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HISTORICAL BACKGROUND

1

C.C. Evans

Tuberculosis is at least as old as mankind, and treatment of the disorder has demon­
and the history of the disorder is intertwined strated perhaps above all other conditions,
inevitably with the history of civilization. the necessity for, and benefits of, clinical
Like no other illness, tuberculosis has taken trials and structured research.
its toll of human life over the millennia, and
has spread literally world wide. It is thought 1.1 ORIGINS OF MYCOBACTERIA
to be the oldest of human diseases, which has
waxed and waned in its incidence, but has Mycobacteria are believed to be amongst the
remained a perpetual threat, often in the back- oldest bacteria on earth, and are ubiquitous
ground without, at least until the present in the environment. They are free-living
links with AIDS, producing the dramatic organisms to be found in soil, animal dung,
epidemics associated1 with smallpox, plague salt and fresh water, mud flats and attached
cholera. Its worldwide incidence and to algae and grasses. They are potentially
’ ’has; never really been established, pathogenic to many animals, including cattle
prevalence
but in Europe in the eighteenth century, John and pigs as well as fish and reptiles.
It has been speculated that cattle were the
Bunyan[l] referred to tuberculosis as the
source
of human tuberculosis infection, and
'Captain of all these Men of Death' and a
that
M.
tuberculosis was a mutant of M. bovis,
century later, Oliver Wendell Holmes[2] de­
which
has
a broad host range capable of
scribed tuberculosis as the 'white plague'.
’
'
‘
j
man
and several other species,
The disease has not only been inseparable infecting
whereas
A4.
tuberculosis
is pathogenic only to
from man's progress, but it has been imposs­
man
and
not
at
all
to
cattle[3].
Interestingly,
ible to disentangle the medical issues from
cattle
first
became
domesticated
in the Neo­
the economic and social life of the commun­
lithic
period[4],
and
studies
of
human
skel­
ity. Tuberculosis has been the natural meet­
etons
from
that
time
suggest
that
Pott's
ing ground for many medical disciplines,
including general practitioner, physician, disease, showing collapse and anterior fusion
community physician, surgeon, pathologist, of adjacent mid-thoracic vertebra, represents
microbiologist, ra<diologist, pharmacologist compelling evidence but not unequivocal
" of' proof, of such a hypothesis. The relatively
and medical officer of public health, all
whom with suitable cooperation have been recent finding of acid- and alcohol-fast bacilli
able to benefit both the patient and the com­ in human remains comes from human skelz the disease etons in Heidelberg, Germany, dating back to
_ ______________________
munity.
In the twentieth century,
has been the launching pad for the specialties 5000 BC (Fig. 1.1)[5]. Similar proof has been
from
of thoracic medicine and surgery and numer- obtained from Egyptian mummies f.~...
around
3500
BC[6].
Other
examples
of
prehisous thoracic societies, and the management
Clnncal Tuberculosis. Edited by P.D.O. Davies. Published in 1994 by Chapman & Hall, London. ISBN 0 412 48630 X

2

Historical background

vertebra andfSon^StK "Reprodured^h

dfcmonstrating

Medmne: An Illustrated History, Published by N Abrams,Tsgz')" fr°m

of 4th thoracic

S' Ly°nS and RJ' PetroceIli-

toric skeletal tuberculosis include a Jordanian
bronze age skeleton from 3000 BC[7] and a but it cannot be proven whether these are
Nesperehan mummy from 1000 BC which evidence of skeletal tuberculosis or, in view
o their abundant presence, mere stylistic
revealed not only Pott's disease of the spine
art
conventions of that culture (Fig. 1.2). It
but a psoas abscess[8J. Scandinavian skel­
should
be noted, however, that the hunch­
etons illustrating Pott's disease have been
backs of the early Egyptian Dynastic period
found in Denmark from about 2000 BCfSI
firSt UK skeletons ‘>re from 20(2 are truly angular deformities, whereas the
400 AD[4J. Similar proof of infection has been hunchbacked flute players of early prehistoric
d'scovered in Southern Peru from about 700 American art have smooth, rounded deformi­
AD|9J, but the first descriptions in North ties, and cannot be accepted as proof of preolumbian American tuberculosis (Fig. 1.3)[8].
America on skeletal remains were all after
Early physicians diagnosed disorders on
Columbus. Similarly, there has been no
the
basis of symptoms and superficial signs,
recorded evidence of tuberculosis in South
and
clear y lacked the precision of diagnosis
Africa, Australia or New Zealand prior to
afforded
by modern techniques. Moreover
colonization.
symptoms of tuberculosis are not always
n.°r C°nfined tO 3 Sin8Ie organ' so
1.2 TUBERCULOSIS IN ART AND
that the historian must be aware of the
LITERATURE
alternative terms used to describe various
The Egyptians left many hunchbacks on tuberculous organ disorders and their differenhal diagnosis that might be attributed to
ynastic tomb inscriptions of about 3500 BC,
those symptoms and signs (Table 1.1).

JL 1

Tuberculosis in art and literature

B.

Ek

Fig. 1.2 Egyptian tomb inscriptions demonstrat­
ing hunchback figures: Dynastic period. (Repro­
duced with kind permission from D. Morse, D.R.
Brothwell and P.J. Ucko, Tuberculosis in Ancient
Egypt, Am. Rev. Respir. Dis., 1964,1590, 528)

thoracic
•trocelli.

?se are
a view
tylistic
1.2). It
mnchperiod
as the
istoric
formi)f pre■3)[8].
rs on
signs,
;nosis
•over,
Iways
n, so
f the
rious
lifferad to

Fig. 1.3 Kokopelli - hunchbacked flute player
shown on pottery bowl of Great Pueblo Period
1300 AD. (Reproduced with kind permission from
K.F. Wellmann, Kokopelli of Indian Paleology, J.
Am. Med. Assoc., 1970, 212, 1680.)
Egyptian medical papyri refer to cases of

cervical lymphadenopathy in

the

Ebers

3

papyri[10] and tuberculous scrofula might
easily be the cause. Chinese writings of 2700
BC describe lung fever and lung cough,
which, coupled with the expectoration of
blood and sputum and generalized wasting,
is strongly suggestive of pulmonary tuberculosis[ll). The Sanskrit writers of 1500 BC
were clearly familiar with pulmonary tuber­
culosis, and the Rig-Veda is an original
surviving record. Mesopotamian writings of
675 BC are more suggestive of pulmonary
tuberculosis[12] and there are no descriptions
to be found in the Old or New Testaments of
the Bible.
Greek literature contains numerous refer­
ences to conditions resembling consumption,
including those by Homer (800 BC), Hippoc­
rates (460-377 BC)[12], who probably intro­
duced the term phthisis, Aristotle (384-322
BC), who recognized the contagious nature
of the disorder[13], and Plato (430-347 BC),
who recommended no treatment because
caring for chronic tuberculotic patients was of
no advantage to the patient or the state[13).
Galen (131-200 AD), practising in Rome,
noticed how contagious phthisis was, and
that bronchial obstruction could result in the
expectoration of calcified bodies in the sputum[13]. Vegetius (420 AD) remarked that
animals were victims of consumption, as well
as man. Aretaeus, whose precise dates of
living are not known, wrote a classical
description of advanced tuberculosis in his
book entitled 'On the causes and symptoms
of chronic diseases'[14].
The Arabic physicians Rhazes (Al Razi 850953) and Avicenna (Ibn Sina 980-1037) linked
lung cavities with skin ulceration and wrote
like the early Greeks, on the benefits to be
had of dry air, good food and the potential
curability of the disorder. These two Arabic
physicians anticipated finding tuberculosis in
young people aged 18-30 years with narrow
chests and a thin body. At about the same
time, Al-Majousi described clubbing of the
finger and toe nails[15].

I
4

Historical background

0

Table 1,1

Historical terms used to describe

Tuberculosis
1

tuberculosis and other possible

Historical synonym

Acute progressive

_________ Differential diagnosis

Galloping consumption

2 Pulmonary

Neoplasms and diabetes
mellitus
Bronchial neoplasm
Rheumatic and
congenital heart
disease
Pneumonia
Lung abscess
Empyema
Lymphoma
Sarcoidosis
Malignancy
Syphilis
Colonic neoplasm
Crohn's disease
Appendix abscess
CDLE
Bacterial meningitis
Encephalitis
Bacterial spinal abscess
Hereditary degenerations

Consumption
Phthisis
Tabes pulmonali
Tissic

3

Cervical adenopathy

4

Abdominal

Hectic fever
Gastric fever
Asthenia
Scrofula
Stroma
King's Evil
Tabes mesenterica

5 Skin
6

Lupus vulgaris
Acute hydrocephalus
Infantile encephalitis
Pott's disease

Meningitis

7 Vertebral

causes of that condition

Source: H.M. Coovadia and S.R. Benatar, A Cen^ of Tutsis. Oxford Un?
iversity Press, 1991, Tables 1.1 and 1.2.

t

tSRENAtSSANCE PATHOLOGY

□urmg the Middle Ages, there was no record

Mortality
w
Mortality, and there
were references in
Shakespeare-s plays, such
• -----1 as 'the consumphve lover ,n Much Ado About Nothing and
scrofula m Macbeth.
S
Paracelcus (1490-1541)

1

t

i
1
t

ixsK

hXg~ s,°j“”8

1
1
r

victims in one month and

w i •

,

Physicians understand-

1
s

(1614-72) correlated
tubercles with various
roughly the same time Thomas Willi ---- ;

X"™:; xtszs
touch[18J.

bestowed

the

SwXex ::

royal

By 1650, consumption was a leading cause
of mortality recorded in London's Bills of

attributable to ------ : systemic manifestations
consumption must result from
;XnQ« "T8 ulcerationt21L Richard Morton
(1637-98) described many pathological tuber­
culous features and gave sound advice about

ii

1
ll

(
c>
ii

Radiographic discovery
t condition

nosis

1 diabetes
lasm
■art

the prevention of phthisis, including the
enjoyment of 'an open fresh and kindly
air'|22|.
Morgagni (1682-1771) believed that there
were many potential causes for phthisis[18],
but Desault in Bordeaux (1675-1737) believed
that the disease was spread by infected
sputum[23] - an opinion to be shared by
Stark (1741-70)[24].

1.4 FRENCH CLINICAL EXAMINATION

n
■s

itis

bscess
icrations
1 and 1.2.

aces in
nsump;ng and
miners'
3-1553)
-’eptible
me 300
al dis­
section
rstand.eyden
mt of
and at
(1621ations
t from
lorton
tuberabout

It was Auenbrugger (1722-1809) who orig­
inally described the technique of clinical
percussion in Austria[25], but it required
Corvisart (1775-1821) in Paris to rediscover
the technique during the golden age of
I’rench medicine[26j. It was he who taught
l.aennec (1781-1826) who subsequently
invented the stethoscope, thereby permitting
him to correlate physical findings with patho­
logical dissected states, which had been
taught to him by Bayle (1774-1816)[27J. There
were opponents to the infective concept of
tuberculosis however, and Virchow (1821—
1902) asserted in the nineteenth century that
phthisis was hereditary[28], whereas South­
ern Europeans in Italy, Spain and the South
of France, centred around Montpellier, came
to regard tuberculosis as infectious. Indeed,
in the Italian Republic of Lucca in 1699,
physicians were instructed to give notice to
the Council of the names of patients sus­
pected as suffering from tuberculosis, and
Ferdinand VI in Spain introduced tuberculo­
sis notification^]. In Naples in 1782 it was
mandatory to destroy the clothing of a
patient dying of tuberculosis, but such fore­
sight into prophylaxis was not sustained, and
was lost until Koch's wonderful discoveries
in 1882[30].

1.5 BACTERIOLOGY
In Northern Europe, in Britain, France and
Germany, the notion existed that tuber­
culosis was indeed hereditary, and that one
inherited the tuberculous diathesis. This so-

5

called eugenic theory was smashed by Villemin (1827-92) who, in 1865, transmitted
tuberculosis from man to rabbit by inocula­
tion of tuberculous material, and subse­
quently from cow to rabbit, when the
transmitted disease was much more
severe[16].
In Berlin in 1882 Robert Koch (1843-1910)
described the tubercle bacillus. Earlier, in his
country practice in Wolstein, he had dis­
covered the anthrax bacillus, and laid down
his bacteriological postulates. Using aniline
dyes and an oil immersion microscope, he
was able to identify the tubercle bacillus in
every lesion in the human or animal victim,
he was able to culture the bacillus outside the
body, and when he inoculated the bacillus
into an experimental animal, it produced
tuberculous lesions. Henceforth, searching
for the bacillus in the sputum of suspected
cases quickly became standard clinical practice[30].
Koch considered initially that there was no
difference between human and bovine tuber­
cle bacilli, but in 1898 Theobald Smith in
Harvard showed that there were micro­
scopic, morphological and toxic differences
between the various bacilli[31]. In all, five
varieties of tubercle bacilli have been dis­
tinguished, and these are human, bovine,
avian, murine and piscine. The human bacil­
lus is now thought to account for 98% of
cases of pulmonary tuberculosis spread by
droplet infection by coughing and sneezing,
and 70% of non-pulmonary forms. Bovine
infection was commonly acquired by drink­
ing infected milk or, rarely, by eating infected
beef. Bovine infection is related to the nonpulmonary forms of the condition such as
cervical lymphadenopathy, intestinal and
abdominal tuberculosis, bone and joint dis­
ease, skin infections and tuberculous men­
ingitis, especially seen in children.

1.6 RADIOGRAPHIC DISCOVERY
In 1896 Rontgen (1845-1923) announced the
discovery of X-rays, which technique was

6

Historical background

quickly applied to disorders of the chest and
tuberculosis in particular. In time, but sadly
not immediately, this advance in <diagnostic
” m
achievement was to revolutionize the
the man
man-­
agement of tuberculosis.

any role in the development of the fatal
scourge. It was the colonizers who brought
the disease to the native population, not only
in the nineteenth century, but as early as the
Mayflower pilgrims in 1620[32] (Chapter 10,
p. 191).

1.7 PUBLIC ATTITUDES
1.9 MIGRATION

I®

■■ I

In the early nineteenth century, during the
time of these pivotal pioneering and scientific European migration in the nineteenth
discoveries, the incidence of tuberculosis was century was also responsible for an increased
of tuberculosis. As a result of the
increasing in Europe and the United States, incidence
.
although precise figures are lacking. It has Insh 1potato famine, many
. Irish immigrants
been estimated that 30% of all deaths under settled in Boston, Massachusetts^], and
50 years of age in Europe could have been Liveipool, England, but smaller epidemics
attributed to tuberculosis. Death certification brought about by immigration were de­
became mandatory in the UK in 1838, scribed, such as the Outer Hebrideans enteralthough tuberculosis mortality was probably in^ the city of Glasg';ow. Migration not only
underestimated because of the reluctance of occurred for economic reasons, but tuber­
were
relatives and friends to have the death so culous victims we
re deliberately encouraged
migrate
and move to regions where their
registered because of the stigma attached to to mi
8rate and
the disease. Such a stigma reflected the public c^ances
recovery would be enhanced by
allegedly
favourable
environmental circum­
notion that tuberculosis was an inherited
stances.
Thus,
many Europeans with tuber­
weakness, and as such might interfere with
culosis
were
tempted to travel to the
potential marriage and employment of other
fashionable, sunny, Alpine resorts of Davos
relatives.
and Leysin in Switzerland, Cape Town in
South Africa[36], Melbourne in Australia[34],
1.8 COLONIZATION
and Colorado in the USA[37J.
The hereditary theory of tuberculosis histori­
cally gained credence because of the apparent 1.10 SOCIOECONOMIC DEPRIVATION
increased susceptibility of various ethnic It is now believed that the common explana^nle5^nt. uP°n th,eir/irs,t exposure tion for the increased incidence oFtuberculoto infected people as a result of colonization, sis both in the colonized and the immigrants
mainly from Europe. The so-called virgin is the r*
socioeconomic decline suffered by
population concept has been seen in the these groups. Loss of land by natives in
in
native populations of North America (Ameri- colonized countries not only ledI to over­
can Indians)[32], South Africa (Africans)[33], crowding,
”
but also to loss of valuable food
Australia (Aborigines) [34], New Zealand sources. Severe overcrowding during the
(Maoris)[34] and Papua New Guinea[34], in European industrial revolution in the seven­
which the natives developed a higher inci­ teenth and eighteenth centuries, caused
dence and more severe form of consumption many people to" be living i
in appalling con­
than the colonizers. Such a concept permitted ditions that were dark, damp and con­
the colonizers to explain the increased mor­ gested. Such people were invariably
tality due to tuberculosis in the natives rather underfed. Whole families lived in rooms
than to admit that the changes they had no more than 3 m2 in urban squalor, where
induced in the natives' environment played they would also be exposed to high doses

Cattle as a source of infection

the fatal
brought
not only
ly as the
apter 10,

neteenth
acreased
It of the
nigrants
•5], and
Hdemics
ere de­
ls enterlot only
t tuberouraged
?re their
need by
circumh tuberto the
f Davos
own in
alia[34].

M
xplana’erculoligrants
red by
ives in
) overle food
ng the
sevencaused
ig cond conariably
rooms
where
doses

Table 1.2

7

Famous victims of tuberculosis

Henry Purcell
Voltaire
Sir Walter Scott
Niccolo Paganini
Percy Bysshe Shelley
John Keats
Elizabeth Barrett Browning
Edgar Allan Poe
Frederic Chopin
Charlotte Bronte
Emily Bronte
Anne Bronte
Fyodor Mehailovich Dostoevsky
Edvard Grieg
Robert Louis Stevenson
Anton Chekhov
Amadeo Modigliani
D.H. Lawrence
Katherine Mansfield

Joseph Boynton Priestley
George Orwell

1659-1695
1694-1778
1776-1832
1782-1840
1792-1822
1795-1821
1806-1861
1809- 1841
1810- 1849
1816-1855
1818-1848
1820- 1849
1821- 1881
1843-1907
1850-1894
1860-1904
1884- 1920
1885- 1930
1888-1922
1894-1984
1903-1950

Composer
Philosopher
Romantic poet and novelist
Violinist
Poet
Poet
Poet
Writer
Composer
Writers
Writer
Composer
Writer
Playwright
Painter
Writer
Writer
Writer
Writer

Source: H.M. Coovadia and S.R. Benatar, A Century of Tuberculosis, Oxford University Press, 1991, Table 1.3.

of infective and infected sputum. In the
USA, Trudeau (184S-1915) demonstrated in
rabbits the significance of such deprivation.
He inoculated ten rabbits with a similar dose
of tubercle bacilli setting five free and confin­
ing the other five to a damp, sunless exist­
ence, and given a poor diet. When those who
had been set free were subsequently cap­
tured and sacrificed, their bodies showed
features of healing from their inoculation, but
those confined all died of tuberculosis[38]. A
similar intriguing observation linking social
deprivation with an increased incidence of
tuberculosis was seen in European Jews
during the Second World War. Ashkenazim
and Sephardim European Jews have been
thought traditionally to have a large racial
resistance to tuberculosis, but during Jewish
persecution, their tuberculosis mortality
exceeded that of Gentiles, having hitherto
been substantially less[29). The increase in
tuberculosis during the Second World War in
Northern Europe has been attributed more to
nutritional shortages than overcrowding and
housing loss.

1.11 FAMOUS VICTIMS
Many doctors, physicians and pathologists
died of tuberculosis, including notably Laennec and Trudeau. Many doctors who sur­
vived the disease were to work in sanatoria,
and to take up thoracic medicine and surgery
as a career. Many famous people suffered
and died from tuberculosis, and until this
century, the disease was thought to confer a
creative energy and skill termed by the
Greeks as 'spes phthisica'. No such real
association is now thought to exist, and it is
not surprising that a disorder accounting for
up to one-third of deaths should have affec­
ted so many people; millions of less famous
people were also victims, but for complete­
ness a list of known creative tuberculotic
patients is shown in the Table 1.2.
1.12 CATTLE AS A SOURCE OF INFECTION

At the start of the twentieth century, the
elimination of infected milk at source was
inaugurated, but not until Koch had acknow­
ledged that there was indeed a difference in

8

Historical background

the bacilli. Such public health measures were
shown to very good effect in the USA from
1917 when there was a dramatic decline in
non-pulmonary causes of tuberculosis[35]. In
Europe, however, where most forms of the
disease were, and are, due to pulmonary
_____ ?
tuberculosis, the elimination of infected cattle
was not associated with any significant
reduction in overall tuberculous mortality.
1.13 MEDICAL MANAGEMENT

, .
Reference has been imade
already to Hippocratic teaching in which the humoral inba­
lance of blood, phlegm, yellow bile and black
bile required to be corrected for the
...e restoration of health. This was thought to be
achieved by venesection or the
f__application
rr.
of
leeches, emetics and aperients, and induction

•',s

country, which, if on an eminence, so much
the better[39J. The neighbourhood should be
dry and high, the soil of a light loam, the
atmosphere free of damp and fogs, and
the cold never too severe to breathe in from
the open air. Exercise was encouraged, and
the physical well-being sustained with a good
diet'andJ generous
wi
L
wine. Bodington's princi­
ples ol treatment were not favoured in the
UK initially however, but were taken up in
Germany in particular. The first sanatorium
was opened there by Brehmer in Silesia in
1859[40], and this was to be followed by his
former patient Dettweiler in Falkenstein. It
was here that rest periods in the open air
gained popularity, and the Black Forest
____________________
Institution of Walther
at Nordrach ve
became
famous[41]. At the same time/s'anatori^wcrZ
i were

ixr

While no fresh air was recommended as a
Many British physicians visited Nordrach
treatment in the Middle Ages, Sydenham and set up sanatoria in Wales, England and
extolled the virtues of fresh air taken while
Scotland, all carrying the Nordrach prefix:
riding on horseback or travelling in an openNordrach in Wales, Nordrach upon Mendip,
air carriage. The antiphlogistic therapy of and Nordrach on Dee at Banchory, Scotvenesection, emetics and ]purgahon conti- land[41J. Alexander Spengler founded the
nued. All sorts and manners o
of( dietary
private
— famous
c----■ ■ sanatorium^ Davos in 1
manipulations were attempted without any which was to be the sX^ for TOomas
attempted without any which
----------------conavoidance of, milk,
d even sanatorium
fatwas dependent on I
ommended by some. Laennec surrounded
the mountain
and forests,
pine forests
and become
------the mountain
and pine
and become

—"ss-ss ““ ~

antimonicals, cod liver oil and astringents
were all fashionable at one time or
another[16).
1.14 SANATORIA AND NAPT

The sanatorium era lasted almost 100 years.
The concept of such an institution was
originated by George Bodington of Sutton
Coldfield, who, in 1840, with remarkable
perspicacity, urged that the tuberculous
patient should be in an airy house in the

-

cure[42].
Koch's discovery of the tubercle bacillus in
1882 gave fresh impetus to the sanatoria
movement. Some cures were achieved, and it
became clear that if oxygen was indeed
harmful to the tuberculous organism, openair treatment would have some scientific
basis.
In the UK in the second half of the nine­
teenth century, many consumptive patients
were nursed and died in Poor Law Institu­
tions, since there were attempts to keep them
out of the voluntary hospitals to protect the

I
Sanatoria and NAPT

so much
hould be
)am, the
•gs, and
• in from
;ed, and
h a good
s princid in the
■n up in
•atorium
ilesia in
d by his
stein. It
>pen air
Forest
became
•ia were
deau at
I efjord,
ordrach
nd and
prefix:
lendip,
, Scoted the
n 1866,
homas
?r Zaunto the
’ecome
lent of
•ecome
by the

tllus in
latoria
and it
ndeed
openentific

nineitients
istituthem
ct the

beds there for patients suffering from poten­
tially curable diseases. Some of these volun­
tary hospitals however were specializing as
chest hospitals for tuberculosis, such as the
Brompton hospital, which opened in London
in 1841. In 1898 the National Association for
the Prevention of consumption and other
forms of Tuberculosis (NAPT) was set up[43].
This was inspired by Sir William Broadbent
who informed the Prince of Wales, later King
l-dward VII, together with Lord Salisbury the
Prime Minister, as well as leading physicians
that 'this terrible waste of life is preventable',
to which his Royal Highness uttered the now
famous comment, 'if preventable, why not
prevented?'
Nearly 20 years after Koch's discovery, the
realization of its importance became appar­
ent, not only to the medical fraternity but to
informed members of national associations
against tuberculosis. They appreciated not
only the scientific achievement of isolating
the tubercle bacillus, but also recognized that
the former unseen killer was now a visible
target against which blows could, and must,
be struck. NAPT was part of an international
movement already flourishing elsewhere. In
the USA, the National Tuberculous Associa­
tion in 1889 fully realized that tuberculosis
was distinctly preventable, that it was not
directly inherited, and that it was acquired
by direct transmission of the tubercule bacil­
lus in sputum from the sick to the healthy
144], Such education needed to be made
available to the community at large, and
similar propaganda was put out by the
League against Tuberculosis, which had been
inaugurated in France in 1892, its German
equivalent established in 1895, and the Dutch
association initiated in 1897. The three areas
in which NAPT concentrated on prevention
were education, the provision of institutional
treatment and the elimination of tuberculosis
from cattle. NAPT advertised, provided
pamphlets and books, and their lecturers
travelled all over the country educating people
about bad food, bad air and bad drink as well

9

as overcrowding, overwork and overstrain. It
was recognized that there was a higher
incidence of tuberculosis in those who were
less prosperous, but NAPT did not have the
power to improve the lot of city dwellers
living in industrialized poverty and squalor.
NAPT attempted to educate individuals to be
personally responsible for not contracting
tuberculosis by improving their lifestyle, but
such advice could be neither understood nor
taken by poor people. Sanatoria were con­
structed by public subscription in the UK and
were a colossal investment at a time when
institutions were an international panacea.
They were certainly attractive objects of
philanthropy, as the donors could see the
results of their charity in a most substantial
way.
Patients were admitted to sanatoria for an
indefinite period. Discipline was stern, com­
plaints were not tolerated, and the physician
superintendent sought a submissive attitude
of compliance at his initial interview. The
atmosphere in many was like a school, and
the attainment of good health was the teach­
ing. Drinking, originally encouraged by Bodington, often resulted in dismissal, but
smoking was permitted. Men and women
were separated, gathering only for meal
times, and the mail was censored in order to
avoid mental agitation. Many sanatoria were
in the countryside, making access difficult for
visitors while at the same time isolating the
sputum-positive victims from the commun­
ity. Most sanatoria faced south, south-east
and south-west, with radial pavilions leaving
no part in the shade (Fig. 1.4). Design was
spartan to resist the notion that luxury led to
survival, lest return home might lead to
relapse. Sunbathing was encouraged, and
ingenious rotating summer houses were
installed to maximize sun exposure in the UK
(Fig. 1.5). The health-giving properties of the
sun were the raison d'etre for the Swiss clinics
of Rollier at Leysin, which specialized in
actinotherapy (Fig. 1.6).
The culture in the sanatorium was for a

10

Historical background

i
v* r'-s-l.'.J '•.L 4-.--i

Fig- 1-4 Leasowe Sanatorium,
Merseyside, showing south­
facing pavillions, all directed
towards the sun.

ih

Fl8’,1-6. Cl?ildren taking sunlight on a pavillion
ward with the Swiss Alps in the background.

conscientious sustained performance of selfdenial, self-restraint and endurance. The
medical issues centred around rest, and
disease activity was judged by the fever
chart. Graded exercises such as receiving the
first visitors were only permitted after a
fortnight without fever, and washing, feedmg and going to the lavatory were then

?n°Wed Pr°Vided that there was no rehJrn of
Fig- 1-5 Revolving summer house at Crosslev
Sanatorium, Cheshire.
J

fever or haemoptysis. Good food and lots of
fresh open air were followed by graded
exercises, all carefully supervised with com­
pulsory rest periods every day. With further

I

Collapse therapy

villion
id.

f selfThe
and
fever
g the
ter a
feedthen
m of
»ts of
aded
comrther

health improvement and weight gain,
patients were encouraged to indulge in gardcning, road making, carpentry and poultry
keeping, and this formed the basis of the socalled 'pick-axe cure' for consumptives,
which was to be the forerunner of the village
colonies developed after the First World War
in the UK. On discharge, patients were
provided with home manuals which con­
tained strict advice as to how to sustain good
health[43J. These were to set patterns of
public behaviour for years, and indeed gen­
erations. Medical follow-up was often carried
out in the UK at the dispensaries, and
additional drug therapy from a vast pharma­
copoeia was tried. These included iron salts,
calcium salts, cod liver oil, arsenic, antimony,
gold, quinine, salicylates, iodine, creosote,
turpentine, carbolic and tuberculin, none of
which was demonstrated to be of any practi­
cal therapeutic value. Tuberculin, which is a
glycerine extract of pure culture of the tuber­
cle bacillus, had been developed by Koch in
1891, and when given subcutaneously in
various strengths, showed positive skin re­
actions in all tuberculous patients. Koch
considered that this potential remedy would
form an indispensable aid to diagnosis. Unfor­
tunately, tuberculin was introduced interna­
tionally prematurely, amid wild enthusiasm
and without critical challenge, so that it
quickly fell into disrepute as a treatment[45J.
It has, of course, remained as a diagnostic
tool.
Although sanatorium treatment remained
one of the main weapons in the fight against
tuberculosis for almost a century, there is no
scientifically acceptable evidence that it
reduced the toll of the disease. Sanatoria did
make some patients feel better, and in others
death was delayed. For some, especially
children diagnosed as pre-tuberculous but
without the disease, sanatorium treatment
must have been harmful, as Thomas Mann
suspected in The Magic Mountain. Compara­
tive results from Saranac, Davos, Brompton
and Norway were all similar, demonstrating

11

that about 50% of sputum-positive patients
survived for 5 years.
1.15 PUBLIC HEALTH

The International Union against Tuberculo­
sis, with its double-barred cross emblem, was
founded in 1902, with offices in Berlin. These
were closed down during the First World
War but reopened in 1920 in Geneva. The
International Union was to encourage a
system of tuberculosis control throughout
Europe, consisting of notification of all cases,
contact tracing and the provision of dedicated
dispensaries and institutions, which were
usually sanatoria. The prototype for these
recommendations had come from Robert
Philip in Edinburgh, who founded the Royal
Victoria Hospital supported by public sub­
scription; this was to become a model to be
emulated world wide for the administrative
liasions between the dispensary in the
community, the sanatoria and the colonies,
the hospital and the Medical Officer of
Health, whereby contact tracing and home
assessments by Health Visitors were intro­
duced and coordinated[46].
In 1913, national legislation was passed in
the UK to verify the notification of all forms of
tuberculosis, and this was soon followed by
the compulsory isolation of tuberculotics.
The 1921 Public Health Tuberculosis Act
made local authorities responsible for these
aspects of tuberculosis care, and the cost was
met from the local rates supplemented by an
Exechequer Grant.
1.16 COLLAPSE THERAPY

In addition to first controlling the pulmonary
disease by physical rest in the holistic sense
in sanatoria, physicians adopted the idea of
resting the lung itself by collapsing it with a
pneumothorax. James Carson, an Edinburgh
graduate, practising in Liverpool, induced
artificial pneumothorax in experimental
rabbits with beneficial results. When he tried
to induce an artificial pneumothorax in man
in 1822, in two cases of pulmonary tuberculo-

12

Historical background

sis pleural adhesions and loculated empyema
prevented a successful outcome[47]. Forlanini 60 years later in Italy induced artificial
pneumothorax using nitrogen introduced via
a needle with 200 ml instalments on a daily
basis[48]. Forlanini's method of repeated
small fill-ups was adapted and modified by
Murphy in the USA, who gave a 1-3 1 largevolume induction of nitrogen under radio­
graphic control[49). It became apparent that
some of Forlanini's patients may have suf­
fered gas embolism, which he termed
'pleural eclampsia' when the needle attached
to the nitrogen cylinder was introduced. In
Denmark, Christian Saugman added a water
^^930^
Pu^monary resect>on. Germany
manometer to the needle and nitrogen source
so that the operator was now able to identify
where the tip of the needle was in the pleural mothorax, collapse of the diseased part of the
space, and thus the safety of the procedure lung frequently^id ] ‘
'
jrxn r-x . ' ,
1
—o ---*i—---- j
not occur due to pleural
was improved[41]. During the early years of adhesions. The idea of severing these adad­
collapse therapy induced by artificial pneu- hesions
was
that
of
Friedrich
in
1908,
and
this
hesions was that of Friedrich in 1908, and this
mothorax, benefit was thought to accrue only was
was brilliantly
brilliantly developed
developed by
by Jacaboaeus
Jacaboaeus of
of
after a long period, but this view was rStockholm
'' ’ ’ ’ using a thoracoscope in 1922. This
challenged by Ascoli
in 1912 who not only
rr
—J enabled him to dissect and divide the ad?bJ!?_ne,d effectlve healmg using only a small hesions under direct vision. This technique
artificial pneumothorax without significant quickly spread throughout sanatoria in the
lung collapse, but he was able to induce Western world, and was known as intra­
bilateral artificial pneumothoraces, further pleural pneumonolysis. Impressed with the
extending the application of the technique results of lung collapse achieved by artificial
to subjects with bilateral pulmonary tuber- pneumothoraces, surgeons began to deliber­
culosis[50).
ately cause lung collapse by other physical
It is surprising how few sanatoria were methods in which the ribs were removed in
capable of performing radiographs in the UK. part or in whole, and there were some heroic
In 1914, only 5 of 17 local authority dispens- assaults on the thoracic cage and the patient
aries and 7 of 96 sanatoria in England and (Fig. 1.7). The early surgi’caf experiencZof
a es provided facihtes for radiography[41). this type caused an unacceptibly high mortalA notable exception had been Lawson, who ity, 1but• thoracoplasty as it was called
& became
installed an X-ray suite in his new sanatorium modified and refined, being performed in
in Nordrach
.
. on Dee in 1900(51].
• ' Morriston
---------- two stages. The first stage involved resection
ttbatjra^oI°gy rwas of of the paravertebral portions of the lower ribs
extreme
the udiagnosis ofr phthi
av r,.™ importance in .u„
•’ • ­ as proposed by Wilms[53], and this was
sis, and that it was <ossenbal before Jaymg followed by the second procedure in which
down a rational scheme of treatment[52].
the upper ribs were resected as proposed by
Sauerbruch[54).
1.17 THORACIC SURGERY
Other forms of surgical collapse therapy,
With the wider use of radiology, it was particularly directed to the upper lobe, were
apparent that after induction of the pneu- invented, and these included extrapleural

f!

BCG

rmany

of the
leural
e add this
us of
.This
e adnique
i the
intrai the
ficial
liber'sical
‘d in
eroic
tient
e of
»rtalame
d in
:tion
ribs
was
hich
i by

>py<
/ere
-iral

pneu monolysis, during which various sub­
stances were inserted into the extrapleural
space in order to maintain lung collapse. In
particular, surgeons used abdominal fat and
moulded paraffin wax, producing a so-called
extrapleural plombage. Collapse of the lung
was also achieved by instilling oil rather than
air into the pleural space, when an oleothorax
was created. These latter procedures were
never adopted universally, but phrenic nerve
damage causing diaphragmatic paralysis
proved very popular. Resection, division and
evulsion of the nerve caused permanent
injury, but phrenic nerve crush induced a
temporary paralysis lasting about 6 months.
Phrenic nerve crush was used in conjunction
with other simple forms of collapse therapy,
but was rarely successful when used on its
own. In the 1930s phrenic crush was often
used in conjunction with pneumoperitoneum
when a 2-3 1 insufflation of air was intro­
duced into the peritoneal cavity to elevate
both diaphragms and cause some lower lobe
collapse.
Thoracic surgical prowess was advancing,
and Carl Semb in Oslo combined a modified
thoracoplasty with dissection of the apical
extrafascial plane, so as to cause collapse of
the upper lobe cavity[55]. This issue had been
unsuccessfully addressed previously in pul­
monary tuberculosis by Monaldi when he
introduced the technique of cavity drainage.
At the Massachusetts General Hospital,
Churchill and Klopstock introduced upper
lobectomy[56], and thanks to the further
elucidation of bronchopulmonary anatomy
by Brock in London, it became possible to
perform pulmonary segmentectomy in tuber­
culous areas[57]. This was usually performed

in the apicoposterior segments of the upper
lobes and the apical segments of the lower
lobes after a technique developed by
Chamberlain.

1.18 THORACIC RESEARCH
The scientific role of surgery in pulmonary
tuberculosis was considerable, but it is diffi-

13

cult, if not impossible, to estimate its value in
reducing mortality and the transmission of
the disease. There was neither controlled trial
nor rigorous testing of any of the techniques,
and such was the faith in collapse therapy
and sanatorium treatment that such a trial
would have been considered unethical. The
close co-operation between physician and
surgeon, however, was to strengthen the
specialty and led to a much more critical and
rational approach to therapy thereafter than
in any other branch of medicine. This co­
operation led to the inauguration of medical
societies composed not only of physicians
and surgeons, but of radiologists and patho­
logists and epidemiologists, and in Britain
the current British Thoracic Society and the
Society of Thoracic Surgeons of Great Britain
and Ireland have in their origins the Society
of Medical Superintendents of Tuberculosis
Institutions, the joint Tuberculosis Council
and the British Tuberculosis Association.
It must be admitted that treatment of
pulmonary tuberculosis up to the Second
World War was more of an art than a science.
The exact size and duration of the artificial
pneumothorax was a matter of clinical experi­
ence not easily transmitted to others by
rational explanation, and other therapeutic or
physical manoeuvres were matters of prefer­
ence and prejudice rather than reason. No
major research work was carried out during
this time, and monies for any research were
directed to NAPT. Nevertheless, the UK
figures for tuberculosis mortality from 1850 to
1950 show an astonishing and gratifying
reduction, with the notable exceptions of the
two great World Wars (Fig. 1.8). It is clear
that socioeconomic features as well as medi­
cal factors were in operation.
1.19 BCG

In 1924 Calmette, working in the Pasteur
Institute in Lille, successfully developed an
attenuated strain of tubercle bacillus that
was incapable of producing tuberculosis in

14

Historical background
1.20 CHEMOTHERAPY
3B0

360

Pulmonary

------------- Eiflland ana Wales
------------- Scoilana

340
320

300

2BO

260
240

220
200
180
160
140
120
100
80
60

40
20 —

If- 3AA nr±rdized
tubercu
.
--------death
- ----- rates
lluul from
nwercuIgsi5 per wo 000 population, England and Wales,
and Scotland: 1850-1950. (Source: Lynda's^dei
Below the Mag.c Mountain, Clarendon Press, 1988,
Fig. 1.)

any laboratory animalsfSS). In France, many
infants received the oral vaccine of the
Bacillus Calmette-Guerin (BCG), but for a
variety of reasons, it was not taken up in the
rest of Europe. Tragically, in 1930 in Lubeck,
Germany, 67 of 249 babies given the vaccine
died of acute tuberculosis subsequently
shown to be due to the inadvertent adminis­
tration of virulent tubercle bacilli stored in the
same fridge as the BCG[59J. The Scandina­
vian countries pioneered the use of BCG and
administered it intradermally; by 1950 this
was being offered throughout Europe in a
mass vaccination campaign to all children'
From 1954, most health^thorities in the UK

In 1944 Waksman in the USA discovered
streptomycin and found that it was bacterio­
static against M. tuberculosis[60]. Clinical trials
were set up in the USA and in Britain, where
they were supervised by the MRC who set
the standard for the scientific assessment of
antibiotic efficacy in tuberculosis. Of patients
treated with streptomycin, 51% showed
radiological improvement of their disease
whereas only 8% of controls did so. Strepto­
mycin was shown to be potentially life-saving
in tuberculous meningitis and miliary tuber­
culosis, but to give rise to adverse effects
most frequently disturbances of balance and
hearing. It was appreciated from the onset
resistance to ^e antibiotic by the tuberC e bacillus occurred after 2-3 months continuous therapyz and that speciaI rhythms of
treatment or additional therapy would be
required to overcome this problem. In fact
this was rapidly realized by Lehmann in
Sweden who detected bacteriostaric activity
of para-aminosalicylic acid (PAS) against M.
tuberculostsiei]. The MRC again supervised a
trial using streptomycin alone, PAS alone
and a combination of both drugs. Unequivoca proof of the action of PAS was estabished, but a much greater consequence was
that combination therapy could be used for
prolonged periods without the development
of drug resistance^]. The adverse gastro­
intestinal effects of high-dose PAS frequently
demanded fortitude and endurance by
patient and physician, so that the discov.ery
7^°bl^ek and Selik°ft in New York in 1952
!--P-

u
’ '
isomcotmicacid hydrazide (isoniazid)
began voluntary
vaccination of 13-year-olds.
was
again
welcomed with uncritical enthuBCG has never been taken up enthusiasti­
siasm[63].
However,
the MRC demonstrated
cally m the USA. Throughout Europe and
rad;
k
that
bacterial
resistance
developed when
tne USA, mass miniature jradiography
’*
lSoniazid was used singly[64], buf in combiwas introduced during the Second "world
War, and this was to play an i inteeral n7 fa;'°"with daily streptomycin it was shown
ntegral part to be the most effective remedy available[65]
in identifying unsuspected cases of tuber­
- ------ ■ The use of prolonged combination chemoculosis.
therapy extended for upwards of 2 years

i

;1

I

References

>vered
cterio1 trials
where
ho set
ent of
itients
owed
>ease,
-eptoaving
uberfects,
? and
onset
uber>ntinis of
d be
fact,
n in
tivity
;t M.
;ed a
done
livo>tabwas
1 for
nent
strontly
by
very
1952
?enzid)
:huited
hen
nbi•wn
65].
no■ars

was pioneered in Edinburgh by Crofton and
colleagues, and it was possible at long last to
envisage cure of pulmonary tuberculosis in
all cases[66].
Such chemotherapeutic success challenged
the role of traditional management of tuber­
culosis of bedrest, sanatorium treatment,
surgery and rehabilitation, all of which were
to become quickly superfluous. Sanatoria
have been found a new role as institutions for
the elderly, collapse therapy is unnecessary,
surgery is hardly ever required unless concur­
rent lung cancer is suspected, and dispens­
aries and chest hospitals have been closed
down in the Western world. With modern
drug therapy, including pyrazinamide intro­
duced in 1954, ethambutol discovered in
1962, and rifampicin discovered in 1969, all
lh.it is now necessary is to take the correct
drugs in the correct dosage for the correct
duration, which nowadays may be as short as
6 months. The tragedy today is that this great
potential has not been achieved universally,
because tuberculotic patients remain undis­
covered, while others remain ill and infec­
tious because money cannot be made avail­
able for effective chemotherapy. Most disturb­
ingly, immunosuppression induced by AIDS is
permitting a Third World epidemic of propor­
tions akin to those experienced in the sixteenth
and seventeenth centuries not with tuberculo­
sis, but with plague, cholera and smallpox.
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itment
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le zur
tuber7.

apy of
Sprextra>uppl.
(1943)
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•nchial
‘ection
trans,
ns &

:ophe
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