War Surgery and Medicine
CHAPTER 16 — Pulmonary Tuberculosis
BETWEEN the First and Second World Wars the development of mass radiography of the chest gave a new method of control of pulmonary tuberculosis in the forces. Chest X-ray of recruits during the Second World War ensured that a number were rejected who would otherwise have become centres of infection in the services, and themselves liable to hospitalisation and possible death. In 1 NZEF overseas there were 149 deaths from tuberculosis, whereas in 2 NZEF overseas there were only four deaths, two from miliary infection, and, as far as is known, only four deaths among the 8000 New Zealand prisoners of war.
Radiography of the chest has also removed the association of neurosis with tuberculosis. After the First World War, in addition to frank pulmonary tuberculosis cases, there were cases which physicians considered probably cases of tuberculosis, but as the physical signs were not definite and sputum was negative, they were classified as cases of ‘chronic pulmonary disease indeterminate’ (CPDI). These cases were often treated in sanatoria. They were warned against too much physical exercise until fit for it, and altogether it was impressed upon them that they were invalids. But they did not get progressively worse or change over the years, and when later radiography of the chest became possible it was seen there was little, if any, lung disease in these cases and these men might have returned to work long before. However, for too long they had been taught to be patients and had been in receipt of full pension. Many of them were still receiving pensions for neurasthenia after the Second World War. With servicemen of the Second World War there was nothing of this. Generally speaking, with modern X-ray and physical examination it is possible to determine whether a patient suffers from pulmonary tuberculosis or not.
Shortly after the start of the Second World War it was decided to X-ray the chests of all soldiers before they went overseas, but efficient equipment was lacking in certain areas, and there was a shortage of technicians, radiologists, and specialists in pulmonary page 589 tuberculosis. By the time arrangements had been made the First Echelon had sailed, and not many of the Second Echelon could be examined. (This point is important, as will be seen in the discussion on incidence.) Thereafter most members of the forces were X-rayed as part of their initial medical examination or else while they were in training camp. Later, chest X-rays were taken on discharge from the forces.
Mass radiography was introduced in order to eliminate the recruit likely to be useless and a burden to the service. It was a rapid and efficient method of detecting latent tuberculosis, and reduced the number requiring specialist examination. In spite of the strain under which they worked, the radiologists missed very few cases, although medical histories could not be made available to them. When microfilm came into use later in the war extra checks on large films were made in 5 per cent of cases.
Between two and three recruits per thousand were rejected on account of an active tuberculous lesion, and these were in men otherwise reported as fit after medical examinations. Many hundreds of cases reported on at enlistment as showing abnormalities relating to tubercular infection, but accepted as having no active disease, served through the war and never had any symptoms of the disease. The methods adopted were justified. Although 71 cases taken into the Army overseas with some evidence of old or latent infection were later diagnosed as suffering from active pulmonary tuberculosis, on the average they gave several years service and 25 were detected only at discharge. If a policy of doubt and fear had been adopted in all suspicious cases the services would have lost many recruits. Great care is required that unnecessary invalidism is not created by mass radiography.
All cases showing radiological abnormality were referred for boarding to specialists in disorders of the chest. Cases of active tuberculosis, however slight, were totally rejected; others with inactive lesions were in some instances graded for limited military duties in New Zealand.
The benefits of routine radiography have been amply emphasized by a survey of records of over 100,000 apparently normal recruits. It was found that the incidence of active pulmonary tuberculosis was 2.4 per 1000—a figure which compares favourably with that obtained from similar surveys in other countries. Reliance on clinical examination alone permitted detection of active tuberculosis in only 3.6 per cent, and suspicion of active tuberculosis in a further 3.2 per cent of the cases subsequently proved to be tuberculous. In other words, in 93.2 per cent clinical examination was negative, and only routine radiography raised the suspicion for subsequent page 590 confirmation by specialist boards. These figures speak for themselves, yet probably do not give an accurate assessment of the true incidence of detectable clinical signs. The conditions under which initial medical boards are of necessity conducted are not ideal for careful auscultation. In any case, the knowledge that a routine X-ray was to follow probably prompted and in part justified a relatively cursory examination of the chest by medical examiners working in adverse conditions. In the small group of cases detected or suspected clinically most had a bad family history, gross symptoms, or obvious physical signs; 33 per cent were Maoris.
Tuberculosis did not constitute any great problem in 2 NZEF. At no time was the incidence high enough to cause any difficulty in management. The cases were, of course, segregated when diagnosed, and returned to New Zealand by the next hospital ship when the condition of the patient was considered to be satisfactory enough to stand the journey. The infectious disease ward of the Maunganui, though small, was always able to accommodate all the tuberculosis cases. There were 115 cases of pulmonary tuberculosis invalided back to New Zealand from 2 NZEF in MEF and CMF during the war. More cases were discovered by routine X-ray at discharge, or became ill after return to civil life, than revealed active symptoms during their service with 2 NZEF.
For some years before the war, and prior to the introduction of X-ray examinations at entry, it had been found that the incidence in the Royal Navy was considerably higher than that of the Army and Royal Air Force. From the inception of the New Zealand Division of the Royal Navy the local incidence had caused no particular concern until just before the war, when seven cases occurred in two years in the Achilles. Certain suggestions for the better ventilation of living and working spaces in the Achilles and Leander could not be put into effect owing to the outbreak of hostilities and the employment of the cruisers on active operations with increased complements.
From the end of 1940 X-ray examination of the chest was part of the standard naval recruiting procedure. Of the 117 cases of pulmonary tuberculosis which occurred in male RNZN personnel between 1 September 1939 and 21 December 1946, the chest X-rays had been clear on entry in 87 cases. This indicated that too much reliance should not be placed on the initial X-ray examination. The conditions of shipboard life make it necessary to keep the page 591 closest watch for any signs or symptoms that might point to tuberculosis. Early recognition and segregation of suspects is essential. Repeat X-rays and vaccination would seem desirable. A careful study of the cases occurring in continuous service personnel of the RNZN before and during the war showed that a significantly large number were members of the same initial training classes. The early training period involved closer common contacts than in any subsequent period of naval service, and it was suggested that some of these groups contained individuals from whom the infection was spread.
In 1949 Dr D. Macdonald Wilson made a survey of pulmonary tuberculosis among New Zealand service personnel, embracing all the cases that had occurred in the ten-year period 1939–49 in a military population of 200,000 medically examined and passed fit for service, of whom about 134,000 served outside New Zealand. In the main this was a specially selected population, but, on the other hand, chest X-rays at discharge from the services, plus pensions applications later, resulted in nearly all those developing tuberculosis being brought within the compass of the review. Up to 31 December 1949, 1412 cases had applied for pension, while there had been 8 deaths on service overseas and 30 among servicemen in New Zealand. Included were 193 cases of pleurisy with effusion. Approximately 37.5 per cent of the cases took ill on service, 42.5 per cent were diagnosed by routine X-ray (usually at discharge), and 20 per cent became ill after discharge from service.
It was found that whereas the Army and Air Force produced numbers roughly corresponding to their relative strengths, the Navy had almost double the number of cases on a comparative basis. This emphasized the fact that exposure to infection rather than the physical hardships of a campaign is the greater cause of tuberculosis in the services. The naval authorities early became aware of this, and routine surveys by X-ray were carried out as frequently as possible, thus enabling many unsuspected cases of active tuberculosis to be diagnosed.
The importance of X-ray at enlistment was emphasized by the higher incidence among those army personnel of the first two echelons who were not X-rayed in 1939–40. The members of the Maori Battalion fortunately were nearly all X-rayed, so removing most of the potential sources of infection (16 per cent were rejected for chest conditions), and the Maoris in the services had an incidence of less than double the incidence for the whole group (13.5 against 7.4 per 1000 over the ten years), whereas in the civil population the Maori rate is nearly five times that of Europeans. By comparison page 592 with the annual civilian Maori rate of 23.5 per 1000 the rate of 13.5 per 1000 for a decade in Maoris who served overseas shows a marked reduction. (It has to be noted that on a comparative basis living conditions were much the same for Maoris and Europeans in the forces, but this is not so in civil life.)
In prisoners of war the incidence was fairly high—over 17 per 1000 over the period, but 84 of the 155 army cases had not been X-rayed on enlistment. Most of the prisoners of war were taken in the early campaigns and had entered the Army in 1939 and 1940 before the X-ray examinations were properly organised. Irrespective of prisoner-of-war privations, this group would have produced a higher incidence than the average. Of the total of 729 cases in the Army overseas, 222 were not X-rayed before going overseas. The First and Second Echelons, with 193 cases, produced an incidence of 14.3 per 1000.
The annual incidence of new civilian cases in 1948 (the lowest on record at that date) was European 0.77 and Maori 3.6 per 1000. The average annual incidence in returned service personnel for the years 1945 to 1949 was European 0.95 and Maori 1.73 per 1000. It has to be noted that the service figures were swollen by the large number of cases brought to light by X-rays taken on discharge after return from overseas in 1945 and 1946.
Results of Treatment
All will agree that the best results of treatment should be obtained in the cases diagnosed early, for whom institutional treatment if required is available without delay, and who are relieved of financial worry should it be advisable for them to cease work. Except for prisoners of war, these two latter conditions existed for service personnel, and in over 40 per cent of cases the first condition was also present as they were diagnosed by routine X-ray before the patients were aware of any illness.
In the treatment of the 1404 cases under review, some 300 required no treatment but were merely kept under observation at the chest clinics. On the other hand, in addition to inpatient observation in sanatorium or hospital required for the remaining cases, the following operative procedures were carried out:
Thoracoscopy with pneumolysis or attempted pneumolysis, 33 cases.
Artificial pneumothorax was produced in 316 cases.
Pneumo-peritoneum was used in 22 cases.
Phrenic crush or avulsion was carried out in 54 cases.
Thoracoplasty was carried out in 27 cases, and 5 cases are at present in hospital for consideration of this operation.
While the production of an artificial pneumothorax was the commonest form of active treatment, more than one of the above procedures was carried out on the same patient in certain cases.
The classifications under which the results of treatment are tabulated have been used as an interpretation of the findings and reports of medical examiners. In examining patients for reports on any indications for treatment and assessments of degrees of disablement for pensions purposes, examiners do not always use the terminology used by the Health Department. Thus, in interpreting reports, it is felt they fall under the following headings:
Apparently cured, where the examiner states there is no disability and recommends cessation of pension, or suggests a permanent minimal pension for a lesion healed and stationary for some years and requiring no further observation.
Quiescent cases, which on examination appear much the same as the above but, owing to the short period the condition has appeared healed, a more conservative view is taken and observation for a further period at long intervals is recommended as a safety measure.
Stabilised cases, where any evidence of progressive disease has been removed but treatment and observation are still required. Included in this group are such cases as those where ‘soft’ shadows have hardened and where an artificial pneumothorax wholly controls the disease but the lung is still collapsed by introduction of air. The patient is allowed to follow his occupation provided it is of not too heavy a type, and if so, he is advised to seek another job in the meantime.
The active class, where the disease is still active even if responding to treatment. The patient is attending for treatment at a clinic or under domiciliary treatment.
Cases in hospital or sanatorium. Admission may be temporary for special active measures in treatment or may be in certain hospitals for an indefinite period owing to extensive and progressive disease not responding to treatment.
Deaths in this series of patients which may be due to pulmonary tuberculosis or other causes. There have been four deaths in the series not due to pulmonary tuberculosis.
Using the above classifications, the following table sets out the results for various groups of the services, giving the percentage in each group for total cases from 1939 to 1949.
|Apparently Cured Per Cent||Quiescent Per Cent||Stabilised Per Cent||Active Per Cent||In Hospital Per Cent||Dead Per Cent|
|All services, overseas and New Zealand||29.3||21.8||17.7||15||10.4||5.8|
|Cases diagnosed by routine X-ray, all services||39.6||20.4||15.6||14.2||7.1||3.1|
|Cases diagnosed by routine X-ray, army overseas||40||22.72||12||14.6||7.1||3.6|
The 193 cases of pleurisy with effusion were included in the survey because the clinicians considered them tuberculous in origin. The results of treatment showed that cases with a sudden onset did well, whereas the rarer cases with a slow insidious onset did badly.
Females: Among females there were 45 cases, 10 with overseas service and 35 with home service only, and there was one death in the Navy in New Zealand. The large majority (29 cases) were aged 20–25. Results of treatment in this group were excellent—23 cured, 8 quiescent, 4 stabilised, 8 active, and 1 in hospital. Some 15 cases diagnosed by routine discharge X-rays had not required institutional treatment.
From the survey it is difficult to compare the incidence of tuberculosis among service personnel with that of the civilian population, as the survey covered a closed group composed in the main of personnel of the age group in which the incidence of tuberculosis is the highest. Taking all factors into consideration, the incidence of tuberculosis in service personnel was much the same as for the civil population. In a group of Maori servicemen it was much lower. Mass radiography reduced the spread of infection, and should always be undertaken before the admission of recruits to camps. Thus radiography, plus improved hygiene and the elimination of overcrowding, seems the best means of reducing the incidence of pulmonary tuberculosis in a military community.
Associated Disabilities Present in the Pensions Cases of Pulmonary Tuberculosis
Tuberculosis elsewhere in the body:
Genito-urinary tuberculosis: 25 cases; with nephrectomy (7) and orchidectomy (4).
Tuberculosis of bones: Spine, 14 cases; sternum, 4 cases; ribs, 1 case; humerus, 1 case.
Joints: Elbow (5), wrist (1), sacro-iliac (3), hip (1), knee (2), and ankle (3).
Tuberculous synovitis: 4 cases.
Tuberculous glands: Cervical (8) and abdominal (5).
Tuberculosis of bowel (1) and Peritoneum (1).
Fistula in ano: 10 cases.
Tuberculous periphlebitis of eyes (2).
Tuberculous meningitis (2).
Erythema nodosum (3).
Other conditions associated with this series of pulmonary tuberculosis are: Diabetes mellitus (6), diabetes insipidus (1), gunshot wound involving the lung (3), dyspepsia (10), duodenal ulcer (22), gastric ulcer (3), anxiety neurosis (25).
|Year of Onset of||Year Entered Service||Annual|
|Total of cases according to enlistment years||112||383||140||71||16||6||1||729|
|Year of Onset||Year of Enlistment||Annual|
|Total according to year of enlistment||41||102||11||0||1||155*|
* Total does not include 4 deaths while PW.