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CHAPTER 15
Management of Tuberculosis: An Eminently Sensible Program
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Part 1. A Remarkable Program of Tuberculosis Management:
The Detroit Experience
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At the 33rd Annual Meeting of the American Roentgen Ray
Society in September 1932, a series of superb papers was delivered
on the general theme of tuberculosis detection and treatment as a
public health problem in the city of Detroit in Wayne County,
Michigan. The description covers the period of the later 1920s and
the early 1930s. As the papers in that Symposium show, this was a
remarkable water-shed period in the medical history of
tuberculosis. In this period, it was learned unequivocally that
just bed rest, good food, and lots of fresh air was NOT likely to
reverse the course of tuberculosis in someone who had already
experienced what is called "cavity-formation" in the course of the
"adult-form" of tuberculosis, which is generally a re-activation
of infection in persons who had been exposed to the tubercle
bacillus earlier and had healed the initial lesion of "childhood"
tuberculosis.
Once cavitation had occurred --- even not major cavitation ---
the person was likely to be spewing tubercle bacilli into the air
with coughing, and NOT to be getting anywhere on the road to
recovery BECAUSE the cavity failed to close. Unless the cavities
can undergo closure, the person continues to cough out tubercle
bacilli, the lesion itself spreads IN the affected part of the
lung, the disease spreads TO the uninvolved parts of the lung (for
example from right to left) and to other people. And the chances
of cure were remote. It became understood that some form of
"collapse therapy" was the key to recovery from tuberculosis. It
was essential to put the affected part of the lung at rest, so
that the cavity could heal over. The chest x-ray, properly taken,
and read by experts, made it possible to tell what was really
going on in the person's lung so far as the tuberculous process
was concerned --- and reliance on the physician's stethoscope was
NOT good enough. Closure of the cavities meant virtually
everything, and this was where the effort needed to be placed.
The possibilities for "collapse therapy" were, in increasing
order of effectiveness, (a) crushing the phrenic nerve to rest the
diaphragm on one side or the other, (b) cutting the phrenic nerve
(since the crushing causes the nerve paralysis only for months to
a year), (c) pneumothorax (introduction of air into the pleural
space), and (d) thoracoplasty, a surgical removal of some of the
rib cage to permit partial lung collapse. We have already
discussed the use of pneumothorax as a procedure which involved
repeated fluoroscopic examinations before and after air
introduction into the pleural space (Chapter 1). That led to very
high doses accumulated to the breast tissue, and a high rate of
later breast-cancer in those who had been treated with
pneumo-thorax.
We should pause here to take note that, while the late results
were breast-cancers in SOME of the women who were so treated, the
enormous benefit to the entire group of people was that "many
lived to tell the tale." What we are saying is that without
"collapse therapy" many, many of the people with tuberculosis
would have died an early miserable death of tuberculosis. There
was little chance of recovery. But with the use of "collapse
therapy" and the x-ray guidance in air refills, cavities DID
INDEED CLOSE, the spewing of tubercle bacilli stopped, the spread
of the disease locally stopped, the spread to other persons and to
other parts of the lung of the person infected with tuberculosis
stopped, and recovery processes proceeded. The two keys in all
this were (a) stopping of spreading of tubercle bacilli, and (b)
insuring (by x-ray evidence) that cavities were indeed undergoing
closure. Both were required to assure that progress toward health
of the individual and the community, not advancement of disease,
was occurring. It behooves us to remember that tuberculosis has
been (and could yet again be) one of humanity's greatest scourges.
Part 2. Case-Finding for Tuberculosis in the Detroit Program
=============================================================
Case-finding had been going on with diagnosis of tuberculosis
in people who had symptoms, which is already late, and with the
vigorous effort to find the contacts of each diagnosed case,
because that is THE major place where the additional new cases are
to be found.
There was a new program in Detroit: Dealing on a large scale
with the apparently healthy persons. Health officials decided to
study 35,000 school children, of which 9,000 were of high school
age. Starting with one high school examined, with x-rays of the
chest in those with positive tuberculin history, they found 14
cases of adult-type tuberculosis --- the really serious immediate
threat. Definite symptoms of disease were found in only 3 of the
14. And a major point was that ONLY ONE OF THE FOURTEEN HAD A
CONTACT HISTORY. So had only the usual program of just seeking
contacts of known cases been in effect, ONLY ONE OF THE FOURTEEN
WOULD HAVE BEEN DISCOVERED TO HAVE ADULT-TYPE TUBERCULOSIS. A
14-fold leap in case-finding !
There was one girl, 16 years of age (out of the 14 cases
discovered in this high school) who had a very markedly advanced
lesion in the left lung. Yet she was well nourished and developed.
She played on two of the school teams, and did not have the
faintest idea that anything was wrong with her. And in attempting
to study the spread of tuberculosis in that school, the officials
found that when checked by "home room" in school, in no case were
more than 2 cases discovered in any home room, except for that
where the 16 year old was, and there 7 of the 14 cases of
adult-type tuberculosis were found. So it was clear that where
large numbers of children congregate day after day, a definite
source of contact with tuberculosis will be found, in this
instance an "innocent" source because the source did not know of
illness.
From all the 35,000 children investigated, there were two
major findings: In the overall high school program, they found
the general average to be 0.5%, or one case of adult-type
tuberculosis per 200 children examined. They found that 4.9% had
childhood type tuberculosis, and an additional 1.5 % were suspects
for possible tuberculosis.
Part 3. Development of the Quantitative Radiation-Data
for Tuberculosis Patients
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Now we will develop entries for our Master Table, Column G.
This chapter does not quantify radiation dose from tuberculosis
screening procedures --- only from management of identified
tuberculosis cases. We start with the data presented by Dr. Henry
Chadwick, in his 1933 article entitled "Tuberculosis Problem in
Detroit," from the American Journal of Roentgenology and Radium
Therapy. The data are for the year 1932.
Determining the Radiation Dose
from Fluoroscopic Management of Pneumothorax Therapy
----------------------------------------------------
There are two parts to the radiation-dose determination. The
first part is to determine the cumulative breast-pair rads for all
the female persons who actually received the fluoroscopic doses.
The second part is to determine what we have been calling "the
population dose," which spreads the dose out into the entire
population of Detroit, so that we get an average dose per person
in the Detroit female population as a whole.
The First Part of the Calculation of Radiation-Dose
---------------------------------------------------
7,383 cases of tuberculosis were on the register in Detroit.
Of the known cases, 30% were in hospitals, and 70% were at home
(often after a period of sanatorium treatment).
In their two hospitals together, over 2,000 pneumothorax
treatments were given each month --- with a roentgenoscopic
examination before and after each treatment. So each treatment
meant TWO roentgenoscopic exams.
The Massachusetts tuberculosis study (Boice et al 1977, p.830)
assigned 1.5 rads of breast-dose for each fluoroscopic exam. If we
assign 1.5 rads to the breast for each fluoroscopic examination,
this means 4,000 times 1.5, or 6,000 breast-pair rads per month,
or 72,000 breast-pair rads per year associated with pneumothorax
treatment. We need to exclude the males, so we cut the 72,000
breast-pair-rads in half, to 36,000 breast-pair-rads from the
fluoroscopic exams during pneumothorax treatment.
The Second Part of the Calculation of Radiation Dose
with Pneumothorax Treatment
----------------------------------------------------
We need to know the female population of Detroit in the
average year of 1920-1960. We know from Chapter 8 that the female
population of the United States was 69,037,400 females, for all
ages combined, as the average value in the 1920-1960 period. We
ask, "What part of that total female population resided in
Detroit, Michigan?"
Detroit had a population of 1,670,144 in 1960 (County and City
Data Book 1962). The U.S. Population in 1960 was 179,333,000
persons. The ratio, Detroit / United States is (1,670,144 /
179,333,000). We shall asssume this ratio was essentially the same
in the mid-period of 1920-1960, and no different for females
versus males.
Therefore, female population of Detroit in mid-period of
1920-1960 = (1,670,144 / 179,333,000) x (69,037,400) = 642,951
female persons.
And, Population Dose = (Total Breast-Pair-Rads) = 36,000
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(Total Female Persons) 642,951
= 0.0560 breast-pair rads per person.
Average dose per female person in Detroit = 0.0560 rads per
person, annually. This entry would apply for every age and we can
generalize this to the United States. This is our by-now-familiar
"population-dose."
However, we should eliminate the dose to the very young.
Collapse management of tuberculosis is virtually absent in the
very young children. A reasonable approach is to re-allocate the
total delivered dose to all ages except those under 10 years of
age by increasing the dose by 10% to those 10 years of age and
older. Then the average per person which is effective is 1.1 x
0.0560, or 0.0616 rads per person. This will be applied for the
entire country.
An Additional Source of Radiation Dosage
beyond the Pneumothorax Fluoroscopy
----------------------------------------
There is an additional item to consider in the Detroit
population. We know that 70% of the cases were at home and 30%
were at the hospital. And we know that approximately 50 % of the
hospitalized cases were not on pneumothorax and hence were not
subject to the before-and-after fluoroscopic exam with each refill
of air, since there were no refills (Table at p.326 in Chadwick
1933). But those not receiving air refills were nonetheless
examined with some regularity to assess the progress of their
disease.
One-half of those in hospital would be (1/2) x (30% of 7,383),
or 1,107 persons. These persons would undoubtedly be having a
fluoroscopic exam at least 4 times per year, so we have 4 x 1,107,
or 4,428 exams at 1.5 rads each, or a total of 6,657 person-rads.
And for the 70% at home, we have 70% of 7,383, or 5,168
persons. We feel certain these were watched with fluoroscopic
exams at least every 6 months. So this is (2 exams) x (5,168
persons) x (1.5 rads per exam) = an additional 15,504 person-rads.
Total additional person-rads = 6,657+15,504 = 22,161
person-rads. We divide by 2 to exclude the males, so the
person-rads = 11,081 for females.
The contribution to population dose = 11,081 person-rads
divided by 642,951 persons = 0.0172 rads to breasts. And with the
1.1 adjustment factor to leave out those under 10 years of age, we
have 1.1 x 0.0172, or 0.0189 rads to to add to breast-dose of
everyone of 10 years of age or higher.
We have no reason to believe that this general experience
would have been different with respect to breast-rad dose in other
parts of U.S. Therefore, total population-dose would be 0.0616
rads + 0.0189 rads, or 0.0805 rads.
But because the program might not have generated as many
person-rads in the first few years of 1920-1960, and because of
tapering off in tuberculosis in the 1950s, we shall reduce all
these doses by 25 %, and enter the following in Col.G in the
Master Table for every female age-year starting with age 10.
(0.75) x (0.0805 rads) = 0.0604 rads per person, annually.
A Word of Appreciation
----------------------
This book is being completed in 1995 --- some 62 years after
the series of papers from the health officials in Detroit who
wrote so well on the public health aspects of tuberculosis. We
wish to express our deep gratitude, these 62 years later, for
their monumental contribution to everyone's opportunity to learn a
major set of medical lessons about this unremitting disease,
tuberculosis. The specific papers in the series are in the list
which follows.
All of them appeared in the September, 1933 issue of American
Journal of Roentgenology and Radium Therapy, in Volume XXX, No.3.
The editors of the Journal at that time deserve commendation for
excellent judgment.
Vaughan, Henry F. Commissioner of Health, Detroit, Michigan
"Public Health and Tuberculosis", pp. 300-302.
Brachman, D.S., "The Value of the Roentgen Ray in Apparently
Healthy Children of School Age" pp. 303-304.
Douglas, B.H., Superintendent, William H. Maybury Sanatorium,
"The Importance of the Roentgen Examination in the Modern
Treatment of Pulmonary Tuberculosis," pp. 305-308.
Morgan, Richard, "Artificial Pneumothorax in a Group of Cases of
Pulmonary Tuberculosis Formerly Looked upon as Hopeless," pp.
309-314.
O'Brien, E.J. "Collapse Therapy in Early Minimal Lesions of
Pulmonary Tuberculosis," pp. 315-320.
Chadwick, Henry D., Detroit Department of Health, "The
Tuberculosis Problem in Detroit," pp.321-327.
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Preview of Another Use: Skin Disorders
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1922
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"It is now pretty generally admitted that the roentgen rays
constitute the most useful and successful single remedy we possess
for the treatment of dermatological diseases. The only competitor
for this distinguished position is radium." And:
"That the roentgen rays constitute the most valuable remedy in
dermatotherapy, or that the roentgen rays and radium constitute
the most useful single agents in the armamentarium of pure
dermatology, is shown by the following list of diseases and
conditions that are amenable to such treatment, over 80 in
number." The list of these diseases is presented.
o - Excerpts from "The Value of Roentgen Therapy in
Dermatology," by Dr. George M. MacKee and Dr. George C.
Andrews, in American Journal of Roentgenology and Radium
Therapy, Vol.9: 241-246. 1922.
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1938
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In the 3rd Edition of his obviously successful "X-Rays and
Radium in the Treatment of Diseases of the Skin," Dr. MacKee
states, p.6:
"Over thirty years ago Dr. William Allen Pusey, one of the
pioneers of cutaneous roentgen therapy, remarked; `It is hardly
too much to say that roentgen therapy is the most widely useful
addition to the treatment of skin diseases that has been made.' In
spite of the foregoing paragraphs and the remarkable advance in
American dermatology during the past two decades, Pusey's
statement may be repeated today. It is the consensus of opinion
that x-rays constitute the most important single therapeutic agent
in the armamentarium of the dermatologist."
A very persistent therapy --- extending over decades.
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