Mass Chest X-ray Surveys Research Articles

A Long Way from Home: The Tuberculosis Epidemic among the Inuit (review)

Reviewed by: A Long Way from Home: The Tuberculosis Epidemic among the Inuit Leonard G. Wilson Pat Sandiford Grygier. A Long Way from Home: The Tuberculosis Epidemic among the Inuit. McGill—Queen’s/Hannah Institute Studies in the History of Medicine, Health and Society, no. 2. Montreal: McGill—Queen’s University Press, 1994. xxiv + 233 pp. Ill. $34.95. Pat Grygier—a clinical psychologist by training, now retired from the Public Service Commission of Canada—has written a moving, sometimes shocking history of the Canadian government’s effort to combat tuberculosis among the Inuit (Eskimo) population in the Canadian Arctic since the end of World War II. Her account is based on extensive research in both published and archival sources and on interviews with surviving participants in the campaign. The Canadian Arctic is a vast area of interspersed land and sea—peninsulas, islands, and inland seas, like Hudson Bay—extending more than 2,500 miles east to west, from the coast of Labrador to the Beaufort Sea, and a similar distance from the southern shore of Hudson Bay to the Queen Elizabeth Islands a few hundred miles from the North Pole. Along the shores of this immense land some ten to eleven thousand Inuit lived formerly in small hunting groups, dwelling through the short Arctic summer in skin tents and through the long, dark winter in igloos. The isolation of Inuit communities made them particularly susceptible [End Page 745] to epidemics of infectious diseases. During the summer the arrival of a ship at a remote community was followed typically by an epidemic of colds and bronchitis, and sometimes of tuberculosis. Following the arrival of a ship at Coppermine on Coronation Gulf in 1929, the government medical officer, Dr. R. D. Martin, watched tuberculosis spread rapidly among the neighboring Inuit groups, until by 1931 a quarter of the people were dying annually. Although he made strenuous efforts to isolate and care for patients with active tuberculosis, the epidemic was beyond his slender resources. The close confinement of Inuit families within igloos during the winter ensured the rapid transmission of the tubercle bacillus from an individual to other members of the family. When Dr. Martin appealed urgently to his superiors at Ottawa for a hospital at Coppermine in which to isolate tuberculosis patients, they ignored his requests and terminated his appointment. During the 1930s tuberculosis ravaged the Inuit throughout the Canadian Arctic, and tuberculosis mortality among them rose to the highest recorded level in the world. Not until 1945 did the Canadian government act to control tuberculosis among the Inuit, and then their action, though effective, was brutal: instead of establishing tuberculosis hospitals in the Arctic, they conducted mass chest X-ray surveys among the Inuit and forcibly sent Inuit patients with active tuberculosis to sanatoria thousands of miles to the south. Police took patients abruptly from their communities without telling them where they were to be sent; they separated children from parents. The patients usually did not speak English, and sanatorium staffs in southern Canada did not know the Inuit language, Inuktitut. The patients did not know where they were, nor what was to happen to them. Their despair can only be imagined. Yet, in its rough way, the removal of tuberculosis patients from Eskimo communities did lower tuberculosis mortality and reduce the incidence of the disease very rapidly. The prompt removal of people who were sources of infection and their thorough treatment were undoubtedly essential to the decline. Unfortunately, in view of the suffering described by Grygier, as recently as 1986 tuberculosis continued to occur among Inuit at a rate twenty-four times higher than in the population of Canada as a whole. 1 The reason appears to lie in the geographical separation of tuberculosis treatment from where the Inuit live. If the Northern Medical Service of Canada is to eradicate tuberculosis from the Inuit, it needs to have several hospitals distributed across the Arctic, where Inuit patients may be treated by staff who speak their language and understand the conditions of their life. Such hospitals might also serve as bases from which tuberculosis surveillance teams could travel to isolated communities to administer tuberculin tests and chest X rays. Positive...

Estimation of benefit and radiation risk from mass chest radiography.

The benefits and radiation risks are estimated from a mass chest x-ray survey in present-day Japan. About 4,000 × 104 chest fluorographies were carried out in 1968: 44,447 cases of active pulmonary tuberculosis and a probable total of 758 curable cases of lung cancer were detected. However, 1.82 leukemias per year or about 46 leukemias and 7 incurable chest cancers in the forthcoming 25-year period are expected among this population. Also, 150 genetic deaths are estimated until the 10th generation.

Spherical and Ovoid Lesions of the Lung

Interest in this subject is attested by pertinent articles in current medical journals. There seem to be valid reasons for this. These include asserted increase in clinical incidence of conditions associated with characteristic x-ray changes, and newer diagnostic methods derived from advancing technology. Also, socio-economic implications may have some role in this respect, namely recent developments illustrate that highly competent diagnostic work-up can be carried out with reasonable safety without having the patient hospitalized. Reports of the 1950s indicated an incidence of 1 to 2 percent of solitary round pulmonary nodules on mass chest x-ray surveys. The typical round or oval x-ray shadow does not in itself identify its underlying pathologic substrate or etiology. Small areas of calcifications in these lesions usually rule out malignant neoplasm, except when the latter develops near the hilar region where it may engulf preexisting small calcified foci. London and Winter reported an unusual case of peripheral solitary round lesion caused by adenocarcinoma of the lung with psammamatous calcifications (Arch Int Med 94:161, 1954). Mass x-ray surveys, with follow-up examinations, revealed that less than 5 percent of these shadows connoted malignant tumor. In contrast, it is well to remember that in a large group of collated clinical cases, malignant lung tumor (primary or metastatic), was observed in 40 percent, with a variety of nonmalignant lesions in 60 percent. The latter comprises a rather high number of granlomatous lesions caused by Histoplasma capsulatum, Coccidioides immitis, other fungi, tubercle bacilli and a small number of pathologic entities due to other causes. Spherical and ovoid lesions may be caused by a great variety of diseases. Among these are benign tumors, such as myoma, hamartoma, chemodectoma, neurofibroma, hibernoma and chondroma. Adult type of chondroma has been listed, according to its composition, under various names, such as chondrohamartoma, chondroadenoma, adenolipofibro osteochondroma, lipochendroadenoma and bronchoma. Weinberger et al aptly comment that although adult type of harmartoma is considered by many experts a late-appearing developmental anomaly, its histogenetic and behavioral characteristics are similar to those of a benign acquired tumor (Ann Thorac Surg 15:67, 1973). Viereck found 60 percent of bronchial adenomas as “coin lesions” (Chirurg 4:309, 1970). There are other entities which may cast round or oval shadow: vascular anomalies (arteriovenous fistula, pulmonary venous varicosities, capillary hemangioma, sclerosing hemangioma, anomalous single left pulmonary vein, aneurysm of an intercostal artery), some instances of Loeffler's syndrome (of parasitic, bacterial, pollen or medicinal origin), ornithosis, primary amyloidosis, gumma, small ectopia of some of the abdominal organs, abscess, infarction, subpleural intrapulmonary lymph node, plasmacytoma and xanthomatous lung lesions. Plasmacytoma may remain histologically and clinically nonmalignant or, for reasons unknown, may assume the characteristics of malignant neoplasm. Spherical lung lesion may be a sequel of nonpenetrating trauma. Interlobar transudate in the horizontal fissure of patients with congestive heart failure may be visualized as a round or oval x-ray shadow (“vanishing” or “evanescent chest tumor”). In the differential diagnosis, it is mandatory to exclude nonpulmonary diseases which may be associated with round or oval shadows in chest x-rays. The seemingly puzzling diagnostic enigma of spherical and ovoid lung lesions can be resolved by due attention to medical history of the patient, possible paraneoplastic symptoms and signs, detection and examination of sentinel lymph nodes, specific laboratory studies, including cytologic examinations, special x-ray work-up, determination of the rate of growth of the lesion, fiberoptic bronchoscopy (biopsy and bronchial brushing), transcutaneous needle biopsy, and exploratory thoracotomy. Availability of modern instruments reduces incidental diagnostic hazards to a minimum and thus permits an aggressive therapeutic attitude. Prompt and accurate diagnosis assures optimal treatment.

Childhood sarcoidosis--a study of 18 patients.

Abstract Of 18 children with a tissue diagnosis of sarcoidosis 11 were symptomatic; seven were asymptomatic, but on routine x-ray study exhibited hilar adenopathy often combined with pulmonary mottling. The children with symptoms were younger, had more extensive disease and a longer and more complicated course of illness than those who were asymptomatic; they frequently required glucocorticosteroids or chloroquine. The asymptomatic children fared better than those with symptoms. Asymptomatic sarcoidosis in children is more frequent than is currently recognized but its true prevalence is likely to remain unknown, since mass chest x-ray surveys and routine chest radiography are not systematically pursued in tuberculin-negative children. Earlier recognition of sarcoidosis in children may prevent some of the complications of this disorder such as blindness and pulmonary insufficiency.

Chemoprophylaxis for Tuberculosis

To the Editor:— In commenting on Chemoprophylaxis for Tuberculosis ( 202 :647, 1967), your editor seemed unaware of the massive effort put forward by doctors, nurses, public health agencies, Christmas Seal distributors, and the public in general to make human tuberculosis an unimportant during the 20th century. He intimates that just the passage of time which he calls history might have brought this dread disease under control without drugs. Tuberculin testing and mass chest x-ray surveys are mentioned as having been used. But these would have been of no avail unless the patient and contacts received further study and care. The tuberculosis hospital, which was a needed haven in order to isolate and treat patients with good food and rest (plus pneumothorax, pneumoperitoneum, and thoracoplasty later), is simply mentioned as something that has been killed off. Even accepting a BCG vaccine effect, infection with tuberculosis does not confer immunity on

Relative risk from lung cancer in Allegheny County, PA. (1953–1958): A [formula omitted] follow-up of a mass chest X-ray survey population

Relative risk from lung cancer in Allegheny County, PA. (1953–1958): A [formula omitted] follow-up of a mass chest X-ray survey population

Followup Study of 844 Neoplasm Suspects Identified in a Mass Chest X-Ray Survey

Followup Study of 844 Neoplasm Suspects Identified in a Mass Chest X-Ray Survey

Experiences with a Mass Chest X-Ray Survey

Experiences with a Mass Chest X-Ray Survey

The cardiovascular aspects of the Los Angeles County mass chest x-ray survey

The cardiovascular aspects of the Los Angeles County mass chest x-ray survey

Detection of cardiac abnormalities by mass chest x-ray surveys.

1) In a group of 154,111 photofiuorograms there were 515 cases in which cardiac abnormality was suspected. 2) Questionnaires were sent to the personal physicians of the 515 cardiac suspects requesting the final diagnosis and other pertinent information. 3) There were 257 complete replies, 244 of which indicated the presence of cardiac abnormality. 4) Of the 244 cases of cardiac abnormality 21 (9 per cent) were previously unknown to the patients' physicians. Further analysis revealed that only eight of these were actually in need of medical therapy or counselling, giving a discovery rate of about 5 per 100,000 persons x-rayed for such cases, which are really the pertinent ones. 5) In evaluating the heart disease case-finding potential of 70 mm. chest x-ray surveys attention should be paid to how many previously unknown cases are found who are in need of medical attention, and not merely how many new cases of cardiac abnormality are found.

Silent nontuberculous lesions of chest disclosed in survey x-ray studies.

FOR SEVERAL years various public health agencies have been carrying on mass chest x-ray surveys to ferret out persons with silent or incipient pulmonary tuberculosis in the campaign to eradicate this communicable disease. As expected, this search has brought to light many silent nontuberculous lesions, and the incidence has far exceeded anticipation. A significant number of these lesions are proving to be malignant tumors, discovered at a time when the prospect of cure by resection is most favorable. A larger number are benign tumors and other surgical lesions. It should be pointed out that there exists in the chest a unique situation for the detection of silent disease. The air in the inflated lungs provides an excellent x-ray contrast medium, against which the abnormal tissue densities produced by disease are discernible before the lesions have advanced beyond a silent or incipient stage. Also certain lesions which are not directly visible

Review of mass chest x-ray surveys.

As the community-wide chest x-ray survey has developed in recent years, it has become, today more than ever, a concentrated attack on tuberculosis. Through the use of the photofluorograph, we now screen entire communities—the adult population of whole cities or large metropolitan areas—and, in so doing, find tuberculosis and gather the information we need to build more effective tuberculosis control. In the achievement of these purposes, the communitywide chest x-ray survey is based on a blending together of the efforts of all the resources, skills, interests, and knowledge of an entire community. This blending together of resource and effort becomes apparent even before the photofluorographic units begin their screening operations. It becomes apparent in the modification of local tuberculosis control resources and practices to meet the special needs of the survey—in the provision of special laboratory services to aid the physician in the essential task of diagnosis, in the provision

Follow-up study of lung-cancer suspects in a mass chest x-ray survey.

THE purpose of this paper is to discuss that part of the recent Mass Chest X-ray Survey in the city of Boston that was concerned with revealing cancer of the lung. It is believed that this is the first such survey in which special procedures carried out by special staff workers have been followed to detect cancer. The mass survey was initiated by Dr. John H. Cauley, commissioner of the Department of Health of the City of Boston, because of the high incidence of tuberculosis in the city. The survey was in operation from September 15, 1949, to February 1, . . .

Single, circumscribed, intrathoracic densities.

IN THE course of mass chest x-ray surveys for the detection of pulmonary tuberculosis, single, circumscribed densities are found that offer difficult problems in diagnosis and management. In the early years of the surveys, it was the usual procedure to follow these lesions by periodic examinations. Whenever an increase in the size of the lesion was noticed, the patient was referred for surgical treatment. All too often, the surgeon was then confronted with a malignant tumor that had become inoperable. Obviously, the opportunity for early removal had been missed. There were two reasons for the delay in the advice of . . .

Surgical experience with asymptomatic intrathoracic growths.

Most patients and many doctors are still shocked by the discovery of widespread and often progressive disease without symptoms. If the nature of the lesion is such that operation is advised, the surprise often turns into panic. The classification and description of disease have been so long based upon symptom complexes that a full recognition of the limitations of signs and symptoms will require a long period of education. Mass x-ray chest surveys, which are intended chiefly to detect tuberculosis, have gathered in the meshes of the diagnostic screens a varied and startling assortment of other intrathoracic diseases. After applying all the known diagnostic criteria, a residue is left in which an absolute diagnosis cannot be made. If the disease is localized, these patients are often sent to a thoracic surgeon for exploratory thoracotomy. The patient or his family usually ask four questions. Is it a cancer? Can it become a cancer? Will it grow larger? How dangerous is the operation? Only the last one can be answered with the statement that exploratory thoracotomy, as such, carries a very slight risk. The source of the material presented in this paper is mass chest x-ray survey, school survey, industrial survey, and chest films taken in the course of a routine individual diagnostic survey. All of the patients were either completely asymptomatic or had slight symptoms which could be elicited only after close questioning. The diagnostic methods are listed. In most of the cases reported here, as many of these procedures were used as were thought necessary or practical before submitting the patient to operation. 1. Clinical History Occupational data Geographic data Tuberculosis contact 2. Physical Examination Extrapulmonary lesions 3. Roentgen Examination Fluoroscopy Laminagraphy Bronchography Angiography Serial observations System review 4. Skin Testing Tuberculin Histoplasmin Coccidioidin 5. Bronchoscopic Examination Bronchial aspiration 6. Laboratory Examinations Sputum: B. tuberculosis, fungi Gastric aspiration: B. tuberculosis culture Blood counts Blood chemistry Serology Agglutinations 7. Pathologic Examinations Bronchial and sputum cytology Biopsy material Aspiration biopsy 8. Diagnostic Pneumothorax and Thoracoscopy 9. Exploratory Thoracotomy Mediastinal Lesions Case 1 (Fig. 1): On mass x-ray survey, a large tumor was discovered in the left lower thorax of a 47-year-old white female who had absolutely no symptoms. Seventeen years previously she had a left radical mastectomy for carcinoma. Physical examination revealed dullness and absence of breath sounds in the lower half of the left chest, posteriorly. The films showed a large, well demarcated tumor occupying the posterior lower half of the left chest. The heart and trachea were pushed to the right. At operation, a large, well encapsulated mass was removed from the posterior mediastinum. It proved to be a benign ganglioneuroma.

Experiment in Glaucoma Case Finding : A Preliminary Report

This preliminary report deals with an ex­ periment in case finding which originated with the Philadelphia Committee for Prevention of Blindness* and to our knowledge is the first of its kind to be undertaken. is based on a mass screening, by ophthalmologists, of 3,923 persons. Since prevention of blindness is generally recognized as a ramification of public health, the committee believes that early discovery of blinding conditions and prompt, adequate, and uninterrupted treatment for them parallels the control of such diseases as can­ cer, tuberculosis, heart disease, and others. To quote from A community organiza­ tion for mass chest X-ray surveys. It is universally recognized that tuber­ culosis is almost symptomless at its onset and may go undetected for a long time until it has reached an advanced stage, not infre­ quently until after the disease has been com­ municated to others. Since the patient will not seek the physician during the early stages of the disease, because he is not aware that anything is wrong, the physician must find ways and means to seek him. The term glaucoma might well be sub­ stituted for tuberculosis except for the im­ plication of communication to others. Motivation for mass eye examinations to locate early actually began when the Pennsylvania legislature enacted a blindpension law. Eligibility for the assistance it provided was established by visual acuity,

Health and growth of aleut children

Summary 1. The general health, growth, and development of fifty-nine Aleut infants up to 2 years of age and eighty-nine Aleut school children from 6 to 16 years of age have been studied over a four-year period and their progress plotted on the Wetzel grid. 2. A well-baby clinic was established for the study of the infants and clinic was held monthly. Instructions in regard to hygiene and infant feeding and care were given the Aleut mothers. As a supplement to their regular diet the infants received daily 20 drops of Infa-Concemin, a vitamin B and iron preparation. They also were given daily the juice of one orange. 3. Of the fifty-nine infants, fifty-five had a physique of medium, normal, or better, and fifty-four showed a normal or advanced physical development. The general health of these infants appeared to be better than average. Illness among this group was at a minimum. 4. A routine of care for school children was set up which included weekly instructions in health and hygiene, weekly physical checkups, and semiannual physical examinations, and a daily toothbrush drill in the interest of oral hygiene. Each child was given daily as a supplement to his diet one Pan-Concemin tablet. All children were immunized against smallpox, typhoid fever, diphtheria, and whooping cough. Those who showed a negative reaction to PPD were vaccinated with BCG. In 1949 a mass chest x-ray survey was made of these children. 5. In terms of physique, sixty-three of the eighty-nine children had a medium type of body build, seventeen were stocky, and six were overly plump or obese; the remaining three were under par in body build. The age schedule of development of these children showed advancement or improvement in thirty-two, no change in forty-four, and a decline in thirteen. Illness in this group also was at a minimum, as evidenced by the fact that the rate of attendance in school exceeded 99 per cent. There have been no cases of communicable disease, except influenza, among these children, and a comparison of the incidence of this affliction during two epidemics in a two-year period showed a decrease from 16 to 4 per cent. On the basis of the mass chest x-ray survey, only one case of active tuberculosis was reported, although sixteen showed increased markings or calcification. Only four of the eighty-nine children had a serious illness or operation during the four-year period.

The Role of the Radiologist in Mass Chest X-Ray Survey

In addition to case finding, a community-wide survey provides a base line for statistical proof of disease incidence, and thus an accurate measure for the needs of a community for public health staff, sanitariums, and hospital accommodations. A repetition of the survey after a definite time interval would provide reasonably accurate knowledge as to the proficiency of preventive measures and an approximation of the attack rate. It is interesting to note the practicability of a community-wide chest survey program hinged on the demonstration that efficient chest film readings can be accomplished in fully clothed patients. The conclusions formed from the original investigative work on this simplified procedure have been amply proved in the large surveys already undertaken. The approval of organized medicine in a community is a basic requirement before the United States Public Health Service will lend its aid to mass chest survey projects. The physicians in each of the communities so far covered have had impor...

Minimal Tuberculosis

The diagnosis of pulmonary tuberculosis by roentgenographic examination, particularly in routine and mass chest x-ray surveys, has become a common practice. This is especially true as regards minimal lesions, where it is admitted that laboratory and clinical findings are often absent or inadequate to help in early diagnosis. Since basic criteria for the determination of the clinical significance of the minimal lesion have not been established, it has become an increasingly frequent custom of chest physicians and roentgenologists to attempt to read from the film the clinicopathologic nature of the lesion for the purpose of proper disposition. The terms used in the roentgenologic description of minimal tuberculous lesions imply a certain pathologic significance for each type of infiltration, i.e., exudative, exudative-productive, productive-fibrotic, and fibro-calcific, Reisner and Downes (1) have provided the following excellent definitions for the roentgenologic character of the infiltration: “Exudative: Roentgenologically, the density usually shows rather ill-defined borders; occasionally it may be well circumscribed; it is ‘soft’ in appearance, either round or irregular in shape. The size is variable, usually ranging from one to two or three centimeters in diameter. The individual lesion may represent either a single focus or it may be composed of several smaller confluent densities. The intensity of the shadow depends on the size of the lesion, it may be either homogeneous or flocculent in appearance. “Productive and Fibrotic: From the roentgenological appearance a distinction may be made between two main forms, namely: (a) discrete nodular densities, usually multiple, of small size, showing well defined borders, ‘hard’ in appearance, either round or irregular in shape; (b) strand-like or linear densities, sharply outlined, often irregular in shape and distribution. The majority of the cases included in this category present a combination of form ‘a’ and ‘b’. “Exudative-Productive: This form may be regarded as an intermediate group between the two preceding types, the roentgenological findings presenting a combination of the features of both the exudative and productive-fibrotic elements in varying proportions. “Fibre-Calcific Form: Roentgenologically, the changes consist of sharply defined nodular densities, showing either round or irregular borders. The nodules are usually multiple; their distribution is scattered; they are generally of small size, measuring several millimeters in diameter, only rarely exceeding one centimeter. The intensity of the shadows is of a type usually interpreted as characteristic of calcium deposition. Such findings often occur in combination with changes indicative of strand-like and linear fibrosis.” In a recent study (2) we attempted to determine the clinical significance and prognosis of minimal pulmonary tuberculosis in a group of 220 sanatorium cases.

A mass chest x-ray survey in Philadelphia war industries.

A mass chest x-ray survey in Philadelphia war industries.