The White Plague

What is tuberculosis?

Also known as “phthisis” or “consumption” (due to the wasting away of the infected individual) and “the white plague”  (describing the pallor of the skin of those infected), tuberculosis was responsible for more deaths in industrialized countries in the 19th and early 20th century than any other cause.  In the early 19th century, in fact, 25% of deaths in England were due to tuberculosis.

Tuberculosis is caused by the organism Mycobacterium tuberculosis. A person with active tuberculosis sneezes, coughs, speaks or spits, emitting numerous tiny droplets containing the bacteria (a sneeze can release up to 40,000 droplets!).  Transmission occurs when one or more of these bacteria-containing droplets are inhaled.

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Public Health Poster c. 1920s / source

Once in the lungs, the M. tuberculosis bacteria invades and replicates within cells. This leads to a response in which the body creates an organized aggregate of immune cells, called a granuloma, around this infected cell in order to contain the bacteria and concentrate an immune response to the area.

After initial infection with M. tuberculosis, about 10% will develop TB pneumonia with infection spreading from the site of initial infection. The remaining 90% of people will remain asymptomatic and noninfectious, with the bacteria remaining dormant in the granuloma.  In most individuals, the infection remains in this prolonged suppressed state called “latency”.

However, in about 10% of infected individuals with latent disease, active tuberculosis will eventually develop, either due to a continuous process within a year or so of infection, or years later after a period of dormancy.  Symptoms of fever, chills, night sweats, fatigue and loss of appetite develop along with chest pain, wheezing, persistent cough with sputum and the coughing up of blood (hemoptysis).  As cells die within these areas of infection, a cheese-like proteinaceous mass of dead cells accumulates in cavities within the lung tissue.

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Chest X-ray of a patient with advanced tuberculosis.  White arrowheads indicate areas of infection.  The formation of a cavity is marked by black arrows. source

What is scrofula? 

Back at L’Hopital, after finding Claire of impressive skill and knowledge as a healer, asked her to help tend the wounds of a boy with scrofula.

Scrofula
Child with scrofula, 1893 / source

Scrofula is a term used to describe the enlarged lymph nodes of the neck caused by infection with tuberculosis outside of the lungs, in this case in the area of the tonsils and adenoids.  While tuberculosis primarily affects the lungs, in 15-25% of active infections, it spreads outside of the lungs and can occur anywhere in the body.  Most commonly involved areas include the central nervous system (TB meningitis), lymphatic system (scrofula), genitourinary system, bones and joints (termed Pott’s disease when it is present in the spine).

Treatment of Tuberculosis

Tuberculosis has plagued humans for thousands of years.  Evidence of tuberculosis infection has been found in Egyptian mummies, ancient China and India and in the writings of Hippocrates. A variety of treatments were applied prior to the era of antibiotics.

In ancient Greece, patients were treated with healthy food, milk, and exercise.  Some recommended eating wolf livers or elephant urine.  Bloodletting was common.  Later, TB sufferers were treated with various treatments with equally varied results such as carbolic acid, gold, arsenic, and cod liver oil.

For many years it was believed that disease could be cured by a king’s touch and this became a common approach for the treatment of scrofula.  This became so common that scrofula became known as “mal du roi” or “King’s Evil.”

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Healing by the “King’s Touch” / source

The Sanatoria Era

The 1880s brought the sanatoria movement or the “rest cure”, an attempt to cure TB and prevent its spread by moving patients in to quite environments, isolated from normal life, with freely circulating pure air.  Surgical treatments became more common in the sanitariums, based on the theory that the part of the lung with TB needed to “rest” in order to heal.  Surgeons would collapse the affected lung by way of various methods, to allow the lung to rest and heal.  This would include causing a pneumothorax, perfuming plumbage (inserting air, oil, wax, etc., into the chest cavity to collapse all or part of the lung), removing ribs to collapse a lung, severing the phrenic nerve to paralyze half of the diaphragm to reduce the functioning of the affected lung.

Vaccination

Vaccination against TB became available and widely used beginning in the 1940s and 50s in the form of the BCG vaccine (bacilli Calmette-Guerin, named for the two researchers who developed it in the 1920s and 1930s).  The BCG vaccine does offer protection against TB meningitis and disseminated TB in children, but does not prevent primary infection or prevent reactivation of latent TB infection.  While it does prevent some severe forms of TB in children, its impact is limited.

Antibiotics

1946 marked the development of the antibiotic streptomycin, the first effective treatment for tuberculosis.  The development of isoniazid would follow in the 1950s.  Antibiotic treatment of TB was so effective that almost all of the sanatoriums closed permanently in the 1960s.  Rates of TB infection dropped steadily until the 1980s, when they again started to rise.  This has been attributed to the rise in HIV infection (patients with HIV have a much higher rate of developing active disease from a latent infection) and the emergence of multi-drug resistant TB.

Because of drug resistance in TB, today the typical initial regimen for treating TB is four medications taken for 6 -9 months. TB can be cured when the regimen is followed but such a regimen leads to issues with compliance, perpetuating the problem.  If a patient fails to complete the treatment or if the infecting bacteria is already immune to one of these antibiotics, some of the germs will survive, adapt and grow stronger, passing on drug-resistant traits as the bacteria reproduce.  Thus, it is vital to eradicate the infection in its entirety with the first course of treatment.

Extensively drug resistant TB (XDR-TB) has recently emerged, complicating treatment further.  This is a rare type of drug resistant TB that is resistant to the two most potent TB drugs in addition to at least 2 other agents used in the treatment of TB. This is, of course, much more difficult to treat and cure has shown to be possible only in about 30-50% of patient with XDR-TB.

The Global Threat

TB remains a significant global health threat, particularly in developing countries. In 2014 alone, 9.6 million people developed TB infection and 1.5 million died from it.  95% of TB deaths occur in developing countries where it is among the top 5 causes of death for women aged 15-44.  Challenges remain in developing fast-acting diagnostic TB tests that can also determine whether resistance is present (currently it can take 6-16 weeks to determine the resistance pattern of an infection), development of a more effective vaccine, and work to increase the reporting and treatment of TB.  The stigma of tuberculosis remains a problem, leading to delay in seeking treatment and lower treatment compliance, allowing further spread of the disease.

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Prevalence of TB per 100,000 people in 2004. / source

CDC Information about Tuberculosis

WHO Information about Tuberculosis

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  1. Pingback: If Mary Poppins Had A Medical Bag – Sassenach Doctor

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