THE CHANGING FACE OF THE GREAT MIMIC: a look at TB through the years

1. THE CHANGING FACE OF THE GREAT MIMIC: a look at TB through the years • Introduction • 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 • 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.”. 1800s 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. 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. Risk factors 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.” 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 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.” Diagnosis 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 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. Treatment • 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: Reid, Thomas – an essay on the nature and cure of the phthisis pulmonalis – 1785. Stokes, William – a treatise on the diagnosis and treatment of diseases of the chest – 1837. Louis, P.C.A.; Walshe, Walter hayle – researches on phthisis: anatomical, pathological and therapeutical – 1844.