Tuberculosis In The Medical Casebook

Microscopy:-

“Microscopy of tuberculosis bacilli.”

 

This Week

This is our 20th blog page, and it is going to be the last. Many thanks to those who have read my blog pages – it has been the first time I have created a blog, and it has been an interesting experience.

Today’s subject is tuberculosis – a horrendous infection in Victorian times, and a disease that remains a difficult to treat infection in modern medical practice.

 

Tuberculosis

Tuberculosis + Sherlock

In Victorian times, tuberculosis was usually called either consumption or phthisis. The disease makes two appearances in the canon.

Firstly it provides the only medical reference in one of the most famous stories, “The Final Problem”. Even readers who have not read any of Conan Doyle’s works will likely know the outcome of this story. Conan Doyle has had enough of writing Sherlock Holmes tales, so decides to kill him off. In his final confrontation with Professor Moriarty, they both fall to their supposed deaths in the Reichenbach Falls in Switzerland. 

Tuberculosis is used as a plot device to get Watson, the faithful companion, out of the way.

The path had been cut halfway round the fall to afford a complete view, but it ends abruptly, and the traveller has to return as he came. We had turned to do so, when we saw a Swiss lad come running along it with a letter in his hand. It bore the mark of the hotel which we had just left and was addressed to me by the landlord. It appeared that within a very few minutes of our leaving, an English lady had arrived who was in the last stage of consumption. She had wintered at Davos Platz and was journeying now to join her friends at Lucerne, when a sudden haemorrhage had overtaken her. It was thought that she could hardly live a few hours, but it would be a great consolation to her to see an English doctor, and, if I would only return, etc. The good Steiler assured me in a postscript that he would himself look upon my compliance as a very great favour, since the lady absolutely refused to see a Swiss physician, and he could not but feel that he was incurring a great responsibility. 

It may have been a little over an hour before I reached Meiringen. Old Steiler was standing at the porch of his hotel.

“Well,” said I, as I came hurrying up, “I trust that she is no worse?”

A look of surprise passed over his face, and at the first quiver of his eyebrows my heart turned to lead in my breast.

“You did not write this?” I said, pulling the letter from my pocket. “There is no sick Englishwoman in the hotel?”

“Certainly not!” he cried. “But it has the hotel mark upon it! Ha, it must have been written by that tall Englishman who came in after you had gone. He said -”

But I waited for none of the landlord’s explanations. In a tingle of fear I was already running down the village street, and making for the path which I had so lately descended. It had taken me an hour to come down. For all my efforts two more had passed before I found myself at the fall of Reichenbach once more. There was Holmes’s Alpine-stock still leaning against the rock by which I had left him. But there was no sign of him, and it was in vain that I shouted. My only answer was my own voice reverberating in a rolling echo from the cliffs around me.

Secondly we revisit “The Adventure Of The Missing Three-quarter”, which we have already encountered in our chapter on gout. The missing rugby player, Godfrey Staunton, is not a victim of a crime. He has married his wife in secret [escaping the disapproval of his uncle, Lord Mount-James], but sadly she is gravely ill. Holmes tracks them down with the aid of a bloodhound called Pompey, but arrives just after she has died. A friend of Godfrey’s, Dr Leslie Armstrong, tells Holmes and Watson the chain of events.

“A year ago Godfrey Staunton lodged in London for a time, and became passionately attached to his landlady’s daughter, whom he married. She was as good as she was beautiful, and as intelligent as she was good. No man need be ashamed of such a wife. But Godfrey was the heir to this crabbed old nobleman, and it was quite certain that the news of his marriage would have been the end of his inheritance. I knew the lad well, and I loved him for his many excellent qualities. I did all I could to help him to keep things straight. We did our very best to keep the thing from everyone, for when once such a whisper gets about it is not long before everyone has heard it. Thanks to this lonely cottage and his own discretion, Godfrey has up to now succeeded. Their secret was known to no one save to me and to one excellent servant who has at present gone for assistance to Trumpington. But at last there came a terrible blow in the shape of dangerous illness to his wife. It was consumption of the most virulent kind.”

Calling the dog Pompey is likely a reference to the nickname of Portsmouth Football Club, which you may remember Conan Doyle helped to form. 

It is maybe surprising to find only two references to consumption in the books, as it was a huge public health issue at the time. It is possible that it was too emotive a subject for Conan Doyle to write about – his first wife Louise [“Touie”] was diagnosed with tuberculosis in 1893, and was an invalid until her death in 1906.

 

Tuberculosis In Victorian Times

This is the second longest Victorian section in the book [after the Insanity chapter]. I found lots of fascinating information on the disease in the textbooks of the time, which I wanted to include. Given it was probably the disease with the biggest societal impact at the time, I am very happy to devote more pages than usual to it. I feel that the excerpts offer an amazing glimpse of Victorian society and its beliefs.  

I used my usual medical texts, but also a specific text on tuberculosis from 1873: “On consumption, and tuberculosis of the lungs” by EH Ruddock [42].

I’ve broken up the Victorian information more than usual in this chapter, as I felt there was so much I needed to comment on. 

Since more than one-eighth of the entire mortality in the country is due to consumption, the acquisition of any knowledge that will augment our powers of prevention or restoration must prove of the highest value. [42]

Phthisis presents itself in a chronic and in an acute form. The chronic variety is by far the most frequent. It is essentially “the consumption” which is such a scourge to the human race. [3] 

There are 3 terms for the disease that are used in the medical texts. Tuberculosis is the name we use today, referring to the tubercles produced by the disease. Consumption is an ancient term, originally meaning a loss of bodily humours, and in Victorian times meaning the impact on the body of tuberculosis. Phthisis [which is hard to spell, and pronounce] is another ancient term, originally referring to any wasting disease, then to wasting lung diseases, and then specifically to tuberculosis. 

The whole subject of the minute examination of the sputum has received a new impetus from Koch’s discovery of a peculiar micro-organism in tuberculous products – the bacillus tuberculosis. Whatever doubt there may be as to this being the cause of tubercle, however uncertain it still is that the parasitic organism is the agent without which tubercular maladies cannot be developed, there is accumulating evidence to show that its presence bespeaks tubercular disease, and that its absence is an almost conclusive argument against the existence of this affection. [3]

This is from an 1883 textbook, which was impressively up-to-date, as Robert Koch only announced his discovery of the tuberculosis bacillus in the preceding year.  Koch was a brilliant German physician and microbiologist, who used innovative microscope techniques to discover a number of disease organisms, also including the bacterial causes of anthrax and cholera. 

It is known that Conan Doyle kept a close eye on Koch’s work. In 1890 an article by Koch regarding a potential new treatment for TB was published in the British Medical Journal [43]. Conan Doyle headed to Berlin to learn about the development first hand [remarkably arriving the day after the BMJ article appeared]. The following is from Conan Doyle’s autobiography, and is an interesting reflection of his personality.

In 1890 Koch announced that he had discovered a sure cure for consumption and that he would demonstrate it upon a certain date in Berlin. A great urge came upon me suddenly that I should go to Berlin and see him do so. I could give no clear reason for this but it was an irresistible impulse and I at once determined to go. At a few hours’ notice I packed a bag and started off alone upon this curious adventure. [19]

Three days after his arrival, a letter entitled “The Consumption Cure” from Conan Doyle was published in the Daily Telegraph [44]. It is a remarkably balanced letter, expressing significant reservations regarding the treatment [which was eventually shown to be largely ineffective]. 

Unhealthy occupations occupy a prominent place among the predisposing causes of phthisis and other diseases of the lungs. Many of the industrial occupations of this country are carried on, to a greater or less degree, at the expense of the health of those engaged in them. Phthisis has been observed to occur in workmen who breathe air loaded with particles of dust, as bakers, needle-grinders, stone-masons, quarrymen, cotton-carders, workers in porcelain, makers of mattresses, furriers, coal-miners, and others. From accurate statistics it has been shown that consumption is five times as frequent in persons occupied within doors as in those following open-air pursuits. In the mining districts of Cornwall and Devonshire, among the most healthy portion of Great Britain, about one-half of the entire numbers of the miners deprived of fresh air and light, die of phthisis. [42]

The sedentary occupations, such as are carried on by milliners, book-keepers, tailors, shoemakers, and many others, are often most unfavourable to health, not alone from the effect of crowding without sufficient access of air, but from the effects of a sitting and stooping posture combined. [42] 

Imprudent and unusual exertions, such as the tremendous respiratory efforts called forth by a University boat-race, or the long marches and steep ascents of a student or literary man during a hurried Alpine excursion; the sitting up, till the early hours of the morning, of the anxious and jaded governess , in order to enjoy converse with books and absent friends; the excitement and effects of badly-ventilated ball-rooms, operating on the insufficiently-clad lady – all these, and many other unwise proceedings, are either voluntarily endured, or through the hard necessities of life enforced, and the seeds of a dire disease, hitherto absent or dormant, germinate and produce their fatal fruit. [42] 

The Victorians were starting to recognise that certain working-class occupations had a terrible impact on your health, and not just the dirty occupations like mining. The statistic that half of miners died from phthisis I think must include other lung conditions such as pneumoconiosis [lung fibrosis caused by repeated dust inhalation].

Needle-grinders were one of a range of workers involved in making sewing needles. They were responsible for sharpening the wire on a spinning grindstone, exposing them both to stone dust and metal shards. Life-expectancy of needle-grinders was rarely beyond the age of 30.

Weeding out the weak. It has been abundantly proved that at an exudation of tubercle is evidence of vital decay: the mission, then, if we may so express it, of phthisis is, the eradication of worn-out constitutions to prevent the perpetuation of enfeebled or diseased generations. In a philosophical sense, says Dr Bennett, tuberculosis is not an inexplicable scourge of the human race, but one of the means by which Providence weeds it of worn-out organisations, incapable of perpetuating healthy offspring. The diseased parent begets diseased children, who, being incapable of continuing the race in its integrity, die off like plants that perish before they blossom and seed, and the earth remains the heirloom of the strong. Were the sickly members of the community to have the power of continuing their race, it would rapidly deteriorate. [42]

The all-pervading law to which we have referred presses heavily, indeed, on individuals who have to be thus prematurely weeded; but individual interests have always to be merged in the general good; and although the operation of the law may appear harsh to the few, it is really an evidence of the existence of that Guardianship which, as a shield, or beneficent Creator has thrown over the human family.   The action of the law has been likened to hurricanes which inflict great individual suffering, but at the same time contribute to the fruitfulness and perpetuity of the human race. [42]

Blimey! I didn’t find such views in any of my other texts, so I am unsure if this represented a commonly held belief at the time.

Beginning usually with a short and insidious cough, with a feeling of lassitude, and a decline in general health; attended at times from its onset with a pain in the affected lung and a somewhat quickened circulation; or giving the first indications of its existence by the occurrence of a hemorrhage; or developing itself after severe bodily or mental fatigue; or traceable to some neglected cold – the disease becomes fully established, with symptoms which hardly need a detailed description. The harassing cough by day and night; the impaired appetite and disturbed digestion; the loss of blood from the lungs; the steadily-augmenting debility; the short-breathing; the exhausting night-sweats; the hectic fever; the deceptive blush which this imparts to the cheek; the increased lustre of the eye; the singular hopefulness; the temporary improvements; the relapses; and the greater vividness of the imagination, so strongly contrasting with the waning frame – are phenomena with which sad experience has made not only every physician, but many a fireside, familiar. [3]

The symptoms vary, especially at the onset, which may be dyspepsia, by loss of flesh, loss of strength, amenorrhoea from loss of blood, cough, diarrhoea, shortness of breath, or hoarseness. Hectic fever, night sweats, bulbous finger and toe ends, incurved and filbert-shaped nails may be specially mentioned. [5]

In rare instances, the cough remains slight throughout the malady; but generally it is a very distressing feature of the complaint, and is particularly worrying at night. Sometimes its violent paroxysms bring on vomiting. Among the less constant symptoms of pulmonary consumption are a troublesome and rebellious diarrhoea, chronic laryngitis and pharyngitis, and the red line around the border of the gum. [3]

The symptoms which precede a fatal termination are various, and depend on the precise manner in which the formidable malady ends. Patients may go on failing for years; or an intercurrent attack of acute tuberculosis, of pneumonia, or of inflammation of the brain or of the intestinal tract may at any time result in death. [3]

The expected fine Victorian descriptions of the disease – our modern medical textbooks have become much more sterile and clinical, and I suspect students would remember far more if we continued to use the more descriptive Victorian approach. I am going to endeavour to use some of the lovely terminology in my clinical notes – “he had a hectic fever, a harassing cough, and rebellious diarrhoea.”

The bacillus tuberculosis is rod-shaped, varies in length from 1/1200th to  1/3500th of an inch, is absolutely motionless, produces spores, and is blunt at both ends. A small drop of sputum is spread very thinly over the surface of a cover-glass, a second cover-glass is then laid upon this, and the two pressed together and then separated by sliding one over the other. The thin layer on the surface of the cover-glass we select to test is then dried, by holding it over a gas or alcohol flame, the side of the specimen being up. The dry cover-glass is now stained by letting the cover-glass lie for twenty-four hours at ordinary temperature in a saturated solution of aniline oil in water, made by adding the oil drop by drop to distilled water in a test-tube until the mixture becomes turbid, then it is filtered and a few drops of a saturated alcoholic solution of fuchsin are added. At the end of this time, all the component parts are stained, including the bacilli. The cover-glass is now immersed for a few seconds in a mixture of one part nitric acid to three parts of water; the color disappears, except that of the bacilli, which are red. This red color is retained if we subsequently color the background blue by immersing the cover-glass in a two per cent watery solution of methylene blue. [3]

This is from the 1883 textbook for use in medical training, the year after these techniques were first described by Koch. Though I don’t imagine such complex microbiological techniques were in common use by doctors of the time.

You should, in all cases, teach the patient to avoid whatever is likely to quicken the progress of the disease. For example, he should never expose himself to damp, cold, night air, or any other circumstance apt to provoke bronchitis. His general health must be strictly watched, and everything tending to diminish his vital powers should be guarded against. [6]

Treatment. Warm woollen clothing, pure fresh air, avoidance of fatigue and of enervating occupations. [5]

Inasmuch as about one-third of human life is passed in bed rooms, airy, well-ventilated sleeping apartments should be ranked with the most important requirements of life, both in health and disease. The sleeping-room should afford a space about a thousand cubic feet for each person [that is, ten feet each way]; and one room should on no account perform the double office of sitting-room and bed room. [42]

Excessive work of the brain must be strictly avoided, and an interest taken in natural objects and operation, such as those of the garden, the farm, the hill-side, and the river. [42]

So readers living in bedsits need to reconsider – let alone those now home-working from their bedsits!

The unrestrained exercises of the muscles and lungs in pure out-of-door air is of high importance, both as a preventative and curative measure. The air, however, should be dry, as on a sandy or gravelly soil, and the situation elevated. Walking exercise secures these conditions to a certain extent; but in walking the arms should be allowed to swing freely, as this brings into play the pectoral and intercostal muscles – the muscles by which the function of breathing is performed, and so tends to enlarge and strengthen the chest-wall and their contents. This suggestion is chiefly intended for females, who usually hold the arms quite still; while a man in walking a mile swings his arms some 2,000 times without inducing fatigue. [42]

Except when a cold north-easterly wind is blowing, children should take open-air exercise every day, as in running, trundling a hoop, or using other out-of-door toys. Frost, and even a moderate amount of damp, need not stand in the way, if the child is taught to move briskly, and a healthy circulation is kept up in the hands and feet. [42]

Except in confirmed and hopeless cases of phthisis, sea-bathing is generally advantageous. The best season of the year is from July to October; and the best time of day is perhaps about two hours after breakfast. The object sought is to produce vigorous reaction. [42] 

Good luck getting your children outside on a frosty morning, with just a hoop and stick for company!

Clothing. This should be sufficiently warm to maintain in vigour the cutaneous circulation; the extremities especially should be kept warm, to obviate congestion in the chest or abdomen. Flannel should be worn in both summer and winter: in the former it neutralizes any variation of temperature, and prevents sudden cooling by evaporation of the perspiration; in the latter it prevents loss of the vital warmth of the body. In winter, the addition of a chamois leather vest may be advantageously worn over the flannel. But flannel should not be worn next to the skin, as it is thus likely to cause unnatural action, and it should not be worn at night. The habit of sleeping in flannel is highly objectionable, and is subversive of the very object for which it is recommended. [42]

Flannel in Victorian times was a soft woven fabric made from wool. Note that any readers wearing flannelette nightwear need to think again!

A person predisposed to tubercular disease should, if possible, reside in the country, and select a house on a gentle slope and gravelly soil, with a southerly or westerly aspect; the bedrooms especially should look in one of these directions. The house should not be too closely surrounded by trees, or in immediate proximity to thick woods, for they both attract and retain moisture, while they exclude much of the valuable influence of sunlight, and thus render the climate damp and cold. At the same time the sight of green hedges, shrubs, and isolated trees has a beneficial tendency. [42]

It is scarcely possible to over-estimate the importance of a change in climate in the treatment of consumption. It combines on one prescription a multitude of remedies for the whole constitution – air, water, food, light, temperature, elevation, natural scenery, and diversified occupation. The climate should be sufficiently mild and equable to permit a large portion of the patient’s time to be passed in the open air. The summer residence should be in a northern and bracing region; but the winter in a southern and warmer, so as to favour the almost constant breathing of outdoor air. [42]

Entire change of climate is a subject of special interest to the inhabitants of this country, as our extensive colonial dependencies, and the comparative ease with which they can be now reached, place the advantages of a suitable climate within the reach of most persons. The climate of New Zealand is, in some respects, a more desirable one than that of Australia for a consumptive patient. Egypt is now much recommended for the consumptive, on account of the dryness as well as moderate warmth of the climate; dryness of air prevailing even on the Nile. At the time of writing, Madras is recommended, by an eminent member of our profession, as a highly advantageous winter residence. [42]

When removal to very distant countries is impracticable or undesirable; and even Nice, Cannes, Mentone, San Remo, Malaga, Cadiz, Madeira, Algiers, or other European health-resorts, are beyond reach, Hastings, Clifton, Bournemouth, Ascot, Dartmoor, Torquay, Ventnor, Guernsey, and Queenstown [Ireland], are places in our own Islands to which patients may be sent with the prospect of excellent results” [42]

I think this is a lovely section. It illustrates a recurring theme in Victorian medical texts – that the diseases are far more prevalent in the working classes, yet the doctors were primarily looking after the wealthier classes, and providing remedies that were only options for the latter part of society.

We are of course at the height of the British Empire at this time, and it is fascinating that this is seen as offering a wide range of locations to send your consumptive patients to. Egypt, however, was never a British colony, and oddly at the time this book was written, was not even occupied by the British.

I love the insight this excerpt gives into the trendy places, in both Britain and Europe, to visit to improve your health.

The diet is of the first importance, and every effort should be used to induce the patient to take articles of a fatty nature. Cod-liver oil is the best of these, and may be given along with acids, or in orange or ginger wine. Gelatinous materials, such as oysters and Iceland moss, are valuable, and may be used at any stage of the disease. Starchy food can often be assimilated where there is an objection to fat, and cornflour, rice, sage, and arrowroot may be freely given. As a general rule, alcoholic stimulants agree and are very useful, especially in the latter stages, all excess being of course forbidden. A liberal supply of animal food should be afforded, both to improve the nutrition, and also to compensate for the loss of albumen caused by the expectoration. [6]

Plenty of nourishing food stopping short of giving the digestive system more work to do than it can undertake. In many cases the crux of the treatment is the maintenance of the digestion. Various invalid foods often prove of much service. Mellin’s food, Denaeyer’s peptones, beef teas, veal and chicken tea, underdone meat, custards and other light food may be prescribed. As much fat as possible should be taken by the patient. Malt and cod-liver oil may agree, or either may be taken alone. Pancreatic emulsions, Loeflund’s Cremor Hordeatus, Kepler’s Malt and Malt and Oil are valuable preparations. [5]

Fatty matter, in quantities as large as it can be assimilated, has been strongly recommended. Cod-liver oil is the substance which has been found most beneficial. It may be considered as an item of food, and its power in checking emaciation and improving the healthy tone of the muscular structures is too well known to require commendation now. At Brompton Hospital more than six hundred gallons are consumed every year. [42]

If the patient is benefited by its use, a moderate allowance of beer or wine. Two or three glasses of Carlowitz, Burgundy, Claret, or Hock, diluted with water, may in some cases be given with good results. [42]

Another section full of fascinating historical snippets. As in other chapters, we get an insight into the Victorian diet. I don’t often recommend that my patients eat a lot of oysters!

Iceland moss is an old remedy for coughs. It is technically a lichen rather than a moss, and apparently does grow in mountainous areas of the UK.

The Victorians look to have had as many wacky dietary supplements as we do today. The following advertisement is from a Victorian edition of the “The Nursing Record” [45]:-

Loeflund’s Cremor Hordeatus [Condensed Cream Emulsion] a delicious Confection of Milk Fat [ie cream] with Malt Extract. Effectually supersedes Cod Liver Oil, being easily digested, and may be spread or dissolved in Tea, Coffee etc, invaluable in phthisis, consumption, and all wasting diseases. 2s. 6d.

I also love the thought that a doctor would not only recommend wine, but specify which grape varieties were the best.

Cough is the symptom to which you are always expected to pay especial attention. Do not use opiates more freely than you can help, as they tend to lessen the appetite and thereby impair the nutrition of the patient. It is a good plan to give some mild sedative, such as chloral or the compound ipecacuanha powder at night, so that the patient may have sufficient sleep, and to trust to small blisters and other forms of counter-irritation to allay the cough in the daytime. In the later stages morphia and other sedatives are necessary to afford the patient relief from his sufferings. [6]

We need, therefore, scarcely add that the knowledge and experience of a physician are pre-eminently necessary, and that every case of suspected disease should be confided to the care of a professional Homeopath. [42]

The Ruddock text quoted latterly here then has pages of detail on suggested homeopathic remedies. Homeopathy was at the height of its popularity in the first half of the eighteenth century, but was starting to fall out of favour when this text was written [before becoming popular again in the 1970’s].

The consumptive should not marry until they have been restored to health and strength. Indeed weakly or sickly persons generally should not marry, for marriage involves a further drain upon the system already too weak to bear efficiently the burdens of life. If the phthisical young man marry before being restored to health this condition often becomes a fresh cause of debility, and he will almost certainly become the father of feeble or tainted children, who often, after a few months or years of suffering, die, and the parent is surrounded with responsibilities and anxieties which press heavily on his weak frame. If the young woman marry, she probably becomes a mother – for marriage in about five cases out of six is followed by a pregnancy, and while she thus exposes herself to the perils of childbirth, greatly heightened in such a disease, she indelibly imprints her infirmity on her offspring. [42]

And to finish our fascinating look at tuberculosis, some very out-dated views on allowing the sick to marry and bear children. In the 1870’s, it was thought to be a hereditary disease rather than an infectious one.

 

The Book

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.