soldiers constituted 9 percent of the total strength, but contributed only 7.5 percent of cases up to April 1944. On 31 March 1945, Negro troops constituted 13.5 percent of the total strength in the theater and, by that time, accounted for 15 percent of the cases of tuberculosis. Analysis by type of case indicated that the disease was of distinctly greater average severity in Negro than in white soldiers. In the former, there were more bilateral cases, more cases with cavity, more of exudative character, and a lower proportion of cases considered inactive. According to data obtained from individual medical records, there were 60 deaths during 1942-45 among U.S. Army personnel admitted for tuberculosis in the Mediterranean theater. Many patients who were evacuated died elsewhere. Of the 60 deaths, 50 were among male enlisted personnel; 30 of the 50 deaths were among Negroes.

Hospitalization.-In the North African and Mediterranean theaters, as in all theaters, tuberculous patients were initially admitted to hospitals of all types. Admissions were about equally divided among soldiers from the Fifth U.S. Army, the Army Air Forces, and Army Service Forces. Unlike the other theaters, the North African and Mediterranean theaters established tuberculosis centers for the reception of cases from other hospitals and for study with a view to appropriate disposition. The following hospitals served this purpose: 6th General Hospital, Casablanca, French Morocco; 24th General Hospital, Bizerte, Tunisia; 17th General Hospital, Naples, Italy, and the 64th General Hospital, Leghorn, Italy. The concentration of medical officers, with special training in a few centers equipped for definitive treatment, in-


355

sured an adequate number of beds and a high type of professional care for patients prior to their evacuation to the United States. These hospitals were frequently visited by Lt. Col. (later Col.) Donald S. King, MC, Chief, Medical Service, 6th General Hospital.

Analysis of data for a representative group showed that the average duration of hospitalization of active cases, prior to evacuation to the Zone of Interior, was 58.5 days. From this figure, based on a large sample, it was calculated that active cases of tuberculosis were responsible for 22,405 days of hospitalization in the theater. Only 24 patients, however, remained in a theater hospital more than 3 months.

Also admitted to Army hospitals in this theater were tuberculous patients from the armies of our Brazilian and British allies, tuberculous prisoners of war, and occasional patients in other categories.

Therapy and disposition-Hospital care being, as a rule, of relatively short duration in the theater, definitive treatment was not so intensive as in tuberculosis centers in the United States. However, in many cases, temporizing was contraindicated; collapse measures were instituted promptly to prevent serious progression, although this practice anticipated the type of care to be given during prolonged hospitalization in the United States and the pneumothorax had to be maintained during evacuation to the Zone of Interior, at ports of debarkation, and en route from the latter to tuberculosis centers in the United States.

The indications for pneumothorax were the usual ones; namely, unilateral excavation, spreading infiltration, and persistent hemoptysis. The following policy was drawn up in the late months of the war with respect to collapse therapy and the type of transportation most appropriate for different categories for evacuation to the United States.28

1. Pneumothorax treatment in the theater should be limited to predominantly unilateral cases, with evidence of cavity formation or rapid extension, for which transportation to the United States is not immediately available, and such cases should be evacuated on hospital ships equipped to continue pneumothorax after this treatment has been established.

2. Bilateral advanced cases and advanced cases for other reasons unsuitable for pneumothorax should be treated by continued rest and returned to the United States by hospital ship as soon as space is available.

3. Unilateral and bilateral cases of active disease of minimal extent, without gross evidence of cavitation, should be sent to the United States by air at the earliest possible moment, and treatment, other than rest and hygiene, in such cases should not be attempted in the theater.

4. Cases of pleural effusion without other demonstrable etiology should be considered as probably tuberculous and evacuated to the United States by hospital ship, after termination of the acute phase of the illness, for treatment and disposition.

5. Under ordinary circumstances moribund cases should not be evacuated to the United States.

28Memorandum, Col. Esmond R. Long, MC, Consultant in Tuberculosis, to The Surgeon General, U.S. Army, 18 Apr. 1945, subject: Visit by Consultant in Tuberculosis, Office of the Surgeon General, in Mediterranean Theater of Operations.


356

6. Individual judgment should be exercised in the case of small, scarred and probably inactive lesions, with evacuation to the Zone of Interior in those cases where the lesion in question is of truly doubtful stability, opportunity for continued observation of the case is unlikely and key personnel are not involved.

Pleurisy with effusion-Pleurisy with effusion, presumptively tuberculous, was frequent in proportion to the total number of cases of tuberculosis. In 1944, there was an apparent increase during the summer months, the reason for which never became clear. It was considered possible that numerous infections might have occurred in crowded quarters during the winter, becoming manifest several months later in the form of effusion.

In 16 out of 33 carefully studied cases, the bacteriological diagnosis determined by guinea pig inoculation, culture, or other means, was positive for tubercle bacilli. A diagnostic problem was distinction from the effusion that sometimes accompanies atypical pneumonia. In general, however, it was believed that large effusions were rare with this type of pneumonia, whereas the effusion of tuberculosis was frequently massive.

Altogether, 265 cases of primary pleural effusion were encountered, of which 229 were evacuated to the Zone of Interior. Two were reclassified to limited service and 30 were returned to duty. The wisdom of the latter course was later seriously questioned, in view of the frequency with which late tuberculous parenchymal infiltration follows pleurisy with effusion. Three-fifths of the cases were in soldiers 25 years of age or less.29

Epidemiology-Much attention was devoted by medical officers to the epidemiology of the disease in the North African-Mediterranean theater. Up to June 1944, the number of cases evacuated to the Zone of Interior, although not considered alarming, was recognized as significant.30 In the summer of 1944, the centralization of patients in special hospitals brought to light the fact that not infrequently there was an abnormally high incidence of disease in individual units, and an index system was set up to aid in tracing sources of infection. New patients were questioned as to previous contacts in the Army, and from time to time, new additions to already known endemic foci were thus discovered. In one medical battalion headquarters and headquarters company, consisting of 50 enlisted men and 7 officers, 8 cases of pulmonary tuberculosis or pleural effusion were found. Contacts with Italian civilians that may have been a source of contagion were believed to occur, but could not be traced with similar accuracy.

In this connection, Circular Letter No. 41, Office of the Surgeon, Headquarters, North African Theater of Operations, dated 29 July 1944, directed the following:

29A postwar study of 141 cases of primary serofibrinous pleural effusion in World War II soldiers, in which observation was continued for 5 or more years after diagnosis, disclosed a high incidence of relapse in men returned to duty following absorption of a pleural exudate. In cases where hospitalization was brief and return to duty correspondingly early relapse occurred in approximately 90 percent of persons (Roper, W. H., and Waring, J. J.: Primary Serifibrinous Pleural Effusion in Military Personnel. Am. Rev. Tuberc. 71: 616-634, May 1954).
30Custer, E. A.: Tuberculosis in the North African Theater of Operations [and appended Comments by the Theater Surgeon]. M. Bull. North African Theat. Op. (No. 6) 1: 30-31, June 1944.


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It will be the responsibility of the commanding officers of "tuberculosis reception centers" to notify the medical officer of any organization, in which an "open case" of tuberculosis is discovered, of the existence of such a case, and it will then be the responsibility of the unit medical officer to initiate promptly such studies as are considered necessary for the detection of pulmonary tuberculosis in intimate contacts of the patients.

Routine surveys, made on several units, were occasionally fruitful. In one survey made after discovery of an open case, no case of definitive active tuberculosis was found among 718 persons, including 52 officers and 123 women, but 16 lesions of minimal extent were discovered, 8 of which were considered possibly active, the remainder, probably inactive.31

Although Italian civilians were always suspected as a source of serious contact, adequate study was not made until after the end of hostilities. Some evidence of special danger was found by the Chief of Medical Service, 15th Evacuation Hospital in a survey of approximately 300 civilian foodhandlers in the Milan-Turin region. Of these, 15 (or 5 percent) had clinically significant tuberculosis of reinfection type.

Evacuation-Patients were evacuated by sea and by air. In the early days of the theater, most tuberculous patients came home on troop transports. Later, the majority returned in hospital ships, when these were available in sufficient number. It was recognized that far better care could be given them on hospital ships, where special quarters could be assigned and where X-ray and pneumothorax equipment and laboratory facilities were readily available. At the same time, isolation technique protected other soldiers from exposure to contagion. Fortunately, there was little communicable disease other than tuberculosis requiring evacuation from the theater. Accordingly, it was possible, in many voyages from Italy to the United States, to use for tuberculous patients the entire section of the ship that had originally been set aside for contagious diseases. This section usually provided airy 8- and 12-bed wards.

SOUTH PACIFIC AREA

Incidence-In reports for the years 1942-45 for the South Pacific Area (New Caledonia and the Solomon Islands), an admission rate for tuberculosis of 1.5 per 1,000 men per annum is shown, except for the year 1942, when the admission rate for the last quarter only is recorded and was 2.1. Incomplete reporting, mistakes in diagnosis, inclusion of readmissions and transfers are mentioned as factors causing inaccuracies. It was believed by the reporter, however, that the errors did not exceed 10 percent. The totals for the 4 years, as reported, were: 1942 (last 3 months), 42; 1943, 214; 1944, 264; 1945, 57. The incidence rates, taken from the statistical health report (WD MD Form 86ab) in the records in the Office of the Surgeon General, were: 1942, 1.38; 1943, 1.20; 1944 (consolidating South Pacific with Central Pacific Area to

31Wyman, S. M.: Report of a Roentgenologic Chest Survey. M. Bull. Mediterranean Theat. Op. 3: 15-16, January 1945.


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make Pacific Ocean Area), 0.71; 1945 (also consolidated), 0.95. The average rate for the Pacific Ocean Area for 1942-45, inclusive, was 0.86.

Types of tuberculosis.-The majority admitted to hospital were cases of pulmonary tuberculosis. It is interesting to note that of 82 cases of chronic reinfection type pulmonary tuberculosis admitted, 32 were recorded as minimal, 38 as moderately advanced, and only 12 as far advanced. In a theater where examinations were usually made on the basis of symptoms rather than through the medium of mass X-ray surveys, the preponderance of minimal and moderately advanced cases indicates that medical officers were on the alert for cases and recognized the need for their discovery before the disease reached the far advanced and generally hopeless state.

Fifteen cases of tuberculosis of the genitourinary tract were positively identified out of a much larger number of cases of genitourinary tract disease in which the diagnosis was questionable. It is noteworthy that in the Central and South Pacific Areas (data for the areas separately are not available) 40 cases of tuberculosis of the genitourinary tract were found, yielding a rate of 2.8 per annum per 100,000 average strength. This may be compared with 1.8 for the Southwest Pacific (based on 28 cases) and 2.7 for the total Army (based on 674 cases). It may be noted here that, although pulmonary tuberculosis was generally excluded through X-ray examination at induction stations, facilities for detection of genitourinary tuberculosis were usually inadequate, so that cases that were asymptomatic at the time of induction were unknowingly accepted.

Of the nonpulmonary forms, tuberculosis of the pleura was conspicuous (9 cases). There were a few cases of tuberculosis of superficial lymph nodes, bones, joints, and meninges. The list included only one case of generalized miliary tuberculosis.

Diagnosis-Diagnostic facilities varied with the type of medical installation and its location. First-class roentgenological facilities were available throughout the theater and, according to the official reports, liberal use was made of them at all times. Every patient with symptoms of chest disease was examined by X-ray. Group surveys were made when special circumstances indicated their value. For example, a Navy steward was found to have advanced pulmonary tuberculosis and about 20 close contacts were studied. It was interesting to note that no active cases were found in this study but that two or three apparently inactive cases were located.

Facilities for laboratory examinations depended upon the proximity of the installation concerned to the front. Laboratories as far forward as clearing companies had all the necessary equipment for making stains for acidfast bacilli. In installations to the rear of clearing companies, facilities were available for concentration methods for the detection of tubercle bacilli, and in such installations gastric lavage was performed. General hospitals made considerable use of cultural methods for detection of tubercle bacilli. Guinea-pig inoculation was resorted to occasionally in medical laboratories, for example


359

in the 6th Medical Laboratory on Guadalcanal. In view of the scarcity of the animals, this was largely restricted to cases in which tuberculosis of the kidney was suspected.

Hospitalization and care-Few officers who had specialized for a long period in tuberculosis were on duty in the theater, which in this respect was worse off than the European and Mediterranean theaters. Because of the great distances involved, the consultant system was not used. The diagnosis and treatment of tuberculosis thus depended upon the judgment and general medical ability of officers in the various installations.

Patients were transferred from installations where the diagnosis was made to general hospitals in the theater for observation, care, and disposition. Therapy was restricted largely to rest and measures directed toward improvement in general nutrition, supplemented by symptomatic treatment for relief of cough and pleuritic pain. Collapse therapy was seldom attempted, since it was the policy of the theater to return all cases needing definitive care as promptly as possible to the United States.

Special problems-Medical officers were on the lookout for special effects of climate and other adverse conditions peculiar to the region.

Climatic conditions were highly variable throughout the area, which, at one time or another, extended from the equatorial latitudes of the Bismarck Archipelago to the Temperate Zone of New Zealand and from the 150th meridian of east to the 150th meridian of west longitude. The majority of the troops in the command lived under tropical and semitropical conditions in the Solomon Islands and in New Caledonia, although a certain number were stationed in New Zealand for extended periods for training or rest. No specific effects attributable to the climate were emphasized by medical officers in the area.

Service in these regions was arduous. Corresponding with the number of troops involved, the amount of tuberculosis discovered was highest in the infantry, in which more than a quarter of the cases detected were found. It is remarkable that the next highest number of cases were discovered in personnel of the Medical Department, and a slightly lower number, in the Corps of Engineers. These three branches accounted for more than half of all the cases of tuberculosis discovered. The highest rate of tuberculosis recorded in the theater was during the period of most intense combat. This, however, was a period when a large proportion of troops that had been relatively poorly screened in the United States were on duty in the theater.32 In the opinion of the reporting official, the relatively high incidence discovered in the first 3 months of recorded data for the theater (end of 1942) was probably the result of this imperfect screening rather than the unusual severity of the service itself.

Likewise, no specific correlation with nutrition was discovered. Nutrition was in fact relatively poor at the time that the troops were most heavily

32See footnote 3, p. 331.


360

engaged in combat and the incidence of tuberculosis was at its highest. Some medical officers attempted to determine if tuberculosis decreased after improvement of the diet, which consisted largely of C and K field rations in the earliest part of the war, but no significant conclusions in this respect could be drawn. Certainly, nutrition improved enormously after the first difficult period, but it was true also that the troops chiefly concerned at this later time had been subjected to much better screening.

In view of the high prevalence of malaria and other tropical diseases, a number of medical officers attempted to determine if they had any effect in activating tuberculosis. No specific evidence of activation of tuberculosis as a result of concomitant malaria or other disease was detected. This corresponds with the results of a number of prewar studies, which failed to show any specific connection between malaria and depression of resistance to tuberculosis.

Mortality-The number of deaths from tuberculosis in the theater was extremely small. In the theater report, only five fatal cases are listed, all of them of acute type. The death rate deduced from these figures was 1.3 per 100,000 men per annum. The figure merely indicates that cases of ultimately fatal issue were transferred to the United States before death occurred. 

Evacuation.-All patients with active tuberculosis of any part of the body were evacuated to general hospitals in the United States. A total of 158 patients were evacuated from New Caledonia and 65 from Guadalcanal. In the early months of the war, a few patients were sent to Melbourne, Australia. Evacuation was ordinarily by direct transfer to a medical installation in the United States. The largest number of transfers was to Letterman General Hospital, San Francisco, Calif.

Patients with active pulmonary tuberculosis were almost invariably evacuated as strict litter patients, whether the transfer was by air or by sea. Patients with inactive or arrested tuberculosis and those with involvement of superficial lymph nodes only, as well as a good many cases of genitourinary and other forms of nonpulmonary tuberculosis, were evacuated as ambulatory patients. Evacuation by air from New Caledonia commenced in 1943 and increased notably in 1944 and 1945. However, even at the end of the war, from this distant area, the majority of patients were returned to the United States by ship. Approximately 13 percent were returned by air. Of the 158 patients returned by ship from New Caledonia, 66 percent were litter patients, 23 percent ambulatory patients, and 11 percent troop-class patients.

SOUTHWEST PACIFIC AREA

Incidence-In comparison with other medical problems, tuberculosis was considered of minor military significance in the Southwest Pacific Area.33 The official report from the area states:

33Timpanelli, Alphonse E.: Tuberculosis in the Southwest Pacific Area [World War II]. [Official record.]


361

* * * in 40,000 continuous admissions for all causes from all sections of the Southwest Pacific area in two large general hospitals operating at various times in three separate areas in New Guinea and the Philippines, only 64 cases of tuberculosis were found * * *. Of these 64 cases studied, 62 were instances of pulmonary tuberculosis and 2 of tuberculous cervical adenitis without clinical pulmonary involvement. Extra-pulmonary tuberculosis was rarely encountered in the area. A review of the pulmonary cases showed that 12 were diagnosed as inactive or arrested, 33 as minimal active, 16 as moderately advanced, and 1 far advanced. None of the patients were critically ill and none died in the theater.

The incidence rates for tuberculosis in the Southwest Pacific Area and other theaters and areas, as computed in the Office of the Surgeon General,

CHART 21.-Incidence of tuberculosis in the U.S. Army, by theater and year, 1942-45

are shown in chart 21. The rate for all theaters and areas during World War II was 1.25.

Diagnosis and care-Medical installations in general were provided with X-ray and laboratory facilities, so that diagnosis was ordinarily made at an early stage. Cases discovered in forward areas were evacuated to general hospitals where, in most instances, one or more members of the medical staff had had specialized training in tuberculosis. Laboratories were regularly equipped for examination of sputum and gastric washings and the determination of sedimentation rates.

Special medical problems-As in the South Pacific, an effort was made to determine if climatic conditions or prevalent tropical diseases played a role in the activation or progress of tuberculosis. No evidence was found that these factors played any part in increasing the incidence or severity of tuber-


362

culosis. Comparative studies showed that prevalent bacterial infections and parasitic infestations were no more common in tuberculous patients than in the general population of patients. The official reporter records:

While the groups of patients admitted in various periods from areas of prolonged and active combat showed, in general, varying degrees of undernutrition and physical exhaustion and a greater incidence of parasitic infestation, they presented no more tuberculosis than was seen among patients from service forces operating under more favorable conditions.

Evacuation-Cases of active tuberculosis were evacuated as rapidly as possible after the final decision was reached by the disposition boards of the hospitals concerned. Wherever possible, tuberculous patients were transferred to the United States by air. It was felt that the best assurance possible for recovery was to minimize delay in the initiation of definitive treatment in a specialized Army medical institution in the Zone of Interior. "In the few instances in which evacuation from the theater for old, well-healed pulmonary lesions did not seem warranted, arrangements were made for periodic examination and evaluation."

In general, definitive therapy was not attempted in the theater; it was felt that the type of treatment to be employed in individual cases should be left to the installation charged with the final care of the patient. The report states further that "the short period of time which the patient spent in the oversea theater hospital was utilized in educating him in regard to the nature of his disease, in his personal care, and in isolation technique. He was kept in isolation and on bed rest during his stay in the hospital and en route to his destination."

The official report states that "air travel was well tolerated by patients in all stages of the disease. No complications incident to air travel arose in patients with tuberculous pulmonary lesions."

The average period of hospitalization between diagnosis and evacuation was 18 days.

WESTERN PACIFIC BASE COMMAND

Incidence-The official report for this command states that about 0.6 percent of a series of approximately 18,000 medical cases were diagnosed as tuberculosis. The incidence rate in the command for the period June through September 1945, as recorded on the statistical health report, was about 1 per annum per 1,000 average strength. The great majority of the cases were of pulmonary tuberculosis. In addition, there were a few cases of genitourinary, miliary, bone, and gastrointestinal tuberculosis, and tuberculosis meningitis.

Diagnosis-The most frequent problem encountered was in early differentiation of tuberculosis from atypical pneumonia. Repeated examination of sputum and gastric washings for tubercle bacilli in many cases resulted in a diagnosis that could not be made on the roentgenogram alone. Bronchiectasis and coccidioidomycosis also required differential diagnosis. Cases of bron-


363

chiectasis were not uncommonly seen, but were not accurately diagnosed, for the medical officers in the area were reluctant to use Lipiodol because of possible future confusion on reexamination at tuberculosis centers in the United States. Cultural methods were employed in isolating tubercle bacilli; guinea pigs were rarely used because of their scarcity in the theater. The standard methods were used for determination of activity of tuberculosis as bearing upon disposition.

Treatment-As a rule, initial treatment only was attempted. The principal therapeutic problem was whether to institute pneumothorax prior to evacuation. This was rarely done, because of (1) uncertainty concerning route, mode, and speed of evacuation, (2) uncertainty whether competent personnel would be in attendance en route to give refills and handle possible complications, such as tension pneumothorax, and (3) the need for a long period of bed rest and observation prior to institution of collapse. Collapse was, however, induced in cases of persistent hemorrhage, cases in which excavation developed in rapidly progressive lesions, and cases in which there was reason to believe adhesions were forming.

Special problems-The official report stated that "* * * no medical officer contacted had definite basis for believing that the tropical climate per se influenced the development of tuberculosis, although it was a factor in determining disposition of certain cases * * *. Nor could the type of military service be correlated with the incidence of tuberculosis. Most of the officers who dealt with repatriated prisoners of war believed that their poor nutritional status undoubtedly influenced their high rate of tuberculous infection." The subject of tuberculosis in recovered prisoners of war is treated elsewhere. It will be noted here that a survey of troops from Iwo Jima, where supplies of fresh food were probably least adequate, failed to demonstrate a clinical deficiency status that could be correlated with the progress of infectious disease of any type. Subclinical vitamin deficiencies were slight, and of no greater severity than were seen in a similar group in the Hawaiian Islands.

Evacuation.-Evacuation by air was considered the ideal form of transportation, but was not available as often as was desired. Prior to evacuation, whether by sea or by air, sedation with barbiturates was given, and provision was made for such complications as spontaneous pneumothorax. All patients with active tuberculosis were evacuated, and a good many with lesions that were without symptoms or signs and appeared to be inactive on X-ray examination were, nevertheless, evacuated to the United States because medical officers in the command did not feel justified in calling such cases arrested without prolonged observation. With the end of hostilities, as the report notes, the tendency of the theater was to be more liberal with the diagnosis of inactive tuberculosis, and, for this reason, numerous patients of types previously forwarded to the United States were held for prolonged observation, and not infrequently returned to duty.


364

MIDDLE PACIFIC

Incidence-The incidence of tuberculosis in the Pacific Ocean Area, which consisted of the combined Central and South Pacific Areas, is shown in chart 21. A sampling comprised of admissions in the Middle Pacific command during the first 11 months of 1945, shows a total of 164,957 cases of disease of all types, including 287 cases of tuberculosis, or 0.17 percent of all admissions. 

Diagnosis and care.-Nothing unusual in diagnosis, not seen in other parts of the Pacific area, was noted in the official report in the Middle Pacific command. Hospitals in the Hawaiian Islands were excellently equipped, so that every procedure that could be carried out in the Zone of Interior was readily available. Because of the accessibility of six excellent general hospitals, definitive care was instituted more frequently than in the more remote areas in the Pacific. Active cases were transported as soon as convenient to the mainland. As in other parts of the Pacific area, medical officers concerned with the care of tuberculous patients did not attribute any particular manifestations of the disease to climatic peculiarities of the region, to the type of service, or to the malnutrition that from time to time affected substantial numbers of troops in combat.

Evacuation-The majority of patients with tuberculosis were transported to the Zone of Interior by water, except that those who were sent by way of the Hawaiian Islands accomplished this part of the journey by air.

CHINA-BURMA-INDIA THEATER

Tuberculosis in military personnel was not considered a serious problem in the India-Burma theater.34 The consultant in medicine in the theater reported that 334 cases were admitted to hospitals there between the first of January 1944 and the end of July 1945. The annual incidence rates per 1,000 average strength and numbers of cases for the China-Burma-India theater, based on preliminary sample tabulations of individual medical records, are as follows:

 


Number of cases

Rate

1942

6

0.69

1943

27

.68

1944

157

.93

1945

240

1.04


On the other hand, Army installations in the China and the India-Burma theaters recorded a high incidence of tuberculosis in Chinese troops. The great majority of tuberculous patients in U.S. Army hospitals in China and

34(1) Blumgart, Herrman L., and Pike, George M.: History of Internal Medicine in India-Burma Theater, p. 118. [Official record.] (2) The U.S. Forces, India-Burma Theater, was created on 24 October 1944 by dividing the U.S. Forces, China-Burma-India into two separate theaters-the China Theater and the India-Burma Theater.


365

Burma were Chinese. Because of this high incidence and the notorious lack of sanitary precautions observed by sick Chinese soldiers, medical and nursing personnel in these hospitals were heavily exposed to contagion. Routine checks by the 48th Evacuation Hospital of hospital personnel failed to disclose cases of tuberculosis that could be traced to contact in the theater. Since, however, tuberculosis is slow in its evolution, and years may elapse between infection and manifest disease, it was recognized by administrative officers of these hospitals that persons who had been employed in them should be carefully observed for some time after their return to the United States.

ALASKAN DEPARTMENT

From time to time, concern was expressed over the extent of tuberculosis in Alaska. Reports from units in the Alaskan service called attention to the excessive admission of men with tuberculosis through the enlistment process at Alaskan stations, where facilities for the detection of the disease were inadequate. Attention was also called to the danger of exposure of servicemen to tuberculosis in Alaska, where the prevalence of the disease greatly exceeded that in the United States. During the war, negotiations were underway for the construction of a hospital for the care of tuberculous patients in Alaska, and the danger to servicemen, through contact with nonhospitalized cases, was cited as emphasizing the need for such a hospital. The number of nonhospitalized open cases in the territory was estimated by the Office of the Surgeon General as approximately 1,000 and, although the distribution of these cases was unknown, it was assumed that their presence in communities where troops were stationed constituted a hazard in contagion.35 In addition, the factor of exposure to harsh climatic conditions, with an adverse effect on small latent or unrecognized tuberculous lesions, was also cited as reason for special consideration of the problem of tuberculosis in the Alaskan Department.

The actual incidence rates for tuberculosis during the war years, however, did not reflect an unusual hazard. The annual rates per 1,000 men, based on preliminary summary reports, were much like those recorded elsewhere:

 


Number of cases

Rate

1942

81

1.61

1943

99

.86

1944

70

.84

1945

44

1.07


Whether evidence of infection acquired by soldiers in Alaska will develop later, could not be predicted.

35Memorandum, Lt. Col. Robert J. Carpenter, MC, Executive Officer, Office of the Surgeon General, for Assistant Chief of Staff, G-4, attention: Col. Carroll H. Deitrick, GSC, Chief, Policy Branch, 15 Mar. 1944, subject: Hospitalization for Tuberculosis Cases in Alaska.


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LATIN AMERICAN AREA

As in Alaska, troops in the Caribbean area and in Central and South America served in regions of relatively high prevalence of tuberculosis in the local population. Also, as in Alaska, the troops on duty included a good many recruited locally from a territory of the United States where the prevalence of tuberculosis was high; for example, Puerto Rico. The total incidence rates, however, up to the end of the war did not furnish evidence of special hazard. The annual incidence rates per 1,000 average strength and the number of cases, based on tabulations of individual medical records, are as follows:

 


Number of cases

Rate

1942

159

1.56

1943

134

1.11

1944

115

1.34

1945

85

1.19

MIDDLE EAST

As the number of troops on duty in the Middle East was not large, the rates were not highly significant. Climatic conditions were variable, and exposure to contagion, as reflected by the mortality in the local population, was high. The heat in Iran was excessive and made it impossible for troops on duty to get normal rest. The annual incidence rates per 1,000 average strength and the number of cases, based on tabulations of individual medical records, are as follows:

 


Number of cases

Rate

1942

3

0.50

1943

47

.89

1944

50

1.08

1945

20

.72


FAR EAST

The number of cases of tuberculosis developing in the U.S. Army in Japan, between the date of initial occupation and the end of 1945, was very small. Only 24 cases were recorded, which yielded an annual rate of 0.24 per 1,000 per annum. The surgeon of the occupying forces, however, in a later report on tuberculosis in Japan, called attention to the prevalence of the disease in the native population, which suggested a correspondingly grave exposure of troops on duty in the islands. The annual mortality from tuberculosis in Japan was recorded, on the basis of figures obtained from the Japanese Anti-Tuberculosis Association, as ranging from 209 per 100,000 in 1941 to 282 per 100,000 in 1946. In view of the known great deficiency of beds for the care of the tuberculous in Japan, it may be assumed that large


367

numbers of open cases were scattered through Japanese communities without isolation or care.

During 1946, the hospital admission rate for tuberculosis, as recorded in the theater, rose notably. Part of this rise, however, particularly in the months of June, July, and August, was the result of rapid discovery of cases in Philippine troops on discharge from the U.S. Army. As the report indicates, however, rates considerably higher than those for troops in the United States prevailed in the theater at the close of 1946.

It was evident that the problem of tuberculosis in troops on duty in the Far East was serious. It was complicated by the presence of numerous Philippine soldiers among the occupying troops, a group with a relatively high incidence of tuberculosis as compared with those recruited in the United States. Continual attention must be given in the future to the factor of contagion in this region.

Part III. Particular Aspects of the Disease

EXTRAPULMONARY TUBERCULOSIS

Extrapulmonary tuberculosis may be a complication of pulmonary tuberculosis, or may occur in the absence of significant pulmonary disease. Figures indicating its prevalence in the general population are based on mortality records, rather than incidence during life, and indicate that about 10 percent of all fatal tuberculosis is predominantly nonpulmonary. In the approximate order of frequency of involvement are the urogenital tract, bones, lymph nodes, serous membranes, and other sites, such as the adrenal glands. In many cases, the contributing, final cause of death is miliary tuberculosis or tuberculous meningitis. The position of intestinal tuberculosis is indeterminate. In the great majority of cases, this form is simply a complication of pulmonary tuberculosis, but not infrequently its manifestations are so severe that they dominate the clinical picture, so that death is reported as due to intestinal, rather than to pulmonary, disease.

Nonpulmonary tuberculosis, the scrofula of ancient times, is most prevalent among primitive peoples and those whose hygienic environment is poor. It is also frequent where the alimentary intake of tubercle bacilli is common, as in localities where bovine tuberculosis is widespread and milk is not pasteurized.

Troops of the U.S. Army met both of these conditions overseas. Among the natives in the Pacific islands the scrofulous types of tuberculosis were relatively common, while bovine tuberculosis was frequent in the British Isles and continental Europe. The reasons for prevalence of nonpulmonary tuberculosis in primitive cultures are complex, including racial factors as well as habits and customs. In the United States, as a result of a combination of circumstances, nonpulmonary tuberculosis is more frequent in Ne-


368

groes and Indians than in white people, and this fact held for troops of these races.

The contagion of nonpulmonary tuberculosis, even more than of pulmonary tuberculosis, depends on the closeness of contact. There was no reason to believe that the contacts of American troops with a population in which nonpulmonary tuberculosis is more common than in the United States would lead to a higher incidence of this type of tuberculosis than normally prevails in our population. Such a result would imply prolonged intimate contacts, as by adoption of primitive customs, such as eating from a common bowl or careless skin contacts with open ulcers or draining sinuses of infected persons.

On the other hand, infection from raw milk, particularly in the British Isles, was clearly recognized as a danger from the outset, and precautions against it during our troops' residence overseas were taken early.

An observation made in the course of military operations in World War I is pertinent.36 The American pathologist, Maj. Eugene L. Opie, MC, stationed in France, called attention to the fact that calcified tuberculosis of primary infection was very frequently observed in the mesenteric lymph nodes of British troops, indicating an alimentary origin, presumably by ingesting infected milk. In the bodies of Americans, in marked contrast, primary infections were almost always in the lungs or tracheobronchial lymph nodes, and so presumably had been acquired by inhalation of tubercle bacilli.

By far the greatest amount of the milk consumed on Army posts overseas was dried pasteurized milk shipped from the United States. There was always, however, some danger from milk from private sources. In the early months overseas, some of the Red Cross canteens served local milk, the safety of which was not assured. Later, about February 1943, this practice was stopped entirely. The U.S. Army Veterinary Corps in the British Isles was constantly on the alert for danger. Up to July 1942, the U.S. Army was on the British ration, which included milk from certain approved sources. The Veterinary Corps came to the conclusion that, in spite of a variety of precautions, "there were too many hazards involved for its general use." Circulars Nos. 40 and 72, Headquarters, European Theater of Operations, dated 5 September and 10 November 1942, respectively, sharply restricted purchase of milk and imposed rigid standards with respect to the source. Relatively few sources satisfied these standards; consequently, after the early months, little British milk was consumed in the official ration. Consumption of raw milk by soldiers in the homes of friends could not be so well controlled, and some infection may have been transmitted in this way, but the total hazard was not great, as relatively little milk was available to the general population.

36Opie, E. L.: First Infection With Tuberculosis By Way of the Intestinal Tract. Am. Rev. Tuberc. 4: 641-648, November 1920.


369

Since tuberculosis is a disease of slow development, it is not easy to determine the source of infection in a given case. Disease acquired overseas may not become manifest for several years. Therefore, it is not known how much nonpulmonary tuberculosis observed in American troops originated there. It can only be said that the incidence (of forms other than pleuritis) showed no rise before the end of the war. The overall rates per 1,000 for the total Army for all forms of nonpulmonary tuberculosis, including tuberculosis of the larynx, trachea, bronchi, and pleura, for the years 1942, 1943, 1944, and 1945, were 0.13, 0.13, 0.17, and 0.23, respectively. Tuberculosis of the pleura is of special interest and is considered under the next heading and elsewhere in this account. Figures for the incidence of the other more common forms of nonpulmonary tuberculosis are presented in table 49.

TABLE 49.-Incidence of nonpulmonary tuberculosis (excludes pleural tuberculosis) in the U.S. Army, 1942-45

[Preliminary data based on sample tabulations of individual medical records]
[Rate expressed as number of cases per annum per 1,000 average strength]

Type


1942-45

1942

1943

1944

1945


Number of cases

Rate

Number of cases

Rate

Number of cases

Rate

Number of cases

Rate

Number of cases

Rate

Genitourinary

674

0.03

50

0.02

190

0.03

210

0.03

215

0.03

Bones or joints

673

.03

100

.03

174

.03

194

.02

205

.03

External lymph nodes

586

.02

19

.01

224

.03

168

02

175

.02

Skin

140

.01

5

.00

9

.00

36

.00

90

.01

Generalized miliary

133

.01

22

.01

48

.01

53

.01

10

.00

Meningitis

143

.01

19

.01

23

.00

56

.01

45

.01

Other1

928

.04

214

.07

242

.04

242

.03

230

.03


1Excludes tuberculosis of trachea and of bronchi in 1942 and 1943. During 1942-43, these two conditions were coded to pulmonary tuberculosis. In 1944 and 1945 there were 30 and 45 cases, respectively, which have been included in the "Other" category.

Differences in incidence overseas and incidence in the Zone of Interior were not significant, and accordingly combined figures for the total Army are given. The total amount of nonpulmonary tuberculosis, other than tuberculous pleuritis, was between 5 and 15 percent of all tuberculosis reported each year, a figure approximately the same as that for the civilian population. It should be noted that the methods of exclusion of nonpulmonary tuberculosis at induction were inferior to the X-ray procedure for detection of pulmonary tuberculosis. It became evident in retrospect that small lesions of the epididymis not infrequently escaped notice, and tuberculous superficial lymph nodes were also not conspicuous enough in many instances to be noted in the course of the usual rapid induction examination. Tuberculosis of the kidney was frequently evident on the basis of symptoms, history, or presence of pus in the urine, but some cases in an early stage were certainly undetected.


370

Racial differences with respect to nonpulmonary tuberculosis are discussed in the section on "Mortality From Tuberculosis." Aronson's studies37 indicated that urogenital tuberculosis was more common in the white race, and tuberculosis of the lymph nodes, of the serous membranes, and of the bones was more common in Negroes.

PLEURISY WITH EFFUSION

Special interest is attached to the subject of tuberculous pleurisy with effusion, because of the indications discovered by Canadian medical officers that this form of tuberculosis in soldiers was a manifestation of recent primary tuberculosis in adult life, occurring with particular frequency in troops from parts of Canada with a low rate of exposure. Figures for the U.S. Army are more difficult to analyze in this respect than those for the Canadian Army, but there are some indications that a similar phenomenon occurred (pp. 403-405).

The medical treatment of pleurisy with effusion in the Army was variable. There was a tendency, particularly in oversea theaters, where demand for personnel was critical, to return men to duty after complete absorption of fluid and a period of hospital convalescence and rest.38 In an appreciable number of cases of frank pulmonary tuberculosis that developed in the Army, clinical history disclosed a previous attack of pleurisy with effusion. In the Zone of Interior, the medical rule that pleurisy with effusion should be considered tuberculous if no other etiology could be proved was generally, although not invariably, followed, and many soldiers with effusion were sent to the Army hospitals used as tuberculosis centers and ultimately were discharged on certificate of disability as tuberculous. Clarification of procedure was brought about by TB MED (War Department Technical Bulletin) 71, dated 28 July 1944, and Change 1, dated 26 November 1946, in which the tuberculous nature of the disease was emphasized, instructions for diagnosis given, and principles for disposition set forth.

In 1942 and 1943, tuberculosis of the pleura was coded with pulmonary tuberculosis, with pleurisy as an associated disease. In 1944 and 1945, separate specific accounting was made of clearly diagnosed tuberculosis of the pleura and serofibrinous pleuritis of undemonstrated origin (table 50). The figures for these 2 years may therefore be used as suitable for comparing pleurisy with effusion with pulmonary tuberculosis, and the occurrence of pleurisy with effusion in troops overseas and in the United States.

It will be noted that the rate was appreciably higher in troops overseas than in those in the United States, where, it will be recalled, the admission rate for pulmonary tuberculosis was higher than in troops overseas (chart 18). However, great significance should not be attached to this apparent

37Aronson, J. D.: The Occurrence and Anatomic Characteristics of Fatal Tuberculosis in the U.S. Army During World War II. Mil. Surgeon 99: 491-503, November 1946.
38See footnote 29, p. 356.


371

discrepancy. The advent of pleurisy with effusion is generally sudden and dramatic with fever, pain, and other symptoms; the diagnosis, therefore, is relatively early and easy. Pulmonary tuberculous infiltration, on the other hand, is usually insidious in origin and diagnosis on a symptomatic basis, relatively late. It is quite reasonable to suppose that almost all of the serofibrinous pleurisy developing overseas was diagnosed there, whereas pulmonary tuberculosis acquired overseas in many instances was not detected until the return of the afflicted soldiers to the United States.

TABLE 50.-Incidence of tuberculosis of pleura and serofibrinous pleuritis in the U.S. Army, 1944-45

[Rate expressed as number of cases per annum per 1,000 average strength]

Category

Total Army

Continental 
United States


Outside continental 
United States


1944


 

 

 

Tuberculosis of pleura

391

75

316

Serofibrinous pleuritis

3,320

1,500

1,820


Total cases

3,711

1,575

2,136


Total rate

0.48

0.40

0.56


1945


 

 

 

Tuberculosis of pleura

745

160

585

Serofibrinous pleuritis

2,520

900

1,620


Total cases

3,265

1,060

2,205


Total rate

0.44

0.36

0.50


All clinical experience indicates that the prognosis of cases of pleurisy with effusion, even without radiologically demonstrable pulmonary infiltration, is doubtful for at least 5 years. Texts and articles on the subject, in general, emphasize the fact that 25 to 50 percent of the cases of effusion inadequately treated, that is, not subjected to a period of rest of several months following absorption of the fluid, develop pulmonary tuberculosis within 5 years; thereafter, the incidence is like that in the general population of corresponding age.39 The Army figures cannot be expected to reveal the total incidence of pulmonary tuberculosis developing in cases of pleurisy with effusion, for the critical 5-year period had only commenced in the majority of cases when demobilization began. It is possible that men who had had short attacks of pleurisy with effusion and were returned to duty with-

39(1)Thompson, B. C.: Pathogenesis of Pleurisy With Effusion; A Clinical, Epidemiological and Follow-up Study of 190 Cases. Am. Rev. Tuberc. 54: 349-363, October-November 1946. (2) Thompson, B. C.: Prognosis of Primary Pleurisy With Effusion. Brit. M.J. 1: 487-488, 12 Apr. 1947.


372

out residua, and ultimately discharged from the Army with negative X-ray films of the chest or no anomaly other than a costal diaphragmatic adhesion, may yet develop pulmonary tuberculosis as a result of the infection manifested originally only by the pleurisy. Care and compensation in these cases will be adjudication problems for the future.

As has been pointed out, in the various theaters the rate of admission for serofibrinous pleurisy in the Army was generally 25 to 30 percent of the rate of admission for pulmonary tuberculosis. In view of the probable tuberculous nature of the great majority of cases of effusion in which tuberculosis could not be unequivocally diagnosed by laboratory methods, it might seem appropriate to add the admissions of serofibrinous pleurisy to those for pulmonary tuberculosis to arrive at a true rate for the latter. This would not be accurate, however, as there would be a not insignificant duplication of cases. Men with a diagnosis of pleurisy with effusion in the admission records who returned to duty after recovery were subsequently, in an undetermined number of cases, given another diagnosis, and entered in the medical statistics of the Army as patients with pulmonary tuberculosis.

In summary, it appears warranted to believe that tuberculous pleurisy did occur more frequently in troops serving overseas than in those who never left the United States, and it seems reasonable, even with due allowance for greater physical strain and other factors that might be pertinent, to attribute the greater frequency, as did the Canadians, to the greater exposure overseas, where civilian populations were more heavily infected than in the United States. Much further research, taking into account the age and home residence of soldiers who developed tuberculous pleurisy with effusion, will be needed to support the Canadian view that the majority of cases of effusion represented recent primary tuberculous infections.

The American experience also indicates the necessity for a long-range view of the prognosis of pleurisy with effusion, with recognition not merely of immediate necessities for manpower, but also the questionable prognosis in the long run, of men seemingly recovering without residua and returned to military duty.

SPONTANEOUS PNEUMOTHORAX

The view once prevailed that the great majority of cases of spontaneous pneumothorax were complications of pulmonary tuberculosis. In 1932, in his textbook on tuberculosis, Fishberg40 expressed the general opinion that 80 percent of cases were in that category. Subsequent investigation showed spontaneous pneumothorax to be not uncommonly an independent development.41 Such, as seen in the Army, it was usually found to be.

40Fishberg, Maurice: Pulmonary Tuberculosis. Volume I. Etiology, Pathogenesis, Symptomatology, Roentgenology, Clinical Forms. 4th edition. Philadelphia: Lea & Febiger, 1932.
41For a study of 58 cases, bibliography, and discussion of pathogenesis see Ornstein, G. G., and Lercher, L.: Spontaneous Pneumothorax in Apparently Healthy Individuals. Clinical Study of Fifty-eight Cases With a Discussion of the Pathogenesis. Quart. Bull., Sea View Hosp. 7: 149-187, April 1942.


373

During the years 1942 to 1945, inclusive, 3,831 admissions to Army hospitals for spontaneous pneumothorax were recorded. The great majority were nontuberculous. This number, in a total of approximately 11 million men, represented about 1 case per 2,700 men in the cumulative experience of 4 years.

The incidence of spontaneous pneumothorax, as indicated by rates of admission and readmission for the continental United States and the oversea theaters during the 4 war years, is presented in table 51.

TABLE 51.-Admissions and readmissions for spontaneous pneumothorax in the U.S. Army, by area and year of admission. 1942-45

[Preliminary data based on sample tabulations of individual medical records]
[Rate expressed as number of new admissions per annum per 1,000 average strength]

Year and area of admission


Admissions

Readmissions


Number

Rate

1942

 

 

 

Continental United States

384

0.14

8

Outside continental United States

56

.10

---


Total Army

440

0.14

8


1943

 

 

 

Continental United States

930

0.18

25

Outside continental United States

163

.10

2


Total Army

1,093

0.16

27


1944

 

 

 

Continental United States

805

0.20

15

Outside continental United States

353

.09

6


Total Army

1,158

0.15

21


1945

 

 

 

Continental United States

585

0.20

20

Outside continental United States

555

.12

---


Total Army

1,140

0.15

20


1942-45

 

 

 

Continental United States

2,704

0.18

68

Outside continental United States

1,127

.11

8


Total Army

3,831

0.15

76


374

As the figures show, the admission rate overseas was consistently less than in the United States, a fact perhaps merely indicating that a soldier predisposed to spontaneous pneumothorax by anatomical defect or other cause was likely to develop it in his early Army training if at all.

In 1943, when there were 930 hospital admissions in the continental United States for this cause, and medical officers were in doubt as to proper treatment, the Subcommittee on Tuberculosis, National Research Council, was asked to study the subject and make recommendations on treatment. This request resulted in the publication of a document by the Office of Medical Information of the Division of Medical Sciences, National Research Council, which was given wide distribution in U.S. Army medical installation S.42 At the same time, an article was published in the Bulletin of the U.S. Army Medical Department calling attention to the frequency of spontaneous pneumothorax, the deficiencies in present-day treatment, the need for individualization in treatment, and the dangers inherent in the several methods available.43 The note pointed out that up to the time of its writing, spontaneous pneumothorax had been considered of sufficient gravity to warrant separation from the service in 15 percent of cases and that the average duration of hospitalization for this condition had been 40 days.

In the document published by the National Research Council, a useful classification was given, with pertinent material on diagnosis and prognosis. The relationship to bullae in the lung was indicated, although it is known that very frequently such bullae cannot be demonstrated during life by any radiological or other method. Conservatism in treatment was recommended. Prompt hospitalization was required, with avoidance of physical effort. Special warning was given against transportation by air. It was noted that the air in the pleural space is absorbed spontaneously in most cases within a few weeks. Aspiration at short intervals may be desirable for a few days at the start.

The chief problem in spontaneous pneumothorax in the Army was recurrence. Waring's review of the literature indicated recurrence in 10 to 20 percent of cases. Most of the discharges from the Army for spontaneous pneumothorax were for recurrence or persistence. In many of these cases, various methods of obliterating the pleural space to prevent recurrence were tried. Two that met with some success were injection of whole blood from the patient and insufflation of powdered talc. In Waring's report, the dan-

42Waring, J. J.: Spontaneous Pneumothorax. Office of Medical Information, Division of Medical Sciences, National Research Council, July 1944.
43(1) Pease, P. P., Steuer, L. G., and Chapman, A. S.: Spontaneous Pneumothorax in Soldiers. Bull. U.S. Army M. Dept. No. 82: 102-107, November 1944. (2) Spontaneous Pneumothorax. Bull. U.S. Army M. Dept. No. 82: 29, November 1944.


375

gers of induced "chemical pleuritis," particularly uncontrollable thickening of the pleura, were discussed.44

In general, the Army experience indicated that spontaneous pneumothorax is a not uncommon phenomenon; that it is favored by exertion, but may occur independently of any physical strain; that recurrence is not infrequent and may necessitate discharge; and that individualization is necessary in treatment. Account was taken of its importance for induction by the requirement, in late revisions of Army Regulations pertaining to physical standards, including Mobilization Regulations, that men with a verified history of spontaneous pneumothorax within 3 years, or recurrent spontaneous pneumothorax at any time, should be excluded from service.

MORTALITY FROM TUBERCULOSIS

Figures on mortality from tuberculosis in the Army are not highly significant. Active tuberculosis was rarely compatible with return to active duty, and accordingly Army Regulations required discharge of patients after diagnosis and such initial hospitalization as was necessary to insure the best results in a Veterans' Administration hospital or civilian hospital after discharge. It was specifically stated in AR (Army Regulations) 615-361, 14 May 1947, however, that moribund cases were not to be discharged. Hence, the deaths that occurred from tuberculosis in the Army represented cases in which the disease was far advanced on discovery, acute in its progression, or first diagnosed and hospitalized in regions where early evacuation was not possible.

During World War II, the annual mortality from tuberculosis in the Army averaged about 3 per 100,000 while in the civilian population of corresponding age the rate was about 50 per 100,000. The corresponding figures for World War I were 67 in the military population and over 150 per 100,000 in the civilian population.

The incidence and character of fatal tuberculosis in the Army formed the subject of a special investigation,45 in which comparison was made of the pathology of the disease in white and in Negro troops. In general, the evidence favored the view that the Negro race has a lower inherent resistance to tuberculosis than the white race, for, in spite of approximate uniformity of environment, Negro troops, representing only 10 percent of the population of the Army, contributed 43.4 percent of the deaths from tuberculosis. Unusual differences were not observed in the extent or character of tuberculosis

44(1) See footnote 42, p. 374. (2) For a further discussion of the treatment of spontaneous pneumothorax see Blades, Brian B., Carter, B. Noland, and DeBakey, Michael E.: Surgical Aspects of Diseases of the Chest. In Medical Department, United States Army. Surgery in World War II. Thoracic Surgery. Volume II, ch. X. [In preparation]-J. B. C., Jr.
45See footnote 37, p. 370.


376

in the different organs in the two races. Highly destructive tuberculosis was somewhat more frequent in the lungs of Negro than in white troops, and healed tuberculosis was a more common incidental finding in white than in Negro troops. In white soldiers, the central nervous system and genitourinary organs were more commonly affected than in Negro troops, and in the latter there was higher incidence of tuberculosis of lymph nodes, bones, and peritoneum. Tuberculous meningitis was slightly more common in Negro than in white soldiers.

In both races, the duration of the disease appeared remarkably short as compared with that in the civilian population. The reason for this has already been given; namely, the likelihood of discharge of chronic cases before death could occur. A relatively high incidence of fatal tuberculosis occurred in recovered prisoners of war who had suffered privations for many months in prison camps overseas.

Although the mortality from tuberculosis among troops actually in service does not yield statistically significant figures, such figures can be obtained by combining the mortality totals for the military population in service and discharged. Figures so compiled indicate that a steady rise has occurred in the mortality from tuberculosis in the group of men accepted for service in the Army since the beginning of World War II.46 During 1942, the combined rate for troops in service and troops previously discharged was approximately 3 per 100,000 per annum; thereafter, it rose to 6 in 1943, 10 in 1944, and 12 in 1945.

This steady rise indicates that tuberculosis continued to increase with time in a group generally well screened by X-ray examination before induction. There is reason to believe that the rise was due to several factors, including slow and ultimately fatal development of previously unrecognized disease present at the time of acceptance and the acquisition of infection from outside sources during the years of military service. For comparison, it may be noted that during the years under consideration the tuberculosis death rate for the civilian population of corresponding age remained, with minor fluctuations, at approximately 52. Thus, the rate for the screened population was far below that of the corresponding unscreened population, which included those screened out because of tuberculosis. The rate which the disease will ultimately attain will depend on many factors, including measures against tuberculosis in the general population and special measures for veterans taken by the Veterans' Administration.

Eight hundred and six deaths from tuberculosis were recorded in Army personnel from 1942 to 1945, inclusive (table 52).

46Long, E. R.: Tuberculosis in a Screened Population. Am. Rev. Tuberc. 54: 319-320, September 1946.


377

TABLE 52.- Deaths due to tuberculosis in the U.S. Army, by broad area of admission, rank, sex, race, and year of death, 1942-45


378

Part IV. Hospitalization and Treatment in the Zone of Interior

GENERAL PRINCIPLES OF EVACUATION

For accounts of evacuation of tuberculous patients from the different theaters, the reader is referred to sections of this chapter in which the experience of each theater is described. In the early days of World War II, evacuation was by transport, for neither hospital ships nor planes were available. The best facilities available on troopships were accorded tuberculous patients, but this mode of transfer to the Zone of Interior had obvious disadvantages. Quarters were crowded, nursing attention was minimal, facilities for proper care were inadequate, and suitable provision could not be made for isolation.

In contrast, when hospital ships became available in sufficient numbers, the transfer of tuberculous patients from oversea theaters was handled in a creditable manner. As a rule, quarters designed for contagious diseases were used, so that isolation was feasible, and both nursing and medical care were more nearly adequate. Hospital ships had good laboratories and suitable X-ray apparatus and, as a general rule, a sufficient number of nurses. Port surgeons issued directives in early 1945 covering the care of patients en route and the sanitary precautions to be taken.

Early in 1945, when the number of tuberculous patients returning from overseas was fairly high, attention was drawn to the fact that convoys were often so large that the surface water, which was pumped into ships for bathing and other purposes, was contaminated to a noticeable degree by sewage from the ships of the convoys. Recognizing the fact that tubercle bacilli might be present in the discharges from tuberculous patients, and be unwittingly drawn into the water supply for scrubbing and deckwashing in rear ships of convoys, the Office of the Surgeon General forwarded a letter in March 1945 to the New York Port of Embarkation outlining principles to be followed to prevent this type of contamination. Suggestions from the Office of the Surgeon General, including a statement on general measures in the care of tuberculous patients en route, were embodied in Circular Letter No. 10 from the Port Surgeon, New York Port of Embarkation, 26 March 1945, entitled "Care of Tuberculous Patients During Water Transportation." This circular established important provisions for sputum control, emphasizing (1) education of patients, (2) use of gauze for cough, (3) use of sputtam cups, and (4) decontamination of quarters following their use by tuberculous patients, as well as the principles of isolation and proper care of utensils and laundry.

It was required that gauze, tissue, sputum cups, and bags containing gauze and other contaminated material be destroyed each day. It was recommended that if burning, the most satisfactory method of disposal, was not


379

practicable, the material to be destroyed should be placed in cloth bags of appropriate size to be weighted and sunk. It was pointed out that this infectious material should not be cast overboard indiscriminately to possibly contaminate the water pumped into the other ships.

The danger from indiscriminate use of sea water around convoys does not however appear to have been great, for tests for the presence of sewage carried out at the rear of large convoys failed to reveal any great amount of contamination, but the effort was considered worthwhile from the standpoint of public health practice.

Circular Letter No. 10 emphasized rest for the patient, avoidance of all unnecessary activity, proper ventilation of quarters, and an adequate diet. It was indicated that a diet including liberal quantities of milk, eggs, butter, orange juice, tomato juice, and meat was practicable on board ship. Ordinarily, the standard diet of the ship appeared suitable if supplemented by midmorning and midafternoon feedings of orange juice, tomato juice, or milk.

Not infrequently it was necessary to administer pneumothorax en route to patients in whom this form of therapy had been instituted overseas. Qualified medical personnel were not always available for this purpose, but in the late months of the war every effort was made to insure the presence on each hospital ship of a medical officer trained in the administration of pneumothorax.

Airplane transportation ultimately proved most desirable for the majority of tuberculous patients. It was suitable for all those with early disease, and for the majority with moderately advanced illness. Patients with large tension cavities and those with artificial pneumothorax were usually not transported by air. A specific study of the effects of air travel on patients with tuberculosis was made by the Army Air Forces. The Office of the Air Surgeon, on request for an opinion, sent the following communication to the Office of the Surgeon General:47

With respect to transportation of tuberculous cases, experience gathered during the past 24 months has shown that patients whose medical condition warrants movement suffer less shock and embarrassment when moved by air than by other means of transportation. Patients with active pulmonary tuberculosis have been flown for long distances at altitudes of 20,000 feet or more (with constant use of oxygen) without ill effect. Air movement of patients is routinely carried on at altitudes between 2,000 and 8,000 feet, except when weather, terrain, or military operations force the planes to higher altitudes.

Sound medical judgment of the responsible medical officer in each individual case must remain the final answer as to suitability for movement of tuberculous patients.

A special report on the transportation by air of tuberculous patients was prepared by the Section for Research on Minimal Tuberculosis, U.S. Army

47Transmittal Sheet, Col. A. H. Schwichtenberg, MC, Air Liaison Officer to The Surgeon General, to The Air Surgeon, 20 May 1944, subject: Evacuation of Tuberculous Patients by Air, first indorsement thereto, dated 18 July 1944.


380

Medical Research and Development Board and University of Colorado Medical Center, at Fitzsimons General Hospital.48

Transportation of patients with artificial pneumothorax had always to be given serious consideration.49 Intrapleural gas doubles in volume at 18,000 feet, and proportionate increases take place at lower altitudes. The excessive expansion at high altitudes might be expected to lead to tearing of adhesions and other untoward results. The problem was one of importance not only in oversea transport, which occasionally required flight at high altitudes to avoid storms and enemy interference, but also in the Zone of Interior, for large numbers of patients were flown to Fitzsimons General Hospital situated at an altitude of 5,000 feet in Colorado and Bruns General Hospital situated at an altitude of 7,000 feet in Santa Fe, N. Mex. Ordinarily, transportation of tuberculous and other patients was accomplished at the usual altitudes of commercial flying.

As the war progressed and the return movements of patients reached large dimensions, it was found that air transport, with proper safeguards, was without hazard. It was so well developed by the end of the war that it was considered the method of choice wherever practicable. Most important, it insured early definitive care in the United States, for such treatment, including collapse therapy, in many cases was not initiated in the theater but left to the judgment of the hospital charged with long-term treatment of the patient.

On such flights, it was essential to provide, against possible emergency, adequate nursing care and technical medical assistance. Ordinarily, a physician did not accompany a flight, but a trained nurse was always present, and the total time spent between the oversea theater and the Zone of Interior was short. As in transportation by water, proper isolation had to be insured. Occasionally, tuberculosus patients were sent on the same plane with other patients, but whenever feasible all entire plane was reserved for their use. This frequently meant holding patients at hospitals of embarkation overseas for some days until a sufficient number had gathered.

The Office of the Surgeon General sent a civilian consultant, Dr. James J. Waring of Denver, Colo., to the San Francisco Port of Embarkation and Hamilton Field, Calif., to advise on transportation by air and by water of patients from the Pacific areas. Air transport from these areas was particularly important because of the great distances involved. From July to December 1944, about 6,000 patients were flown from the Pacific areas to Hamilton Field, and of these 140 were tuberculous.

48Roper, W. H., and Waring, J. J.: Air Evacuation of Tuberculous Military Patients. Am. Rev. Tuberc. 61: 678-689, May 1950.
49(1) Minutes, Subcommittees on Tuberculosis, Committee on Medicine, National Research Council, 21 Feb. 1942 and 10 June 1944. (2) Bridge, E. R., and Bridge, E. V.: Effect of Altitude on Abnormal Accumulations of Air in the Chest. Am. Rev. Tuberc. 51: 532-537, June 1945. (3) Tuberculosis Abstracts, National Tuberculosis Association 19, No. 10, October 1946. (4) Duff, F. L.: Physical Factors in Air Evacuation. Bull. U.S. Army M. Dept. 7: 860-868, October 1947. (5) Air Transport of Tuberculous Patients. Bull. U.S. Army M. Dept. No. 87: 8. April 1945.


381

In the United States, tuberculous patients were delivered at debarkation hospitals, whether arriving by ship or by air, and after appropriate triage were transferred for further care to Fitzsimons and Bruns General Hospitals, a large number of them by air. Hospital commanders made every effort to forward tuberculous patients in plane and carload lots to avoid exposure of nontuberculous patients.

The final conclusion as a result of this experience was that airplane transportation was most appropriate whenever it was practical. For cases not suitable for air transport, hospital ships rather than transports should be used. Emphasis should be laid on proper isolation of cases, on safety, sanitary precautions, and avoidance of emergency. Finally, experience showed that medical officers with training in tuberculosis should be assigned to duty at embarkation hospitals overseas and debarkation hospitals in the Zone of Interior to insure proper care throughout the course of transfer.

SPECIALTY CENTERS FOR TREATMENT

Discovery and treatment of tuberculosis in hospitals overseas has been described for the several theaters. Hospitals at stations with a troop strength of over 5,000 men were authorized to discharge patients with tuberculosis on certificate of disability, and a large proportion of the total number of certificates of disability for discharge for this cause were granted at station hospitals. In all cases of doubt, however, where the diagnosis could not be established in a station hospital, the patient concerned was sent to a general hospital. Many were sent to Fitzsimons General Hospital which was a center for treatment of tuberculosis throughout the entire period of the war and received the majority of commissioned officers and noncommissioned officers hospitalized for tuberculosis.50

In the course of the War, two other hospitals were made specialty centers for tuberculosis: Bruns General Hospital, and Moore General Hospital, Swannanoa, N.C. Bruns General Hospital, which was activated on 18 February 1943, was made a center in August 1944,51 for the treatment of "patients requiring special evaluation or prolonged care in an Army hospital specializing in the treatment of tuberculosis." It had become necessary to supplement Fitzsimons General Hospital to provide care for the numerous patients with tuberculosis evacuated from overseas. It was directed52 that, if male tuberculous enlisted personnel and officers whose homes were in the Eighth Service Command were evacuated from overseas, they were to be transferred from debarkation hospitals to Bruns General Hospital. Women were sent to Fitzsimons General Hospital. It may be noted incidentally that Bruns General Hospital, chosen for reasons of climate and availability, by happy coincidence was named after one of the Army's outstanding specialists in tuberculosis,

50War Department Circular No. 338, 18 Aug. 1944. 
51War Department Circular No. 347, 25 Aug. 1944. 
52See footnote 13, p. 337.


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Col. Earl Harvey Bruns, MC, who had trained many medical officers during and after World War I and was for years after the war, Chief of Medical Service at Fitzsimons General Hospital.

The third specialty center for tuberculosis, Moore General Hospital, was established in the late months of the war, when many tuberculous patients were being found at separation centers.

The official annual reports for the three hospitals named, which are on file in the Office of the Surgeon General, give full details on the size of the medical and surgical staffs, the personnel changes that occurred during the war, the number of tuberculous patients treated, the types of therapy employed, and special problems encountered. At all hospitals, standard methods of therapy were employed, with principal emphasis on rest and the use of collapse measures in appropriate cases. The extent to which different collapse procedures were employed depended on the type of case, the special skills of the hospital staff, and the length of stay of patients. The frequency of collapse therapy was in inverse ratio to the length of stay in the hospital. Prior to 1946, except for a few special cases in which Promin (glucosulfone sodium) and Promizole (2-amino-5-sulfanilylthiazole) were employed, chemotherapy was not practiced in the Army. Subsequently, the Army participated actively in study of the treatment of tuberculosis with streptomycin.53

In addition to their function as treatment centers, the hospitals trained medical personnel for positions of responsibility overseas and in the Zone of Interior. Indeed, frequent changes in personnel, inevitable under the circumstances, interfered seriously with the efficiency of the treatment given.

Fitzsimons General Hospital-Col. George F. Aycock, MC, was chief of medical service throughout the period covered by this history. Lt. Col. (later Col.) John B. Grow, MC, was chief of surgical service, and Maj. (later Lt. Col.) Richard H. Meade, MC, was assistant chief and later chief of the thoracic surgery section.

Cases of tuberculosis exceeded those of any other disease, since the chief purpose of the hospital was "to give treatment under [the] most favorable conditions to patients [suffering] with tuberculosis."54 During 1942, 1,273 enlisted men were admitted to the tuberculosis section55 and 106 officers including nurses were admitted for tuberculosis. At the end of the year, 800 enlisted men were under treatment. The practice was to retain cases of pulmonary or predominantly pulmonary tuberculosis on the medical service, and cases of genitourinary, bone, joint, and lymph node tuberculosis on the surgical service. Artificial pneumothorax and pneumoperitoneum were practiced on the medical service, and phrenic nerve operations, intrapleural pneumonolysis and extrapleural thoracoplasty, as well as less frequent operative proce-

53U.S. Veterans Administration: The Effect of Streptomycin Upon Pulmonary Tuberculosis. Preliminary Report of a Cooperative Study of 223 Patients by the Army, Navy and Veterans Administration. Am. Rev. Tuberc. 56: 485-507, December 1947.
54Army Regulations No. 40-600, 6 Oct. 1942.
55Personal communication, Executive Officer, Fitzsimons General Hospital, to Col. E. R. Long, MC, 19 Mar. 1947.


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dures, were carried out on the surgical service, with return of patients to the medical service following convalescence. During 1942, 320 artificial pneumothoraces were induced and an additional 147 were continued after previous induction. Thus, more than a quarter of all the patients admitted were treated by pneumothorax. On the surgical service, 171 thoracoplasties, 187 pneumonolyses, and a small number of pneumonectomies and lobectomies were performed during 1942.

The report for 1942 indicates that 20 percent of all cases of tuberculosis had nonpulmonary tuberculous complications, of which tuberculous laryngitis, tuberculosis of the genitourinary tract, tuberculous enterocolitis, and tuberculosis of the bones were most common. Of nontuberculous complications, diabetes was most frequent. One-third of the cases under pneumothorax treatment developed pleural effusion, a figure that had held during several years of previous experience.

In 1943, there were marked fluctuations in admissions and discharges of tuberculous patients. The tuberculosis section remained the largest section on the medical service; 1,405 enlisted personnel were admitted. However, the census dropped sharply following publication of War Department Circular No. 109, 26 April 1943, which directed discharge to the Veterans' Administration of men unfit for military service and so abrogated the previous practice of holding patients for at least 6 months. During the year, there were 1,332 direct admissions of enlisted men for tuberculosis, and 634 tuberculous patients remained at the end of the year. There were 1,585 discharges from the section, chiefly on certificate of discharge for disability, and 65 deaths.

The proportions on different forms of collapse therapy were approximately as in the preceding year. There were 239 pneumothoraces initiated and 12,044 refills given. On the surgical service, 428 operations for tuberculosis were performed, including 180 thoracoplasty stages, 184 phrenic nerve operations, and 49 intrapleural pneumonolyses.

As in the preceding year, pleural effusion developed in 33 percent of the pneumothorax cases, usually (85 percent) serofibrinous, but occasionally (15 percent) purulent. Nonpulmonary tuberculous complications were of the same frequency and nature as before. Among nontuberculous complications, coccidioidomycosis was the most frequent, its incidence in the Army having notably increased as a result of desert maneuvers.

During 1943, with the longer progress of the war, there was a noteworthy increase in the number of officers admitted (277 males and 86 females). Of this number, 132 were discharged, chiefly by retirement.

In 1944, the number of admissions for tuberculosis (1,895) was somewhat larger than in preceding years. The number of cases given collapse therapy was somewhat smaller, and the number given pneumoperitoneum slightly larger, the indications for the latter therapy having become more clearly defined. Pneumoperitoneum was considered of value in those cases of tuberculosis in the exudative phase in which it was unwise to attempt pneumothorax,


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as well as in cases with basal and perihilar excavation. A remarkable constancy was apparent in the incidence of pleural effusion as a complication of artificial pneumothorax, as it occurred in 32 percent as compared with 33 percent of cases in each of the preceding years.

In 1944, there was a sharp curtailment in the use of surgery; only 33 thoracoplasties were performed. This was due to the shorter average stay of patients, owing to the heavy demands on the hospital not only for cases of tuberculosis but also for other illness. During this year, however, 15 lobectomies were performed, the indications for this operation having become clearer within the preceding year. In general, cases with an excavated, but well-stabilized lesion, confined to one lobe, were considered most suitable for lobectomy.

During 1944, the number of cases in enlisted men evacuated from overseas, which had heretofore formed a substantial proportion of the total, decreased markedly, as a result of the designation of Bruns General Hospital as a center for such cases. However, the number of officers from both overseas and the Zone of Interior increased greatly, with 647 admissions (561 male and 86 female). There were 419 tuberculous officers discharged by retirement or other procedure.

A significant development during 1944 was the activation, in January, of the Section for Research on Minimal Tuberculosis. This section was developed by the Office of the Surgeon General on the advice of the Subcommittee on Tuberculosis, National Research Council. It was sponsored and supported financially by the Army Medical Research and Development Board. The subcommittee felt that the Army, with its large number of well-studied cases, afforded a unique opportunity for investigation of the prognosis of minimal tuberculosis and the reasons for the breakdown of small or incompletely stabilized lesions. A contract was drawn by the board with the School of Medicine, University of Colorado, Denver, located only a few miles from Fitzsimons General Hospital, and Dr. Waring, Professor of Medicine, School of Medicine, was designated as responsible investigator, with Colonel Aycock, Chief of Medical Service, Fitzsimons General Hospital, and Colonel Long as consultants. Capt. (later Maj.) William H. Roper, MC, formerly chief of the section for chest diseases at the Station Hospital, Fort Bragg, N.C., was assigned, through Seventh Service Command Headquarters, to Fitzsimons General Hospital for the detailed prosecution of the investigation, which was to be based on an intimate study of the history and progress of 1,000 cases of tuberculosis of minimal extent.

By the end of the year, 400 cases had been studied with care. In June 1946, the final number was 1,108. This number included 648 cases of active and 350 cases of inactive minimal parenchymal disease; in addition, there were 110 cases of pleural effusion presumed or proved to be tuberculous in origin. In 397 cases, the investigation included an intensive psychiatric examination to determine the influence of emotional and personality factors


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upon breakdown with tuberculosis. This examination was conducted by Dr. John M. Lyon, Department of Psychiatry, School of Medicine, University of Colorado.56

During 1945, the tuberculosis section of Fitzsimons General Hospital was more active than in any preceding year. There were 2,474 admissions to the enlisted men's section. The average number of patients was greater, and collapse therapy was carried out on a larger scale than heretofore. There were 448 initial pneumothoraces, and the total number of refills, in spite of the relatively short duration of residence that was necessary in order to accommodate new cases, was 11,265. Pneumoperitoneum was induced in 136 cases. On the surgical service there were 3 pneumonectomies, 34 lobectomies, and 7 partial lobectomies for tuberculosis.

During the 4 years of the war, Fitzsimons General Hospital admitted more than 8,100 patients with tuberculosis. The morale of both staff and patients was excellent, and the treatment was equal to that in the best civilian hospitals in the country. In view of the usual early transfer of patients, rehabilitation measures were not extensively employed, although there was provision for occupational therapy. Long before the maximum results of treatment could be attained, regulations required discharge of patients to the Veterans' Administration or other institutions for care. Results in terms of cases arrested or improved, or stationary or unimproved, cannot, therefore, be given for evaluation or comparison with results at other hospitals. Only through careful followup of cases handled by the Veterans' Administration will it be possible to determine the effectiveness of several months of treatment at Fitzsimons General Hospital in bringing about lasting arrest of cases.

The pathology service, under Col. Hugh W. Mahon, MC, made careful studies of necropsies and maintained a series of records that were of unusual value, because of the wealth of photographic reproductions included. The majority coming to autopsy were chronic cases, fibroulcerative in character, although there were some more acute cases, including a number with fulminant tuberculous meningitis. In general, post mortem observations made in the Army were not significantly different from those in large civilian hospitals and sanatoriums for tuberculosis.

Discharge and retirement constituted a problem that was, at times, difficult. Since patients could not be held for the many months required for complete arrest of the disease, discharge had to be effected on the basis of disability, with such compensatory benefits as accrued. In cases of advanced tuberculosis, no problem was involved. In cases of early tuberculosis of minimal extent, apparently well scarred after a few months of treatment, the appropriate course generally appeared to be to discharge patients on the basis of disability, even though no symptoms persisted and prognosis was excellent. This disposition also appeared generally indicated in cases of

56Waring, J. J., and Roper, W. H.: Minimal Pulmonary Tuberculosis in Military Personnel: World War II. Am. Rev. Tuberc. 75: 1-40, January 1957.


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healed pleural effusion in which all fluid was absorbed, no pulmonary infiltration was evident, and exclusion studies indicated that the process was presumptively tuberculous. Since tuberculosis is a disease prone to relapse if a proper regimen is not followed, it was necessary to consider such cases as potentially active for some years. Similar considerations applied to tuberculosis of lymph nodes when nodes with doubtfully active tuberculous lesions had been removed and tuberculous foci were not found elsewhere in the body. Such cases were finally resolved in favor of the soldier, and usually on the basis of proved tuberculous activity during military service.

Bruns General Hospital-This hospital was designated a specialty center for tuberculosis in August 1944, with an allocation of 750 beds for tuberculosis. Lt. Col. (later Col.) George J. Kastlin, MC, was chief of Medical Service until December 1945, when he was succeeded by Maj. (later Lt. Col.) George C. Owen, MC, with assistant chiefs in charge of two large sections for tuberculosis. When the directive of August 1944 was issued, 26 wards were set aside for patients with tuberculosis. The relatively small number of physicians on the staff at the time who were well qualified in the treatment of tuberculosis was augmented as rapidly as possible. Capt. (later Maj.) Lawrence H. Kingsbury, MC, was brought in from the surgical service at Fitzsimons General Hospital as chief of thoracic surgery, and the work at the two hospitals was coordinated by mutual visits.

The hospital had a difficult task, however, for the report57 for 1944 noted that the rate of growth was more rapid than the officer, nurse, and enlisted personnel could properly handle. All services felt the impact of the abrupt designation of the hospital as a specialty center. At the end of the year, 697 tuberculous patients were in the hospital. During 1944, 6,118 X-ray films of the chest were made, out of a total of 13,752 films of all parts of the body. Pulmonary tuberculosis accounted for 17 percent (123 cases) of the discharges for disability. The majority of discharges were to the Veterans' Administration and convoys seriously depleted the force of officers necessary to care for patients.

Since Bruns General Hospital was designated to care for cases of tuberculosis from overseas, the morale problem was exceptionally difficult. The hospital was isolated and filled with patients who had not seen their families for months or years. Unusual measures, which proved notably successful, were projected to meet the problem (pp. 388-390). Education was a principal objective, directed particularly to teach acceptance of continuing care at the hands of the Veterans' Administration after discharge from the hospital.58

In 1945, it became necessary to increase the allocation of beds to more than a thousand because of the continuing influx of cases from overseas. The problem was complicated in the second half of the year by the arrival of many

57Annual Report, Bruns General Hospital, 1944.
58The Care of Tuberculous Patients Pending Discharge From the Army. Bull. U.S. Army M. Dept. No. 74: 44-46, March 1944.


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patients with severe disease who had been liberated from Japanese prison camps. Personnel needs were great and, unfortunately, could not be well met, because demobilization of medical officers was under way.

In spite of these difficulties, an excellent professional spirit was maintained. Staff conferences, on the model of those held at Fitzsimons General Hospital and leading civilian hospitals for tuberculosis, were held at regular and frequent intervals, and cases were expertly presented and discussed. A pulmonary function unit was established in order to introduce the latest methods used in the study of respiratory physiology.

Close contact was maintained at all times with the Office of the Surgeon General, which was called upon for more direct assistance than was required by the longer established Fitzsimons General Hospital. The system of supervision, the methods of treatment and disposition, the proportion of cases on collapse therapy, and the system of clinical conferences were similar to those at Fitzsimons General Hospital and civilian hospitals for the care of tuberculous patients.

Moore General Hospital-The third specialty center for tuberculosis, established in 1945 at Moore General Hospital, was necessary because demobilization of men at separation centers resulted in the discovery of cases of tuberculosis in numbers exceeding the capacity of Fitzsimons and Bruns General Hospitals. The lesions found were usually symptomless and of minimal extent, although occasionally moderately advanced cases were encountered in men who, surprisingly, had been doing full duty and were not aware of any respiratory disease.

Since Moore General Hospital was not staffed or equipped for tuberculosis, it was necessary to bring in new personnel and to specify that patients requiring thoracic surgery were not to be sent there. Army Service Forces Circular No. 456, 29 December 1945, established the center and specified that (1) cases of minimal extent, (2) unilateral cases of moderately advanced tuberculosis appropriate for pneumothorax treatment, (3) cases of suspected tuberculosis requiring prolonged observation for diagnosis, and (4) cases of pleurisy with effusion were to be sent to Moore General Hospital. Cases requiring extensive surgical procedures and cases in which the prognosis was bad were to be referred to other general hospitals or discharged directly to the Veterans' Administration. Tuberculosis patients were placed on the medical service, of which Lt. Col. J. Murray Kinsman, MC, was chief when the hospital was designated as a specialty center for tuberculosis.

Cases within the first three categories named were frequently found at separation centers, and the space assigned for tuberculosis at Moore General Hospital filled rapidly. Within a few months, there were more than a thousand patients at the center. Most of these had lesions of minimal character, many of them difficult to establish definitely as tuberculosis, being of slight extent and without demonstrable tubercle bacilli. Thus, many patients remained for several months for exhaustive study to establish diagnosis of the


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disease itself, and its state of activity. The principles in practice were later summarized in TB MED (War Department Technical Bulletin) 221, dated 29 April 1946, and change 1 thereto, dated 27 December 1946. Moore General Hospital was ultimately (1946) transferred to the Veterans' Administration, obviating physical transfer of patients designated for Veterans' Administration care.

The three general hospitals designated as specialty centers for tuberculosis normally received medical records and X-ray films of cases originating overseas when the patients were transferred to these hospitals. The reports from Bruns General Hospital indicate that the records were of good quality. All three hospitals also made extensive use of induction films of patients obtained from the X-ray file of the Veterans' Administration in Washington, D.C., where they had been stored immediately after induction. These films proved highly useful in evaluating the age of lesions as a guide in treatment and disposition. The experience at Fitzsimons General Hospital indicated that early in the war, when cases were not infrequently overlooked at induction, the patients sent to the hospital were predominantly those in whose induction film a lesion could be seen. In the second half of the war, lesions requiring hospitalization did not, in the majority of cases, appear to represent an extension from a lesion visible in the induction film, but rather a new development during Army service.

ORIENTATION AND REHABILITATION

The problem of rehabilitation of tuberculous patients in Army hospitals could not be met in the same manner as with diseases of short duration or wounds and accidents leaving a mechanical handicap. With these, the reconditioning services of Army hospitals were highly effective during the period of convalescence. As regards tuberculosis, however, it was impractical to retain patients in Army hospitals long enough for arrest of the disease and rehabilitation. AR 615-361, 14 May 1947, required discharge when the diagnosis of active disease and the need for prolonged care were established, although specifically prohibiting transfer as long as the health of the patient would be jeopardized.

In practice, this regulation was interpreted as authorizing that degree and extent of care in an Army hospital necessary to prepare patients for transfer-enlisted men to the Veterans' Administration and officers to their own care-in the best condition to profit by continued hospital treatment. In the three tuberculosis centers of the Army, enlisted men were retained on an average for 4 months. Officers were held longer on the basis of the possibility of their retention for continued service.59

Although reconditioning of tuberculous patients in Army hospitals was thus not possible in the same sense as for patients recovering from pneumonia

59See footnote 3, p. 331.


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or fracture of bones, the need for thorough orientation with respect to the disease was clearly evident. In 1945, on the advice of the Office of the Surgeon General, a department for orientation was established at Bruns General Hospital under the direction of Capt. (later Maj.) Bernard D. Daitz, SnC. Captain Daitz, with an extensive background of civilian experience in rehabilitation of patients with tuberculosis, introduced modern methods of instruction of patients, winning their confidence, and stimulating an improved morale. He prepared TB MED (War Department Technical Bulletin) 222, dated 16 May 1946, while assigned to Bruns General Hospital, which proved a model for other Army hospitals caring for tuberculous patients, and this was later modified to meet the special problems of patients under care of Veterans' Administration hospitals.

The ideal program in the care of tuberculous soldiers embraced a proper integration of medical treatment, social work, vocational counseling, and intelligent use of the patient's leisure time. The immediate and most important objective was to educate patients concerning their need for continuing medical treatment. This involved, first, educational measures on the nature of tuberculosis and, second, measures to overcome the apathy, or even resentment, with which soldiers reacted to provision for their treatment by the Army or other Federal agencies.

To train ward officers and other hospital personnel as teachers, a system of staff indoctrination was devised, which included lectures and discussions on (1) problems of tuberculous patients, (2) pathogenesis and treatment of tuberculosis, (3) psychology of tuberculous patients, (4) problems in nursing, (5) problems in nutrition, (6) occupational therapy, and (7) the best utilization of the Red Cross in the program. A tuberculosis advisory council was established to implement the program of staff indoctrination and teaching of patients. All of the services concerned in the care of patients were represented.

The orientation program for patients was coordinated by an officer from the medical service. Since the great majority of the tuberculous were bed patients, ward officers were made responsible for instruction of patients on the nature of the disease. On arrival at the hospital, each patient was given a copy of "What You Should Know About Tuberculosis," an educational pamphlet published by the National Tuberculosis Association and modified for Army use by the Consultant in Tuberculosis, Office of the Surgeon General. Medical officers with proved special capacity for instruction were sent from ward to ward to discuss medical problems with patients.

Counseling on other than medical problems was made the responsibility of those best qualified in the various fields concerned, including the educational reconditioning services, the personal affairs division, the Red Cross, the librarian, and others. It was important at the outset, and concurrently with the program of medical instruction, to reassure patients as far as possible with regard to the future and to ascertain and develop their educational


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and vocational interests and capacities. Since most of the patients would ultimately be beneficiaries of the Veterans' Administration, the system of care at Veterans' Administration hospitals and their rights and privileges as veterans under the Vocational Rehabilitation Act (Public Law 16, 78th Cong.) and the Servicemen's Readjustment Act of 1944 (Public Law 346, 78th Cong.), more commonly known as the G.I. Bill of Rights, were carefully explained. At the same time, patients were asked to discuss freely their personal problems and their complaints. These principally centered on their isolation from friends and relatives. Most of the patients had been overseas for many months, and the long separation from home brought their morale to a low ebb. Everything possible within reason was done to overcome this sense of isolation. The specific complaints most frequently heard were about diet, and these were more concerned with its palatability and serving than with its basic quality. Serious attention was given to these complaints, and noteworthy improvement in dietary service was accomplished.

Motion pictures of both educational and diversional character were presented on a schedule adapted to the strength of the different groups of patients, and extensive use was made of the library. Many patients undertook studies that yielded academic credit. The vocational interests of patients were studied by the Kuder vocational interest test (Kuder Preference Record), and patients were made acquainted with the correspondence courses available through the United States Armed Forces Institute.

Occupational therapy was carried out on a scale commensurate with the patients' strength. The various forms of light occupation used in Army hospitals were employed, and a large majority of patients availed themselves of some form of occupational therapy. Indeed, a major difficulty was to restrain them. Light occupation was often sought by patients whose medical regimen demanded strict bed rest.

Orientation programs on a less formal basis were in effect at the other Army hospitals for the tuberculosis. The period of time during which the plan formally established at Bruns General Hospital was in operation was too short to determine how effective it could be. Some good was definitely accomplished. This was substantiated by the information obtained from questionnaires filled out by patients and by their attitude later in veterans' hospitals. Had the need developed for continued hospitalization of tuberculous patients in Army hospitals, it is believed the program as developed at Bruns General Hospital would have proved highly effective.

Part V. Care of Recovered and Captured Prisoners of War

RECOVERED PRISONERS OF WAR

Tuberculosis in recovered prisoners of war has already been discussed in the sections on the individual theaters in this chapter. An increased incidence, as compared with the general rate for troops in the theater, was found


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in men who had been prisoners of the German and Japanese military forces for some months. Exact studies of the incidence were not made, because of a number of circumstances arising at the time. In the European theater, the liberation of prisoners in the course of rapid movement of American troops through Germany occurred at a time of grave shortage of X-ray film in the theater. Accordingly, roentgenograms of the chest were not made on all recovered prisoners, as had been the hope of the Office of the Surgeon General, but only on those who were hospitalized for one or another reason. As has been pointed out (pp. 344-345), the incidence of tuberculosis discovered in the hospitalized recovered prisoners in the European theater averaged about 6 men per 1,000, or approximately six to eight times the general average for troops in the theater. However, the group examined by X-ray were selected simply because of malnutrition or evident illness, and it is reasonable to suppose that the incidence of tuberculosis was higher in this group than in recovered prisoners who appeared in good health.

Rates recorded for prisoners recovered in the Pacific area were somewhat higher. Several reports indicated that approximately 1 percent of the men recovered in the Philippines had what was believed to be active tuberculosis. However, prisoners were recovered at such a wide number of points, where facilities for X-ray study were not available, that an overall rate for the Pacific is unobtainable. A board appointed by The Surgeon General, including representatives of several medical specialties, examined 4,618 repatriated prisoners at West Coast debarkation hospitals. Out of 3,742 who were checked with roentgenograms of the chest, 101, or 2.7 percent, showed evidence of active pulmonary tuberculosis.60 A preliminary examination by Major Roper of films made at Letterman General Hospital on prisoners recovered in the Pacific area brought to light 8 cases of active minimal and 3 cases of active moderately advanced tuberculosis, and 2 cases of pleural effusion. Of this group, only 2 of the minimal and 2 of the moderately advanced cases, and 1 of the cases of pleural effusion, had been reported on admission to the hospital. The total incidence of active cases, assuming that the pleural effusions were tuberculous, was thus 13 in 966 or about 13 per 1,000, a figure much higher than the average incidence in nonprisoner groups at separation. (See chart 19 for incidence at separation in troops with and without foreign service.) Various other individual reports on sample liberated groups, all showed rates much above the average for troops on duty in the Pacific theaters. Hence, there is good reason to believe that a general increase of tuberculosis occurred in prisoners. This was attributed to one or both of two principal reasons: (1) Breakdown of small latent lesions that might otherwise have remained stable, and (2) actual acquisition of new infections as a result of exposure in prison camps. The latter was believed to be much more of a factor in the Pacific area than in the European theater.

60Morgan, H. J., Wright, I. S., and Van Ravenswaay, A. C.: Health of Repatriated Prisoners of War From the Far East. J.A.M.A. 130: 995-999, 13 Apr. 1946.


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In the European theater, as a rule, American prisoners were quartered in barracks separate from those used for other prisoners, or were quartered with British prisoners. In either event, there was relatively little opportunity for exposure, as the incidence of tuberculosis was comparatively low in both armies. However, as medical officers in the theater pointed out, and as noted elsewhere in this chapter, frequently prisoners lived in quarters that had been grossly contaminated by previous occupants.61 The incidence of tuberculosis in Russian and other prisoners of war was very high, and from time to time prisoners from the U.S. Army were housed in quarters that had been previously occupied by Russian and other troops and still contained material that might have been infected, such as bedding, furniture, and kitchen utensils.

In many recovered prisoners of war in whom tuberculosis was discovered, the disease was complicated by malnutrition. Prisoners in both European and Pacific theaters had been on an extremely low caloric diet and in general had suffered great loss in weight. Whether this had a specific effect upon the progress of tuberculosis could not be determined on the basis of exact studies, but a relationship between malnutrition and tuberculosis is generally accepted, and it is logical to assume that impaired nutrition in U.S. troops favored the development and spread of tuberculosis among them.

Not a few of the troops had other diseases, such as dysentery and malaria, and it is reasonable to suppose that resistance to tuberculosis was lowered also to some extent by these concomitant diseases.

Special attention was devoted to prisoners on their return to the United States, as noted elsewhere in this chapter, and a good followup was maintained. In view of the hardships that many of these men endured, and the notorious tendency for tuberculosis to make its appearance years after the acquisition of infection, it was considered advisable that these men be followed as a special group in the Veterans' Administration for years to come.

CAPTURED PRISONERS OF WAR

The medical treatment of captured German and Japanese soldiers who were found to be afflicted with tuberculosis was a part of the general program of hospital care in each theater. As prisoners were taken, they were transferred to appropriate hospitals in the communications zone, which were usually of station hospital type. When the number of patients became sufficiently large, entire hospitals were reserved for sick prisoners of war. Each of the hospitals devoted to the care of sick and wounded enemy prisoners had some patients with tuberculosis. As the number increased, it was found advantageous to designate certain hospitals with suitable medical personnel for concentration of patients with tuberculosis. The same practice, it may be stated, was followed by the Germans.

61See footnote 17, p. 340.


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Insofar as possible, hospitals designated for the care of sick and injured prisoners of war were staffed by captured members of the Italian, German, or Japanese medical departments. Certain hospitals moved forward with the advancing army, so that the transportation problem in taking care of sick prisoners was minimized. For example, the 7029th Station Hospital, which was in the neighborhood of Pisa in the last weeks of the war and housed a good many tuberculous Italians, had been designated for the care of prisoners of war many months previously in North Africa. The 334th Station Hospital (German staffed), near Florence, served an adjoining stockade for German prisoners and contained a few patients with tuberculosis. A group of hospitals near Isigny in Normandy were combined to form a hospital center for prisoners of war; one of these, the 8274th General Hospital (Provisional), Calvados, France, was designated to house a considerable number of captured Germans proved to have tuberculosis. Certain hospitals in England, particularly those that had been previously well staffed with officers experienced in tuberculosis, including the 304th Station Hospital near Henley-on-Thames and the 327th General Hospital near Blockley, were designated as centers to which German patients with tuberculosis could be sent.

The general principle followed was that prisoners with tuberculosis should be sent to those hospitals where German doctors with particular experience in the disease were members of the staff. A wide variation was found in the caliber of the men concerned, but in general it was good. Diagnosis by radiological and laboratory methods was excellent in certain of the hospitals just named, and care was superior within the limitations of equipment available. The discipline among patients was especially noteworthy. The same amenability to discipline in German prisoners was noted when they were treated for tuberculosis in the United States. Pneumothorax was practiced expertly by German physicians, many of whom were graduates of medical classes after 1935.

After the termination of hostilities, as conditions became more stabilized for medical care in Germany, patients with tuberculosis were transferred to hospitals within the American occupied zone in Germany.

Treatment in the United States

Cases of tuberculosis were discovered in all groups of prisoners in the United States, and care entirely comparable to that given American patients with tuberculosis was accorded them. Special provision was made for tuberculous prisoners of war by War Department Prisoner of War Circular No. 11, 8 February 1944, which directed that those afflicted with pulmonary tuberculosis be sent to the prisoner-of-war camp station hospital in Florence, Ariz. At this hospital, they were to be examined by a mixed medical commission of representatives from neutral countries with a view to repatriation. It was directed that cases of nonpulmonary tuberculosis be sent for care to certain


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general hospitals designated in each service command for the care of prisoners of war. Subsequently, when the station hospital at Florence was abandoned as a center for such patients, about 50 tuberculous German and Italian prisoners of war were sent to Fitzsimons General Hospital, where a number had already been sent from other places pending final determination of policies governing the treatment and disposition of sick prisoners of war. On 5 January 1945, a telegram from the Office of the Provost Marshal General to several service command headquarters directed that, pending further revision of policy, prisoner-of-war patients with pulmonary tuberculosis should be transferred as follows: German prisoners to Glennan General Hospital, Okmulgee, Okla., Italian prisoners to Bruns General Hospital, and Japanese prisoners to the prisoner-of-war camp station hospital, Camp McCoy, Wis. Wherever German prisoners of war were concentrated, a sharp difference of opinion was found to exist in the Nazi and anti-Nazi groups, and it was generally necessary to house them in entirely separate wards.

Relatively large numbers of Italians were found to have tuberculosis. The German Army appeared to have been screened in a much more thorough manner than the Italian. In fact, the number of tuberculous Italians was so high in certain areas that it was considered advisable by Army Service Forces Circular No. 342, 14 October 1944, to make mass X-ray surveys of all Italian service troops for the discovery of cases of tuberculosis.

The total number of Japanese prisoners in the United States was relatively small, and therefore the problem of tuberculosis in Japanese prisoners was minor. A small number were kept for care at the station hospital of Camp McCoy. No significant differences were noted in the character of tuberculosis in the different groups, but the experience at Fitzsimons General Hospital indicated that the German prisoners, as a rule, made better progress than Italian, a fact attributed to their better discipline and acceptance of medical direction.

A comprehensive report on the medical care of prisoners of war in a general hospital in the United States was made by Col. Louis B. LaPlace, MC, at Glennan General Hospital.62 Glennan General Hospital was in close proximity to a number of large prisoner camps and was well adapted to care for prisoners. Ninety percent of the patients were Germans and Austrians, and the remainder were nationals of Axis satellite or invaded countries. It functioned as an installation specifically for prisoners of war from August 1944 to May 1945. Glennan General Hospital was ultimately converted to a general hospital for American personnel, and all of its prisoner patients were transferred to Prisoner-of-War General Hospital No. 2, established at Camp Forrest, Tenn., which had the great advantage of a large barracks area where patients unfit for duty, but not requiring hospital care, could be accommodated.

62LaPlace, L. B.: Tuberculosis at a Prisoner of War Hospital. Bull. U.S. Army M. Dept. 7: 398-399, April 1947.


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To the greatest extent possible, Glennan General Hospital and Prisoner-of-War General Hospital No. 2 were staffed with German medical department personnel, including medical officers and enlisted men. The professional aptitude of the German medical officers varied considerably. A number with excellent qualifications were on duty, but as among the patients, there was a definite difference in attitude among them, based on adherence or opposition to the Nazi party.

The staff of the medical service at Glennan General Hospital was composed of two Americans and eight German medical officers. The number of German ward attendants averaged 50 for the 11 wards utilized by the medical service. Only one American enlisted man was needed to supervise the entire medical service. American nurses were not utilized on the wards. 

Approximately 31 percent of the German patients at Glennan General Hospital had tuberculosis of the respiratory tract. This relatively high incidence was due to the fact that Glennan was the only hospital for prisoners of war designated for the specialized care of tuberculosis. As Colonel LaPlace pointed out, the tuberculosis section constituted a special problem. It admitted 304 patients in whom the diagnosis of tuberculosis of the lung or pleura was established. Because of anticipated repatriation, active cases could receive only conservative treatment, including pneumothorax. Since repatriation was slow, these patients accumulated in the hospital until they filled 6 of the 11 medical wards. In spite of the severity of a large percentage of the cases, only five deaths occurred on the tuberculosis section; of these, three patients were prisoners of Russian origin who had accepted service in the German Army. The clinical course of the disease, in the majority of instances, was relatively benign.

Special diets were available to patients who needed them. All patients on the tuberculosis section at Glennan General Hospital, according to Colonel LaPlace, received a routine diet of 2,500 calories daily, with vitamin supplements. Colonel LaPlace's report pointed out that Glennan General Hospital was a noteworthy example of this country's full adherence to the terms of the Geneva Convention. Prisoners of war were hospitalized in one of the best constructed and equipped of any except permanent Army hospitals.

The number of tuberculous patients admitted to the medical service constituted 2.6 percent of all admissions to the hospital. Among the 10 percent of patients in the tuberculosis section who were not Germans or Austrians were Russians, Poles, Czechs, French, Yugoslavs, Arabs, and others. Most of these had been persuaded to join the Wehrmacht or Arbeitsdienst by a period of starvation and exposure in a concentration camp. In many cases, it is believed that mistreatment had caused activation of tuberculosis.

In this connection, it may be noted that the admission rate for tuberculosis in German prisoners of war, as recorded in the Medical Statistics Division of the Office of the Surgeon General, was 1.9 per 1,000 per annum in


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1944. This, for the most part, represented admission because of symptoms. Occasionally, groups were surveyed more specifically for tuberculosis; such surveys increased the rate. An unusually high rate was observed in one conducted in the First Service Command. The combined figure for active and inactive tuberculosis of reinfection type and chronic fibrotic tuberculosis found in this survey was 55 cases in 4,041 examinations.

The tuberculosis section at Glennan General Hospital was a subdivision of the medical service and was accommodated in seven standard wards. One of these, a so-called international ward, was designated for the Russians, Poles, and anti-Nazi Germans who required protective segregation from the other Germans in the hospital.

The tuberculosis section was supervised by an American chief and assistant chief of the medical service and one sergeant. The international ward was administered directly by American medical officers. Otherwise, all medical officers in attendance were members of the German Sanitätsdienst who were classified by the Geneva Convention as protected personnel rather than as prisoners of war. The German chief of section was a relatively well qualified specialist in tuberculosis who, prior to capture, had served in a submarine and at an outpost on the Arctic Circle.

Certification of patients for repatriation was an important part of the work and caused many difficulties. According to the Geneva Convention, all prisoners of war who had active pulmonary tuberculosis, as indicated by the finding of acidfast bacilli, were to be returned to Germany as soon as possible. As a result, patients attempted to substitute a known positive sputum for their own. According to Colonel LaPlace, the German-protected personnel were accused of being collaborationists if they did not help in this subterfuge. Sputum reports were therefore considered unreliable, and the activity of tuberculosis was often almost impossible to determine.

Treatment included principally rest, a high caloric diet with vitamin supplements, and pneumothorax as indicated. Radical surgical therapy was not undertaken because of the prospect of repatriation for definitive care. Many patients became arrested cases in the hospital and were returned to light duty.

Of the 304 cases of tuberculosis, 267 were pulmonary and 37 had tuberculous pleurisy with effusion. In 14 cases, both pulmonary involvement and pleural effusion were present. Extrapulmonary cases included tuberculosis of the larynx, epididymis, joints, kidney, meninges, peritoneum, and cervical lymph nodes. In all, there were 14 nonpulmonary cases.

The experience of Glennan General Hospital has been recorded in detail, because of the comprehensive character of the report on tuberculosis at that hospital. The problems and care as outlined may be considered as representative of the service at the other hospitals for prisoners of war in this country.


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TREATMENT UNDER THE MILITARY GOVERNMENT IN GERMANY

The control of tuberculosis formed an important part of the public health program of the office of military government in each of the occupation zones. It was accentuated in Germany by the total disruption of tuberculosis services following the collapse of the Nazi government. Prior to World War II, Germany had a well-organized program, which was rapidly diminishing the prevalence of tuberculosis in the Reich. Following the First World War, German public health experts had adopted a program based on improved dispensary facilities for discovering cases of tuberculosis, better care in homes and sanatoriums, increase in facilities for treatment, and centralization of finance in general measures for control. At the outset of the Second World War, case-finding surveys with roentgenograms were progressing on a huge scale, but after the middle of 1943 the intense bombing of German cities destroyed so many facilities that the X-ray program came almost to a standstill.

The breakdown in the general public health program had resulted in admitting to industry a good many workers with tuberculosis who, in prewar times, would not have been accepted for work. It is generally believed that this breakdown in service resulted in the spread of tuberculosis within the German population. The admission of tuberculous persons to industry was rationalized by the Nazi officers for tuberculosis control by official communications stating that the danger of transmission of tuberculosis had been exaggerated in the past.63

In addition, during the war, large numbers of laborers were imported from adjoining countries with little or no screening for tuberculosis. It is probable that many cases of communicable tuberculous disease were admitted in this way, for the general tuberculosis rates in surrounding countries were much higher than in Germany.

When the U.S. Army took over the public health program for the American Zone, the control of tuberculosis was proceeding on a purely local basis. Central control, previously located in Berlin, was no longer in operation and, in fact, many of the former leaders of the program, having been prominent adherents of the Nazi party, were under detention in Army headquarters. 

The local unit of tuberculosis control, the Fürsorgestelle, was in operation in most communities, ostensibly in the same manner as before the war. However, qualified personnel was much reduced in number, and many of the German clinics had been forced by bombing to leave their regularly constituted quarters and to take up operation in inferior dwellings, often with inadequate equipment. Moreover, the visiting by Fürsorgestellerinnen to the homes of tuberculous patients had been almost discontinued because of the

63Dr. Kayser-Petersen, General Secretary: Arbeitseinsatz von Tuberkulösen, Bericht über das Geschäfts jahr 1940-1941, Reichs-Tuberkulose-Ausschuss. Berlin. [Captured German document.]


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lack of transportation. No motor cars were available, as a rule, and in the rare circumstances where motor transportation could be obtained, gasoline was very short, so that few visits could be made. At the same time, facilities for reporting tuberculosis were much reduced, so that no clear picture of the prevalence of tuberculosis was obtainable in most localities.

In September 1945, a tuberculosis section was organized in the Preventive Medicine Branch of the Public Health Branch of Military Government for Germany (United States) in Frankfurt and Berlin. Preliminary surveys were made by Capt. S. C. Stein, MC, and the office was taken over by the Consultant in Tuberculosis from the Office of the Surgeon General on a temporary duty basis on 1 September 1945. Every effort was made in the succeeding months to promote restoration of the German program to its prewar condition. Insofar as personnel qualifying under the denazification rules were obtainable, suitable public health officers, experienced in tuberculosis control, were appointed in the Länder, Kreisen, and smaller units. In November 1945, the section was taken over by Lt. Col. Leo V. Schneider, MC, who, in addition, acted as aide to the chief of the public health branch. Under his direction, great progress was made in improving reporting and in the provision of beds for tuberculous patients throughout the U.S. Zone. Subsequently, Lt. Col. Gilberto S. Pesquera, MC, was appointed tuberculosis consultant for the Office of Military Government. In a series of reports to the Director of the Public Health Office of Military Government in May 1946, further progress was indicated, including better utilization of beds-particularly with respect to the distribution of beds for German civilians and displaced persons-and the control of dissemination of disease from open cases.

In each major division of the occupied zone, an American medical officer in the office of the chief of the local public health branch was assigned the specific task of stimulating the program for control of tuberculosis. Forms were prepared for proper reporting, and constant effort was made to increase the number of beds available for care of tuberculous patients discovered in the German population.

The 9 October 1945 memorandum of the Consultant in Tuberculosis, Office of the Surgeon General, called attention to the progress effected in the transfer of tuberculous German prisoners of war from Army hospitals to German hospitals and sanatoriums for civilians and to the measures followed in handling tuberculosis among displaced persons. The latter proved a large and difficult problem, which was jointly attacked by the army of occupation (Third, Seventh, and Ninth U.S. Armies), the Office of Military Government, and the United Nations Relief and Rehabilitation Administration, the chief public health officer of which was supplied by the U.S. Public Health Service. This report outlined in detail the responsibilities and shortcomings of the German civilian public health organization for tuberculosis control at and below the Land level. It laid special stress on the inadequacy of reporting, the insufficiency of clinics and of hospital and sanatorium beds


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for tuberculosis, the number of open cases in homes, the serious housing problem and resultant crowding, and the impaired nutrition of the population. It was pointed out that in a typical city of about 140,000 (Augsburg, Germany, was cited as the example) more than 2,000 persons with open tuberculosis were believed to be resident in homes, rather than in sanatoriums. The housing shortage in the American Zone was such that the number of occupants per room in the large cities had more than doubled as compared with the prewar figure. The official food ration at the time provided only 1,300 calories a day, and although this was supplemented by 300 calories of nonrationed foods by many persons with access to rural areas around cities, at best the diet fell far short of that believed essential to maintain normal resistance to disease.

The mortality from tuberculosis was far greater in Berlin than in other parts of the American Zone. Recorded annual rates for Berlin regularly exceeded 200 per 100,000 population, whereas the rates reported in other parts of the zone occupied by American troops seldom exceeded 70. It is believed, however, that in the majority of instances the records were inaccurate and incomplete. Before the end of the year, a reasonably good program was in effect, the future of which depended upon the full organization of the general public health program in Germany.

In the report last cited, in addition to recommendations for American supervision of German medical organization and the continued effort to increase facilities and personnel for the care of tuberculosis in the U.S. Zone, the need for some central German civilian advisory service was indicated. This recommendation was entirely in line with general policies being developed not only in the public health field but also in the realm of economics and civil government. Unfortunately, German civilians of the required caliber were not available. The former General Secretary of the Reichs-Tuberkulose-Ausschuss was living in the zone but was not eligible under the regulations prevailing with respect to persons with previous Nazi affiliations, nor was it possible during the period covered by this history to find anyone with comparable qualifications who was eligible.

At the end of 1945, it appeared likely that a rise in the tuberculosis rate would ensue, as it did after World War I, but it was believed that improvement in the local organizations, supplemented by assistance from a partially unified Germany, if this were ultimately effected, would stem this in time.

Part VI. Tuberculosis in British and Canadian Military Forces

Published accounts offering valuable material for comparison with the experience of the U.S. Army are available from the Royal Navy, the Royal Air Force, and the Canadian Army.


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ROYAL NAVY

The military forces in Great Britain required a physical examination but not an X-ray examination prior to induction into service. A substantial fraction of the Royal Navy,64 however, was examined by 35-mm. fluorography after varying periods of service, and many of those so examined were reexamined 1 to 2 years later. The following summary of the first examination was made by the Consulting Physician in Diseases of the Chest to the Royal Navy, who was in responsible charge of the examinations:65

Fluorography of 479,373 apparently healthy male personnel of the Royal Navy showed that 6,077 (12.7 per 1,000) had radiological signs of adult-type pulmonary tuberculosis. In 47.9 percent of these the lesion was "minimal."

Of 23,344 WRNS, 213 (9.1 per 1,000) had similar evidence of tuberculosis, and the lesion was minimal in 55.4 percent of these.

Similar investigations among civilians will no doubt bring to light large numbers of cases of pulmonary tuberculosis of this slight degree, raising difficult problems of disposal and treatment.

In some of these minimal cases the disease is arrested, or is retrogressive, but in others it is progressive. Careful study is needed to decide whether the infection is active, and investigation in hospital is essential. When 2,911 sailors with minimal lesions were first studied in hospital 16 percent showed evidence of active infection, while in 63 percent the disease appeared to be inactive but the stability of the lesions was doubtful. In 21 percent the disease was arrested.

Naval personnel with apparently inactive minimal tuberculosis have been placed on light shore duties and kept under observation. Study of these cases shows that the younger the patient the more likely is the disease to become active, and the relapse to be serious.

A significant finding, quite comparable to the results in induction stations in the United States, was a rise in the diagnosis of tuberculosis with advancing age in both males and females. In the four decades from 10 to 50 years of age the rate per 1,000 for males was 8.8, 10.7, 19.7 and 32.8, and for females 6.9, 9.1, 14.9, and 12.7. (The number of females in the 40- to 49-year period was too small to make the figure fully valid.)

An equally significant feature of the examination was the number of cases discovered in the minimal stage, the percentage being much higher than that discovered by the conventional methods of physical examination.

This is in accord with general experience in mass radiography. It is of interest to note that the percentage of all tuberculous cases discovered in the minimal stage did not vary significantly in the different age periods. Followup studies indicated clearly that the younger the patient with radiological evidence of minimal tuberculosis, the greater the likelihood of its displaying activity.

64History of the Second World War, United Kingdom Medical Services. Medicine and Pathology. London: Her Majesty's Stationery Office, 1952, pp. 319-332.
65
Brooks, W. D. W.: Management of Minimal Pulmonary Tuberculosis Disclosed by Fluorography. Lancet 1: 745-748, 10 June 1944.


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The average for the whole force examined was 12.7 per 1,000 for men, and 9.1 for women, figures slightly greater than those for rejections for pulmonary tuberculosis at induction stations in the United States.

A later summary of the experience of the Royal Navy66 threw further light on the relation of age to prognosis. Naval personnel with apparently inactive tuberculosis were placed on light shore duty and kept under observation. Almost all of those whose lesions proved active with the passage of time were under 25 years of age.

This last summary discloses that by the end of 1944, 91,959 ratings passed as normal on a first fluorographic examination were reexamined, and 479 cases with radiological evidence of tuberculosis were discovered. Comparison with the original film showed that in 123 the lesion was previously existent but missed. This yields a figure of 1.3 per 1,000 of those fluorographed, which agrees very closely with the estimate of 1.0 to 1.5 cases per 1,000 of significant tuberculosis missed at induction in the United States, as calculated by Long and Stearns from a rereading of 53,400 induction films. In both groups, the reasons for failure of detection and recording were the small size of the lesion, presence of the lesion behind skeletal structures that cast a denser shadow, proximity to the dense hilus structures, and, in some cases apparently, clerical error.

Of the 479 cases found on reexamination, however, the great majority showed no evidence of disease in the initial film. These must have represented new infections or manifestations of endogenous spread from an unknown focus elsewhere. It was significant that of the new group 73 percent were found in the minimal stage, a figure contrasting sharply with that of 48 percent found for minimal tuberculosis on initial fluorography. Further analysis showed that the total amount of new tuberculosis discovered on the second examination increased with the length of lapsed time since the first fluorography. In men who had their second examination within a year or less, the rate was 2.4 per 1,000; in those reexamined only after an interval of 3 years, the rate was 7.3. The average for all groups was 3.4. In about one-third of the cases, there was definite evidence of activity.

In studying these figures, it is of interest to note that an appreciable number of cases of tuberculosis developed in the course of time also in United States and Canadian troops who had been screened before acceptance and that this increase was greater in those who had had military experience overseas than in those who had not;67 also, that the annual mortality from tuberculosis in the Army and in the ex-Army population rose steadily during the war years.68

66Some Problems of Fluorography. Roy. Nav. Med. Bull. No. 20: 1-9, 1945. 
67See footnote 13, p. 337.
68(1) Adamson, J. D., Warner, W. P., Keevil, R. F., and Beamish, R. E.: Tuberculosis in the Canadian Army, 1939 to 1944. Canad.  M.A.J. 52: 123-127, February 1945. (2) See footnote 41, p. 372.


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The analysis published by the Royal Navy of the invasions by disease and deaths of ratings from 1934 to 1944 indicated that approximately 2.5 men per 1,000 were invalided each year for tuberculosis from 1941 on. The rate for officers was somewhat lower. This figure is several times the discharge rate for tuberculosis in the U.S. Army, in which the relatively low rate is explained by the radiological screening carried out prior to induction.

In this place, it is not out of order to point out that the British were at all times less conscious of the problem of compensation than the Americans. Whether tuberculosis was discovered before induction or after was a vital matter in the United States and Canada. The disposition of cases discovered in both categories was approximately the same in Great Britain, but the financial issue was of less concern.

The death rate for tuberculosis in Royal Navy personnel dropped after 1942, following several years at a constant level. It was the hope of the officers concerned that this was the forerunner of the benefits to be expected in the future from mass radiography in the service and discovery of cases in an early and favorable stage.

ROYAL AIR FORCE

The Royal Air Force also made extensive use of 35-mm. fluorography. A report on 190,076 males and 59,951 females was made by Air Commodore R. R. Trail and associates in 1944.69 All of the subjects of the survey were already in service, and all had been accepted for service on the basis of physical examination. The men had been physically examined 3 to 12 months previously, some very strictly because of their special duties, and the women, all members of the WAAF, 6 months previously on the average. The great majority of each group was under 30 years of age.

The total incidence of tuberculosis was 7.7 per 1,000 in men, the difference, in comparison with the 12.7 discovered in the Royal Navy, being in part attributable to the younger age of the Air Force personnel. In women, the incidence was 9.4; that is, approximately the same as the rate of 9.1 discovered in women in the Royal Navy. Followup examination indicated that the incidence of active tuberculosis was 2.8 per 1,000 in men and 3.6 in women. In men, the figures with respect to age differed from those of the Royal Navy in that active disease was not discovered preponderantly in the youngest age groups, but in increasing extent in the groups up to 40 to 44 years. In women, the peak in the incidence of active disease was in the 20- to 24-year period.

An interesting finding common to the experience of both the Royal Navy and Royal Air Force was the rise with advancing years in the incidence of calcified lesions interpreted as the residua of healed tuberculosis of childhood

69Trail, R. R., and others: Mass Miniature Radiography in the Royal Air Force; Report on 250,027 Consecutive Examinations of R.A.F. and W.A.A.F. Personnel. Brit. J. Tuberc. 38: 116-140, October 1944.


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type. This rise could signify that childhood-type tuberculosis was much commoner years ago than now, or that the type of lesion terminating in calcification occurred in later years, so that a cumulative rise occurred in the number of healed residua.

As in the U.S. Army, a higher increase in incidence was observed in recovered prisoners of war who had spent many months in prison camps in Germany. A survey of 7,146 recovered Royal Air Force personnel in April and May 1935 showed an incidence of active pulmonary tuberculosis about twice as great as that found in Royal Air Force personnel who had not been prisoners.70

CANADIAN ARMY

The control of tuberculosis in the Canadian Army was remarkably effective, and the scientific study to which data on tuberculosis were subjected proved illuminating in the general understanding of the pathogenesis of tuberculosis.

X-ray examination was a requirement on induction in the Canadian Army. As in the U.S. Army, some troops were not examined by X-ray in the early months of mobilization. Subsequently, roentgenograms were made of the chests of men who had been inducted without a film, and those found to have significant lesions were discharged. Approximately a million and a half persons, equivalent to a quarter of the male population and half of all persons of Army age were examined by X-ray in the induction examinations.71 The incidence of lesions discovered was about 1 percent; a third of the cases discovered, about 5,000, were considered clinically significant and reported to the civil authorities. This byproduct of the war was of notable value to the general program of tuberculosis control in Canada.

A feature of great importance, rendering the results of exceptional value for understanding the hazards of tuberculosis in military service, lay in the sharp distinction maintained by the Canadian military organization between the Army in Canada and the Army overseas. In both, the prevalence was very low by civilian standards, as would be expected in a group well screened by roentgenographic examination. The distinction lay in the fact that the Army in Canada was subjected to a hazard of exposure no greater than that in the civilian population of the provinces, while the Army overseas was exposed to contagion in countries in all of which the death rate, and presumably opportunity for contact with open cases, was much greater than in Canada. For the years 1939-44, the average incidence of tuberculosis discovered in troops in the Army in Canada was 24 per 100,000 per annum, while in troops overseas it was 40. These rates were estimated, respectively, as 15 and 25 percent of the rates in the civilian population in Canada. The

70Personal communication, Air Commodore R. R. Trail to author.
71Adamson, J. D., and Keevil, R. F.: Tuberculosis in the Canadian Army. J. Canad. M. Serv. 1: 404-411, July 1944.


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rates in each group increased with length of service, ranging, however, from 9 per 100,000 for home troops and 35 for oversea troops in 1941 to 40 and 60 per 100,000, respectively, in 1944.

An even greater difference between troops at home and those overseas was evident in the incidence of tuberculous pleurisy with effusion. In 1941, the rate for the Army in Canada was 30 per 100,000 and that for the Army overseas was 20. In marked contrast, the rates for 1944 were, respectively, 23 and 75 per 100,000.

The increase in the tuberculosis rate with length of service in both groups was attributed, in part, to the foreseeable development with the lapse of time. The excessive increase overseas, however, was explained on another basis; namely, the excessive exposure to tuberculosis in countries with a much greater prevalence of the disease than Canada.

The figures for pleurisy with effusion were believed particularly significant in the latter respect. Analysis of the figures according to the native province of the men who became ill showed that the highest percentage of new cases developed in men from Ontario and the western provinces, where the incidence of infection, as already known from civilian surveys, was low. It seemed logical to believe, therefore, that the high rate of effusion in troops overseas represented the acquisition of primary exogenous infection, a frequent early manifestation of which is pleurisy with effusion. In reaching this conclusion, the Canadian medical officers made allowance for the fact that some of the pleurisy with effusion, diagnosed as tuberculous, might have been due to acute, transient respiratory infections. It was in fact noted that a rise in wet pleurisy occurred in every epidemic of acute respiratory disease. However, after due allowance was made for the discrepancy between home troops and those overseas, the similar trend in cases of pulmonary infiltration and pleurisy with effusion lent strong weight to the view that the latter represented exogenous tuberculous infection overseas. Adamson and his coworkers believed the phenomenon "the natural epidemiological results of a tuberculin-negative group coming into contact with a tuberculous environment."

Canadian authorities carried the lesson into practice by specifying in two directives (14 November and 21 August 1944) that more strict attention be given to a history of pleural pain and to the examination of soldiers with known contact with tuberculosis.72

The second directive, and a subsequent note appended to it, indicated that about 4.3 percent of all medical discharges from the Army had been for tuberculosis and that approximately 2.9 percent of medical repatriations were for this disease, of which 1.9 percent (or about two-thirds) were for pleurisy with effusion.

72(1) AGO Directive, 14 Nov. 1944, to departmental commanders. (2) DMS Order 286, 21 Aug. 1944.


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These figures for the Canadian Army are of unusual interest. It is unfortunate for the study of epidemiology that in statistics for the U.S. Army, in the Zone of Interior and overseas, a comparable easy separation of troops on the basis of origin cannot be made. Whereas in Canada a large share of the home Army was from the eastern provinces and remained in Canada, in the United States the home Army was constantly a transient force in training for oversea service, and the Army overseas had proportional representation from all parts of the country. Subsequent analysis on the basis of geographic origin may be possible. In the meantime, it appears significant that an unusually high rate of pleurisy with effusion, presumed to be tuberculosis, occurred in young U.S. Air Force troops in Italy (pp. 353-357) .

Part VII. Significance of Army Experience for Control of Tuberculosis

For many years prior to World War II, tuberculosis mortality in the United States had been declining. The reduction in mortality continued during the war, but at a somewhat lowered rate. Among the reasons for the slowing in the curve of decline were shortages in personnel for civilian public health and hospital practice, increased tempo of work, with corresponding general strain, and absence from the country of a large number of men of an age period with a low general death rate, who were removed from the population on which mortality rates were calculated.

Counterforces were in effect, however, which offset these factors. Although the intensity of labor was increased, wages were far higher than before the war, and although prices were elevated also, the general result was a rise in the standard of living in segments of the population in which mortality from tuberculosis is usually high.

During the war, also, in spite of personnel shortages for public health work, a notable advance in machinery for tuberculosis control took place in the establishment, for the first time, of a Tuberculosis Control Division in the U.S. Public Health Service. This was organized by congressional action in the Bureau of State Services of the U.S. Public Health Service in July 1944. Funds became available shortly thereafter to supplement measures for combating tuberculosis through grants-in-aid to States, enabling the latter to expand their programs in clinics, case finding, and hospitalization.

The examinations at induction stations, as indicated in detail elsewhere in this chapter, brought to light thousands of canes of previously undiscovered tuberculosis. A substantial number of these were placed under treatment immediately. In addition to the saving and prolongation of life thus effected, there resulted a reduction in community exposure to tuberculosis, with presumably a corresponding decrease in development of new cases. The accomplishment in this respect was far from maximum, as reporting of cases was not complete, and followup programs to insure hospitalization of open cases


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discovered were not well developed in many parts of the country. In large communities, with well-organized public health programs, followup was good, but in other regions little or none was attempted. Although not specifically mentioned in AR (Army Regulations) 40-1080, dated 31 December 1934 and 10 December 1943, tuberculosis was considered a communicable disease to which the reporting requirement applied. Because of a recognized laxity in reporting cases of tuberculosis, a reminder (specifically mentioning tuberculosis) as to the reporting requirement in AR 40-1080 was issued on 24 July 1944 in War Department Circular No. 313. In some cities, however, by special arrangements between health departments and induction stations, direct report was made immediately, without waiting for report through the normal channels of the State selective service organizations, and State health departments. In New York City, for example, a representative of the Bureau of Tuberculosis of the Department of Health visited the large New York City induction station every night and received direct report on cases of tuberculosis discovered during the day.

The system of hospitalization for tuberculosis in the Army and the normal discharge of patients to Veterans' Administration hospitals for further care, resulted in the treatment of thousands of cases and in corresponding reduction in opportunity to spread the disease to others. Army hospitals and Veterans' hospitals were required by their respective regulations to report cases to State health departments. Special check, however, indicated that reporting was not complete. With changes in personnel, which occurred constantly in Army hospitals, required procedures were not always continuous. To make up in part for deficiencies in reporting, the Consultant in Tuberculosis, Office of the Surgeon General, established a direct relationship in 1944 with the newly established Tuberculosis Control Division of the U.S. Public Health Service, so that all discharges for tuberculosis were reported by States of origin of the men concerned. The Tuberculosis Control Division, in turn, forwarded these reports to individual State health departments. With all the imperfections in the reporting measures, and the lack of suitable followup programs in many States, and in spite of the many tuberculous veterans who refused sanatorium care in the months immediately succeeding discharge, steadily increasing control from the point of view of public health resulted, which should be reflected in a decline of tuberculosis mortality in the future.

In evaluating the effect of the Army's control program on the general antituberculosis campaign, the educational efforts of Medical Corps officers should not be overlooked. In addition to direct counsel given patients with tuberculosis or suspected tuberculosis, they were provided with literature from the National Tuberculosis Association and its affiliates, and hospital patients in general saw motion pictures on the diagnosis, care, and aftercare of tuberculosis. Probably a still greater educational effect resulted from the vast amount of roentgenographic study of the chest done in the Army. X-ray


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examination at induction and separation, and the huge number of chest examinations by X-ray in dispensaries and hospitals, made millions of young men and women aware of the danger of tuberculosis and the special measures available to combat it.

On the whole, the tuberculosis control program of the Army was well integrated with the public health program of the country and may be expected to be of continuing favorable influence in the reduction of tuberculosis in the population in postwar years.

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