i i \Main" | 2003/12/20 | 17:33 | page 29 | #31 i i Journal & Proceedings of the Royal Society of New South Wales, Vol. 136, p. 29{43, 2003 ISSN 0035-9173/03/020029{15 $4.00/1 `The Celluloid Strip' | Mass Screening for Tuberculosis in New South Wales, 1950{1975 dr peter j. tyler Abstract: Tuberculosis was a significant cause of mortality at the beginning of the Second World War when the technique of taking miniature X-ray photographs on movie film was introduced to Australia as part of the medical examination of men enlisting in the armed forces. Immediately after the war, the Anti-Tuberculosis Association of NSW expanded its existing diagnostic clinic in Sydney to provide a mobile X-ray service to country areas and industry. That experience provided a model for the subsequent national campaign which the Commonwealth Government funded to detect and treat the disease. Coincidentally, at the same time as the compulsory national screening program com- menced, the first effective therapy for the disease became available. Antibiotic drugs soon achieved results that long periods of rest in a sanatorium had never accomplished. Government funding was withdrawn after the incidence of tuberculosis diminished, so that by 1975 the ubiquitous X-ray caravans began to disappear from street corners around Australia. This paper describes the logistics of the mass screening campaign during the third quarter of the twentieth century, and the technological developments that made it possible. Keywords: tuberculosis, camera, radiography, screening, X-ray, Anti-Tuberculosis Association The White Death, consumption, phthi- the Mycobacterium tuberculosis bacillus in sis, TB { by whatever euphemism it was 1882, medical practitioners realised that the known, tuberculosis was one of the most disease had a microbiological origin, and feared human diseases for at least three was not a hereditary affliction or punish- millennia. Despite the romantic deaths of ment for a dissolute lifestyle as previously operatic heroines like Mimi and Violetta, believed. Understanding the aetiology was the reality for most people was more stark. one thing; developing effective therapy that Lassitude and nightime sweating were early could overcome these germs was another symptoms of pulmonary tuberculosis, fol- matter. lowed by a chronic cough, loss of weight and a pallid complexion as the disease pro- In the late nineteenth century, the gressed, until the terminal stage when the favoured treatment was bed rest, fresh air victim was spitting blood. If the patient and a diet rich in saturated fats, preferably was the male breadwinner, most families taken at a sanatorium in a fashionable re- then faced destitution. sort on a `Magic Mountain' in the Swiss Alps. For most people this was out of the When the German bacteriologist Robert question. In Australia, from the 1870s there Koch devised a technique to visualise were small private or charitable sanatoria i i i i i i \Main" | 2003/12/20 | 17:33 | page 30 | #32 i i 30 TYLER that catered for a handful of patients, but procedures such as reducing dislocations most sufferers stayed at home infecting the or fractured bones. Some physicians also other family members who shared their bed recognised the potential of the technique or eating utensils. If a patient was too ill to for revealing abnormal pathology in the be cared for at home, or had no family, he or lungs, particularly tuberculosis, but their she went to one of the State Asylums to die, more conservative colleagues were scepti- surrounded by the demented and insane. cal, claiming that their own experience en- It was 1911 before the NSW Govern- abled them to identify tuberculosis sufferers ment opened the large Waterfall Sanato- by physical examination and auscultation rium for Consumptives, and by this time of the chest through a stethoscope. Pathol- there were smaller establishments run by ogy tests did become routine, however, with the Red Cross Society and the Queen Vic- sputum specimens subjected to microscopic toria Homes on the Blue Mountains and in examination to determine whether the tu- the Picton area. Sanatoria were some help berculosis bacillus was present. in preventing the spread of infection, but In New South Wales, the first X-ray few of the patients recovered their health. equipment dedicated to the diagnosis and Various other treatments were tried. assessment of tuberculosis was installed at Koch himself developed Tuberculin, which Waterfall Sanatorium in 1929, to be fol- was popular for a period, and seemed to im- lowed shortly afterwards in 1930 by the prove the condition of certain patients. Less Anti-Tuberculosis Association of NSW at reputable practitioners advocated their own its chest clinic at Albion Street in Surry miracle cures, such as Spahlinger's Serum Hills. Their Kelly-Koet apparatus was and the expensive, but ineffective gold ex- a Heath Robinson contraption by modern tract Sanocrysin. ‘Artificial sunlight' en- standards, and of relatively low efficiency, joyed a vogue in the United Kingdom, but although at the time it was described as Australia seemed to have enough of the nat- `one of the most delicate instruments of its ural variety. Throughout this period, the kind in existence'. The radiologist could ex- incidence of tuberculosis in the community amine the patient directly through a fluo- was actually declining, which gave physi- rescent screen placed in front of the chest, cians an unwarranted sense of optimism or a large piece of specially-coated photo- about the treatments they were advocat- graphic film would be exposed in a light- ing. Nevertheless, in 1910 tuberculosis re- tight magazine, to give a life-size image that mained, after heart disease, the most com- could be processed and examined later. mon cause of death in New South Wales. The Anti-Tuberculosis Association of In 1895, Wilhelm R¨ontgen discovered New South Wales, later known as Commu- the remarkable powers of certain electro- nity Health and Tuberculosis Australia, had magnetic emissions to penetrate the human been founded by a group of influential con- body, and to visualise the internal organs cerned citizens in 1911 to grapple with the on a fluorescent screen. By the end of the misery caused by tuberculosis amongst the first decade in the twentieth, primitive X- impoverished residents of Sydney who could ray machines were installed in the main not afford private treatment. Many of the Sydney teaching hospitals for orthopaedic Association's practices became a model for i i i i i i \Main" | 2003/12/20 | 17:33 | page 31 | #33 i i THE CELLULOID STRIP 31 other voluntary organisations and govern- Wunderly kept a pile of old medical books ment agencies throughout Australia. This nearby so patients of different sizes could paper refers mainly to the New South Wales stand at the correct height for the screen. experience because that can be regarded as Some practitioners were sceptical that such a microcosm of the later national campaign. a small image (36 mm x 24 mm) would be Early X-rays were a great help in con- useful, compared with the image on the firming a diagnosis of tuberculosis, but it conventional 17 inch by 14 inch (430 mm was a slow, inflexible and relatively expen- x 360 mm) sheet film. However, by view- sive procedure. With only a handful of ing the 35 mm negative through a suitable machines available, the technique could be magnifying viewer, experienced radiologists used only with high-risk groups. To illus- found that they could detect major abnor- trate this point, the Anti-Tuberculosis As- malities almost as easily as with the larger sociation recorded only 351 X-rays in its film. first year of providing this service in one New approaches to treatment were also of the poorest parts of Sydney, where there being introduced. The most common inter- was a high incidence of tuberculosis. It was vention was known as artificial pneumotho- 1937 before more than one thousand X-rays rax, where an incision was made in the chest were taken in a single year. By 1941 this wall to collapse a diseased lung. To main- had risen to almost three and a half thou- tain the collapse, nitrogen or compressed air sand, with 172 confirmed cases of tuber- was introduced into the pleural cavity. The culosis detected, a rate of one in twenty, theory behind this procedure was that a col- which was a rather disturbing result that lapsed lung, being relieved of its breathing was never equalled in the later mass sur- function, was given a chance to rest and re- veys. cuperate. Patients could still live reason- The obvious limitations of the early ably normally on the remaining active lung, technique stimulated researchers to look for but had to return to a clinic every six or a simpler, cheaper solution. In 1936, Dr eight weeks to have a ‘refill’ of the gas, a Manuel de Abreu in Rio de Janeiro be- simple outpatient procedure. gan the first mass survey experiments with When the Second World War erupted, a camera using 35 mm cinema film. He the Australian military authorities decided mounted the camera in an enclosure be- that it was necessary to screen all recruits hind the fluorescent screen so that he could for tuberculosis before enlistment into the photograph the image, using a wide-angle armed services. This was intended not only lens and the faster film emulsions that were to weed out those who were unfit for ac- becoming available. After reading about tive service, but also to prevent transmis- these experiments, Dr Harry Wunderly im- sion of the disease to healthy personnel. Dr provised some equipment along the same Wunderly and others continued their exper- lines in his Adelaide consulting rooms in iments to convince the medical establish- 1939.