Transcript Tuberculosis by Jaffar Al-Sheikhli

THE CHANGING FACE OF THE GREAT
MIMIC: a look at TB through the years
Introduction
Risk factors
•Tuberculosis has been known by many different names over the centuries; such names include the phthisis, consumption, scrofula and
the white plague.
•Not only has the name changed, but our understanding of this important disease has also developed over the years.
•In this poster, we will consider how the content of the Plymouth medical society’s historic collection reflects our changing
understanding of this notorious condition over the last few centuries.
1700s
1800s
Medicine in the 1700s was far less advanced
than it is today. Therefore the risk factors
were mainly based on observations. From
the books available within the collection,
Thomas Reid provides the best description
in his “essay on the nature and cure of the
phthisis pulmonalis”(1785):
•He suggests a hereditary nature, “in such
cases it may with some degree of truth, be
termed an hereditary disease.”
•He also gives a good description of the
patient who may be more susceptible, “this
disease usually attacks people of a delicate, weak
tender constitution.”.
Doctors developed a much better
understanding of the risk factors for TB in
the 1800s. In the fifth chapter of their book
titled “Researches on the phthisis:
anatomical, pathological and
therapeutical” (1844), Louis and Walshe
describe the risk factors as “Age, female sex
... Delicacy and weakness of constitution ...
Respiration of impure air; habitation of
confined places”
They also challenged some of the older
beliefs that the condition had a hereditary
influence or that it was effected by the
type of climate a person lived in.
Diagnosis
1700s
Doctors in the 1700s did not have many tools
for diagnosing disease. In fact a basic tool
such as the stethoscope was only invented in
the 1816, in Paris by Rene Laennec. therefore
many diseases, including TB, were diagnosed
on the basis of their clinical presentation.
Once again Thomas Reid provides a good
description of this in his “essay on the nature
and cure of the phthisis pulmonalis”:
“I would define the phthisis pulmonalis when
confirmed, to be an expectoration of purulent
matter from the lungs by means of frequent
coughing: attended with a fever of a peculiar kind,
having morning sweats and remissions in the
afternoon, occasioning a wasting of the flesh and
strength.”
Treatment
1700s
The treatment of TB was once again
limited by the lack of tools at the time.
Therefore, as described by Thomas Reid
in his “essay on the nature and cure of
the phthisis pulmonalis”, non-targeted
therapy was usually used:
“principles of which are bleeding, blisters,
issues, caustics, and drains of every kind,
bark and tonics, oils, balsams, and
pectorals.”
But even the author recognised how
ineffective this type of therapy was, this
is put best by a quote from the same
book.
“I fear the observation has been but too much
verified “that more die by the lancet than the
lance.””
1800s
Rene Laennec invented the stethoscope
in the early 1800s, which had a
significant impact on the diagnosis of
respiratory disease. Doctors were no
longer limited to the symptoms that the
patient displays, but they could elicit
specific signs on examination. William
stokes provides a good description of
this in his “treatise on the diagnosis and
treatment of diseases of the chest” (1837):
“in some a single occasional mucous bubble
is the only sign, while in others the
respiration is altogether masked by a
combination of the sonorous, sibilous and
muco-crepitating rails, these signs are
audible under the clavicle.”
1900s and beyond
The books within the historic
collection do not cover the risk factors
for TB in the 1900s. This means that we
are unable to describe how that may
have differed from our current
understanding
Modern text gives a very detailed list
of risk factors for TB, which includes
living in areas where the disease is
common and having a weakened
immune system. This knowledge has
developed as a result of our improved
understanding of the pathophysiology
of TB.
1900s and beyond
The content of the collection
highlights the introduction of
medical imaging techniques to the
diagnosis of respiratory disease.
Seymour Shanks and sir peter Kerley
provide a very detailed look at the
use chest x-rays for diagnosis of
disease in their book “a text book of
x-ray diagnosis: in four volumes”
(1950).
Sadly the collection does not include
any books that highlight the use of
microbiological techniques in the
diagnosis of TB, which were
introduced in the late 1800. and early
1900s.
1800s
Doctors in the 1800s continued to use the same
general measures as their older counter parts.
William stokes recommended in his “treatise on
the diagnosis and treatment of diseases of the
chest (1837) that:
“leeches are to be applied in small numbers
alternately to the sub-clavicular and axillary regions
of the effected side”
Other doctors recommended more targeted
therapy. Charles scudamore (1834) produced
many cases recommending the use of
inhalation therapy:
“i prescribed a weak solution of iodine, with the
addition of some saturated tincture of conium,
mixed with water of 120 degrees of heat, to be
inhaled for fifteen or twenty minutes, three times a
day.”
1900s and beyond
This is not covered within the
content of the collection, but our
management of TB was
revolutionised in the 1900s for two
reasons:
•The discovery of a vaccine by A.
Calmette and C. Guerin in 1920.
•The discovery of antibiotics in
1929, which revolutionised the
treatment of infectious diseases
such as TB.
Current management of TB
involves the use of combination
antibiotics to prevent resistance,
which was an issue with earlier
therapies.
Summary
•Tuberculosis has effected the people of this country for many centuries and as Thomas Reid described it in
his 1785 book titled “the nature and the cure of the phthisis pulmonalis”, this prevalence has always been
difficult to explain:
“consumption of the lungs has been considered peculiarly endemical to the inhabitants of this country, whether
occasioned by the infinite variety, and sudden transition of the climate, by our insular situation, or manner of living”
• Its prevalence and impact on the population is likely to be the reason behind the great interest, and
abundance of literature on the topic.
•By exploring the Plymouth medical society’s historic collection, it became clear that our current
understanding of TB has developed over many years. Therefore we should always consider how this
knowledge may change over the next few decades, and how that may influence our current approach to
managing the disease as it continues to have the same devastating impact on the worlds population.
Further reading
If you are interested in learning
more about the history of TB, we
recommend the following books
from the collection:
1. Reid, Thomas – an essay on
the nature and cure of the
phthisis pulmonalis – 1785.
2. Stokes, William – a treatise on
the diagnosis and treatment of
diseases of the chest – 1837.
3. Louis, P.C.A.; Walshe, Walter
hayle – researches on phthisis:
anatomical, pathological and
therapeutical – 1844.